This episode focuses on concepts of bad behaviors and attempts to understand why our colleagues, our institutions, and us as individuals may behave poorly. Understanding negative thinking is the first step in addressing and improving individual behaviors and institutional cultures and, in general, taking better care of each other. Reading and References: Think Like a Monk, Energy Leadership, The Truth of Yoga, Mindfulness for Beginners.
Welcome back to operate with them. In this episode we're going to focus on behaviors. I'm going to talk about both good and bad behaviors. And I wish we could spend the majority of time talking about good behaviors. But unfortunately, we really need to understand why people may behave badly. And while and why negative thinking and our capacity for negative thinking can create poor behaviors. Once we understand the rationale and theories behind bad behaviors, we can then work towards improving our thinking and act more positively in our surgical selves. So a great place to start is with a classic sociology study. Many of you may be aware of the Zimbardo Stanford prison study, which was conducted in 1971. The study was designed to examine the effect of roleplaying labeling, and social expectations have on behavior over a period of two weeks, but was stopped after only six days, due to some really disturbing behaviors among the participants. Briefly, young men, Vol young male volunteers, were randomized to either be prisoners or prison guards in an experiment on the Stanford campus. But unfortunately, the situation deteriorated relatively rapidly, where within the first 24 to 48 hours, the prisoners rebelled. And a minority of prison guards about a third of them became so hostile, cruel, and inventive, inventive in forms of punishment, that the study had to be stopped. And it brings up a number of important phenomenon and capacities that we have as humans. The first thing that's worth bringing attention to is that these were normal male volunteers. These are not men with prison records or a history of poor behaviors. And it brings us to the point that there are very few inherently bad people we've all seen, especially in medicine and surgery colleagues, partners, who behaved poorly, behaved poorly to patients behave poorly in the operating room behave poorly to other people in the institution. But it doesn't mean they're bad people. And so we have to understand why people may behave badly in these situations, that will give us the opportunity to reflect on ourselves and improve our own behaviors. So the first thing we're going to do is try and understand how institutions can create situations that foster poor behaviors. And in that setting, talk about how people can act negatively, when they have a fear or loss of their core emotional needs. For instance, challenges to their, their understanding of peace, love, or safety. And this brings us back to Maslow's hierarchy of needs, which we discussed in in the self, a sense of self podcast. But basically, as humans, we all have physiologic safety, love and esteem needs that need to be met before we can work on self actualization or achieving our full potential, you could use the same analogy to say that we we need to meet the same needs, we need to have an understanding of safety and physiologic needs of love and self esteem. Before we can act truly with positivity, and when we're lacking in one of these needs, that may be the reason people are lashing out because they're feeling either unfulfilled, or they're seeking to fill one of those needs with something else. And so when we look inwards, we see negative behaviors in ourselves. And we often one of the easiest times to do is see when we are critical of others. And it's really important to reflect back and looked at when you criticize others, you're actually looking or reflecting the bad in yourself. On the flip side, when you notice the good in others, you noticed the good in yourselves. So the first behavior we can be aware of and modify is to be less critical of others and less critical of each other, be more accepting of mistakes and working with people to to remedy those mistakes or to act better, rather than just being critical. And we've all been in situations where we need to vent right, we want to vent about our terrible day in clinic or the challenges we had in the operating room. But remember, venting is a negative behavior. And while it may feel good to get that out, and there is something cathartic about expressing those, doing it in a negative way, can actually increase some of our our physiologic responses in a negative way we can increase cortisol secretion, and if you look at this in some of the scientific studies over time, you can see decreased size and hippocampus you can see decreased immune response in study subjects who had increased cortisol secretion over an extended period of time due to persistent negative behaviors. And when we think of ways as individuals that we can challenge those negative beliefs or meet some of those needs, we may want to employ a mindful approach. And when we think about activities based on self interest, like greed, animosity, delusion or violence, these are bad behaviors. And they're often coupled with mindlessness, as opposed to being aware, or mindful, and expressing feelings of interconnectedness, cooperativity and kindness, which can help us fill our needs, fill our gaps and act in a more beneficial or positive way. I'll give two examples from mindfulness for beginners by Jon Kabat Zinn, who's one of the founders of kind of the Western schools of mindfulness and meditation. One is greed, right? When we see a greed, it can be described as a never ending cascade of dissatisfactions, right, you need one thing and when you get that one thing, well, guess what you're not satisfied, you need something else. And there's always something else. But when you act in a mindful or aware sense, and say, when what you have is enough to do what you need to do, it can end that cascade of dissatisfaction. And leave you satisfied in the moment. We see this in medicine specifically, where you may get caught in a cycle, or I need a nurse practitioner or physician assistant or another nurse to support my practice. But when in reality, what you really need is just support of your practice. And you may just need more appreciation, or support from your administrators or leadership. And it's not the person or persons you need to generate the support for your practice. By addressing that foundational need, you can end that never ending cascade of dissatisfaction and work towards more positivity. Another example is a version that's desire to be away from someone or something. So instead of acting out, when we feel that sense of aversion, we can actually sit there and reflect and contemplate Why are we feeling averse to the situation, or this person is an opportunity to learn and to grow. And so when we think about the institutions that we are in, they certainly can create environments, or foster social contracts that favor good or bad behaviors, or positive or negative thinking. Once again, I'm going to focus on the negative thinking here, and the negative social constructs so that we can work to identify and remedy them. So back to the Zimbardo study, once again, a third of the guards became violent and cruel, simply when given authority showing that a person's position in a hierarchy can alter their behavior. In addition to prevent evil behavior, don't want to necessarily focus on changing that individual, but you can focus on changing the situation that enable them to behave badly. Similarly, within our own medical institutions, we can focus on changing the systematic issues that are creating bad behaviors. And we're going to talk about some of those in kind of social sciences or the social constructs, you can see these as the deferral of responsibility to authority, where an authority figures should take responsibility for an individual's bad behavior, we say, well, it's not my fault. It's because we have poor leadership. There can also be diffusion of responsibility, not necessarily upwards in a hierarchy, but among a group. So it's not my responsibility, but it's our group's responsibility. And that's why these things are going poorly. Identity change is really common in medical institutions, particularly academic metal and medical institutions. Where you see, it's not necessarily a uniform as it was in the prison study, but it's a title, or it's empowerment of a position that allow people to behave differently to others. And lastly, is the power of the situation. Depending on the day, the week, the setting, we all have good and bad character traits that can reveal themselves. And I think most commonly where we all see this is in the operating room. We all know, colleagues or peers are trained with people who were very different people in and out of the operating room. And somehow when they walked into the operating room, their demeanor changed, and they become domineering, or mean or aggressive, something that's very distinct from their normal characteristics. And so importantly, we need to learn to recognize those situations, recognize these environments and social constructs so we can change them. Some of the other triggers for social identity conflict that we see and commonly we see this with things like sexual harassment, or no as we talk about diversity, inclusion, and equity in organizations that don't favor D AI. Here are some of the triggers that we can see First of all, we see differential treatment, right? different groups of people are treated differently, or different hierarchies are treated differently, right leadership is treated differently than then kind of the working class surgeons or physicians, we see a simulation simulation where we expect minority groups to accept the thoughts or behaviors of the majority. Rather than listening to our entire organizations or our entire group. If we permit insulting acts, or humiliating acts, we are allowing for conflicts or bad behaviors. Lastly, when we fail to rectify different values or beliefs, we're allowing people to exist in a state of conflict. And we can work to create safe spaces or third spaces with a common goal of bringing people together rather than highlighting our differences. And we see this often in medicine right as specifically in surgery, in my field, urology, it's male dominant, there is there can be an organizational tolerance for harassment, right? urologists, in specific, specifically are known for their jokes in the operating room, but that can create a culture of inequality or discrimination or harrassment, which needs to be recognized. Surgery is hierarchical, by nature, attending surgeon, fellows, residents, medical students, nurses, techs, there's a hierarchy in the operating room, there's a hierarchy in our departments, there's a hierarchy in our institutions. And, and just because there's a hierarchy, may may change our responsibilities or or change the hierarchy of responsibilities. But it doesn't change how important each of us are contributing to the mission of surgery or the mission of that day, or the mission of that patient, or the mission of the institution. And so, we need to recognize that while hard, hierarchical structures may exist, they don't necessarily say that one person or one situation is better than another. And the last is creating isolating environments. We see this in medicine, we've seen this a lot through COVID, where instead of interacting, face to face or person, a person, there's a lot of electronic communications, text messages, emails, chats, through epic, instead of interacting with people and breaking down the isolation. And when people are isolated, it leaves the opportunity for bad behaviors. The last place we see this is in leadership. And, and we've all seen poor leadership in our lifetime. And one of the examples for this, as you can see command and control managers. These are people who actually who may have a distaste for work, they like to have others do the work for them. They need to be closely supervised, they avoid responsibility and like to delegate, they have little m bash ambition, and they value security over productivity or other other values. Were good leaders or, or good leadership. Working with them is natural, they often exhibit self control and work towards greater values, rather than their own individual security. And so how can we improve bad culture? How can we improve the institution's we're in? Well, to be honest with you, most of us aren't in leadership in leadership positions. And so it can be a little challenging from the bottom. But I like to think of one of the tenants of Hinduism and actually yoga here, where where were in the principles of reincarnation patterns of suffering, pass on to others, as well as on to ourselves until we change those patterns, and sort of free ourselves from unhelpful habits. We need to root out their source, find the cause of the problem, remedy that problem and break the cycle. That's the whole concept of rebirth to awakening. And so if you have leadership or a hierarchy, that insulates itself from subordinates, they're not feeling the pain of the people beneath them. And so we if you don't feel the pain of your subordinates, you're not learning from the consequences of your actions. And so we need to level the playing field. And once again, while hierarchies are very reasonable and very important for responsibilities and patient safety, and such, it's they're not necessarily important four behaviors and lowering the perception of hierarchy can improve our our behaviors. And a great quote from john quincy adams that if your actions inspire others to dream more, learn more, do more and become more than you are a leader. And you don't need a leadership title. To be a good leader. You just need to behave in a positive way and that will affect others. So to become better, we need to act with positivity and we need to understand our capacities for negative thinking. So how do we deal with negative people? Well, the first thing you can do is create distance and set boundaries. Recognizing as much of as just said, we want to act positive, positively and have that affect others around us, surrounding ourselves in negative energy can, can affect our behaviors, and recognize the way that we categorize and treat people certainly has consequences. Think back to the prison study. If we call people prisoners, we treat them like prisoners, if we call people subordinates than they are subordinates, but if everyone is on the same playing field, then we act together, we support each other. And one of the challenges that with to get to positive thinking can be energy blocks, things that prevent us from acting positively. And in general, there are four energy blocks. And this is put forth by Bruce Schneider in energy leadership. And the first is limiting beliefs. These are beliefs that we learn from books and media and mentors. And because we don't believe something is possible, we're not going to attempt it. And so instead, so it can prevent us from acting in a truly positive way. Because we don't believe that the outcome can happen. So how do we challenge limiting beliefs, we need to look for evidence of the contrary, we need to explore the effect of that belief on someone's life and look for proof look for truth. Another energy block is false assumptions based on past experiences. This happens in surgery and medicine all the time, right? This is the classic n equals one phenomenon. because something happened in the past, and typically, the near past, it's going to happen again, this is similar to our limiting beliefs, but it's based on personal experience. And it's deeply seated in our emotional roots. So when you recognize that's happening, need to try and remove the emotion from that n equals one experience, and really try and think more objectively, right? Something in the operating room led to a bad outcome. I'm never doing that, again. That's not really rational thinking. And we need to, we need to overcome those energy blocks to move forward in a positive direction. Another energy block is false interpretation. And as scientists, we're pretty good at challenging our beliefs sometimes. But we can fall into the pattern that a single interpretation is the only explanation for an event. So use our scientific method, consider alternative explanations and hypotheses wide in the field. Think about what other options, or what other opportunities a problem may present with us, instead of having just one solution, or one answer or one challenge, think about the broad spectrum of implications that a certain outcome may have. And then the last energy block has to do with confidence or the lack thereof. And a lot of us fail to be to act in a positive way, because we lack confidence, or there's an inner critic, that that provides fear that prevents us from acting. So when we're the biggest way to overcome this energy block is to recognize that you have an inner conflict that your met, your confidence is being challenged, and then take action to correct that. So in addition to energy blocks, there are also perceptual biases that we all carry, and perceptual biases have to do as opposed to energy box with the way we interpret the world, or the way our mind works. And this comes more from the kind of behavioral economics literature. So one of the first perceptual biases negativity bias, and then is we are more motivated to avoid a loss and then to gain something. For instance, there's a number of classic studies that said, Well, if you bet on a horse race, and you gain $130, if you win, but you lose $100. If you lose, most people will not take that bet. We see the same thing in medicine all the time. When we're trying to figure out the right outcome for patients, we are more fearful of loss or complications than we are for gain and that is a very human very natural phenomenon. So how do we work around negativity bias? Well, we have to recognize the benefits of what is lost and that nothing is permanent. While we may lose something or there may be a complication today, we may be working towards a greater good or greater outcome for that patient or practice or the hospital. a specific example where I encounter this in my practice is with some patients with advanced renal cell carcinoma, and every one of those surgeries that involves a tumor thrombus, which is going in the vena cava has a small but significant risk of mortality in the operating room. However, the positive or the gain from making someone cancer free and potentially offering them a durable survival despite having a locally advanced cancer is a big upside and in some Patients it can be really challenging to parse out the negative from the positive thinking. And it's just a good example of this bias. Another perceptual bias is emotional bias. And Paul Ekman was a scientist who coined something called the emotional refractory period. And this is where our emotional filters focus on what fits the current situation in the current emotion. For instance, many of us have been in relationships, we overlook the shortcomings of a partner, because we love them. And this emotional refractory period often arrives quickly, and you feel it coming on. A lot of us have gotten emails or had interactions or conversations where we feel this big negative energy coming on. And it's really important not to talk to anyone or make decisions when you're in that emotional refractory period, your mind isn't functioning as it normally wants to. So take time away. The longer or the more stressful that emotional refractory period, the greater Our distortion of reality and the greater time we need to recover and make a more rational and sound decision. So when you're feeling emotionally strong, take time off, give yourself space. And where this often works is when you receive a nasty email and you want to send or you want to send a nasty email, write the email, put it in your outbox, and sleep on it. If you feel the same way in the morning, go ahead, send that nasty email out. But by giving yourself time to let the emotions pass, you'll often make a more rational and sound decision. The last perceptual bias I'm going to talk about is value bias. And we've all created an individual hierarchy of values. And this bias can be triggered when we see someone acting against our values. For instance, we see someone acting unkind towards another person, or via acting violently or abusive. And for many of us, we have to think about what value wins out over others. Is it honesty? Is it kindness do we want to be liked? Do we want others to treat us with kindness, and every value has an associated strength and weakness. For instance, kindness may make us susceptible to be taken advantage of by others. Honesty, if that's our primary virtue may cause us to not be liked by other people if we're completely an always honest with them. And if we always want to be liked by people, we may not be able to be completely honest with them all the time. And certain values may be viewed differently by others than in the way we perceive them. Alright, so for instance, capability is a strength. But someone who is narcissistic, can perceive people who are incapable as failures, where it's not necessarily that they're failure, they just may have a different set of strengths than you. And one of our only values that does not have a negative or hypocritical point is conscious awareness or mindfulness being kind of present being aware, there's really no negative to that behavior. So instead of taking our individual values and our hierarchy and projecting negativity onto others, when they fail to meet that hierarchy, consider they may have a different hierarchy, they may have a a different reason or a different thought process, and offer them a gracious explanation for their behaviors. You see this most often in the car, somebody cuts you off, they're doing 90 miles an hour on a highway in front of you. Well, yet, more than likely they are jerk. But maybe they've got a pregnant wife in that car. Give them a gracious explanation, avoid falling into a cycle of negative behaviors yourself, and let things move on. We see this in medicine often too. And we fail to recognize that our colleagues or our partners have lives outside of the hospital. So maybe if someone is acting in a way that's not consistent with their personality or their typical behaviors, we should take the time to talk to them or ask them Hey, what's going on today? Why are you acting like a jerk? Because you don't typically behave that way. It can also be that someone's consistent behaviors is created by consistent problems in their life. For instance, trouble at home whether it's a bad relationship, an ongoing divorce, problems with children problems with finances, there can be lots of reasons why people can behave badly. And we should think or consider gracious explanations and work towards helping them and providing them with empathy or, or, or thinking empathetically, rather than just condemning them for their behaviors. The last place we see this is in poor behaviors in our patients. And sometimes when someone is lashing out at you or your staff It may be because they're scared about their condition or their cancer or they're really nervous about surgery. So once again, when patients act badly, sometimes we need to think of a gracious explanation as to why they may behaving badly. Now I'm not saying every behavior in every circumstance offer should be given a gracious explanation and a past, there are certainly behaviors that are, should not be tolerated and should not be accepted. But when we see behaviors that are out of the norm for someone, we certainly consider that something else could be contributing to this. And so by recognizing energy blocks and perceptual biases, we can be mindful and act on those feelings, to generate more positive behaviors. JOHN Chow, who's a Thai Buddhist monk said anything which is troubling you anything which is irritating you, that is your teacher. And so when we are cued by these negative thoughts, these biases or these energy box, we should be it's a trigger that we can be acting better. So in the last couple of minutes here, how are we going to manage negativity. So first, let's dig to the root of the issue. Remove the emotional response, because try to become an objective observer. And if that's in someone else, help that person back away. If it's in ourselves, try and step away or seek the help of others to neutralize the negative. Be a good listener, and you can listen to others but you can also listen to yourself. Recognize you don't need to solve every issue for every person. Sometimes just being a good year and letting a person reflect or giving yourself time to reflect will allow you to manage a lot of negativity. And we'll get to this more when we get to coaching and mentorship. But it's a really important skill to just be able to listen to people and help them achieve their own outcomes. We should really try and surround ourselves with uplifting people and think like a monk Jay Shetty, says, 75% of our time should be should be spent with uplifting people. And when we're around positive and other people were going to act better. So whether if it's positive people at work great. And if it's not positive people at work, seek out things like retreats or classes or recreation with positive people that make you feel better and act better. And remember, letting go is not getting rid of negativity, but detaching and dealing with it. If we're just letting it go, we're pushing it often into some dark corner. But by recognizing it and detaching from negativity, we can behave better. Remember that thoughtful complaining or communication with others is productive and beneficial, while venting and being negative is not. And most importantly, to manage negativity, we need to learn to take joy in the successes of others. When other people do well, it's not a slight against us. When somebody else does well, we all do well. And we need to take joy in that. We see that a lot in medicine, we get offended or upset when colleagues or collaborators or competitors achieve something that we wanted to. I used to get upset. You know, I read a lot on small renal masses in active surveillance if I see someone else publishing in the field, and I've learned over the years that that's amazing. What that does is it's improving our understanding of the disease and the disease process in the management. I'm supporting their work there supporting my work, we're making the world better. And we really need I think it's a really important lesson that's not so easy to learn, it took me years. And the last really important specific thing we need to talk about in surgery is how we manage bad surgical or medical outcomes. I once had a really good colleague and friend said that you need to be a little bit of a sociopath at some level to do big surgery, because you're going to have big complications, and people are going to get hurt and maybe even die. And I think there's some truth to that in. You know, we can't let a complication or a bad outcome, ruin our lives. But we certainly can take in those feelings and work towards transforming them. And so instead of just forgetting about the bad outcomes or pushing them away, detaching from them is a better term a better consideration. And what we need to do is detach from the ego or how that negative or bad outcome affects us, and transform that into a productive response. How can we now take that negative and make it better for that patient? How can we learn for making better for the next patient? How can we transform that into something positive for our patients and our institution and our outcomes? Easier said than done? And some of the ways to do this is to journal or write things down? Specifically, to detach you try to become an observer. Think about it from the outside, detach yourself from the emotion and detaching from the emotion doesn't mean forgetting what this made you feel like, but it actually means taking in all that emotion, bathing in it, letting that feeling set in and then letting get washed away. So you can start objective really evaluating the situation and how you can be better. And think of think of what you were trying to achieve rather than that specific outcome. In the Bhagavad Gita, which is a ancient Hindu text, they say what belongs to you today, belong to someone else yesterday, and will be someone else's tomorrow. All of this exists in a spectrum. And while we may feel awful today for what happened to our patient, or this outcome, things are going to get better for us and for that, that person or that family, and this will happen again, unless we do something to to create a more positive cycle. So respond to the situation, not the insult, what can be learned, what can be avoided, and how you can help others avoid it. And the last part is creating anabolic energy energy that builds yourself and builds others. And to do that we want to let go of fear, worry, guilt, and anger. Those are destructive energy states, catabolic energy, and positive energy states can help us create instead of Detroit destroy, Buddha said give attention to what you do or fail to do today, and not others. And by living positively, and thinking about our own behaviors and our own actions, we can improve those of the people and institutions around us. So to summarize here, bad behaviors and outcomes are rarely because we or others are bad people. They can be situational, they can be influenced by external forces in our institutions. So we have to learn to understand and recognize those external forces, specifically energy blocks and perceptual biases that can adversely influence behavior. We need to learn to detach and reshape and experience towards the positive. understanding our individual behaviors can influence others, our leadership, colleagues, our patients and our loved ones. Thanks for listening. Look forward to talking to you soon.