EP438: Recognizing Cognitive Dissonance and Thinking About How to Overcome It When in the Belly of the Beast, With John Lee, MD

For a full transcript of this episode, click here.

Cognitive dissonance is kind of rampant in the healthcare industry. Cognitive dissonance is when what someone winds up doing, their actions, are in conflict with what they believe in. Cognitive dissonance also can mean when someone holds two contradictory beliefs at the same time.

Let’s say a person believes they want to do well by patients but their performance review depends on, as just one example, making care less affordable for patients. But somehow, this individual is able to conclude that what they’re doing is a net neutral or a net positive despite (in this hypothetical, let’s just say) obvious indications that it is not.

In this hypothetical, there are, say, clear facts that show that what this person is up to is indisputably a problem for patients. But yet at every opportunity, this person talks about their commitment to patients. This rationalization, or earmuffs don’t look, don’t see, is cognitive dissonance.

Now, it’s harder to engage in cognitive dissonance the closer you are to patients because you see the impact up close. This is probably why moral injury and burnout is most associated with clinicians who are seeing patients. Unless these at-the-bedside clinicians enjoy a robust lack of self-awareness, those who are seeing patients don’t, a lot of times, have the luxury of pretending that what is going on is good for patients when they can see with their own two eyes that it is not good for patients.

The further from the exam room or the community, however, the easier it is to not acknowledge the downstream impact—if you can even figure out what that downstream impact is, which is also worthy of being mentioned. When the machine is really big, sometimes it’s legitimately difficult to connect the dots all the way down the line to the customers, members, or patients.

Kate Wolin, ScD, talked about this in an episode (EP432) a couple of weeks ago. But this whole dissonance exploration was a big reason why actually I created my manifesto, which is episode 400, because almost everything that we do in healthcare wherein we are making money or helping someone else make money is dissonant to some degree. And it literally keeps me up at night contemplating how much dissonance is too much dissonance or how much self-interest is too much self-interest. This is tough, subjective stuff. So, again … episode 400 for more on at least how I think about this.

But in this healthcare podcast, I am talking with John Lee, MD, about what to do in the face of all this when working in the, as I call it, belly of the beast—working for a large healthcare organization such as a hospital. Because hospitals sometimes (and we certainly do not want to put all hospitals in the same category—they are a wildly diverse bunch), but sometimes some people at some hospitals do some things which are not things I think they should be doing anyway. They’re fairly egregious breaches of trust, actually.

But yet within that same organization, you have doctors and other clinicians or others who are working really hard to serve patients as best they can. This is the real world that we’re talking about. And the question of the day is … so, now what? While it would be amazing if someday we build a whole new health system that didn’t include some people doing things that I don’t think they should be doing, that day is not today. And it’s not tomorrow.

I’m gonna hope that there’s other people in our village who are full-on doing the disruption thing. But if we’re not able to do that personally, for whatever reason, but we still want to inch forward within the existing environment and do the things that make us feel like we’re achieving our mission, what’s the best way to think about this?

That is what I asked Dr. John Lee, and that’s what our conversation is about today. Summing up his advice, which is really good advice, Dr. Lee talks at length about how it’s so important to celebrate the small wins and feel good about care that is a little bit better than it was six months ago.

He talks about acknowledging that you can’t do everything. He talks about incremental improvement that helps both patients but also colleagues, and that’s not insignificant to really consciously consider how to work together and help to support each other.

Look, I just finished reading a post on LinkedIn about toxic medical culture and just how brutal and cruel some physicians and physician leaders and others can be to their colleagues.

Ann Richardson writes about topics like this a lot. Follow her on LinkedIn if you’re interested. So does J. Michael Connors, MD. But just saying, it’s pretty cognitively dissonant to talk about the potential of team-based care and then condone or engage in toxic behavior with those same team members. There’s like 90 studies on this whole topic linked to this book.

But bottom line, fixing cognitively dissonant paradigms in any sort of durable or scalable way is, for sure, going to require a culture that inspires constructive criticism, innovation, and collaboration. It also requires—and this is Dr. Lee’s last piece of advice—it’s really important to seek out like-minded individuals as sounding boards and as a support network to commit to supporting each other. And I hope, all of you, that you feel like you’ve found your tribe here at Relentless Health Value. You guys are an amazing bunch, so know that and don’t hesitate to reach out to each other when you need help.

John Lee, MD, is both a practicing emergency physician and a highly regarded clinical informaticist. He has served as chief medical information officer at multiple organizations and has an industry reputation for maximizing the utility and usability of the electronic medical record (EMR) as a digital tool. He was the recipient of the HIMSS/AMDIS Physician Executive of the Year Award in 2019.

He has deep expertise in EMRs, informatics, and particularly in Epic. He has multiple analyst certifications, which gives him a unique advantage in delivering solutions to Epic organizations.

His vision is a healthcare system that is driven completely by transparent data, information, and knowledge, delivered efficiently.