HOW I FOUND MY RHYTHM WHEN THE MUSIC STOPPED

At a time in everyone’s life, we come to find ourselves in a situation where the music stops, and we must go on.  The unfortunate truth about life is that the unexpected will happen. Some of us learn from it, some of us change because of it and some of us find our life’s calling because of it. The latter was the case for me.  After our dad picked us up from middle school, we spent that afternoon like we had every afternoon that month. We went to the oncology unit at the hospital, where my brother was admitted.

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THE MAN IN A BLUE SARONG

I remember him. I remember the man in the dark blue sarong the same way I remember the lines on back of my own hand. He was hunched over next to a column on a dirty platform at a railway station in Calcutta, India in the middle of the harsh summer sun. His hands were withered, his fingers and toes looked like tiny nubs, and he was completely malnourished and alone. He had opaque blue eyes, as if fog had taken place of his irises and pupils.

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PATIENT “OWNERSHIP”

I studied insects in college; my favorite insects were the bees (I found them diligent and so helpful to humankind).  One of my favorite classes was about medical diseases caused by insects. My professors noticed my interest in the medical side of things and connected me with a professor who did clinical research. Our work focused on a clinical trial for children with intractable epilepsy and exposed me early on to patient care and patients.

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change is possible (step 2). As the individual merges into the process of change, as step 3 indicates, questioning begins. In step 4, the person develops an action plan to make the changes, and then when success in the change is apparent, the new behavior is maintained... what has been possible has now occurred, noted in step 5.


What originally began as a threat to the self noted in step 1, ends in step 5 with the changes; the maintenance of success is based on a continuing realization that the behavior has successfully changed and continuing practice is required to keep the new behavior in place.


The Neuroscience of Change

The study of the brain, particularly within the fields of social, cognitive, and affective neuroscience, is beginning to provide some underlying brain insights that can be applied in the real world (Lieberman, 2007). Two themes are emerging from social neuroscience. First, much of the motivation of human beings driving social behaviors is governed by an overarching organizing principle of minimizing threat and maximizing reward (Gordon, 2000). Secondly, several domains of social experience draw upon the same brain networks to maximize reward and minimize threat and are also the same brain networks used for primary survival needs (Lieberman and Eisenberger, 2009).


The "SCARF" model developed by David Rock (2008), includes five domains of human social experience for collaborating with others: 1. status, 2. certainty, 3. autonomy, 4. relatedness, and 5. fairness. The SCARF model uses the old approach - avoid response that has been reported in the medical and psychological literature for generations. This principle represents the likelihood that when a person encounters a stimulus (the new change), the brain will either tag the stimulus as  “good” and engage in the stimulus (approach), or the brain will tag the stimulus as “bad,” and then will disengage from the stimulus (avoid it). The approach - avoid response is a survival mechanism that has been in humans since caveman walked the earth and it is designed to enable people to stay alive by quickly and easily remembering what is good and bad in the environment (an automatic brain valence [+-] system).  However, this causes substantial physiological and psychological stress for persons who are adapting to change. The amygdala, a small almond-shaped object that is part of the limbic system, plays a central role in humans for conditioning us to whether something should be approached or avoided. By using small cycles of change, as noted in Figure 1, a person can more easily adapt to required changes, necessary for them to adjust to their environment and to teams.


Our brain wants things to be certain. The brain is a pattern-recognition machine that is constantly trying to predict the near-future.  The brain wants to know the patterns occurring moment-to-moment. It craves certainty, so that prediction is possible. When we are confronted with a new electronic health record or a new demand from our medical supervisor, this interferes with the brain’s ability to predict and it must use dramatically more resources, involving the more energy-intensive prefrontal cortex to process moment-to-moment experiences. This uncertainty, in turn, produces an “error” signal in the orbital frontal cortex and takes the attention away from an individual’s goals, forcing him/her to pay attention to the “error.”


By understanding the domains in the SCARF model noted above and finding personalized strategies to effectively use brain insights for small cycles of change, we can become better leaders, managers, facilitators, coaches, teachers, and physicians.


Resources


As physicians, we are required to master changes on a daily basis. Very shortly, we will have to deal with changes in the Accountable Care Act. At some point, we will be required to deal with changes in our electronic health record system. Medical organizations are struggling with the demands of physicians to make changes in the Maintenance of Certification (MOC) process. Everyone wants some kind of change from us, and adaptation is the watchword.


Change is integral to life, and it accounts for evolution. It is certainly built in to all biological systems on this planet. If change has always been an integral part of life, why do we resist it so? Why, in every generation do we have Luddites? What goes through a person’s mind when they are informed of or predict change? Is my position safe? What will I have to do? What will I need to know? Am I capable and confident with new direction? Do I have any say about this, or any control over what is about to happen? Do I really need to change? Do I have time for this? How am I going to do that and this? How will this impact what I have already done? (Crowder and Friess, 2013).


The Psychology of Change

As Crowder and Friess (2013) describe in their book, the amount of changes and their effect upon us is protean. Their text describes Theory Z: This is described as “consensus decision-making,” and it establishes strong bonds of responsibilities between team leaders and team members with a high importance placed on finding people with  

BY ROBERT P. GRANACHER JR., MD, MBA

the right skills, both “hard” skills (e.g., technical), and “soft” skills (e.g., creative thinking) for team creation. Consensus decision-making is currently taught to medical students by incorporating advanced registered nurse practitioners, physician assistants, doctorates of nursing, and a plethora of other medical providers as members of medical teams.


These new team demands are challenges to us as individuals. The psychology of change has been studied by self-affirmation research (Cohen and Sherman, 2014). Whether people see their environment as threatening or safe marks a dichotomy between the perceptions of environmental challenge to one’s self-integrity.  Psychological threat represents an inner alarm that arouses vigilance and the motive to reaffirm the self. Psychological threat can sometimes trigger positive changes, but it also can impede adaptive coping.


As Cohen and Sherman (2014) point out in their article on the Psychology of Change, self-affirmation is necessary for coping strategies and adaptations. Figure 1 describes a cycle of change in mental strategy. In the first step, when the person begins to contemplate change, it is not unusual to deny that this is possible. As contemplation continues, the individual comes to the realization that the expected

ROBERT P. GRANACHER, JR., MD, MBA

Robert P. Granacher, Jr., MD, MBA practices clinical and forensic neuropsychiaty in Lexington and Mt. Vernon, KY. He is a noted scientific author and past president of the Kentucky Psychiatric Medical Association. He is currently president-elect of the Lexington Medical Society and Clinical Professor of Psychiatry at the University of Kentucky College of Medicine.