In memory of our friend, Jerry Sternin, PhD
It was nearing the end of a block (a period of time that a physician commits to covering a particular hospital-based service) where a colleague was serving as the attending physician on their hospital’s teaching service (a service that works with physicians-in-training and cares for patients who do not have attending physicians of their own). One of the responsibilities was to evaluate certain physician-in-training skills through observing their interactions with patients. One of the first year residents asked her to watch him provide instructions to a patient being discharged to home. Mr. Johnson had entered the hospital over a week prior, having been admitted in respiratory failure due to emphysema. He had spent several days in the Intensive Care Unit on a ventilator, though he was now nearly back to his baseline status. The resident was convinced that this flare-up was due to Mr. Johnson not correctly taking his medication, and this was going to be the focus of his instructions. For over ten minutes the resident spoke to Mr. Johnson in earnest tones about the importance of taking his medications regularly. He reviewed with Mr. Johnson how to take them reliably, reminding him what could happen (again) if this didn’t occur. Mr. Johnson nodded in agreement; he had clearly been shaken by this hospitalization and didn’t want a recurrence like this in the future.
At one point the resident asked Mr. Johnson to describe how he took his medications. Mr. Johnson replied, "Well, in the morning I usually take them before breakfast. Then I take them with lunch and dinner later in the day.” The resident eventually reached the end of the interaction, provided the written instructions to Mr. Johnson matching those he had spoken about, and he then turned to my colleague. "Do you have any questions for Mr. Johnson?” the resident asked.
"Well,” she said, "I do have just one. Mr. Johnson, I believe I heard you say that you usually take your morning medications before breakfast. When I hear someone say usually, to me that means that sometimes it doesn’t happen that way. Is that correct? What gets in the way of you taking your medications before breakfast?”
Mr. Johnson nodded and gave a sheepish grin. "You know, in addition to having emphysema I also have diabetes. So first thing when I get up I take my insulin. And I know I have to have breakfast within 15 minutes or so or else my sugar will drop and I’ll get sick. Sometimes one of my friends will call me on the phone after I take my insulin but before I take my lung medicines. I’ll talk to him for a while and then I’ll remember I need to eat some breakfast. So I’ll get off the phone with him and make breakfast, and, I guess, some of those times I don’t remember to take my morning lung medicines.”
"So, what ideas do you have as to how to prevent that from happening?” sheasked.
"I guess I should tell my friends that I can’t talk if they call first thing in the morning and that I’ll call them back after I’ve taken my medicines and finished my breakfast- that should do it, I think,” he replied.
When Jerry Sternin of the Positive Deviance Initiative was coaching us years ago about how to facilitate "discovery and action dialogues” to come up with ideas and actions to prevent MRSA infections, he referred to the technique of "catching butterflies.” You need to listen with your whole self, particularly listening for the ideas (the butterflies) that can be converted into concrete actions. By "whole self” I mean being fully committed to experiencing the totality of the conversation- hearing all the words spoken, looking at facial mannerisms and other visual cues that may add meaning to the words, allowing your heart and head to connect with the experience, and being sensitive to your initial spontaneous reactions and perspectives. As the words and ideas are spoken, imagine them to be butterflies floating up. Which ones seem to be actionable? Perhaps the action is for you to ask clarifying questions if something is confusing or doesn’t seem to fit, or maybe there are latent action potentials for the speaker that you can help become explicit. The listener/facilitator gently catches them and holds them up to the individual/group, asking questions like, "What do you think? What could you do next?” In this particular conversation the physician’s goal was to help Mr. Johnson create a reliable process for taking his medications. Reliability implies "always” and so "usually” was the butterfly - a word requiring action.
Catching butterflies requires the listener to couple an interest in exploration and discovery with a specific goal or outcome. Our focus at Plexus Institute is to translate concepts derived from the science of complex systems into actions so that communities can resolve intractable challenges they’re facing. In my blog I’ll be trying to gently capture stories/concepts and hold them up to the Plexus community, looking to use our collective wisdom to create actions leading to good enough solutions.
Kind of like catching butterflies.
Jeff Cohn, President