More on the dance of anger. (Part 2--Physician Anger).

KEY CONCEPTS

* Physician Anger

* Assaults upon the Ego

* Behaviors Elicited in Response to Stimuli

* Comparative Bases

* Realistic Assessments

* Changing Ourselves

THE LAST ISSUE OF THE Physician Executive (March/April 1999) is overflowing with commentary on the concerns of physicians about the current turbulent environment in which they find themselves. Presumably the causes Include: managed care, the shifting economics of health care, technology, the 'intrusion' of government, third party carriers, non-medical administration, and other professions vying for a 'piece of the pie.'

The perceived value consequences for physicians include loss of: autonomy, independence, security, authority, control, power, a sense of worth, status, esteem, respect, recognition, appreciation, money, and even self-esteem. The emotional consequences are listed as: fear, anger, worry, angst, anxiety, stress, tension, grief, regret, frustration, irritation, and hostility. Some of the psychological reactions are: guilt, depression, blaming, complaining, rationalizing, scapegoating, and externalizing. Behavioral outcomes reported include: 'burn-out,' leaving the profession, interpersonal and intergroup conflict, impatience with others, fatigue, and other negative manifestations.

This article is a follow-up to an interview with Charles Dwyer, PhD, which appeared in the 1999 March/April issue of The Physician Executive. He described how physician executives can change the perceptions of today's beleaguered physicians and help them cope with change. We then asked him for some hands-on strategies to deal with physician anger, fear, and resentment. After much contemplation on providing a list of "fixes" that will restore each of us to a state of greater satisfaction, Dr. Dwyer concludes that there are no generalizable solutions because there are too many variables that come into play in each organization, individual, or group. Attending to the self can provide both individual rescue from these turbulent times and the best hope for changes in the system from which patients and health care providers can benefit. If physicians are to regain their power and maintain, or even improve, their quality of life, clearly changes are called for. And these are changes that require persistent effort an d uncomfortable adjustments.

My own read of this is that much of these phenomena have to do with ego and the fear of assaults upon ego. We can each accept (often with equanimity) great pain, loss, and difficulty in our lives if we perceive it to be the consequence of 'impersonal' forces, such as war, famine, natural disaster, and other mega-elements that all are subject to and by which all are suffering. Likewise, when we consciously and deliberately make decisions, realizing that these negative accompaniments may be the tradeoffs or the consequences, we can accept them with some measure of equanimity.

But, when others are imposing these upon us, disrupting our lives, and often in ways by which they gain at our expense, then it is totally unacceptable. When we seem to be singled out as the individual or group that is to pay the greatest price for societal change, then it is experienced as too personal, as 'unfair' in the extreme. This is particularly disturbing when recent history has treated us well, a history in which we had both power and value satisfaction given to us by virtue of our membership in the 'noble' profession.

If physicians are to regain their power and maintain, or even improve, their quality of life, clearly changes are called for. And these are changes that require persistent effort and uncomfortable adjustments.

We are accidental and arbitrary

We are each an arbitrary and accidental self--a combination of genetic and environmental components over which we have exercised little, If any, influence. We have been taught to think in certain ways, feel certain emotional responses, and elicit certain behaviors In response to internal and external stimuli. That is the basis for all of the discomfort presently being experienced by physicians.

One of the keys to the quality of our lives is the comparative bases with which we assess the desirability or undesirability of nearly everything in our lives. These, in turn, arise from the accidents of our experiences which then set our expectations of how the world is to treat each of us, how it is to react to each of us. These bases set our notions of what is and is not appropriate, 'fair.' acceptable, and worthy of our attention. They are also within our conscious control if we chose to make them so and they are completely malleable to our wishes. We are reluctant to accept these claims because it means that we are ultimately responsible for what we think, how we feel, and what we do.

For example, how much money is enough to make you comfortable? The answers are, of course, widely divergent. And, they change for people over their lives. The American answer is, "Ten percent more than I am presently making. If you view money as a tool in the conduct of life, then almost any amount is adequate. If, however, it is viewed as an end unto itself, then almost never is there enough. Likewise, if you have become dependent upon the accidental and arbitrary amount you are presently making for the quality of your life, then money has become your master rather than your servant. We each have only the most tangential influence on how much money we make. But, we don't want to believe that either. Our talent and efforts are part of the story, but for their effect they are dependent upon a whole series of serendipitous circumstances over which we have no ultimate control. Luck plays a large part, but it is un-American to think that.

Furthermore, once you have established a pattern of income within a certain range, an income that is always dependent upon a tentative and fragile frame of circumstances, you expect it (unrealistically) to continue as long as you apply the talent and energy that has worked for you in the past. When it does not, you get angry, resentful, depressed and fearful. "The world is not as it should be. It is unfair, unreasonable, unacceptable!'

Consequence of chance events

If we look at health care and medicine as an arena of comparative bases, we will see the same sort of accidental, arbitrary, uncritically accepted comparative bases at work. If, for example, you insist that the world of medicine be at least as good to you as it has been in the past in terms of value satisfactions, then you are going to be deeply disappointed. You will suffer many of the emotional, psychological, and physical conditions already described. If, on the other hand, you realistically assess the present and probable future of medicine and make it work for you and your values, then you need suffer none of the painful and dysfunctional consequences listed.

Suppose you found yourself (for no reason having to do with you, or your behavior, or your merits as a human being, i.e., unjustly) in a war-torn county, or in a concentration camp, or in a famine-ravaged country. Would you complain bitterly about the conditions in which you found yourself, moaning that this is not how the world should be? Would you focus on what you did not have available to you in terms of facilities, supplies, equipment, pharmaceuticals, and the like? Would you lament the deterioration in the level of your income or the diminution in your life-style?

I suspect not and l hope not. You would assess the situation and do the best you could in your capacity as a physician for others, given the dreadful circumstances in which you found yourself. Simultaneously, I suspect that you would look to improving the condition of those in your care and perhaps your own condition as best you could. We are nearly infinitely malleable in terms of our ability to adjust to the circumstances of our environments and maintain an acceptable, if not ideal, quality of life. But, since you have not been subjected to anything as clear and dramatic, you do not adjust. You call for the world to become what you want it to be. Why should the world be as you wish it, rather than as others wish it?

"I complained about having no shoes until I met a man with no feet."

This is not quite the same point as that made by our parents who reminded us of the starving people in India as a reason to finish our own dinners. It is a subtler point that most of us are, in fact, the psychological prisoners of accidental, arbitrary, and unquestioned comparative bases that determine the level of satisfactions in our lives. One's current comparative bases are solely a consequence of chance events. But, these bases are subject to our individual, personal design and control.

Maintain, modify, or replace?

The first step Is to be aware of your comparative bases and decide whether or not you wish to maintain, modify, or replace them. To hold a comparative base in the face of external conditions that you cannot control and that will bring you misery is clearly not wise. Thoreau, in providing one of his most salient pieces of advice, said, "Simplify! Simplify! Simplify!" Most of us Complicate! Complicate! Complicate! our lives.

Some would argue (and I have some sympathy for the argument) that any attempt to look to the external world for life's ultimate quality is a mistake. That it is the internal world that is subject to total control by each of us and that, therefore, we can each determine the quality of our lives independent of what goes on 'beyond our skin.' Since I have not yet personally arrived at that point, I can provide no compelling, personal testimony. But, it looks both achievable and desirable from my point of view and it has much support, particularly in the literature of the East.

The irony is that the more one achieves such inner direction, the more effective one is in affecting and shaping the external world for others. The more one achieves inner direction, the less one is subject to the automatic, negative, emotional responses that impede the power we each have, in potential, to shape the world. While this may sound New Age, my approach to it is very much in terms of what we know about the neural-chemical structure and functioning of the brain.

The most likely scenario

Another dimension of the discussion about anger, fear, etc. that I find somewhat troubling is the apparent belief that there are some 'fixes' out there in the world that will restore each of us to a state of greater satisfaction. That these 'fixes' will, in some way, take us back "to the good old days" when physicians did not have to exert effort to maintain power in their lives. There may well be some actions at the margins of health care administration and in the patterns of organizational design and functioning that produce Improvements in the quality of health care without further sacrifices by physicians. But, the belief that these are sufficient in scope and realistic applicability to reduce substantially the tradeoffs involved seems to me to be wishful thinking.

I believe that the most likely scenario we face includes a deterioration in the overall quality of health care, an increase in the cost of health care, and a decreasing set of (or at least a substantial change in the character of) satisfactions available from the professional practice of medicine to those who enter it. That does not mean that nothing can be done to check some of the deterioration in quality, or the rise in costs, or the satisfactions available to the physician. But, using the recent past and the present as our comparative base, it seems likely that the forces pushing in unwelcome directions will, to a substantial extent, prevail. I seriously doubt that most of the remedies currently being offered, (including those in the last issue of The Physician Executive) will, in fact, be widely implemented despite the rhetoric accompanying them. They look impressive and even hopeful on paper but the energy, resources, sacrifices, talent, and fortuitous circumstances that must come together for successfu l Implementation in any given setting seem unlikely at best.

Again, this is not to argue against trying. Some progress is possible. But a restoration of what was is close to impossible (and perhaps undesirable). That means to me that only those who do the appropriate work in their heads will continue to have a satisfying life in medicine and are also the only ones likely to make positive substantive differences in the practice of medicine and the overall quality of health care. Some have clearly already made such changes both in their heads and in the world. But it starts for each of us inside oneself.

No generalizable solutions

A further complication rests in the fact that many seem to believe in generalizable solutions to the dilemmas being faced. There is growing evidence in social science that the availability of generalizable principles drawn from largescale studies of social institutions and social phenomena may have limited applicability to specific situations. Likewise, the transferability of ideas, programs, and initiatives from one setting to another is being deeply questioned.

Even in medicine, we know that treatments have often quite different effects on the individual chemistry of individual patients. But, in medicine there is sufficient regularity and commonality across individuals that some generalizable effects are to be expected and, therefore, some general prescriptions can be given with confidence.

In the sphere of social science, less uniformity seems to exist. The power and salience of local conditions is coming into the thinking of those who concern themselves with changing the world as the dominant variables affecting the success of implementations. This suggests caution in believing that we will come up with solutions to issues in health care that are broadly applicable to even most (to say nothing of all) settings.

It seems that the specifics of the personalities involved, the history of interpersonal relationships, the idiosyncratic distribution of power, the motives of the key actors, and the contextual environment of the organization all have substantial roles to play in whether an idea succeeds in delivering what it promises or not in a given setting. In short, the people involved and the details of their behavior seem to have more to do with the outcome of a new initiative than the characteristics of the initiative itself. Levers big enough to move the world may be unattainable.

Conclusion

If we take this notion of the relevance of the 'local' to its logical end, then one powerful place to begin the process of change is inside the head of each of us individually. "Everyone talks of changing the world. Few talk of changing themselves." Attending to the self can provide both individual rescue from these turbulent times and the best hope for changes in the system from which patients and health care providers can benefit.

Charles E. Dwyer, PhD, is the Academic Director of the Managing People Program at the Wharton School of the University of Pennsylvanian as well as an Associate Professor of Education in the Graduate School of Education. He is a faculty member of the American College of Physician Executives' Physician in Management program, where he teaches physician executives about understanding organizations, human influence, and personal development. He recently facilitated a cyberforum on physician anger and resentment. Dr. Dwyer will be presenting an overview of how other Industries have coped with difficult changes at the Spring Institute's Senior Executive Focus on Dealing with Anger. Fear, and Resentment on May 1214 in Las Vegas. He is the author of The Shifting Sources of Power and Influence. He can be reached by calling 610/328-6328 or via email at [e-mail].