James Adams, MD
Professor and Chair
Department of Emergency Medicine
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
In the absence of feedback, or attention to
feedback, people tend to see what they want
“I was shocked to find out…”
“I was shocked that we lost the contract…”
“I could not believe that they did this to
We value what we have more that others
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.
Feedback is the great teacher
– Constructive feedback is the teacher
– Experience improves confidence, but not
– Feedback makes us rational
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?
– 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
What causes our behaviors?
Deep seated needs and emotions
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
We control emotions and instincts
– Our beliefs about other doctors
– Other services
– Nurses, etc etc
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
The cost of the fight
– Being right,
– Winning feeling,
– being justified.
The cost of the fight
– Real influence over others,
– self expression,
– 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
Calm the voice in your head
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
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
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?
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.