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Transition to Practice: A Journey to Authenticity David C. Leach, M.D. Executive Director, ACGME February 22, 2007 Objectives To enjoy some poems To examine the formation of health professionals as a journey To imagine institutional culture as it ought to be

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Transition to practice a journey to authenticity l.jpg

Transition to Practice: A Journey to Authenticity

David C. Leach, M.D.

Executive Director, ACGME

February 22, 2007


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Objectives

  • To enjoy some poems

  • To examine the formation of health professionals as a journey

  • To imagine institutional culture as it ought to be

  • To imagine how we might redesign relationships in ways that may be helpful


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A moment of gratitude

Before we begin….


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The Way It Is

There’s a thread you follow. It goes among

things that change. But it doesn’t change.

People wonder about what you are pursuing.

You have to explain about the thread.

But it is hard for others to see.

While you hold it you can’t get lost.

Tragedies happen; people get hurt

or die; and you suffer and get old.

Nothing you do can stop time’s unfolding.

You don’t ever let go of the thread.

--William Stafford


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The Task…

  • Substance is enduring; form is ephemeral. Preserve substance; modify form; know the difference.

  • Dee Hock


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The Tasks…

  • How can we be both faithful and effective trustees of the values our professions offer society?

  • …and how can we prepare the next generation of doctors and nurses to be faithful and effective?


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The Context of the Work of Healthcare

  • Relentless economic/time pressures

  • A focus on safety, quality, transparency….

  • More regulation, duty hours, etc.

  • New knowledge and technology

  • Fragmentation of care, alternative medicine, consumerism

  • Demographics – population, generational gaps…


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Three Naming Problems (Batalden)

  • The doctor-patient relationship

    • From one-one to many-to-one

  • The science of disease biology vs. the science of clinical practice

    • From naming diseases to relieving burdens

  • The Cost/Value equation

    • Until we get it right others will continue to offer us things like DRGs, HMOs, P4P, etc.


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The (Internal) Context of the Work of Healthcare

  • Truth telling (or lack thereof)

    • The 38/54% problem

  • Promises and forgiveness

  • Seeking goodness …for whom???

  • Imposed external controls

  • Discontent

  • A need for authenticity


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The National Context of Health Professional Formation

  • Students or employees?

  • National or corporate standards?

  • Impending workforce shortages

  • Outmoded educational models

  • Expedient vs. improving patient care?

  • Individual formation: role of context


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The Institutional Context for Healthcare Work

  • Frenzy


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There is a pervasive form of modern violence to which the idealist … most easily succumbs: activism and overwork. The rush and pressure of modern life are a form, perhaps the most common form of its innate violence.


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To allow oneself to be carried away by a multitude of conflicting concerns, to surrender to too many demands, to commit oneself to too many projects, to want to help everyone in everything is to succumb to violence.


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The frenzy of the activist neutralizes his (or her) work … It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitful.Thomas Merton


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  • From frenzy to wisdom… It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitful

  • …as individuals and as professions


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A Journey to Authenticity… It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitful

  • …it begins as an inner journey


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  • Another Poem It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitful


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The Journey It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitful

One day you finally knew

what you had to do, and began,

though the voices around you

kept shouting

their bad advice-

though the whole house

began to tumble

and you felt the old tug at your ankles.

“Mend my life!”

each voice cried.

but you didn’t stop.

You knew what you had to do.


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The Journey (cont.) It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitful

…little by little,

As you left their voices behind,

The stars began to burn

Through sheets of clouds,

And there was a new voice

Which you slowly

Recognized as your own,

That kept you company

As you strode deeper and deeper

Into the world,

Determined to do

The only thing you could do-

Determined to save

The only life you could save.

Mary Oliver


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  • It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitfulJourney to Authenticity?”


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Authentic It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitful

  • …conforming to fact or reality; trustworthy; not imaginary; not an imitation; genuine; bona fide


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The Journey to Authenticity… It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitful

  • As a person

  • As a professional

  • As a profession


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Thomas Merton It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitful

“We exhaust ourselves supporting our illusions.”


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The Journey to Authenticity It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitful

  • Sorting out False Self from True Self

  • Hearing your own wisdom….


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Journey to Authenticity It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitfulThe Whole Nurse/Doctor Shows Up

  • Incomplete Self vs. True Self

  • Inviting the whole person to show up

  • The inner teacher

  • Life on the Mobius strip


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The Journey to Authenticity It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitfulValues – From the Inside Out

  • Individual Values

    • Unconditional imperative – Karl Jaspers

    • A command of my authentic self to my mere empirical self; defines who I am; timeless

  • Professional Values

    • Shared assumptions

    • Foundation for action


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Working with Nature: It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitfulThree Faculties and Their Objects

  • Intellect – seeks Truth

  • Will – seeks Goodness

  • Imagination – seeks Beauty


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Human Faculties and It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitfulthe Work of Medicine

  • Intellect

  • Discerns the truth

  • Will

  • Makes good clinical judgments

  • Imagination

  • Does so with harmony, creativity and beauty


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Primary Values with which to Arm Oneself It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitful

  • Integrity

    Discerning and telling the truth

  • Altruism

    Putting what is good for the patient before what is good for the professional

  • Practical wisdom (Prudence)

    Beauty in judgment

  • Arete: Integrating all the virtues to excellence


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The Dreyfus Model and Transitions It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitful

  • Novice

  • Advanced Beginner

  • Competent

  • Proficient

  • Expert

  • Master


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The Dreyfus Model and Autheticity It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitful

  • Learning the rules

  • Learning Context

  • Prudence (Phronesis)

  • Getting things done

  • Improving

  • Integrating with style


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Arete: Excellence It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitfulIntegrated Virtue in Action

  • The quality of patient care, the quality of professional formation and the quality of system performance are inextricably linked.


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A Question: Relationships… It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitful

  • What types of relationships invite authenticity?

  • …to improve patient care?


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As We Consider the Journey… It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitfulThink about Organizations:

  • As they were

  • As they are

  • As they might become

  • As they ought to be

  • Dee Hock


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Authentic Community: It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitful The Cohesive Forces

  • Purpose

  • Principles

  • People

  • …or scapegoating


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Purpose It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitful

  • Improve patient care


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Principles: It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitful

  • Integrity

  • Altruism

  • Practical Wisdom

  • Arete


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Clarify Assumptions It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitful

  • Using people to get work done, or…

  • Using work to develop people.


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People: It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitfulAnother Aspect of the Journey

  • Character



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Another Consideration: determined by character.

  • Authentic leaders are not made nor are they born; they are enabled or disabled by the organizations in which they work.


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How would we begin? determined by character.

  • We must become the change we wish to see in the world….

  • Gandhi


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We have something else to offer the larger society… determined by character.

  • Why it’s really important that we get this right….

  • especially now.


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Postmodernism determined by character.

Reality cannot be known with certainty

Reality is a social construct

Perception is reality

Analogy – spin doctors

Critical Realism

Reality does exist

It can be known

Analogy –real nurses/doctors

At this time we live in a culture….:Postmodernism vs Critical Realism


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Avoiding Fundamentalism determined by character.The role of humilityThose who have no absolute values cannot let the relative remain merely relative; they are always raising it to the level of the absolute.Flannery O’Connor


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Values are enduring; rules are ephemeral; preserve values; modify rules; know the differenceDee Hock Modified


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Community leads to clarity; clarity leads to courage modify rules; know the difference


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I Will Not Die an Unlived Life modify rules; know the difference

I will not die an unlived life.

I will not live in fear

of falling or catching fire.

I choose to inhabit my days,

to allow my living to open me,

to make me less afraid,

more accessible;

to loosen my heart

until it becomes a wing,

a torch, a promise.


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I Will Not Die an Unlived Life modify rules; know the difference

I choose to risk my significance,

to live so that which came to me as

a seed

goes to the next as a blossom,

and that which came to me as

blossom,

goes on as fruit.

Dawn Markova



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To Teach/ practiced.Learn/Lead is to create a Space/Community in which obedience to truth is practiced.


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