My recent travels to Southeast Asia (Thailand, Cambodia, and Vietnam) have given me pause to ponder on the way we react to change in our clinical environment. I was particularly enamored by the Khmer people, and the 500-year rule over the region that, in part, was based on the geographic position of advantage around the largest fresh water lake in the area.
The entire region both benefits and suffers from the availability of water and humidity during the marked seasonal changes. Water lines on the river and lake size are so notably different between the dry and rainy seasons. At its peak, the lake swells more than six-fold!
The impoverished floating village that we visited by bamboo boat was accustomed to moving with these changes, and anchored on the inside of the river mouth during the rainy season, or far out beyond the delta in the dry season. The crucial role of rice in their agriculture is a direct product of this amazing climate. The fall of the Khmer rule in Angkor more than 600 years ago may have been influenced by climate changes that affected their food supplies.
Living in Southern California with the recent and frequent droughts, I appreciate the importance of water to everyday living. The people of this region have also had to adapt and endure many man-made changes, including wars, foreign colonization, political instability, and even genocide.
Particularly in Cambodia and Vietnam, there were many motor bikes on the roads and highways of these countries. They apparently number as much as one for every other person. What was fascinating to watch was the flow of traffic that occurred in the busy streets of the major cities. With dozens of motorbikes passing by, there seemed an impossibility for one to be able to cross the street safely in the absence of lights (truthfully even with traffic lights this appeared perilous).
I witnessed an old woman and her middle-aged daughter proceed to cross the street with no hesitation. They both partially raised their hands and simply walked perpendicular to the flow of traffic. I was mortified at first, thinking this was going to be a call for my medical background to kick into high gear. Instead, the oncoming traffic sensed their presence, slowed, and then proceeded to flow dangerously close around them like they were rocks in a fast-flowing river. Interestingly, no calamity ensued. No honking, no cursing, no profane gestures occurred. Both parties appeared to know what was going to happen and responded actively and peacefully. They moved individually and as one. It was beautiful to see. Nevertheless, my wife and I still dared not cross in this manner and found the closest gap we could see. We weaved more like a game of Frogger than anything seamless like we just saw.
What causes this to occur? The primary religion across most of Southeast Asia is Buddhism. I am not Buddhist, but there are elements that I admire of the Buddhist culture. These include an attraction to pacifism, the concept of karma, and belief that service is important to society. Buddhist monks can be seen from afar with these incredible cloaks of bright orange that are both startlingly ostentatious and austere. Could the religious background of the people of this region be the basis for this kind of “flow”? But I have seen similar “flow” in other countries with different religions. Does their history of adapting to unique climate and political change help? Does cultural homogeneity and elevated appreciation of societal identity help support this? Or could poverty and adverse conditions redirect any wasted time and energy on anger and frustration to accept a different set of rules that acquiesce to the ambient flow of traffic, including the apparent changes that impact this flow?
In North America, we often respond more emotionally to similar changes in the road conditions. The road rage I see here at home is an interesting phenomenon that most of us have witnessed or felt personally. We react to what appears to be a slight in our journey, a deviation on the expected and predictable path we have chosen. We feel an anger towards the feeling of dominance of others on our space, privilege, or opportunities. We are frustrated with the injustice of people not following the rules, at least the ones we believe are at play. Does our privilege or our relatively more individualistic culture drive this behavior?
Experience and habit
I see some interesting parallels in the NICU.
The management of the care of a precious infant is complex and engages many sequences of events, that when performed well, flow like a river.
Think of the best resuscitation you’ve been in with your team when you had a very sick newborn, and your team was able to respond in a manner that was fluid and intuitive, all knowing their roles and executing them seamlessly, responding to the changes to attain the best management plan for that infant. However, at other times we see change in the NICU as disarming, threatening, and scary.
We know a way of doing things and we are good at it, so when new things are presented to us there is often considerable energy fighting these changes. We receive positive feedback when we see a child get better with our management. Unfortunately, many times these stories are ones that we have made up in our heads like a broken memory that is our basis for continuing on with this care. Think of the all the unnecessary intubations and meconium aspirations we did in the past on vigorous and non-vigorous newborns with the mistaken belief that it was good for them.
Quality improvement is founded on the basis that standardizing our approach to medicine will improve outcomes even in the absence of the unequivocal evidence.
As the outlier in southeast Asia traffic flow, I was much more dangerous than any of the natives in the countries I visited. I was more likely to disrupt and damage, or be killed myself. Knowing the rules, mannerisms, body language, and unwritten rules of crossing the road would have greatly improved my engagement in their roadways.
Similarly, in our NICU, we have seen great success in redefining the culture for practices that include human milk nutrition, antibiotic stewardship, and neonatal abstinence syndrome. We found that efforts to align and conform our practices could greatly influence our desired measured outcomes. We have come to see the magic of clinical alignment as an important foundation for responding to or introducing change.
However, and perhaps because we have an acute awareness of our own experiences through the privileges of our free society, we often go through the stages of grieving whenever changes has to take place. First is denial. Second is anger. Those are followed by bargaining, depression, and then finally acceptance.
We often don’t accept changes that readily. We question, we consider experience, we argue the value of the new changes. These are all part of us working through these steps that are important components of psychological health. The only time I see quick acceptance is when the changes have been asked for by us, and have taken much longer than expected so that when it occurs acceptance can be immediate.
Challenging change each time is inefficient. Efficiency is inherently time dependent. Better efficiency means doing the same amount of work in a shorter time. Getting more for less energy expended. Motorbiking in Vietnam would be greatly inefficient if each impasse was met with frustration, anger, and expletives.
Rather, can we build a system whereby we have greater acceptance that change will happen with regularity and that diversions or deviations are naturally a part of the process of continual improvement. But what does it take to accept these changes more readily? What dictates when we resist a lot versus permit the changes to take place? How can be accept change better?
For this I look again to the Southeast Asian culture and see some incredible opportunities for us. They identify themselves greatly within their communities and perhaps take advantage of the cultural homogeneity over Western culture that puts a greater emphasis on individualism. Some of the Thai attendees I met in Bangkok covered the NICUs for their fellows so they could attend a teaching session that several of us provided for them at a conference in a resort several hours away. They then came down the following day to attend the same meeting as well, but had to brave much more traffic (five hours for what should only take half that time; think LA traffic on steroids).
They showed this commitment to their trainees with a belief that this next generation will be able to set up a better world for their future children. It was great to see such collective communal interest from these neonatologists.
In closing, here is a summary of some of the lessons learned from Southeast Asia that could help us in the NICU:
- Create a pervasive and tangible culture that envelopes your unit. When everyone understands the written and unwritten rules of interaction, tensions are lessened and flow can happen with greater efficiency.
- Share and discuss the common purpose of your NICU as you aim to improve the condition of babies and their future. Create a visible mission statement that supports the common goals and objectives.
- Trust each other to do the right thing. Believing in each of your teammates to be your ally will embolden the team’s success. Share your interpretations and values directly to resolve conflicts so that there are no impediments to team fluidity.
- Accept that change is inevitable and that part of the culture requires a positive and embedded response to change.
Overcome pain of change. My recommendation is to be like water – learn to “flow.”