From NASA to Novels: What Can Adler Teach Physicians?

As NASA’s first Black female engineer, Mary Jackson had to face the realities of racial segregation prevalent in the Jim Crow South.1 She recognized the need for specific training to advance her engineering career, even if it meant attending classes at a segregated, all-White school. Instead of accepting the status quo or letting the indignities of racism deter her, Jackson petitioned the court and obtained special permission to attend these classes and pursue her goals. Despite facing heavy discrimination, Jackson’s steadfast commitment to her values of education and equality presents one answer to the question “Would you rather be your authentic self and risk being disliked, or compromise who you are and your values to gain universal approval?” In The Courage to Be Disliked,2 over the course of a 5-night conversation with a philosopher, a young man comes to realize that every individual is in control of his or her life’s direction, independent of past burdens and the expectations of others. Much of the dialogue follows Adlerian (individual) psychology—a holistic and goal-oriented therapeutic approach developed by Alfred Adler, an Austrian physician and psychotherapist in the early 20th century. His approach emphasizes understanding individuals within their social context, the importance of feeling connected with others, and people’s innate drive to overcome feelings of inferiority and contribute to society. These Adlerian concepts are explored in The Courage to Be Disliked, centered around the message that pursuing change in one’s life requires courage, and that true happiness and self-acceptance are closely tied to one’s sense of belonging within a community. We discuss 3 salient concepts and their applicability to health care. These concepts explore the way control presents itself in our daily lives, influences our intrapersonal and interpersonal relationships, and ultimately affects our ability to find the “courage to be disliked,” lead happier lives, and find meaning by contributing to society. However, it is worth noting that many schools of thought and philosophical traditions present these concepts as dichotomies. DO NOT LET YOUR PAST DEFINE YOU “No experience is in itself a cause of our success or failure. We do not suffer from the shock of our experiences—the so-called trauma—but instead we make out of them whatever suits our purposes. We are not determined by our experiences, but the meaning we give them is self-determining.”2 In essence, Adlerian psychology claims that one’s past experiences and trauma do not cause present misfortune, but rather, such trauma is used to justify its continuation. This somewhat controversial statement requires an understanding of the juxtaposition between Adlerian and Freudian psychologies. Freudian psychology aligns with etiology—the cause of something—often emphasizing the influence of unconscious processes, childhood experiences, and internal conflicts on human behavior and personality development. Adlerian psychology falls under teleology, which seeks to understand the purpose of something. Unlike Freudian psychology, Adlerian psychology looks at present goals, rather than past causes.2 For example, if someone has difficulty making friends due to anxiety, an etiological explanation might attribute this to childhood bullying. A teleological explanation would argue that the individual’s inability to connect with others serves the purpose of justifying their insecurities and lack of confidence. In this view, the individual’s present goal is to avoid exposing their insecurities to others, and their anxiety helps rationalize this avoidance. Teleology does not claim that past trauma does not exist; rather, it considers past trauma a strong influence, rather than a cause.2 The past may influence one’s present circumstances, but it has no inherent control over one’s present (or future) circumstances. There are costs to dwelling on past experiences. Dwelling on past experiences keeps individuals from fully engaging in the present and leads to missed opportunities. Reliving negative experiences can lead to feelings of regret, sadness, and anxiety, each of which affects mental well-being and may create tension and hinder healthy communication in interpersonal relationships. Moreover, dwelling on past mistakes impairs growth by hindering one’s ability to learn and grow. Within the health care context, what steps can be taken to mitigate the effects of permitting the past to influence the present? Commonly used to treat mental health and behavioral conditions in cognitive behavioral therapy, cognitive restructuring is a technique that helps patients identify, challenge, and reframe unhelpful thought patterns that contribute to negative emotions. For example, patients may turn to surgical interventions to resolve underlying issues with self-esteem or anxiety. Cognitive restructuring can help these patients confront the root causes of their dissatisfaction, rather than relying on surgery to do so. Cognitive restructuring can also be used as a preoperative screening tool to help surgeons assess whether a patient has a psychological condition that puts them at high risk for poor psychological outcomes.3 For example, patients with body dysmorphic disorder may be more likely to fall into a cycle of continuous surgery in the pursuit of an unattainable ideal. Moreover, cognitive restructuring can help inform a patient’s realistic postoperative expectations and reduce the risk of outcome dissatisfaction.3 Motivational interviewing is also used to help patients reframe undesirable thoughts and promote healthier behaviors. One study evaluated a 2-session motivational intervention designed to encourage a change in health risk behaviors among low-income, self-identified Black patients with adverse childhood experiences.4 The intervention featured a set of 5 guiding principles: expressing empathy; developing discrepancy (ie, helping patients recognize inconsistencies in their lives, such as wanting health but continuing unhealthy habits, to generate motivation to make changes); dealing with resistance; supporting self-efficacy; and developing autonomy. The majority of participants reported a high rate of satisfaction, emphasizing the importance of talking with a trained professional who would listen without judgment, understand patient challenges, clarify patient goals, and facilitate informed behavior change plans. Motivational interviewing is often used when the patient is hesitant about a medical treatment. For example, a patient may be hesitant to quit smoking or pursue an important surgery because of a bad past experience. Physicians may use the OARS (open-ended questions, affirmation, reflective listening, summary) model when counseling patients to help them restructure their thoughts of the past (Fig. 1).5Fig. 1.: OARS model for motivational interviewing.Open-ended questions (O) can be used to help patients generate and justify their motivation for progress.6 For example, a surgeon may ask a patient questions like “What are your thoughts on how smoking might affect your recovery after surgery?” or “What has worked for you in the past when you have made a difficult change?” Affirmation (A) occurs when physicians instill a sense of possibility and capability in patients.6 Surgeons may validate their patients’ efforts and strengths by saying “Your dedication to finding a solution is commendable” or “Dealing with this amount of stress would be challenging for most people.” Reflective listening (R) is the most crucial, yet challenging, step. Good reflective statements are more likely to elicit elaboration from the patient because they serve as a “verbal mirror” of their underlying thoughts and motivations.6 A surgeon might respond to patient’s worries by saying “You are concerned about potential complications with healing and want the best possible outcome from your surgery, but are unsure if you can manage to quit smoking right now.” Here, it is important to allow the patient to confirm whether the physician’s reflective statement is accurate or not before adjusting accordingly. Summary (S) provides an opportunity for the surgeon to relay the information back to the patient in a more “organized manner and encourage him or her to reflect on its significance.”6 A surgeon may summarize by saying “Let me pause for a moment to summarize and determine our next steps. I understand that you had reservations about attending today because of the following reason. You recognize that your quality of life would improve if you quit smoking, but you are uncertain about the possibility of maintaining long-term success. Considering this, I’m curious, what motivated you to come in today?”6 LET OTHERS SOLVE THEIR OWN PROBLEMS “All interpersonal relationship troubles are caused by intruding on other people’s tasks or having one’s own tasks intruded on.”2 Here, “tasks” is synonymous with “responsibilities,” which encompasses a person’s thoughts, feelings, choices, and actions. Adlerian psychology asserts that when people are able to separate their tasks from those of others, they are able to maintain happier and healthier interpersonal relationships. The “separation of tasks” involves identifying whose task is whose, drawing a boundary between those tasks, and taking action only on one’s own tasks. For example, Frida Kahlo’s distinctive self-portraits, which explored themes of pain, identity, and politics, were often dismissed by art critics during her time. However, she persisted in creating her powerful and intimate artwork, which has now earned her global recognition as an icon of resilience and radical honesty.7 Kahlo’s tasks were to continue painting and determine how to respond to critics. The critics’ task was to judge her art. Their disapproval was not something that Kahlo could do anything about.2 Or, as Kishimi puts it, “Not wanting to be disliked is probably my task, but whether or not so-and-so dislikes me is the other person’s task.”2 The separation of tasks has both intrapersonal and interpersonal benefits. For the self, separation of tasks fosters self-empowerment as individuals learn to take ownership of their own actions and choices. With others, separation of tasks may lead to healthier relationships—preventing codependency and unnecessary conflict—and foster a sense of mutual respect by preventing overinvolvement in other people’s lives. However, we often fail to separate tasks because we seek approval from others and are anxious about their judgment. This self-created anxiety results in uncertainty regarding whether one should do more to appease another, which becomes a self-feeding cycle (Fig. 2). As Adlerian psychology posits, “when one is tied to the desire for recognition, the interpersonal relationship cards will always stay in the hands of other people.”2 That is, when one is constantly worried about the judgment of others, the nature of that relationship will always be dictated by others.Fig. 2.: Failure to separate tasks is part of a self-feeding cycle.How can the separation of tasks be applied in a team setting and in the workplace? At the onset of any project, it is important to clearly define the roles and responsibilities of every team member. This helps reduce any confusion regarding who is accountable for which outcome. In addition, the task of team leadership is to avoid micromanaging, although for newer team members, it may be appropriate for leadership to be a bit more hands-on in the beginning as the team members get acclimated. Task separation also applies when team members struggle to fulfill their assigned tasks. To overcome this, tasks may be redelegated as necessary and at leadership’s discretion. However, if possible, it is best to allow the original team members the opportunity to complete their assigned tasks. Team leaders and teammates can help identify the struggling team member’s original goals and use that as a source of motivation. Team leaders can also talk with the individual to identify and remove any perceived barriers. The separation of tasks manifests itself in the health care space as well. In particular, honoring patient autonomy is synonymous with task separation. Medical paternalism—the idea that a physician’s role is to promote patient welfare, even if it comes at the expense of patient autonomy—prevailed in the past.8 This framework assumed that due to their medical expertise, physicians knew what was in the patient’s best interest. Today, however, patients are less dependent on physicians as a primary source of health information and resources.8 Given this, the new age of patient autonomy advocates for a shared decision-making model that involves physicians and patients working together to make health decisions that are informed by patient values and preferences.8 Consider a patient who has prematurely stopped the reconstruction process after mastectomy, also known as “reconstructive burnout.”9 Given that breast reconstruction helps improve psychosocial well-being and quality of life, a surgeon might feel obligated to encourage a patient to follow through with reconstruction completion. However, patients may think that such benefits do not outweigh the difficulties associated with potential postoperative complications, comorbidities, or cancer therapies.9 Patient autonomy argues that it is a physician’s job to provide objective information and permit patients to make decisions that align with their values and preferences. TREAT OTHERS AS EQUALS “We are all on the same level playing field, where there are people who are moving forward, and there are people who are moving forward behind them. Though the distance covered and the speed of walking differ, everyone is walking equally in the same flat place.”2 Put simply, we are all equal, but not the same. Here, “equal” refers to the value of human life, whereas “not the same” refers to each person’s varying accomplishments and circumstances. In Adlerian psychology, although everyone has different strengths and weaknesses, and takes different paths to achieve goals, everyone has the same capacity to contribute to society. Within a health care setting, the presence of interprofessional teams is a manifestation of “equal but not the same.” Leveraging interprofessional teams can produce a number of benefits, including increased efficiency, resource optimization, enhanced job satisfaction, reduced burnout, fewer medical errors, and improved patient outcomes.10 Moreover, good physicians understand that there are many different roles that synergistically work together to provide holistic patient care. During clinical rounds with an interprofessional care team, a good physician will listen and consider team members’ opinions to ensure that they are able to contribute to the care of the patient. There is a perceived power imbalance between physicians and other health care team members in terms of medical decision-making; failure on the physician’s part to value team members’ expertise may negatively affect patient outcomes if staff are less likely to voice concerns. Lessons on interprofessional collaboration can be taken from other areas, such as competitive sports or business, and applied to medicine. For example, an individual reflected on their experiences as both an athlete and as a pharmacy student, identifying 5 key ingredients necessary for success in a collaborative team.10 First is role clarity, in which individual contributions are valued, but the overall focus is on team success. Second, team members must be confident in their own abilities so that the team can develop trust. Third, teams must have the ability to overcome adversity and remain committed to the collective goal. Fourth, teams must be able to overcome personal differences. Fifth, practicing collective leadership helps take the pressure off a single individual and disperses it among the team members. In the workplace, interprofessionalism can be implemented using 5 strategies (Fig. 3).11 First, foster a collaborative culture. Teams can meet regularly and use interdisciplinary case discussions to facilitate cross-departmental teamwork.11 Second, promote effective and clear communication, including regular team meetings, communication platforms, and multiuser documentation systems.11 Third, develop interprofessional education and training initiatives. Such programs may focus on improving communication skills, learning conflict resolution, and understanding the roles and perspectives of other departments.11 Fourth, use collaboration tools such as workplace chats, project management software, virtual collaboration platforms, and task management tools (eg, Chanty, Asana, Zoom).11 Fifth, continuously evaluate and improve. Feedback can help identify areas for improvement and refine collaboration strategies.10Fig. 3.: Five strategies to implement interprofessionalism.Implementation of interprofessional health care teams and education has largely been well-received. Within hospitals, efforts have been made toward implementing multidisciplinary rounds teams, which consist of hospitalists, nurses, dieticians, pharmacists, therapists, and others. The model is a collaborative approach that “optimizes patient care through shared goals, electronic record access, regular reviews, and patient involvement...to reduce patient mortality, complications, length of stay, readmissions, and enhance patient satisfaction and utilization of ancillary services.”12 For example, the increased use of advanced practice providers, such as nurse practitioners and physician assistants, within surgery enhances clinical productivity and ensures continuity of care.13 Interprofessional education initiatives also exist, with the goal of enabling effective collaboration and improved health outcomes, such as the Interprofessional Education Collaborative and the American Interprofessional Health Collaborative.14,15 On an international level, the World Health Organization–developed Surgical Safety Checklist, which promotes interprofessional collaboration in the operating room, has helped reduce surgical complications, improve patient safety, and enhance cooperation among surgical teams.11 Although the Adlerian concepts discussed may appear extreme, they underscore an important principle: recognizing what is within one’s control—and what is not—can foster healthier relationships with oneself and others, and that every individual has unique strengths that can be leveraged to help better society. These concepts can be applied to improve health care team relationships, physician–patient relationships, and patient outcomes. DISCLOSURE Dr. Chung receives funding from the National Institutes of Health and book royalties from Wolters Kluwer and Elsevier. G. K. Tran has no financial interests to disclose. No funding was received for this work.