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Drawing Out the Modern Mind

By Tom Janisse, MD, Editor-in-Chief
In this third issue of The Permanente Journal, I would like to continue my comments on communication from the second issue, but broaden the scope and context. We know how important communication is and how it often could have been done better. We hear how we can't communicate enough, how we communicate more by our actions than our words, and how we remember visuals better than words after a lecture. In the last couple of years I have been actively trying to draw "pictures of ideas" to aid in explanation. These pictures are visual representations of a concept or a process I am discussing with someone. (Box 1: Pictures: desktop computer, mouse-generated drawing symbols. Box 2: Pictures: palmtop, stylus-generated sketches.) Other pictures I use routinely are metaphors and stories.

Box 1. Pictures: desktop computer, mouse-generated drawings

 

Box 2. Pictures: palmtop, stylus-generated sketches

 

Physicians, patients, and other healthcare workers have responded well. They seem to understand me better or feel a picture or diagram has clarified our discussion. This response has encouraged me to seek new ways to picture ideas to improve my communication skill and effectiveness. Because we increasingly understand the value of innovation in health care delivery, tools to enable and diffuse innovations can benefit us. The Permanente Medical Groups will better define, clarify, and implement Permanente Practice innovations if clinicians communicate more effectively with each other. Drawing can complement other communication tools we use--electronic, audio, video, oral, and written.

Visual Explanations
To approach visualizing ideas from a different perspective, as an editor I work to enhance the environment in which words appear. For example, I encourage authors to include tables, graphs, and diagrams with their articles. Further enhancements include: placing these articles in a more visually pleasing and diverse environment populated with drawings, photographs, icons, and borders; the graphic use of white space; and attention to the format and type style of text. Through these methods pages don't appear so dense with words. I believe that these efforts enhance communication. It gives the author and the reader the greatest opportunity to connect with each other. Each is more highly stimulated by the content and the context.

Because as editor of The Permanente Journal I oversee all aspects of each issue, I spend time with the production staff looking at the layout, selecting the cover art and the visuals inside, as well as attending to the balance, tone, and order of articles--the "feel" of The Permanente Journal. To improve my graphic sensibility I have begun to read magazines like, Critique: The Magazine of Graphic Design Thinking, and books like Edward Tufte's series, The Visual Display of Quantitative Information, Envisioning Information, and Visual Explanations. It was an article in Critique that stimulated this editorial. It is called, "Drawing Out the Modern Mind." The following comment introduces the article: "Contrary to old beliefs, the human mind is not a computer: instead of working in a predictable, logical, sequential way, our minds work in a flexible, perceptual, all-at-once way. The modern mind achieves power by combining logic and intuition. And you can sharpen the perceptual skills that underlie intuition by strengthening your drawing skills."

What's The Difference?
You may be asking yourself at this point, how does this make any difference to me? In the Health Systems Management section of this issue a roundtable discussion appears on "Primary Care and the Specialties: Relationships and Access." When you read it you will engage in a conversation with 6 physicians from across the country who discuss what they have learned from innovative practices they have implemented. You will hear and understand more about access to specialists than is present in the words on the page. You will import something from the conversational context in which the words are embedded, the relationships between the different practices, and the matrix created as the ideas and practices intertwine. You will connect these ideas to your own experience and so enliven them. You will come away with a picture greater than the words on the page.

Well, how else can this matter to me? Most physicians struggle a little with how to improve their interaction with patients; with how to improve their communication. I was struck by a recent comment I read where a patient said they wished the doctor would have explained it better; they wished he would have drawn a picture. Not many of us are artists or can even draw. But we
can, and do, create pictures in the form of metaphors or stories--two of the four tools of intuitive thinking along with images and symbols. These tools help to bring the elusive complexity of medical science to a common place for people--a description of the dilemma or the concept in everyday language or events. I hesitate using the following dark-side example; however, I practice clinically as an anesthesiologist, and when people come to surgery they are most afraid of not waking up, of dying under anesthesia. They come to the operating room on terms with the surgical procedure, but not with the loss of control of unconsciousness. People often ask, "What are the odds?" Currently, death occurs from anesthesia in about 1 of 200,000 encounters. That doesn't mean much to those who aren't statisticians. So some of us say, "You have a greater chance of dying when you walk across the busy four-lane street out in front of the hospital." They relate to that. It places their impending surgery and anesthesia in a common context.

Adults have different learning styles. Not all learn through cognitive means. Some people learn much better by experience, by actually trying something out, by doing it. Some learn through conversation, and some learn through reflection. Some patients want the numbers and the facts; some want your best hunch. And some just want to know that you're giving it your best effort. Some people just want to know that you care, and then they feel safe and reassured.

Draw Me a Picture
Drawing a picture on paper or speaking in visual terms may be a way to expand the effectiveness of our communication. In the article I mentioned, "Drawing Out the Modern Mind," (Critique, Autumn 1997) the author describes "the seeing strategies that underlie the global skill of drawing, without regard to medium or subject:

Giving these "seeing strategies" a medical context will demonstrate their value as perceptual tools, in addition to being drawing tools. Each of these has application for me in the practice of medicine.

"Edges" can refer to the boundaries of primary care and specialty care scope of practice and to the points of interaction between the two disciplines. As physicians have noted there is some overlap in practice, and this is a fertile area for exploring enhancements in service and patient care. The concept of edges also has meaning in the realm of physicians and affiliated clinicians as they begin to work in teams and in some cases redefine their real value as practitioners. Kaiser Permanente has pioneered the delivery of medical care through the use of nurse practitioners, physician assistants, and nurse anesthetists, to name three.

"Spaces" can relate to the environment in which we practice: the space of the exam room or "the room to move" we have in ordering tests or prescribing medications, or the time to see patients, pauses in conversation, or our "personal space." How we perceive and use these spaces is critical to our effectiveness.

The perception of "relationships" often determines our interaction with clinicians in other departments, and with patients. A positive relationship with a patient may result in better care. As a medical group, we are more aware of a local community and a national market; how we perceive each guides our healthcare strategy.

"Lights" are our resources, positive attitudes and influences, expanded perspective, enlightened solutions, regard and constructive feedback, innovation and wisdom. These are tools for a better
practice. We can see "shadows" as barriers, the unknown, the feared, constraints, the downside or oppositional view. Both lights and shadows are essential components in achieving perspective and a balanced approach to understanding.

The "gestalt" is the whole, the system, the big picture, the context. We speak more about holism in healthcare now: taking into account the whole person--the emotional, behavioral, and spiritual along with the physical--in arriving at diagnoses, etiologies, and best treatments or outcomes.

What's The Point
While we can use "seeing strategies" to draw, we can also perceive a current problem from a new perspective by using a different frame of reference or by looking at it in a different light. I often remind myself of how we look at the heart electrically from 12 leads across the chest, from 12 positions or views. Most of our clinical practice exists, and can be viewed, in ever-larger contexts. The Permanente Journal is designed in a layered context. We look at "Clinical Contributions"the core practice of Permanente medicine--and at "Health Systems Management"the systems or processes in which we practice--and at "External Affairs"those environmental, legislative, media and market forces that impact our practice and systems. Physicians may benefit by evaluating their practice in a larger context and from an external view: that of a colleague, another department or discipline, as a customer, from a competitor view, or over the long term.

Try drawing a picture, though if you don't take up drawing, or even doodling, or create pictures of ideas, you may want to encourage or engage your intuitive mind more actively to see or speak more clearly. Use 1 of the other 3 tools for intuitive thinking: a metaphor, a symbol, or a story. In addition, "staring into space" and "looking at nothing" are two human activities that tend to close down the analytical side of your brain and open up the intuitive side. This is an example of applying one of the five "seeing strategies": the perception of space. The outcome I would hope for is to heighten understanding and enhance communication between us for the benefit of the Permanente Medical Groups, our Health Plan partners, and our members.

 

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External Affairs

By Scott Rasgon, MD, Editor
The External Affairs section in this issue of The Permanente Journal will be exploring such topics as cultural diversity, brand strategy, and new ways of getting medical news to physicians in a computer-based system. We will also be taking a look at what's happening with the President's Commission on Managed Care.

Jean Gilbert PhD, from the Southern California Permanente Medical Group introduces the importance of cultural diversity in both medical practice and marketing health care. The marketing concept of brand strategy and branding Kaiser Permanente is discussed by Kathy Swenson and Vaughan Acton .

In the information age more medicine and health related articles are available every day than anyone can possibly keep up with. Tom Debley from the California Division reviews a system using computers to get important media related information out the health care providers.

Don Parsons, MD, our Washington lobbyist looks at the activities of the president's commission on managed care reform.

I am sure the issues discussed are dealt with on a daily basis. I hope you enjoy these articles and find them interesting and relevant.

 

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Clinical Contributions

By Arthur Klatsky, MD, Editor
The Clinical Contributions in this issue include a variety of topics which present a highly gratifying image of Kaiser Permanente medicine. The review entitled "Managed Genetic Care in the Largest HMO: The Challenge of Providing Genetic Services to 2.5 Million Members" by Drs. Bachman and Schoen presents a view of an area in which the authors and Kaiser Permanente are on the cutting edge of services offered in a field of rapidly increasing interest and practical importance.

The review entitled "A New Era in Colorectal Cancer Screening and Surveillance" by Dr. Grossman is a forthright authoritative opinion statement by a distinguished recently retired Kaiser Permanente physician; he and other clinicians and researchers in our organization have played a major role in this area of preventive practices to reduce morbidity and mortality from one of the commonest cancers in both sexes.

"Natural Rubber Latex Protein Allergy Prevention and Exposure Control" by Drs. Macy, Ms. Eck, and Dr. Huber reviews a common and vexing clinical problem and supplies much information about how this is handled in one of our largest Regions.

"Ambulatory Open Shoulder Surgery" by Dr. Sachs and Ms. Smith provides a fully documented clinical series about innovative management of an important common problem, with sufficient detail so that other facilities can--if they wish--adopt the procedures.

Finally, this issue includes a reprint of "The Management of Pneumonia (A Review of 517 Cases)" by Dr. Morris Collen, originally published in July, 1943 in the Permanente Foundation Medical Bulletin. This is a beautiful article, of high academic caliber, which provides a glimpse of Kaiser Permanente practice more than 50 years ago, and still includes much clinically relevant material. This article is placed into perspective by Dr. Elizabeth Andersen, MD, an infectious disease specialist in Oakland, who knows Dr. Collen.

This issue provides a variety of findings, reviews, analyses, and practice programs of interest and importance. Some, hopefully, will stimulate controversy. Civilized comment, critique, dissent, and objection are welcome; a lively Letters to the Editors section would add spice to the Journal.

 

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Health Systems Management

By Lee Jacobs, MD, Editor
In this issue of The Permanente Journal, a panel of six Permanente physicians from six different medical groups discuss their views on the primary care provider and specialist relationship, especially as it relates to referrals. As I listened to the panel discussions, I was impressed with the quality of the Permanente people working on this issue. I believe that you also will be impressed as you read about the innovations and approaches discussed by the panelists, representing frontline physicians on both sides of the primary care-specialist fence. However, what I found especially impressive was how the solutions that the discussants presented continuously had the patient in the forefront. Such a mindset is crucial as we design our future systems in this extremely competitive world.

It is the hope of those of us at The Permanente Journal that this round table discussion will create a dialogue across the Permanente Groups so that other views and approaches to this major systems challenge can be heard. Let us know your opinion! This is the role of The Permanente Journal--to provide a forum for such discussions. How well our Permanente Groups get the important issues on the table; how well we capture the deliberations through articles and reports; and how well we as Permanente Medical Groups leverage the knowledge gained, will in the future define our competitive advantage.

 

 

 

 

 

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