I have a renewed interest in focusing upon and discerning process rather than content.
The definitions for “process” are varied and, because of limitations of language (i.e. content), do not fully capture its essence. Perhaps I am also making process more complicated than it really is.
Content refers to the “face value” of communication. Process refers to the implications and impact of communication. We can never be certain of the messages we receive in interpreting the process (because both senders and receivers of information can (in)advertently distort the signal), but we can certainly generate hypotheses based on the data we receive.
Illustrations may be more illuminating:
>> In the realm of blogging, someone may leave a public comment such as, “I linked to your site on my weblog.”
Content: “I linked to your site on my weblog.”
Process: (1) “I read your weblog.” (2) “I want other people to know that I read your weblog.” (3) “I am directing other readers to your weblog because I find the content in your weblog useful/entertaining/thoughtful/etc.” (4) “I want more traffic to my weblog and hope that because I linked to you, you will link to me.” (4) “I want you to know that I exist.” (5) “I want your readers to know I exist.”
>> In the realm of clinical interactions, a patient may remark upon first meeting a resident, “You’re awfully young to be a doctor.”
Content: “You look young for a doctor.”
Process: (1) “Do you know what the heck you’re doing?” (2) “Am I your guinea pig?” (3) “Will I receive appropriate care from you?” (4) “I don’t trust you.” (5) “I want an older doctor.”
>> In the realm of social interactions, a man may attend a black-tie optional gala wearing tattered jeans, a tee shirt with a surfer logo on it, and sneakers—despite full awareness that it is a black-tie optional event.
Content: He is dressed casually at a formal event.
Process: (1) He doesn’t care how he appears to others. (2) He is purposely defying the expected social norms. (3) He is trying to attract attention to himself. (4) He is not socially sophisticated.
There are aspects of speech that fall into the sphere of process. Consider the phrase “have a nice day”. The actual words communicate a certain idea, but how someone says that phrase may communicate something else. What if someone mumbles that phrase softly, such that there is no way the intended recipient hears it? How about a sarcastic tone of voice? What if the phrase is shouted: “HAVE A NICE DAY!!!” It can be said quickly, slowly, irregularly, in pig latin.
Body language also falls under the purview of process:
- Avoiding eye contact and already starting to walk away, he mumbled, “Have a nice day.”
- He clasped her hand in his and, after taking a deep breath, said, “Have a nice day,” while gazing into her liquid green eyes.
- His shoulder propelled his arm back and forth, as if it was a gigantic windshield wiper, as he shouted, “HAVE A NICE DAY!!!”
- He didn’t wipe the tear that was slowly trickling down his ruddy cheek as he murmured, “Have a nice day.”
Same words, different meanings.
The wise Lance Mannion recently posted something that addresses content versus process:
Here are the four most important qualities Zinczenko [in a Men’s Health article] says his readers want in the woman they fall in love with. They want her to be:
1. A woman with a passion in something other than him.
2. A woman with no problem with guy time.
3. A woman with a strut.
4. A woman with good taste in ties.
An intelligent eye will spot immediately, without having to look over Zinczenko’s “analysis,” that boiled down what Zinczenko’s readers are looking for is a hot woman who will leave her man alone except when he wants sex or dinner.
I suspect that life experience, exercises in critical and creative thinking, and attending to metacommunication hones our abilities to regularly recognize (1) the process and (2) the possible messages within the process.
I’m impatient.
23 Mar 2007 | 6 comments.
Just a Little.
I originally posted this in August of 2004. I am considering using this piece—after some editing—for a public reading.
It’s just a little after five o’ clock in the morning and I’ve come to see you. I ask if I can perform a pelvic exam on you; you reluctantly say yes. I try not to think about it too much as I insert my gloved fingers into your vagina, feeling your body tense with pain as I try to hasten my examination. I withdraw my hand from you, the fingers glistening with millions of particles of HIV.
It’s just a little after five o’ clock in the evening and I’ve come to see you. You’re not in the room, but your vomit is. Bright, chunky, thick red stuff that has splattered all over the white tiles of the floor. You didn’t even have to stick a finger down your throat. You’re 19 with a variant of anorexia and bulimia. All you have to do is think about it and you can make yourself throw up. You’re thin, almost too thin, but you think you’re terribly fat. You’re also terribly lonely, terribly empty, and terribly beautiful, but never beautiful enough.
It’s just a little after one o’clock in the morning and I’ve come to see you. You’re ignoring me but you roar to life when I dig my knuckles into your chest. You shout at me that you fucking have respiratory problems and that you have a fucking difficult time breathing and that you fucking just want me to leave you alone, goddamit, because you’re in the fucking hospital and why can’t you just fucking be left alone in the fucking hospital because you just don’t feel like you can fucking breathe, goddamit. So why don’t you fucking just go away, goddamit. And then you ignore me completely, pretending you are asleep.
And then you assault the nurses and we put you in three-point restraints.
It’s just a little after two o’ clock in the afternoon and I’ve come to see you. There is only one thing left to do before we can send you home. You’re doped up on morphine because your back is killing you. Your mother died last year, your wife died this year, and you live alone with your seventeen-year old daughter. Alcohol helps take the pain (which pain?) away. Neither you nor I are pleased about what I need to do, but we get it done quickly: You roll over, I pull down your pants, you shift slightly, I put on the glove, you breathe in, I insert my finger, you tense up, I withdraw my finger, and we both exhale in relief.
No blood in your stool, sir. Now we can send you home.
It’s just a little after two o’ clock in the afternoon and I’ve come to see you. Your feet are purple, your face is red. Chocolate brownie is in your hair and tears stream down your face. You lean forward, I try to sit you up. You keep leaning forward, choking on your tears, drowning in your love for methadone. If you don’t have it, surely your heart will break. You’re acting weird, why? Your body is acting weird, why? I want you to get better now, now, NOW, because I want to go home. I’m tired and I can’t think straight. And yet you look sicker and sicker and sicker.
It’s just a little after four o’clock in the morning and I’ve come to see you. The water reflects the slightly orange lights of the city. Layers of grey clouds coat the horizon. I see the trails of lights of the city streets. It is a different world, a silent world, a world where people aren’t sick. It seems so far away, even though the realms are separated only by a plate of thick glass.
21 Mar 2007 | 4 comments.
Demoralization.
Drs. James Griffith and Lynne Gaby wrote a thoughtful paper entitled “Brief Psychotherapy at the Bedside: Countering Demoralization from Medical Illness“. I obtained a copy of this paper from a more senior resident during one of my months on the consult service and reviewed it earlier this evening. The phrase “the patient is likely demoralized” thereafter appeared frequently in my notes in consultation requests for assessments of depression.
A definition of demoralization included in the paper states that it refers to the
“various degrees of helplessness, hopelessness, confusion, and subjective incompetence” that people feel when sensing that they are failing their own or others’ expectations for coping with life’s adversities. Rather than coping, they struggle to survive. Demoralization occurs so commonly that it can be regarded as universal human experience.
As such, the dimensions of demoralization described in the paper are applicable not only to patients dealing with medical conditions, but also to physicians in training. I have wondered if the studies on clinical depression in interns and residents actually reflects the demoralization that most, if not all, of us have experienced.
This paper argues that there are two distinguishing features between demoralization and major depression:
- In demoralization, “responsivity of mood is usually preserved, in that cessation of adversity rapidly restores a capacity to feel enjoyment and to hope.”
- Demoralization features “subjective incompetence due to uncertainty over what course of action to take” while in depression, “apathy predominates even when a needed action is clear”.
Thus, demoralization and depression reside on the same spectrum and may overlap in some respects, but they are not identical.
The axes of “existential postures of vulnerability and resilience to illness” as applied to medical training is as follows:
Confusion versus coherence. Residents—particularly interns—may feel confused about their roles in providing care to patients—what are the limits of their responsibilities? what are their appropriate roles? Getting bogged down in details may result in pursuit of goals that patients (and/or attendings) do not endorse. Navigating an unfamiliar medical system (where are the charts? what information does the attending want? where are the bathrooms?) may make doing the actual work frustrating and fragmented.
Communion versus isolation. Residents may not have many opportunities to commiserate with other trainees about their experiences. We all know of people, either in medical school or residency, who retreated to the bathroom or stairwell to cry due to the perception that no one else (1) understood or (2) cared about uncomfortable or unfortunate events that involved patients, other trainees, or other staff. Fears of “being too sensitive” and “not fit for medicine” often surface, along with the beliefs that no one else shares these exact same thoughts.
Hope versus despair. Physically, intellectually, and emotionally taxing experiences in the hospital can result in residents wondering if they are (1) smart enough, (2) skilled enough, (3) tough enough, and/or (4) resilient enough to complete training and become a “real doctor”. Few people are fully prepared to witness codes, deliver bad news, and humbly handle mistakes of varying degrees that can adversely affect patient outcomes. If one does not have hope in oneself and one’s resilience, one does not have the motivation to learn more about the craft and associated skills. Unfortunately, sometimes the hospital, with all of its barely restrained chaos, does not offer as many positively reinforcing experiences for residents, further facilitating feelings of despair.
Purpose versus meaninglessness. The practice of medicine may deviate significantly from what traineess believe it to be. People entering primary care may envision personal delivery of “holistic care” and opportunities to get to know the patient as a person, not merely as a set of diagnoses, only to learn that health care economics essentially prohibits these possibilities. Surgeons may desire opportunities to perform both life-saving and life-improving procedures under well-rested and clear-minded states, only to realize that the most intense and critical procedures may occur when they are significantly sleep and energy deprived. Psychiatrists may dream about mastering different types of psychotherapies to help optimize the lives of patients, only to learn that they are pigeon-holed into prescribing pills. This disappointment may lead residents to question their roles as doctors and in the health care system.
Agency versus helplessness. Hospital and clinics can be ravenous machines that consume and assimilate residents. The system (whether that be the actual organizational system or the hierarchy of physicians) may prohibit the resident from pursuing ideal therapies and interventions; the personal preferences of senior staff may also override what autonomous decisions the residents would have otherwise pursued. There is also the frequent fear of patient death; fully accepting that 100% of people will die, often in spite of what we do, is difficult. We would all like to control all variables, but those are not the rules of the game.
Courage versus cowardice. As with all other things in life, there are risks in the various aspects of practicing medicine. Residents learn where their boundaries are with patients, superiors, colleagues, and the system. Some residents will always kowtow to their superiors; others will find the courage within themselves to assert themselves against what may be unreasonable forces. Learning to defend one’s position, often as an advocate for the patient, can cause apprehension, as can efforts to avoid collusion in ethically murky situations (e.g. interactions with pharmaceutical companies).
Gratitude versus resentment. Trainees commonly grow weary of their duties: patients surreptitiously transform into “hits” or lose their identities completely (”the nurses are calling about the HIV liver guy again”). The lack of sleep makes people irritable and the thought of interviewing the (annoying and whining) patient for more information induces groaning and eye-rolling. The perception that people are taking the interns for granted only incites ire in those first-year residents who literally make things happen on the front lines. It is difficult to remember to be grateful for these opportunities to affect positive changes in the lives of people; the focus is instead on the barely tolerable, cumulative stressors contained within the health care system.
As with patients, residents benefit from opportunities to reflect upon their resilience and chances to demonstrate to themselves that they are not incompetent, but are undergoing the rigors of training and are experiencing natural reactions to these events. Insight does not necessarily result in behavior change, though it can certainly facilitate it. It is difficult to counter demoralization alone, however, and though most residents can commiserate with other members of their cohort and receive support from friends both inside and outside of medicine, we are not all so lucky.
19 Mar 2007 | 4 comments.
Link-o-Rama.
In following the example of Kevin, MD, here are some items of note that I recently perused while wandering The Internets:
>> The Brain on the Stand. A thoughtful, if not mildly disturbing, discussion about The Brain versus The Mind. (As I had remarked to a couple of my colleagues for our “informal journal club”: “To me, this reflects the ongoing medicalization of everything—”incidentalomas” in the brain will suddenly mean something drastic; the definition of “normal brain” (or, I guess, “no acute pathology” on those MRI reads) will be tweaked to no end; thoughts will take on definitive meaning (so much for our oft-used phrase for suicidal patients; “a thought is just a thought”)… it’s almost as if there is a 1:1 correlation between thought and action. And we all know that that just ain’t true.”)
>> The 7th Guest. I recall urging my father to purchase this game for me shortly after it was released (1992!); I subsequently spent many hours working my way though the puzzles and getting totally freaked out—I couldn’t restrain myself from playing this game at night. I never “won” the game.
>> Crime Library: Ted Bundy. Ted Bundy was likely still working for the crisis clinic (presumably as a telephone counselor) here in Seattle when he began his career as a serial killer.
>> Groovie Movie. A nine-minute film, made in 1944, about swing dancing (the “modern dance” of the “hepcats”—”solid!”) that features hokey humor and good dancing.
>> Lindy Hip Hop. Two guys—both with excellent dancing skills—who throw in hip-hop moves into standard lindy hop. They capture the spirit of the dance well… and it pains me to see a guy who is a better follow than me!
>> How to Make a Complete Map of Every Thought You Think. I am not ambitious enough to follow this guy’s example, though perhaps I shall glean some insights about optimizing my “peripheral brain” (because my inner GTD minion demands it). The author must have been in Seattle when he wrote the text, as he makes a reference to the city’s online bus schedules. (There must be something in the Puget Sound water.)
>> Report of the APSAC task force on attachment therapy, reactive attachment disorder, and attachment problems. I read this article to learn more about “reactive attachment disorder” (an ill-defined diagnosis for kids). I reeled in disbelief upon reading this:
In the Newmaker case, a technique called rebirthing was used to simulate the psychological death of the angry unattached child to allow the child to be psychologically reborn (Lowe, 2000). This technique involved the child being held down by several adults, rolled up in blankets, and being instructed to fight her way free. In rebirthing and similar approaches, protests of distress from the child are considered to be resistance that must be overcome by more coercion.
Thankfully, “Rebirthing has been repudiated by many practitioners, including those who recommend other controversial techniques….” Egads.
>> Chickens lay unfertilized eggs. I am overly educated and I did not know this. All of these years, I thought I was eating a two-celled chicken fetus embryo when I ordered eggs.
18 Mar 2007 | 5 comments.
Status.
After he had unloaded the books onto the table, he dug around the inside of his bag while his eyes surveyed the coffee house.
Two of them had the signature white iPod buds trailing from their ears. Three of them were sitting in front of laptop computers, their faces glowing an unnatural white from the monitors. Two of them shared a table and appeared to be engrossed in serious conversation. Three of them were reading books and taking notes.
When his fingers stumbled upon the desired item, he smiled to himself and removed the eyeglass case from the inner pocket.
He ran his right hand through his hair before rubbing his jaw to assess the status of his five o’ clock shadow—it’s not that he forgot to shave; he knew he would be making an appearance at the coffee house this evening. His fingers slipped the glasses onto his face in one sleek motion before he purposely positioned the textbook on the table so anyone and everyone walking by would notice it: Principles and Practice of ___________.
The glasses made him look smart and sophisticated. This is the impression he wanted women to receive.
In the hospital hallway he unbuttoned his long, white coat and pulled his PDA from the left pocket of his grey slacks. He glanced at his watch as he waited for his PDA to awaken.
5:42pm, he thought. I’ll get to the restaurant around 6:30pm. Perfect.
“Hello, Dr. Pavo,” a sugary voice greeted. “How is my favorite doctor doing?”
“Hello,” Chris Pavo reflexively replied, still unsure who owned the lovely voice that was speaking to him. Upon turning around, he found himself looking at Allison, brunette, 25 years old, a physical therapist, likes dogs.
He hoped their conversation would be short.
“You look great, as usual,” Allison said.
“I try,” Chris coolly answered, granting her a small smile.
“Are you done for the day?” she persisted.
“Yes—in fact, I’ve got reservations at 6:30 and I’ve got to get going. Nice to see you, though,” he answered, allowing his smile to grow.
“Nice to see you, too,” Allison said. “Have fun.”
“I will,” Chris said, already walking away from her.
Allison. She was cute. They had gone out a few times last month and he thought she wouldn’t put up a fight. He gave her three tries, but since she didn’t put out by their third date, he moved on.
Chris Pavo lingered outside of the restaurant and again consulted his PDA.
“Thursday, October __, at 6:30pm” he muttered to himself as he scrolled through his calendar. “Who am I meeting again?”
His eyes quickly skimmed over his notes: Melanie. Brunette. 24 years old. Works at Macy’s. Likes movies. #2.
His stylus accidentally advanced the calendar by one day: Lisa. Brunette. Over 21 years old. College student, studying psychology. Likes dancing. #3.
“Well, Lisa will be off the list if she doesn’t have sex with me tomorrow,” he said to himself as he turned his PDA off. “That’s the rule.”
While looking at her from across the coffee shop, he willed her to look at him. You will look up. You will look at me. You will look at me.
She turned a page in her book.
Come on, you can feel me watching you. Look up.
She glanced in his direction. She returned to her book. She suddenly looked back up again and looked at him.
He smiled and winked at her.
She smiled back.
He coyly pointed a finger at himself, then pointed it at her. He repeated the motion several times.
She continued to smile and waited a beat—
—and then nodded.
An exaggerated expression of joy mixed with relief on his face, Chris ran his right hand through his hair before rubbing his jaw to assess the status of his five o’ clock shadow. His left hand casually picked up the textbook and he ambled to her table.
“Hi,” he said. “My name is Chris. Mind if I join you?”
“Sure,” she answered. “My name is Mae.”
He sat down and dropped the textbook on the table in a conspicuous fashion. She read the title: Principles and Practice of ___________.
“Whatcha reading there?” Mae asked. “Looks like hefty stuff.”
“Oh, you know, stuff for work,” Chris casually answered. “The learning never stops for a doctor.”
“A doctor, huh?” she echoed, leaning forward, the smile growing on her face. “I like guys who are smart.”
Yeah, I know.
17 Mar 2007 | 2 comments.