In “Inside Out”, Pixar Animations 2015 blockbuster movie, we watch as 11-year old Riley, whose life to-date has been largely driven by Joy, learns the value of Sadness as she comes to grips with a life changing event. In so doing she has to let go of a piece of her childhood self but ends up a better balanced person and closer to her family.
What most movie-goers don’t know is that the story has an academic foundation in the work of, among others, Dacher Kelter, a psychology professor at the University of California Berkeley and an expert in the social functions of emotion, whose insights also have reflective implications on the practice of medicine and delivery of care.
In a 1993 paper1, Dr. Keltner and his colleagues added valuable detail to our understanding of how emotional states affect cognitive processing, specifically our appraisal of others, clarifying that “when we are angry…(others) seem lazy, manipulative, and intentionally obtuse; when we are sad we may see the very same behaviors as signs of overwork, real need, or genuine misunderstanding”
The frustration, dissatisfaction and anger of the medical community, and their perception of their well-being as threatened by system-level factors, has been the subject of much attention recently2. Considering Dr. Keltner’s research, we can see how a physician’s underlying emotional state may have adverse effects on their capacity for clinical appraisal and potentially interfere with their ability to meet societal expectations for quality of care and clinical outcomes.
In my role as Chief Medical Officer of primary care network serving exclusively complex/fragile patients, I regularly observed the “Keltner effect” in action; physicians with with the most complaints were generally angry, bitter and disappointed in their careers and the changing role and place of physicians in society. In many of these cases, a genuine listener is all that was necessary to re-orient the patient relationship and improve quality and patient satisfaction.
But what about those doctors? In truth, the foundation of successful medical practice is not the scientific method, but the willingness to truly shoulder the work of worry about another, unrelated, human being. Making space in your heart and taking on the extraordinary depth of responsibility for life-changing (and potentially life-taking) decisions for other people’s lives requires energized focus, discipline, concentration and confidence, all of which must be nurtured and cannot survive in a vacuum. Our society seems to understand the importance of this dynamic when it comes to protecting and supporting the performance of elite athletes and movie actors, but we can’t seem to make the same respectful accommodations to the critical performance of those we entrust with our health and our lives. Given our ambitious goals for healthcare quality improvement, it may be in the best interest of society to provide some level of emotional security for physicians to support their inherently intrinsic motivations to positively change people’s lives.
A recent editorial lamented the increasing prevalence of process improvement methodologies in clinical operations4. While it has been well established that evidence-based process measures can have a significant effect on utilization patterns and costs in a defined population5, we do not yet understand the variables that may amplify that performance to the next level. The question then becomes: what makes the difference between achieving a 20% reduction in hospitalizations and $68 PMPM savings based on process measures alone, and achieving 60% reduction in hospitalizations and $800 PMPM savings (all things being equal in patient complexity and fragility)? At some point, it is factors beyond evidence and engineering that will influence patient outcomes.
Keltner has also established that emotions influence interactions in relationships, where they serve to a) “help individuals know others…beliefs and intentions, b) evoke complementary and reciprocal emotions in others and c) serve as incentives or deterrents for other individuals…behavior.”3 Given the power of emotions to influence knowledge, attitudes and behavior in relationships, we need to consider how human connection and depth of patient-provider relationships may be important drivers of the Triple Aim. While we typically seek to keep emotions in check in medicine, we may want to consider a more active role for them in the design of our care delivery and value-based payment systems.
In an internal study designed to define priorities for value-based care, we discovered that more care is not necessarily better when too many different providers are involved. Our analysis revealed that when a patient is ‘connected’ to a specific primary care team at the threshold of providing 75% or more care, line item costs for primary care, testing and medications may increase, but there is a dramatic drop in overall costs, specifically around inpatient care and use of other outpatient and specialty services.
Our assessment, reinforced by Keltner’s findings, is that our capacity to achieve dramatic levels of Triple Aim performance is driven by our commitment to continuity of patient-provider relationship and some associated consequences of relationship continuity which have been referred to as “professional intimacy”.
Our model of home-based primary care makes it almost impossible to maintain traditional “professional distance” and, as such, increases the likelihood of personal connection and accountability, creating a space where patient and provider find meaning and value from each other, and, in doing so, also within themselves. Professional intimacy becomes the power driving improved regimen compliance, information sharing, collaborative care planning and the desire and motivation to achieve more in one’s life.
Professional intimacy uses the power of human connection to help us better understand each other, share emotional experiences together and “serve as incentives or deterrent for …behavior.” Under it, providers and patients remain present in each other’s lives even when they are absent from our daily schedule, and, as such, the influence of the relationship extends beyond the immediate encounter.
Professional intimacy is not the same as empathy, nor is does it necessarily require blurring of professional boundaries, but is based on both parties being fully present for each other, generating a level of closeness, confidence, and affection (a’ la Carl Rogers unconditional positive regard), and generating a new level of affinity and loyalty based on mutuality, respect and acceptance (even in the face of imperfection).
At the end of “Inside Out”, Riley and her parents each have to break through their respective defenses – for Riley, anger to the point that her feelings shut down completely; for her parents, it is the faux enthusiasm they engender to help get the family through a tough transition. Only then do they find themselves on the same side, as they embrace the sadness they share, albeit for different reasons.
Perhaps the medical community needs to have a similar catharsis. Much of the situation physicians find themselves in has been shaped by outside forces wielding their influence without any values prevailing towards their well-being. With this history in mind, resistance to change on the part of physicians may, in fact, be simply a desperate attempt to achieve some level of equilibrium, when prior trends have proven to have adverse professional risks or never sustained enough traction to warrant personal investment.
However, just like Riley, maybe it’s time healthcare professionals acknowledge to themselves their sense of loss and the sadness about how the healthcare system has changed, feelings we seem to share with our patients (albeit for different reasons); by letting go of our past expectations and embracing the shared humanity of our professional relationship, it may just allow us to find a better balance and connect in ways that revitalize our relationship and our experience of giving, and receiving, care.
1. Keltner, D, Ellsworth PC, Edwards K. Beyond Simple Pessimism: Effect of Sadness and Anger on Social Perception. J Personality and Social Psychology 1993; 64: 740-752.
2. Ariely D, Lanier WL. Disturbing Trends in Physician Burnout and Satisfaction With Work-Life Balance: Dealing With Malady Among the Nation’s Healers. Mayo Clin Proc 2015; 90: 1593-1596.
3. Keltner D, Haight J. Social Functions of Emotions at Four Levels of Analysis. Cognition and Emotion 1999; 13: 505-521.
4. Hartzband P, Goopman J. Medical Taylorism. N Engl J Med 2016; 374:106-108.
5. Javitt JC, Steinberg G, Locke T, et al. Using a Claims Data–Based Sentinel System to Improve Compliance With Clinical Guidelines: Results of a Randomized Prospective Study Am J Manag Care. 2005; 11:93-102.