Dishabituation to Healthcare’s New “Normal”
(Part 1 of 3)
THE EMPEROR IS NAKED
My friend and surgical colleague Katherine sent me a New York Times editorial yesterday with a note that it made her think of my work. By "your work," she means Metamorphosis Medicine and perhaps more specifically that I might be an agent of dishabituation. The title of the editorial is "Why People Fail to Notice the Horrors Around Them." (I've included the link at the end of this letter.) Even though I have problems with the authors' conclusions, I think the questions they ask are so good and decidedly at the heart of my work that I'm going to reference them anyway. They ask why, from the vantage point of hindsight, ". . . weren't the horrors halted earlier?" and "How could people have lived with them?" Their argument centers around the phenomenon of habituation which they define as "a pivotal biological feature of our brain . . . our tendency to respond less and less to things that are constant or change slowly." Habituation, they argue, not only numbs us to terrible things unfolding around us, it makes us more likely to participate in them. They also note that some people don't habituate and rebel against the horrors; they dub these "dishabituation entrepreneurs." A disclaimer before I proceed. No matter how sexy neuroscience is right now (and it is sexy), we shouldn't believe everything neuroscientists say just because, well, they're scientists. Let's distinguish observations from conclusions or broader applications of a finding. Retain a bit of skepticism. Things should pass the sniff test.
It will also help to explain why Katherine thinks of me as a dishabituation agent. I'm saying "agent" like "having agency" or "being an agent of change" because "entrepreneur" implies using dishabituation as a financial opportunity. While I hope to be paid for my work, I forged this path out of my very personal quest to find authenticity, alignment, and personal health through my work as a surgeon rather than despite it. I trust symmetry in relationships and ecosystems, give and take, mutuality, and reciprocity. In the field of medical practice, I challenge assumptions about the terms of practice that interfere with my well-being and the essential, relational aspects of the work of doctoring, with each other and with patients. I challenge things that subvert, contradict, or distort the core purpose of medicine, which I summarize as helping people live the richest, fullest, most integrated expression of ourselves that we possibly can. It has taken decades generally and 10 years specifically to know this and be able to express it succinctly. It delights me to have found that my definition is surprisingly consilient with interpersonal neurobiologist Dr. Dan Siegel's definition of mental health, his ideas about chaos, rigidity, and harmonic flow.
So now I am going to say the first of several very harsh things that I've come to slowly and considered carefully about the healthcare industry, so if that feels like a sacrosanct topic, you may just want to bypass this particular email newsletter.
Just to be perfectly clear, I do NOT believe this is the organizing principle of industrial healthcare which has a completely different, three-fold drive:
Extract from medicine as much wealth with the least investment of resources as possible,
Exploit the cultural values that make medicine an almost limitlessly deep pocket, and
Distribute the gains asymmetrically, favoring the architects of the industry.
Habituation really has to do with attention and with prioritizing and filtering sensory inputs from the environment or our inner sensations (interoception) because we have limited capacity (bandwidth) for focused attention and the conscious processing of sensory inputs and our responses to them. We might think of this as a mental economy. The authors call this an adaptation that happens when the new situation or sensation is sustained which normalizes it. They argue that horrific situations develop through a stepwise series of small habituations and small compromises, each new level normalizing and permitting the next, more serious concession to be made. They also suggest that some people are resistant to this or can be taught not to succumb to it. These are the dishabituation entrepreneurs--make that agents, people who don't desensitize, people who remain aware of the horror that is developing.
What happens to the sensations and the messages carried by them when we become habituated? Do we just go offline? There is no discussion in the editorial about diffuse awareness which is a different kind of attention nor of daydreaming. Diffuse awareness is what takes over while we're driving and our focused awareness is on a conversation with a passenger or on our cellphone or attending to directions. We are still monitoring the flow of traffic, the condition of the roadway, signage, and our route. Even when we sleep, we are not completely shut down, devoid of mental activity, or immune to sensation. Experiences can register in our repository of implicit memory even when our ability to integrate an experience in a logical, linear fashion that is pinned to a timeline and in which we can see ourselves in the memory is either not yet developed or interrupted by trauma, including perhaps most profoundly repetitive, habitual trauma.
My journey to discover what has happened to medicine and me in medicine and to other people and to figure out how I might help create a contemporary expression that honors the inheritance that spans this history of humankind and beyond has required me to dismantle limiting ideas and create bigger frames for perceiving myself, our profession, and modern times. It has required that I be clever and not compromise, to look more deeply, to keep going back to the river. Metamorphosis Medicine asks what medicines doctors need to be the doctors Medicine needs. That means understanding what called us and not being taken in by illusions or false gods. Who says we're not capable? Why do we who were called to this work and are inspired by it see ourselves as powerless?
So here's what I think. It's also harsh, so buckle your seatbelt. I think corporate healthcare is an abysmal contemporary phenomenon that cannibalizes the primal instincts of healing intention which are rooted in the self-organizing, self-healing properties of complex systems, including humans. I believe these principles exist in continuity from the material to the ephemeral, psychic dimensions of being. I think corporate healthcare masquerades as medicine and eats away at it like a cancer, sometimes intentionally and sometimes just because it's so very different. I think our preoccupation with the business of medicine distracts us from evolving the deeper structures of its work and processes which leaves a vacuum of wisdom about the healer's art and how to practice it in ways that sustain us and give us life through our service. If the healthcare industry is the emperor, the emperor has no clothes. It's not that the emperor has no power. It's that the power the emperor has is predominantly what we accord him and is in direct proportion to the amount of our own power that we cannot or refuse to see. Let me correct that by saying the power isn't ours per se; it's power that flows through us when we are aligned with purpose, with what called us to this work. There is something essential about allowing this power to work through each doctor or healing arts practitioner in distinctive ways. We know it when we feel it because it's numinous; we feel like we're a part of something larger than ourselves because we are. I don't mean that each person just makes up whatever they want. I mean that when we discover and elaborate how to practice the art of healing in ways that reflect our particular constellation it becomes an expression of true adaptability and creativity that are characteristic of diversity. We then become the living evidence of what we propose.
I have more to say about this editorial as well as some other generous and connected ways to think about why we stand by too often when bad things are happening, but it obviously can't be compressed into one email newsletter. I will send a second part soon. It is not my intention to offend anyone, but so many doctors have told me that they fear they will lose their ability to practice medicine if they say what they think, if they are critical of the system. If you want to engage in deeply exploratory conversations like this and experiences curated to promote feeling into them, not just talking and thinking about them, then make time to talk confidentially with me about attending a small-group week-long experience, an Intensive. You can schedule a time to talk with me here. There's no need to be shy or lurk. If you're curious, there's a reason for it. If you want to know more about Dan Siegel's definition of mental health, focused and diffuse attention, implicit memory, and trauma, I think his audiobook The Neurobiology of We is a really fine place to start. If you want to know more about the importance of daydreaming, here's an introduction to Dr. Kalina Christoff's work. For a totally surprising and rich discussion of mental activity and sleep, read or listen to Dr. Matt Walker's Why We Sleep. You can read the subject New York Times editorial here.
We can all be lulled to sleep by the field of poppies. Sometimes it's nice to be woozy, but don't lose your way! Keep your wits about you! Stay true to your path, the one that only you can walk.
With my deepest respect for staying the course of doctoring, as always.
