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[00:00:00] Hey guys, welcome back to the podcast. I'm Amanda. I'm Laura. And I'm Kendra. And today Kendra is going to introduce our topic. Okay. Today we are talking from our favorite book, Brené Brown's Atlas of the Heart. We are unpacking how paradox, irony, sarcasm, and cognitive [00:01:00] dissonance affect both our patients and ourselves.
So we're going to define each one of these, see how they're a little bit interrelated, but distinctly different and why understanding these complex emotional dynamics is critical for physicians and how we interact with each other as colleagues, but also with our patients. We're going to start with cognitive dissonance in medicine.
And just as a reminder, cognitive dissonance is that mental discomfort that we're experiencing when we are holding two conflicting beliefs at the same time. And you're like, how does this even happen? And just notice. It actually happens more often than you might think.
So one example would be the story of this evangelist from the 1950s that predicted doomsday and that their followers would be rescued and. It didn't happen according to their prophecy, but the most invested members [00:02:00] of this cult or organization actually doubled down and became even more invested stating that it was going to happen.
So if you think about things like Stockholm syndrome, where you have people who have been abducted. And their freedom taken away, they're even being abused, and somehow they form a protective instinct towards their captors and they form a bond with them. So it happens in relationships all the time, abusive relationships all the time, where it's very common for people who are in abusive relationships to be protective of their abuser.
Definitely common thing that can happen. It can range from minor pangs of discomfort to deep anguish. And oftentimes attempts are made to reduce the dissonance by making sense out of contradictory ideas. So, you can have a situation where you're recommending lifestyle changes [00:03:00] to a patient that you have not made those lifestyle changes for yourself.
So, an example would be if you're out on cardiology rounds as a trainee, and your attending goes out to smoke in between patients. It's probably less common now, but it certainly was common when we were doing our training. Things like that. So, Dr. Brown in Atlas of the Heart discusses how recognizing and naming these feelings can reduce their power.
So we can embrace self awareness, what are the motivating factors that may cause these behaviors? Be curious. Not judging, not judging our feelings or thoughts or our actions. Just be curious about why we might be saying or doing things that we do. Seek alignment between our personal values and professional recommendations.
This is super important to help us as we're trying to deal with and avoid burnout, to know what our values [00:04:00] are, what is really important, what feels true to the best version of ourselves, who we want to be, who we are at our core, what are those values and how can we align our lives, our words and actions, our thoughts, and our professional recommendations with those same values.
So, you know, if we find that we're not doing things that we're recommending for our own patients. Let's look into how we can start developing those habits even just a tiny, tiny bit at a time, even just beginning by thinking about, I'm going to develop this habit of exercise, or I'm going to work on my sleep, or I am going to start drinking one more cup of water a day.
Whatever it is, we will feel better if we start to live in integrity and align our values with what we say and do.
Fostering a non judgmental space for [00:05:00] patient discussions will also help with cognitive dissonance. I remember when I was a resident, very clearly, I had this COPD patient who came in and, you know, often the COPD patients will come in time and time again, same thing, still smoking.
And, I was super judgmental of this guy. I was like, you know why you're here, like, why do you keep smoking? And wow, like looking back, so cringy, like so naive of me. Number one, to even to be that judgmental. Number two, like how naive to think it's just that simple as just wanting to quit. It's not.
It's very, very, very difficult to quit. So it's really important. And that guy was like, you don't, you know, you don't get to treat me like that. He actually did. I think I've changed my practice quite a bit and changed me for the better. So it's probably good that that happened, but anyway, it's cringy looking back on it.
So don't recommend. And I think that's another way to [00:06:00] build trust because you know, for ER docs, we're always trying to hack that because we have like literally met these patients in five minutes and sometimes it's the worst day of their life. But I think just meeting patients where they're at by, you know, fostering that nonjudgmental space, man, that's a quick way to build trust right there in the five minutes we have while we're trying to like get them back from the reaper.
Right. So if I could go back, what, and what I say to people now is I know, you know, that smoking doesn't help this situation. And I know it's so hard to quit. And I don't even know if you want to quit. But if you do, I just want you to know that I'm happy to support you in any way that you need and I'm going to take great care of you, even if you choose to continue smoking.
And that, that just, it feels better to me and it, it feels better to the patients too. So resist choosing comfort over courage. Remember our brains want to conserve [00:07:00] energy, seek pleasure and avoid pain. Our brains are always trying to choose comfort rather than having us do the right thing. If you are in a situation that requires you to do something different—to live more in alignment with your values—even though it's going to be uncomfortable.
Just remember that growth happens in discomfort. Everything good and everything that you want is on the other side of discomfort. And so just notice when your brain is trying to get you to sit on the couch and watch Netflix or scroll and chips.
It's trying to keep you out of growth. It's trying to keep you safe and alive and growth feels challenging to it and scary. It's not ultimately what you want. Brain is designed to help us survive, not to thrive. So we have to override it sometimes. I love Adam Grant, an organizational psychologist at Wharton. He is brilliant. He says, intelligence is traditionally viewed as the ability to think and learn yet in a turbulent world, there's another set of cognitive skills that might matter more, the ability to rethink and unlearn. So notice the things that you have thought and learned that maybe are not serving you right now and in your future and decide what you might need to rethink and unlearn.
Yeah, for cognitive dissonance, I think that us knowing about this can help us be more compassionate when you see somebody digging in for beliefs that don't line up with reality. Doubling down when the person they admired isn't who they thought that they were. When their loved one isn't acting in their own, it's just to have compassion [00:09:00] for people because the brain dislikes it so much.
Yeah, that it turns out this person isn't as advertised, that sometimes it is a lot easier to double down on that than to deconstruct what you've believed your whole life. That is uncomfortable, ungodly uncomfortable. And so I do think that that's an incredible quote that he says is like the ability to rethink and unlearn what you have been taught to never question before.
Wow. That is doing some big work.
Yeah, and that takes courage. Oh, it's scary. I had to do it a couple times in my life and it was not fun. Yeah. Okay. So in this same vein, we're talking about paradox and paradox is a situation involving contradictory, yet interrelated elements that exist simultaneously. So the Greek origin of the word para is contrary to, and then [00:10:00] doxa is opinion.
So contrary to the opinion, the Latin term paradox and means seemingly absurd, but really true. So, what does this look like in clinical practice? Well, balancing empathy with objectivity. So, advocating—this could look like advocating for aggressive treatments while respecting the patient autonomy. This kind of came up recently at a case, you know.
Poor lady was just getting some really aggressive chemo and radiation and just suffering and needed to be admitted. You know, oncology was really wanting to get her back on track, get her on their schedule, but she is just really needing—we just need to take her up, like, get her back to baseline and so just really, you know.
Being that person, the voice of the patient sometimes advocating for what they have disclosed to you or for what you're seeing and kind of experiencing with them and using that as a voice to, you know, the admitting physician or the consultant for us that are in the E.D. It's just, it seems [00:11:00] like, you know, for us, like, hey, can we pause on this aggressive chemoradiation, stabilize this patient, or get this patient feeling better, and then we can resume.
Like, I'm just hearing her—in the moment she's saying, no, I just want comfort care, hospice, but I'm not sure if she really wants that. Maybe if we could get her feeling better, she would be open to resuming treatment. You know, something like that, where it seems like these are contradictory, but they're existing at the same time, and Brené talks about this as being more on the spectrum of the both rather than the tyranny of or.
And so sometimes, especially with our all-or-none thinking and our perfectionist brains, we are black and white. It's an or. We can't even fathom that we would entertain a both–and. But really, it's the truth. Brené in her book talks about, like, what would this look like though, if we could embrace—or emphasize the importance of—how do we get to an understanding?
How can we do a both-and scenario? And let go of what she calls the tyranny of or, an either-or [00:12:00] situation and from the quote in her book that I just love: vulnerability is the first thing we look for in other people and the last thing we want to show them about ourselves. And that really is being vulnerable.
You know, speaking up for your patient, especially to a colleague or consultant that you may or may not have a hard time getting patients admitted anyway, and they're pushing back. The only way I'm admitting is if they resume their chemo and radiation, whatever, whatever. But what it is, is it just takes, you know, the courage to say, "Hey, I've spent some time with this patient…
I really feel like we'll get, you know, a lot further down the road if we embrace both and can we stabilize her and then resume treatments after." So, just opening up your mind to considering, like, how can we come to an understanding? How can we get in an agreement? How can we entertain what the patient wants?
Because in essence, they do have the power to choose. They have their autonomy, but also, getting you know, what is clinically important in the moment. Paradox really is an emotion. Alice of the Heart, we—[00:13:00] she talks about, you know, these are all the different kinds of emotions or feelings.
Paradox really isn't an emotion, but it brings in emotion when we start to feel that tension. When we have two different sides pulling—seemingly, they seem to be contrary—but is there a way that we can make it a both-and? And so, it does raise quite a few emotions and feelings in it, not in itself, but as a result of.
And so, one of the ways, the strategies that, you know, we can incorporate every day in clinical practice is just really cultivating an idea of comfort with ambiguity. So just saying, like, could we, or is there a possible way, you know, leaving all parties at the table with a voice in the matter and practicing reflective listening.
So hearing your patients, reflecting back what they're feeling, and then even on the phone with the consultant or the admitting physician—if you're in the ED—like reflecting back what they say, like, "I hear you say we need to get back on track." It's the best case for survival of this cancer, whatever, whatever, but could we [00:14:00] and just, you know, really listening to understand—we've talked about this quite a bit—the outcome, letting go of the outcome and really listening to understand. I really feel like that would kind of build that bridge and help in these kind of uncomfortable situations at times.
Yeah. I think a paradox for physicians is starting to give yourself self-compassion and grace when you have built your identity as this resilient worker, you know, who keeps her head down and just battles her way through. I think this whole thing is like just becoming comfortable with…
both—and instead of either-or. We're so black and white. We're so all or nothing. When something bad happens to you, you can both give yourself time to grieve it and pick yourself up by your bootstraps and carry on. You can do both. They're not mutually exclusive. And also, you [00:15:00] can make mistakes and still be an excellent doctor.
All doctors make mistakes. Even the best doctors do sometimes. Love that. We should probably have an entire podcast on that.
Okay, next one that we're going to discuss from Atlas of the Heart is irony. And so this is a situation where the outcome contradicts expectations.
So, an example would be dying from the illness that you chose not to get vaccinated [00:16:00] against. I think about that—a lot of s'mores, that's all, yes—and people would argue all the time that that's not actually irony. She's explaining something. That's just unfortunate. Anyway, so yes, the technical definition is where the outcome contradicts the expectations. I see it a lot, and people who—having done the integrative medicine fellowship thing, the people who are excluding any allopathic medicine for something natural with no understanding whatsoever—I'm like, "You do realize that lavender on your skin is an endocrine disruptor, right?"
And that if anything is effective, too much of it could be deadly. Like with those sorts of patients, I'm like, "You realize too much water will drop your sodium and give you a seizure, right?" Like that. So that would be ironic if somebody was increasing their water intake to be healthy only to give themselves seizures.
That would be ironic, right? So, in Atlas of the Heart, Brown explores irony as a tool for understanding [00:17:00] complexity and resilience, and she suggests strategies of using irony thoughtfully to foster insight without alienating patients. Again, you don't want to be, like, confrontational about this sort of stuff where they double down with the cognitive dissonance.
Using these insights thoughtfully is the better option, and we are encouraging the use of professionalism while you navigate unexpected outcomes. I can think—my brain is like, I wonder what other examples of irony; I'm sure if I thought about it there'd be like 8 billion. Mhm.
And then, I got this one because of sarcasm. This may be my wheelhouse. And this is the use of sharp, cutting remarks, often intended to be humorous. The definition is from Lee and Katz in 1998. Although I'm sure there were definitions of this other than that—that's one thing about coaching: we're interested in the results you get. How you get there matters too, but if the things that you're doing aren't giving you the results that [00:18:00] you are intending, then you need to take a look at it and see if you really are attached to that or if you're more attached to the result that you're hoping.
So, for instance, you might joke with colleagues about difficult patient interactions with the intention of connection, right? Or relieving stress or detaching from—if you're having compassion fatigue, right? It might make sense why you are using sarcasm. But, Brené Brown just cautions that there is the potential for sarcasm to alienate the bond.
If you don't really know your colleagues, sometimes you might be downright offensive with the things that you think are funny. It just depends on the context. And sometimes sarcasm is contemptuous. You just really have to check in with what you're doing. What are you trying to accomplish here?
So some strategies are to avoid sarcasm in patient interactions. Prioritize clear and empathetic communication. This actually came up for my son. He is a kind-hearted person and was joking around with someone that he didn't know that well, and that person was sensitive and thought he was coming from a place that left them shocked that it could have been misinterpreted—because they should have just known that it was just a joke or whatever—unless you have that connection and those emotional deposits in that bank account of, like, being able to trust and know where that person's coming from.
Like, that was a concept that I recently had to teach my kids: you don't have anything in that bank account, so they're not gonna just know that you're coming from a good place rather than a bad place. And it's the same with our patients, especially if it's a first-time encounter.
Same thing with your colleagues—please, I'm so tired of some of my colleagues assuming I have the same political views that they do. Clearly I have not engaged, because they're saying things and I'm like, I absolutely do not agree whatsoever, but they just assume that I do, so I don't know what sort of [00:20:00] vibe I'm giving off, but anyway, just…
Just sometimes it's good to read the room before you just go on with your sarcasm or whatever it is that you're doing. Use humor judiciously. After you know that person well enough to go there—especially if you're trying to use it for camaraderie—you might be backfiring big time with your assumptions.
Yeah, yeah, so basically with this discussion today, just pointing out that, you know, these are places we go when we are trying to connect, but they can actually make a disconnect, and just some awareness around when to use it, when not to, how to make sense of it all. Just notice, like, next shift, next workday, you know, when you are trying to connect with your patients.
How are you connecting? You know, you have some patients that love humor and love sarcasm, and that is an appropriate place. You have some patients that are extremely sensitive and it will go right over their head and they may even be offended by it. So I tell my [00:21:00] kids all the time, you know, like, try to be the thermostat, not the thermometer—like, don't race to the tip of the room; keep yourself in check and just, by taking that first step of awareness and reading it, it can really go a long way.
So, if you have some personal experience with that or some funny stories, please share them with us. We'd love to give examples, read about it on the air. So email us at [email protected] and please leave us a review. We love that. It makes our ripple that much bigger. And one closing quote I love from Brené Brown in this book: when we have language to articulate what we're experiencing, we can begin to heal and connect.
So let us know what you thought about this episode. And we do want to tell you about our new free video. It's called How to Crush Physician Burnout for Good Without Cutting Back Hours, Quitting Medicine or Sucking It Up in Silence. So scroll down in the show notes and click the link today. Until next time you are whole, you are a gift to medicine and the work you do matters. [00:22:00]
