#43 Is it Really All or Nothing?

When clinicians interact with patients and their families, we fall into some very well-worn patterns of thinking that really do not serve us or our patients well. I call these thought distortions because what we think, really isn’t true. In many instances we have a belief that we were taught during our years of training that we believe to be the only way to get the thing done or how to approach a certain problem. A belief is a thought we have over and over again. Can we question our beliefs?

One very frequent pattern that physicians and nurses adopt is all or nothing thinking. Sometimes we refer to the phenomenon as black and white thinking, a term which brings along another set of unwanted baggage. The notion is that there is only one way to do the thing or solve the problem or approach the issue. Everyone at Big City General Hospital does it that way, so that is the only way that it must be done.

Of course, when you set up shop at Rural Community Hospital, things don’t go that way at all. We discover that there are other ways to get things done or approach a particular problem.  More than one medication can be used to treat the illness.  Different imaging can be used. Families can stay with the patient when previously they could not.

How else do we see all or nothing thinking play out? Situations are reduced to only two choices: wonderful or terrible, right or wrong. I’m right, and you are wrong. If you want a patient admitted and the consultant doesn’t agree, all or nothing thinking can lead you to feel frustration and anger. If you are in a power struggle with a difficult patient and you both want different things, all-or-nothing thinking leads you to believe that there are only two options: either you get your way or they get their way.

A lot of my colleagues (and I confess: me as well) think, “I am the DOCTOR.” Implicit is I have the training and the experience and I know best.  If you don’t follow my advice or recommendations, you must think ai am unqualified or incorrect. “You can do it my way, or you can sign our against medical advice.” Is that the strict binary that will help our patients: my way or the highway?

 One of the four ethical principles of medical care is that patients have autonomy. Patients who are competent to make decisions have the autonomy to accept or reject the plan of care the physician offers. They have the right to leave the hospital, refuse the vaccine, or not take the medication. Our patients have the autonomy to make decisions we believe are unwise or dangerous. We have to document our advised plan and the negative consequences of not following our plan in the medical record.

 All-or-nothing thoughts are easy to identify by identifying absolute terms like never, always, no one, always, everyone, or worst. Some examples are quite obvious. All the druggies are faking their symptoms to get more. None of the clinic patients take their medicines. These examples are easily noted.

 Some all or nothing thoughts creep into our minds in sneaky little ways. Some thoughts actually express our most fervent wishes. Sometimes they even masquerade as kind or useful thoughts like, “children should never die” or “I want to make everyone happy.” These sound like lovely thoughts. One even contains the word happy in it.

But believing all or nothing thoughts such as these actually makes us suffer. Sometimes children die and feeling sad about that is absolutely normal. Believing a death or injury should not have occurred will not change the fact that it did. Can a physician really make everyone happy? Will the patients, the nurses, the attendings, and the hospital administrators support every decision that we make? It will never happen and believing that it should, will make you a miserable, people-pleasing, controlling individual.

I discuss this common thought distortion in Chapter 9 of my book: Changing How we Think About Difficult Patients which can be found here.  We use all or nothing thinking in our roles as clinicians, and we also turn it on ourselves in terrible ways. We engage in lacerating self-criticism.

Here are a few of the all-or-nothing thoughts we use against ourselves:

•         I can never identify rashes.

•         Nothing I can do will help this patient.

•         Shoulder reductions are just not my thing.

•         I never get the vacation time that I request.

 In reality, most situations are not black and white, all or nothing. Most are filled with nuance and layers of complexity. The facts lie somewhere in between all or nothing and include all sorts of extenuating circumstances.  You can find some middle ground with colleagues where everybody wins. You can find something helpful to do for all of your patients, even if it’s getting them out of the cold for one night. You can reassure them and tell them what illness they do not have.

Once you identify those all-or-nothing thoughts are crowding your brain, you can start thinking with more intention. Just having awareness that you are thinking this way will give you a lot of leverage over changing the habit. For example, when you notice a thought in your brain that uses the word never or always. Oops! There it is. Can you question that belief? Does it ALWAYS happen that way? Are there really ONLY two options?

Here are some questions that you can ask yourself when you find yourself thinking all or nothing:

Could I be wrong about that? Can another approach work?

Can I arrange follow-up for the person who needs to go home and take care of their disabled child? I would rather that person stay for admission, but I respect that their inability to comply is justified. Wouldn’t it be better if we could come up with some mutually agreeable plan that would get the patient part of the care that she needs?

What if the patient or his family is unable to afford the medication I prescribe? Is there an affordable medication that I could use that would also do the job? Can I bring in social services to assist with medication coverage?

When we are at an impasse with a colleague or patient, or family we could ask these questions:

Could what the other person is saying also be true?

How might I be wrong about that?

 How could we acknowledge both people’s beliefs and needs in reaching a solution?

When I disagree with a colleague or a patient:

 How could both of these things be true or how can neither of them be true?

 What might be true instead?

Is there a third or fourth or eighth way of finding a solution that I have not considered? Can we split the difference in the solution to our disagreement?

Sometimes, we dig in our heels with all or nothing thinking because of what we make it mean about ourselves if we are wrong or if we don’t get our way.  But being wrong or seeing more than one side of things doesn’t mean you are stupid or unqualified or unworthy as a physician. It only means that you are pragmatic and sensible.  Finding a solution with a colleague or patient serves the interests of the patient first and foremost. We want them to get treated, to follow-up, to heal. We want for them to get treatment, even when they don’t do EVERYTHING we suggest.

 Accepting that their way may not be our way will be a tremendous step in smoothing out some of those difficult interactions. This is the normal way that two humans interact. No one has to win and no one has to lose. Nothing has gone wrong here. Don’t beat yourself up when you catch yourself in all-or-nothing land. Moving away from all-or-nothing thoughts will open your mind to a world of possibilities.