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       James Adams, MD
       Professor and Chair
Department of Emergency Medicine
     Northwestern University
        Chicago, Illinois
       Let‟s First Face Reality

 We   are not rational
   – We are emotional and constrained by our
     own psychological tendencies
 Professionalism is not natural.
  – The truth is that we must overcome our natural
    impulses that undermine us.
  – Success requires insight and the ability to use
    language to positive effect.
    Human Nature works against us:
 We tend to view our experiences as
  flattering to ourselves
 We remember successes more than failures
 This impedes learning
          Confirmation Bias

 In the absence of feedback, or attention to
  feedback, people tend to see what they want
  to see.
 “I was shocked to find out…”
 “I was shocked that we lost the contract…”
 “I could not believe that they did this to
          Endowment Effect

 We value what we have more that others
  value it.
 We think more highly of ourselves, our
  contributions, our skills.
 We are willing to pass up good deals
  because of the endowment effect
 We often turn potential wins into losses.
   Experience is not a great teacher
      » You will not have 20 years of experience,
        you have 1 year of experience 20 times over.
      » The same successes, failures, frustrations,
        aggravations will keep repeating.
      » Unless…
Feedback is the great teacher

– Constructive feedback is the teacher
– Experience improves confidence, but not
– Feedback makes us rational
          Myth Dispelled:
      We are not rational, we are

   The mouse in the maze
    – The mouse tries another approach.
    – The mouse eventually gets the cheese.
           Dealing with conflict

   What to do when someone comes at you?
    – Fight/flight
    – Risk seeking for loss: a lot to lose, little to gain.
    – We need to defend ourselves
   What would happen if you did something
    –   Shake hands
    –   Embrace it
    –   Let it pass by (the matador)
    –   Don‟t engage in a reciprocal relationship

 When behavior is derived from core value
 A chair without a leg lacks integrity
 A person whose behavior is discordant with
  core values lacks integrity
 Consistency
    What causes our behaviors?

 Environmental stimuli
 Deep seated needs and emotions
 Instinctive reactions
     Resistance and Conflicts are
Resistance and Conflict are caused by words
  and actions that are impulsive, instinctive,
  driven by emotion.
Language is the space between people where
  good or bad things occur
Authentic listening, suspending judgments.
  – Quiet the voice in our heads
  – Decrease anger, frustration
     Private Conversation vs Public
   The private conversation in your head.
    – Be silent for the next 30 seconds.
    – The ability to override these voices means we
      are sane
   We control emotions and instincts
    – Our beliefs about other doctors
    – Other services
    – Nurses, etc etc
            “Do Something”
 A neurology resident came to the ED to
  evaluate a patient with atypical weakness.
 The resident said, “get an MRI” and left
 The nurses and attending began to complain
 The patient clearly needed to be admitted
 The nurses and other residents said, “You
  have to do something.”
   A surgery resident came down to the ED
    and „took‟ a hand tray, for an inpatient on
    the 12th floor. As he was walking out…
    – What did the ED nurse say?
    – What did the surgery resident say?
    – What did the attending say?
   A surgery resident needs a hand tray
    – For a patient in need
    – In the middle of the night.
    – To do the right thing
   A 21 year old man came to the ED with a
    finger amputation. The resident on the hand
    service did not respond to 4 pages. The
    attending was called. The resident came
    storming down….
             The cost of the fight

   Benefits:
    –   Being right,
    –   domination,
    –   Winning feeling,
    –   surviving,
    –   being justified.
               The cost of the fight
   Costs:
    –   Real influence over others,
    –   credibility,
    –   hospitality,
    –   vitality,
    –   affinity,
    –   leverage,
    –   self expression,
    –   fulfillment,
    –   goodwill,
    –   reputation,
    –   mutual support,
    –   long term success.
          Dealing with conflict
 Most resistance disappears if there is no
 Resistance is an illusion, framed in
 Creating your own reality
    – Power comes from positive expressions, setting
      expectations, responding to empty threats with
      the attitude you want the other to adopt.
    – Pick your battles
                  How to win

   Choose your battles.
    – Know what is valuable
   You don‟t topple the wall by punching it
    – Cultivate allies
   Understand that your actions are decisions
    – Don‟t be ruled by your emotion
    – “Professional” actions create happiness
         Seek to Understand

 Breathe
 Calm the voice in your head
 Breathe, re-focus
 Re-frame
 Seek to understand
 Blend and redirect

 Reality exists in language.
 Perception of value resides in language.
 “Good” and “Bad” determinations reside in
  impulse, emotion, and are communicated in
  body language, tone of voice.
 Our use of language creates reality
    Turning „Bad‟ Technicians into
         „Good‟ Technicians
   2001: An EKG technician performed an EKG and
    placed it in the chart. The rule was for the
    technician to hand it to the doctor.
   2004: All technicians consistently handed the
    EKGs to the doctor.
   2007-8: Technicians occasionally placed the EKG
    on the chart
   2008: What action should we take?
    Controlling Reality and Emotion:
             Power vs. Force
 Force = Domination
 Power = Ability to create a result
    –   Proper use of language
    –   Insight into emotion, motivations
    –   Productive language
    –   Relationships
             What is real?

 One surgical resident „hated‟ the ED
  because people were rude and unhelpful.
 The other surgical resident found everyone
  friendly and helpful
 Why the difference?
           Using language

 Use language to build the life and career
  that we want
 Use language to create our reality
 Declarative positive statements.
 We become what we think about every day
        Why do you hate me?

 You put out a schedule and a resident
  comes to you to complain.
 You get irritated and the resident complains
  to the residency director that you are not
        Caught in the Middle

 You have a scheduled meeting with the
  residents, who begin to complain about the
  residency director. A select few loudly
  complain that they do not „feel supported‟
  and are always under the gun. They clearly
  are stirring up trouble.
 The residency director confides in you
  about low-performing trouble-makers.

 Our emotional instincts and psychological
  tendencies work against us.
 Reality is created through language
 Conflicts, barriers, enemies are usually
 We can create our own reality by
  understanding ourselves, others, and
  committing to positive possibilities
    – You will get more than you bargained for!!!!
There is no virtue, there is no
 vice, there‟s just the things
 that people do.
 – John Steinbeck, The Grapes of Wrath.