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A Neurologist’s View: Organizations Whose Employees and Teams Succeed

2012-04-11T21:06:00.000-07:00

What is the best way to ensure employees and teams succeed? Some executives and managers praise, encourage, let people work at their own pace and time, let them work in their own ways, and from time to time make gentle suggestions for improvement.

Others say this is “soft,” “touchy-feely”. They direct people firmly, or ride them, or tell them exactly what to do, or chastise or punish errors or falling behind, or compare people unfavorably with colleagues, or use favoritism as carrot-and-stick. Some use do these without realizing it.

Is the first approach soft? Do any of the second ones work?

What we neuroscientists now know about the brain tells us about both approaches. The brain is hard-wired to turn off creativity and intuition if the brain senses danger of any kind. It is the brain that interprets something as danger; we don’t decide. Scientific studies show that a firm, chastising, criticizing management style signals danger. A hint of disapproval turns off most of the brain. Only a small sliver still thinks. That sliver can only function in a tight box of linear thoughts (aàbà c). It’s not very productive.

The same studies show the first method is highly effective. Praise, encouragement, freedom to work how one wishes, and gentle suggestions motivate success and do it well. They turn on nerve cells and circuits in the brain that inspire individuals and teams to do their best.

Why? Dr. David Rock reviewed the science in The Neuroleadership Journal 1 (2008). He summed up influences on traits he calls “SCARF”:

Status,
Certainty,
Autonomy,
Relatedness, and
Fairness.

Increasing these five traits increases productivity by increasing comfort, creativity, and intuition. Going against any one of the traits, just one, shuts down effectiveness and productivity. They shut down in a fraction of a second; it takes hard work over a long time to get them back.

Status in Rock’s terms means social status, intellectual status; or a personal sense of honor and worth within a group, a department, an organization, or a company.

Certainty means knowing from moment to moment how an action will influence efforts. The efforts may be to get a effect one wants or they may be to avoid errors. Certainty is a subconscious state of the brain when planning or carrying out complex tasks.

Autonomy means freely choosing between possibilities. Autonomy gives a person or a group the sense they are in control of what they are doing.

Relatedness means feeling part of a group of friends. Lack of relatedness is what someone feels when s/he has to face an enemy or believes they are outsiders instead of members of a clique.

Fairness means feeling that authorities treat you just as they treat others: no prejudices, no insiders, no favoritism.

All of us like these traits. Your reports like these traits and know when the traits are gone. You as a report or subordinate feel these traits and their absence. You as a manager probably don’t feel them, whether you use them with your reports or avoid them.

A manager who is abrupt or uses a carrot-and-stick may not intend to undercut the SCARF traits. S/he may not recognize s/he is undercutting anything. What counts is how the reports feel. How reports feel determines their effectiveness and productivity.

What is going on in the brain? Most of the brain deals with subconscious actions and with reflexes. A critical part of the brain is the nerve cells and connections that trigger reflexes to get us out of danger. They make sure we avoid enemies or threats. This is survival. It is a basic need.

Figure 1. Drawing of the Human Brain from the Left. The “cap” of the mushroom is the forebrain or cerebral hemisphere (it’s mirror image – almost mirror image – is the hemisphere on the right side). Coming down as the stem of the mushroom is the brain stem (BSTM) which will meld into the spinal cord. Under the hemisphere, overlying the lateral aspect of the brain stem, is the cerebellum (C). The frontal lobe (F) is divided from the parietal lobe (P) by a major fold or fissure called the Rolandic fissure. At the back of the brain is the occipital lobe (O). Below the frontal lobe and parietal lobe, and in front of the occipital lobe, is the temporal lobe (T).

The need to survive is much stronger than its opposite gratification. Gratification is wanting to be with people we love and things we love, wanting to stay with a supportive group, enjoying what we are doing, getting rewards. The reflexes in the brain that support survival are much stronger than the reflexes that underlie gratification.

Fig. 2. Drawing of left side of brain colored to indicate major areas and functions. Frontal Lobe: Motor Functions, production of language (speech), and pre-frontal cortex. The primary motor strip codes for movements of individual muscles. The premotor strip codes for movements of parts of the body related to function and “purpose”. The pre-frontal cortex (mostly on the inner or medial surface of the frontal lobe) is the thin ¼ inch strip of cortex that codes for linear logical thinking and that is area of “thinking” turned on in “fright-or-flight” when most of the rest of the thinking and feeling brain is turned off. Parietal Lobe: Sensations from skin, joints, muscle. Temporal Lobe: Emotions, memory, smell, sounds, balance, putting visual information into meaningful pictures.bOrigination of language is in angular gyrus and planum termporale at the interface of the parietal and temporal lobes. Occipital Lobe: Vision.

The parts of the brain that deal with survival are small, on the front surface of the brain and low down on the front sides. They are nerve cells in the ¼-inch-thin outer layer or cortex. The area is what deals with linear, logical thinking. It’s called the “pre-frontal cortex” (see Figure 3).

Fig 3. Mesial Surface of the brain (as if cut down the middle between the hemispheres from front to back). Blue: grey matter (nerve cells, cortex, nerve nuclei). Orange: white matter — axons connecting one part of the nervous system to another. Grey: cerebrospinal fluid in ventricles. The "pre-frontal cortex" is shown in brown. The limbic system which subsumes memory and links to emotion is shown in purple (especially the "cingulate gyrus" above and around the central white matter of the hemisphere). The outflow from the hemisphere and the inflow from the spinal cord go through the brain stem, from above down: the beak-like structure of the “midbrain” or mesencephalon, the forward bulge of the pontine nuclei and the brain stem immediately behind it called together “the pons” and the lower portion merging below with the top of the spinal cord, “the medulla.”

The cerebellum is behind the brain stem — a series of “leaves of a tree” of cortical neurons whose axons are in the middle of each leaf and connect to the central region.

The grey oval in the lower middle of the hemisphere and in a triangle between the brain stem and the cerebellum is cerebrospinal fluid in the lateral ventricle (in the hemisphere) and the third ventricle (between brain stem and cerebellum).

Fig 4. Drawing of the deep nuclear structures of the left hemisphere in relation to the hemisphere as a whole. The amygdala (red) is a nucleus or cluster of nerve cells deep in the frontal half of the temporal lobe. It is an extension of a major set of motor cells deep in the fronto-parietal lobes, the caudate nucleus. All these nuclei are paired -- one in each hemisphere, as are the ones described next.

The thalamus is a deep sensory nucleus through which sensory information of all kinds goes from the spinal cord and brain stem to the cortex of the hemisphere on its side, again, paired with one in the other hemisphere.

The putamen and the striatum (indicated by the “poles” extending from the upper curve of the tail of the caudate to the main body of the caudate) are deep motor nuclei that function in conjunction with the caudate.

When the amygdala perceive a threat, they act instantly to put the rest of the brain into “fight-or-flight” mode. Emotions switch to fear and anger (temporal lobe, see Figures 1, 2, 3, and 6). Bad memories come up, memories of fearful events and things that made us angry (hippocampus, Figure 6). Part of the brain signals disgust and nausea (the insula, see Figure 6). The intuitive functions of the brain shut down. The only thinking part of the brain that is active is the prefrontal cortex (see Figure 3). This thin layer works only with learned, linear, logical behaviors; nothing else. All of this together is survival mode.

Fig. 5. Drawing of the limbic system of the left hemisphere. Above: in relation to the hemisphere; Below: as if the rest of the hemisphere were removed.

The drawing shows structures on the left. The limbic system (cingulate gyrus, hippocampus of the temporal lobe, and their connections) is mesial to (to the side of) the thalamus and extends in front and behind the thalamus, but to the side.

The limbic system connects with the area for smell (tip of temporal lobe, signals for scents coming in from the olfactory bulb). This connection is the anatomical basis for the strong connection between smell on the one hand and memory and emotions on the other hand.

All of these — limbic system and its parts and olfactory or system for smell —have connections with the tail of the caudate and with the amygdala.

The smaller drawing shows these systems as if the rest of the brain were removed.

Fig. 6. Drawing of a brain sliced from top to bottom perpendicular to the groove between the hemispheres, towards the front half of the temporal lobe. The slice vaguely resembles a butterfly. Top is marked TOP.

Blue-purple is grey matter (nerve cells gathered together in the cortex and in various nuclei).

Orange is white matter (axons connecting one area of the brain with another).

The temporal lobes are the lower bulges on either side — the lower wings of the “butterfly”.

The frontal lobes are the bulges above — the upper wings of the “butterfly”.

The white inverted triangle in the middle is the two lateral ventricles (full of spinal fluid) covered by the (orange) connection between the two hemispheres (corpus callosum).

The area of the cingulate gyrus and the area of the amygdala are labeled. So is the insula on either side. The insula is a cortical region involved with the sense of taste and from which can originate sensations of disgust and nausea.

Managers and executives beware: the more often peoples’ subconscious brain structures perceive threats to survival at their workplace, the worse the consequences. Behavior gets worse. Efficiency and productivity go down. It takes longer and longer to restore people’s brains to a neutral state, let alone an aligned, creative state. And yes, simply working the wrong way with reports and teams in your organization makes their subconscious brains interpret what is happening as a matter of survival, not as simply being told to work a certain way!

Aren’t there exceptions — firefighters, soldiers, emergency room doctors and nurses — people trained to deal with emergencies and disasters? These highly-trained people are actually hyper-focused in the survival mode of their expertise. In this mode they, too, use linear logic instead of creativity. They are not exceptions. They’ve just been trained in many specific linear processes the rest of us don’t know.

I only know one protection from automatic fight-or-flight. It is to get trained in tools of consciousness that include skills to block negative emotional responses and to discreate the unpleasant emotions that are stirred up. How to do it is beyond the scope of this white paper. Contact me.

What we know about the brain gives a clear message to executives, managers, organizations and companies. Encourage the SCARF traits.

1) Treat employees, staff, colleagues, and teams so they feel valued.

2) Treat them so they are certain that whatever they try to do will be appreciated whether it succeeds or fails.

3) Treat them so they know they can make their own decisions about what to do, how to do it, and when to do it.

4) Make them feel they are valuable members of an organization in which superiors, peers, and people who report to them are friends, not rivals.

5) Make sure no-one supervising them plays favorites.

Successful executive coaching and successful organization development follow also these rules. For example, in his book, “What Got You Here Won’t Get You There”, executive coach Marshall Goldsmith considers 20 flaws in interpersonal behavior that damage relations in a company. Let me link these flaws to SCARF categories. I don’t minimize the deep and broad analysis Goldsmith gives. I merely want to show that there is common ground between Goldsmith’s approach and Rock’s.

Problems with status seem to me to underlie Goldsmith’s flaws of

needing to win too much,
needing to add too much value,
needing to tell the world how smart we are,
needing to make excuses,
needing to cling to the past to deflect blame,
refusing to express regret,
and an excessive need to be “me”.

Undermining certainty is likely

when a sentence begins with “no,” “but,” or “however”;
when you “explain why that won’t work”,
when you withhold information,
and when you “speak when angry: using emotional volatility as a management tool.”

Being unwilling to let people have autonomy underlies

making destructive comments,
sarcasm,
cutting remarks;
withholding information,
and claiming credit you don’t deserve.

Several flaws destroy the sense of relatedness:

passing judgments,
making destructive comments,
speaking when angry,
failing to give proper recognition,
claiming credit you don’t deserve,
making excuses,
clinging to the past to deflect blame,
refusing to express regret,
failing to express gratitude,
and passing the buck.

Fairness is damaged by

failing to give proper recognition,
withholding information,
claiming credit you don’t deserve,
playing favorites,
and punishing the messenger.

Patrick Lencioni’s “The Five Dysfunctions of a Team” is about management consulting, about organization development. Again, my intent is to show common ground. I’m not trying to simplify or minimize Lencioni’s work.

Absence of Trust is the bottom of Lencioni’s pyramid of dysfunctions. Absence of trust includes a lack of a sense of relatedness.

The members of a team may be assigned together,
but they are suspicious
and even afraid of each other.
They do not feel they are a group of aligned friends.
Often, they may be juggling for a sense of status.

The absence of trust and its underlying issues – restoring status and relatedness -- is the first problem that needs to be solved when using Lencioni’s paradigm.

Fear of Conflict is the second layer of the pyramid. Fear of conflict is

a fear of an open, free-flowing discussion.
Why? Because people on the team don’t trust each other.
Fear of conflict is an issue of relatedness.
Fear of conflict also means that the members of the team don’t feel autonomous
and lack certainty about their part in a discussion.

Lack of Commitment implies a lack of

certainty
and relatedness.
Lack of commitment also means the teams’ members fear lack of autonomy
and that their status is threatened.

Avoidance of Accountability can come from problems with

certainty,
autonomy
and relatedness.
Avoidance of accountability is made worse
if the team’s members sense lack of fairness.

Inattention to Results comes from the sum of these problems. The sum can be stated in Lencioni’s paradigm or in David Rock’s:

people on a dysfunctional team don’t pay attention

to the results they get
or to the results they should be getting.
They can’t do it.
The amygdala and the pre-frontal cortex are on.
Much of the rest of the brain is off.
They are in fight-or-flight mode.

The message is clear.

Pay attention to SCARF traits and needs!
Are you reinforcing the traits with your colleagues, reports, and subordinates,

letting their work gratify them?

Are you mistakenly undermining the traits,

consciously
or unconsciously,
putting your colleagues and subordinates into flight-or-fright mode
whose long term consequences prevent effectiveness and productivity?

Work of Full Circle Consulting - SF Bay: Resolving a Common Conflict in Medical Ethics – The Child from the Other Coast

2012-04-08T14:09:00.002-07:00

Mother was dying slowly. She could no longer communicate. Her health care proxy (this was in New York) wanted to follow Mother’s wishes and keep her comfortable – palliative care – and to withhold artificial food or hydration when matters got to that stage. The relatives who lived nearby all agreed.

At 11 pm, the son from California, who had not seen her for 20 years, arrived on the ward unannounced and proclaimed that “everything must be done” to keep her alive. By “everything” he meant artificial everything – tubes for food, tubes for hydration, artificial breathing on a machine, a cardiac monitor and any resuscitation that might be indicated: a full-court press in the ICU.

Only 10% of us die quickly. An accident, murder, a massive heart attack or a stroke carries us off suddenly or we die quietly in our sleep one night. The other 90% of us have a long, protracted downhill course over many months, and with diseases like Alzheimer’s, over a few years.

In the early stages of a potentially fatal disease, say, cancer, there are curative treatments. Cancer might need surgery, maybe followed by radiation or chemotherapy. If the cancer recurs, a different form of chemotherapy may be worth a try, but the likelihood of cure becomes less and the probability of unpleasant side effects greater. By a third round, the patient or the doctor may hope “cure” but the reality is that in the unlikely event the new cocktail will at best prolong life a few weeks, maybe a few months. It is almost certain the patient will have side effects that are hard to tolerate. Many patients who had been through three rounds have told me the side effects were worse than the disease.

If the patient, the family, or the doctor are adamant that “everything should be done” matters progress sooner or later to an ICU. Life support means mechanical respirators, intravenous tubes, nasogastric tubes or direct stomach tubes, dialysis, heart monitors. The ICU has constant noise, constant bright lights, rare privacy. It is expensive setting. The attitude “everything must be done” is responsible for the adage that we Americans spend more on a medical care in the last few months of a person’s life than in all the rest of their life combined.

The alternative to “everything” is called palliative care. It provides more care, more effective care, and more preventive care than “everything.” Palliative care is often given in a Hospice, the hospital, in a special house, often at the patient’s own home.

There is lots of treatment. It is directed at relieving the many symptoms every terminal illness produces as one organ system or another begins to slow down and shut down. Other treatment helps patient and family cope with problems getting around or using hands and arms, and with social needs and problems, and with legal issues, and with psychological issues and needs, and with the spiritual issues that invariably arise at the end of life.

Does the patient feel abandoned by God? Are there life goals that need to be completed? Does forgiveness need to be requested or accepted?

An entire team of doctors, nurses, social workers, therapists, counselors, and spiritual experts work in unison to help patient and family. Other experts, like lawyers, may get involved from time to time.

This has led to a paradox. In many parts of the country, ¼ to 1/3 of the patients who are admitted early to hospice end up surviving with a good quality of life for two or three years longer than expected. It is due to the quality and breadth of care, which are greater than care provided outside Hospice. The Hospice team pays a lot of attention to preventing problems and to catch and reverse them quickly. Many people who work in Hospice think the relief from spiritual worries and social concerns plays an important role.

There are notable legal cases in which world-renowned Hospices were sued by the Federal Government for fraud because so many of their patients lived so long after admission. Luckily, this foolishness seems to have ceased.

What about the conflict between the son from California and the rest of Mother’s family? It’s a fairly common issue. (When Mother lives in California, the outsider is the “daughter from New York”.)

The key is the 20-year absence. There has been estrangement, deliberate or not, maybe in reaction to some disagreement or slight, maybe not. The son has a mixed emotions and needs. He feels guilty. He is longing for love from Mother, and to be able to talk with her either to give forgiveness or more often to seek forgiveness. He was not around and did not participate in the discussions the medical team had with Mother and the family, so he does not understand the futility of “everything” care, and that it actually makes matters worse, increases the patient’s suffering, shortens life, and costs family and society emotional and spiritual anguish and at least as much money as all the other medical costs throughout Mother’s life: all for a futile gesture. Futile, but well meant.

In our hospitals, three of us from the ethics committee would meet the son in a conference room on the ward. My colleagues were a nurse or social worker and someone from the community, usually a businessman with a strong interest in business ethics and medical ethics. I was the physician. We were joined by a senior nurse from the ward, the ward’s social worker, and sometimes the nurse who had cared for Mother the most in recent days.

The explanation was given kindly, gently, with compassion; never arguing. Each of us took part spontaneously. The gist of it was, “we understand. This has happened before. It doesn’t upset us. Your wishes are an expression of your love for Mother and your wanting to do the most for her, her comfort, and her happiness. Perhaps you are hoping against hope that she will wake up, by some miracle, and you’ll be able to talk with her. You’d like to make up, apologize, forgive or be forgiven. Actually, even though she is in a coma, we know she can feel and hear. If you stroke her forehead, hold her hand, talk quietly to her, some part of her will know, will understand, will appreciate what you are doing.”

Only when the son grasped this would we go on to explain that the kind of “everything care” he sought would make things worse; and we would talk about that only if he needed more reassurance that everything reasonable and helpful was indeed being done.

What We Do at Full Circle Consulting - SF Bay: Saved 4-fold ROI by Aligning a Team

2012-04-08T13:52:00.000-07:00

Saved medical center hundreds of thousands of dollars annually by reducing patient re-admission rates from 20 per month to almost none, by creating a high-performance 10-member team and aligning them to use modern treatments:

Patients with epilepsy at a major hospital in the South were being readmitted almost every month. They were either having break-through seizures or complications from their medicine.

Break-through seizures come despite someone taking a seemingly correct dose of an accepted medicine. Sometimes a second problem has come up: stress, another illness. Sometimes the medicine isn’t really the right one. Sometimes the medicine isn’t monitored and the patient is actually getting too little or too much. Sometimes a well-meaning healthcare provider, untrained in neurology, adds a second medicine arbitrarily because the patient had a breakthrough seizure, so the seizures come more often and are more severe.

The treatments at this hospital were within accepted national standards, but the details were outmoded. Several problems were occurring and reoccurring.

The hospital wasn’t using the newer medicines which had fewer side-effects and fewer break-through seizures. Doses weren’t being monitored: neither blood levels in the morning before the first dose of the day, nor patient’s or the family recording on a calendar each seizure, (with a note of other matters: a cold. flu, an argument). ER doctors and nurse-practitioners merely increased the dose of the medicine after a breakthrough seizure was on, or added a second one, without getting advice from a neurologist.

The medical center asked me to create a new neurology service with 18 inpatient beds and a weekly clinic. There were excellent nurses, therapists, social workers, neurologists, and residents to staff it. They needed to be formed into a team, aligned, and inspired to high performance. Of course each one had been taught in school or early in clinical training to care for epilepsy, had done it for years, thought they knew how, and were no more interested in change for change’s sake than anybody else.

There was what was done; there was how it was done.

What was done is given below. It’s technical.

How? People on the team were already bothered by the frequent readmissions of their epilepsy patients. Even the people most adverse to change were willing to try a new approach for 3 months to see if it made a difference. Over those months fewer and fewer patients were readmitted, and as more and more showed up in clinic grateful for the improved control of their epilepsy, the entire team became advocates for the new methods and used them enthusiastically: we developed into an aligned, high-performance team. The team was eager to learn how to improve care for other neurological diseases.

The patients had better treatment and better quality of life. The readmissions decreased to essentially none. Each readmission cost the hospital thousands of dollars, and the dozens of seizure patients had in total 20 readmissions each month. The new approach and aligned team saved the medical center several hundred-thousands of dollars annually, well over four times my annual salary, a clear Return On Investment.

What was done was discussing and writing down modern approaches and teaching them to everyone on the team (including the neurologists and residents who rotated in for a month or two). The approaches were 1) using brand-name anti-epilepsy drugs (whose blood levels are more constant from refill to refill than generics), 2) using new drugs for the specific forms of epilepsy they treated best; 3) measuring blood levels before the first dose of the day (“trough” levels) once a month and 4) getting a trough level the morning after any break-through seizure; 5) having the ER physicians call a neurologist about patients who came in with a break-through seizure instead of arbitrarily changing the regimen, 6) adjusting doses so the blood levels were in the therapeutic range, avoiding side effects, 7) using seizure calendars as guides, and 8) following the patients regularly in the clinic.

What We Do at Full Circle Consulting - SF Bay: Motivated Failing Toastmasters Clubs to Succeed

2012-04-08T13:50:00.000-07:00

Motivated failing Toastmasters club to succeed by inspiring members to align purpose, mission, and activities; and coached a club that had failed with an earlier coach to achieve Select Distinguished status, the second highest club award:

In Toastmasters clubs, members teach each other to improve public speaking skills and to develop leadership skills. The Toastmasters International (TMI) vision describes reality: “Toastmasters International empowers people to achieve their full potential and realize their dreams. Through our member clubs, people throughout the world can improve their communication and leadership skills, and find the courage to change.” (TMI website, http://www.toastmasters.org/Members/MembersFunctionalCategories/AboutTI/MissionVisionandValues.aspx

One club near me was sliding towards failure because the two people were doing all the work and were burning out. Another club was failing by having too few members, and continued to fail despite nine months’ work by another coach and Division officers. I present these problems together because I used similar methods to change matters.

Clubs are ranked each year by TMI by objective criteria that measure how much the club provides for its members’ success: not rated, Distinguished, Select Distinguished, and Presidential Distinguished. To succeed, each club needs enough members to spread work from meeting to meeting over the 6 months of each term and to provide a variety of perspectives in speeches, evaluations, and leadership. New members need to join to bring in new ideas and to replace members who leave.

In 2008, I was Area Governor for a group of Toastmaster Clubs. The task was to help each club, to build on its strengths, to succeed, and to flourish. The first club was failing because there were only two committed officers. They took most of the 7 or 8 roles in each meetings and they were getting tired and discouraged. Yet there were 20 or more members and new members joined at almost every meeting.

After attending several meetings and establish rapport, I got the club’s permission to take half an hour at a meeting to discuss the club. Everyone gave input on what was important to them about a Toastmaster club and why. We explored why each of those answers was important. I was careful not to comments myself except to agree and ask for more input.

The process inspired members to take on roles, to run for office and work hard at the officers’ duties. It inspired the exhausted officers to continue and to delegate. The Division Governor and I trained the new officers of the club. I continued to attend club meetings, and when asked, made suggestions from which the club chose solutions. Key members of adjacent clubs agreed to participate in meetings to set examples and they agreed to hold joint meetings. By the end of the year, the club was succeeding and now, three years later, it is flourishing.

In late January, 2010, I was asked to coach a club that had failed, and that again failed despite nine months’ work by another coach and Division officers. Clubs should have 20 members; this one had only four. It needed at least 13 to continue. After establishing rapport, I asked them what was important and why, aligned them to want to succeed, set examples at meetings of how fill roles; and when asked, made suggestions from which the club chose its solutions. By late June, 2010, the club had 15 members and was Select Distinguished, the second highest level of excellence.

What We Do at Full Circle Consulting - SF Bay: Alignment under a Conflict over Vision and Drivers

2012-04-08T13:48:00.000-07:00

Need for Modern Driving Regulations

What kind of vision cards should be used to test people for a driver’s license? New York State’s DMV in the late 1990s used cards like those in a doctor’s office. There was a large black letter at the top, and, descending row by row, smaller and smaller, less and less black letters ending in a line of really tiny letters.

These had practical and theoretical problems – not as used by a doctor or an optician, but as used to qualify drivers. A driving applicant would read the card with one eye, moving to successively smaller print, and then do the same with the other eye – but the applicant had already read the card and could give correct answers with the second eye for a line of print the second eye couldn’t see clearly. There were other problems: for example, the way light fell on a card in one corner of a DMV office instead of another part could affect whether an applicant would pass or fail.

Members of the Vision Committee were at loggerheads. The committee had half of the newly-formed Medical Advisory Board to the NYS Department of Motor Vehicles. The Department’s Commissioner and senior staff needed the Board’s input to craft new regulations and to defend them to the State Legislature. This was the first question the Commissioner and his staff had posed to the Advisory Board.

The question was whether or not to move to an entirely new form of vision cards. Newly published work in the medical-scientific literature showed that a different kind of card was more accurate for driving tests, less influenced by variations in lighting, and less susceptible to cheating.

The new cards had 5 or 6 lines of 5 or 6 letters, different letters in different orders, all letters the same size. The lines were chosen arbitrarily from the entire set of combinations of 26 letters taken 5 at a time in whatever order. The print size was the minimum an applicant had to be able to read standing at the DMV counter and looking at the card to show vision was sufficient for driving.

The DMV agent would pick out a line at random – “please read line 5 with your left eye,” and then another, “now, line 2 with your right eye”. No one could learn all the lines while concentrating on one, and there were too many variations in cards for anyone to memorize them ahead of time.

The Advisory Board had a mixture of professions. There were one or two physicians, research workers and other healthcare providers in each of the specialties the Commissioner thought would be helpful; representatives from state agencies dealing with aging, social services, and public safety; and representatives from enterprises and institutions throughout the state concerned with driving or with illnesses that might influence driving, the American Automobile Association for example. We were all assigned to one of two committees, Vision, and Loss of Motor Control (seizures, epilepsy, diabetes, sleep disorders, muscle disease).

I’d heard about the bitter division in the Vision Committee and as chair of the other committee, outside the conflict, I offered to help.

The first observation was that the physician-healthcare provider-scientist group were unanimously for the change. They had found a series of good, published research pointing to the need for change and to an effective method. They had not found anything that disagreed with these papers. They went through the articles with me and showed me why they felt this way.

The other representatives were all adamantly opposed, the ones whose background was in law or policy, not medical research. I asked, “why don’t you like the proposed change?” They pointed to the discussion section in the two most important papers. The authors had written that theirs was only one study, and the results should not be accepted until other laboratories had replicated the work. They had studied only a limited number of people – enough to give statistical validity, but perhaps a larger study would give different results. They had studied people of only one or two racial and ethnic groups living near their research center: things might be different with other groups in other parts of the country: “more research was needed.”

“See,” the opponents said, “the scientists themselves don’t believe their conclusions are warranted.”

I explained. If the authors of a scientific paper did not put in disclaimers, editors and readers would worry the authors had been biased in favor of the what they found even before they started the work. People would worry the authors might have ignored details and information contrary to their conclusions. Any piece of research is considered interesting but it is not definitive until other groups, somewhere else in the world, have duplicated the results. Almost all scientists want to continue to have funding for their work – these last sentences were code for “please give us additional funds so we can do more and learn more.”

Once the non-medical members understood the conventions of scientific work and writing, they agreed that the new system made sense and had clear advantages over the old. The committee wrote a unanimous recommendation to the Commissioner. The new cards were in use throughout the state within a few weeks.

Full Circle Consulting -- SF Bay: Examples of Work: Finding Alignment under Conflict to Change a Law

2012-04-08T13:46:00.000-07:00

What happens if someone who is dying no longer wants food or water and can’t communicate this? What if the food or water is causing pain, breakdown of tissues, and increased suffering?

In the mid 1990’s, medical ethics emphasized patient choice and autonomy for quality of life and care in the last months of life: a patient should have the quality and the care s/he wanted. New York State’s law dated back several decades, to a time before ICU care or the modern conception of end-of-life care. It forbade removal of artificial hydration and nutrition.

What if the patient didn’t want them or the treatments were harmful? If a patient couldn’t communicate, they stayed – no matter prior conversations with doctors or with the medical proxy set up by a newer NY State law. Some hospitals and nursing homes felt the law allowed them or required them to impose their religious and moral beliefs on all patients in their care.

The bioethics committee of the state medical society debated the issue for two or three meetings. The committee consisted of 30 physicians, from academia, private practice; researchers on medical ethics, lawyers, administrators, and religious leaders. A few members of conservative religious and political backgrounds argued adamantly that the law could not be changed. Most of the liberal group couldn’t see a reason not to change it.

A year later, the state legislature and the Governor decided to revisit the law. They needed a decision of this committee: yes or no? We re-opened the debate. Again the conservative members dug in their heels. Again, the liberal majority couldn’t understand not updating the law.

When I explored, we all saw that each of the liberal members had withheld food and water when they thought that was the correct thing to do, ethically and medically. Had there ever been individual circumstances when the conservative physicians had withheld tube feedings or intravenous fluid from a particular patient who was dying?

Yes, they had often taken subtle cues from individual patients and then ceased artificial support. For example, a elderly man might tug at his nasogastric tube angrily to try to pull it out, over and over. Clearly he didn’t want it anymore; it was removed. An elderly woman consistently pushed away the baby-bottle full of Ensure given to her to suckle. Again, the sign was unmistakable and feeding was stopped.

The group in the minority could not imagine such subtleties being enshrined in law. That was the real issue.

I got unanimous consent from the committee to state this entire position as our consensus to the government: “a minority did withhold food and water in individual cases but believed the reasons too subtle to be enshrined in law; the majority thought the law should be changed.”

This I testified about in detail before the legislature and the Governor’s staff, being compassionate and truthful to both sides. The law was changed to allow patients and their proxies to withhold unwanted or harmful care, no matter the ethics or religion of the institution they were in.

Full Circle Consulting -- SF Bay: Examples of Work

2012-03-17T12:16:00.002-07:00

Finding Alignment under Conflict to Change a Law

What happens if someone who is dying and can no longer communicate no longer wants food or water? What if the food or water is actually causing pain, breakdown of tissues, and increased suffering?

What if the patient didn’t want them or the treatments were harmful? If a patient couldn’t communicate, then and there, that they should be removed, they stayed – no matter prior conversations with doctors or the medical proxy recognized in a newer NY State law. Some hospitals and nursing homes felt the law allowed them to impose their religious and moral beliefs on patients in their care.

The bioethics committee of the state medical society had debated the issue for two or three meetings. The committee consisted of 30 physicians, from academia, private practice; researchers on medical ethics, lawyers, administrators, and religious leaders. A few conservative members argued adamantly that the law could not be changed. Most of the liberal group couldn’t see a reason not to change it.

A year later, the state legislature and the Governor decided to revisit the law. They needed a decision of this committee. We re-opened the debate. Again the conservative members dug in their heels. Again, the liberal majority couldn’t understand not updating the law.

I explored. Each of the liberal members had withheld food and water when they thought that was the correct thing to do, ethically and medically. Had there ever been individual circumstances when the conservative physicians had withheld tube feedings or intravenous fluid from a particular patient who was dying?

Yes, they had often taken subtle cues from individual patients and then ceased artificial support. For example, a elderly man might tug at his nasogastric tube to try to pull it out, angrily, over and over. Clearly he didn’t want it anymore; it was removed. An elderly woman consistently pushed away the baby-bottle full of Ensure given to her to suckle. Again, the sign was unmistakable and feeding was stopped.

The group in the minority could not imagine such subtleties being enshrined in law. That was the real issue. I got unanimous consent from the committee to state this entire position as our consensus to the government: “a minority did withhold food and water in individual cases but believed the reasons too subtle to be enshrined in law; the majority thought the law should be changed.” I testified about this in detail before the legislature and the Governor’s staff, being compassionate and truthful to both sides. The law was changed to allow patients and their proxies to withhold unwanted or harmful care, no matter the ethics or religion of the institution they were in.

Reformated: Resume as Executive Coach & Organizational Leadership Consultant

2011-08-25T14:05:00.000-07:00

Pieter Kark, MD

Mountain View, California

Tel: 650.380.9717 E-mail: pieterk@post.harvard.edu

http://www.linkedin.com/in/pieterkark; www.pkark.com

CONSULTING FOR ORGANIZATIONAL DEVELOPMENT and EXECUTIVE COACHING

SUMMARY

Consultant and coach who finds consensus under conflicts to create aligned, high-performance teams; and who coaches key people to polish interpersonal skills so they can inspire others to succeed. Sees underlying nature of problems, creates constructive suggestions, and motivates alignment and success. Enabled improved state law by resolving conflict, trained 1500 professionals to train their colleagues in compassionate end-of-life care; authored 89 medical and ethical communications by coaching individuals and teams. Reputation for inspiring people of many backgrounds, cultures, and positions to tackle thorny problems and turn them around quickly and ably.

CORE COMPETENCIES

· Organizational development

· Communication in teams

· Conflict resolution

· Reconciling cultural diversity

· Executive coaching

· Tools of consciousness

· Facilitating seminars and workshops

· Editing, writing, speaking

CERTIFICATION

Certified, American Board of Psychiatry & Neurology

Trainer of Trainers (Facilitator), Education for Physicians (Professionals) in End-of-life Care

Licensed Avatar® Master

PROFESSIONAL EXPERIENCE

Consultant practice in neurology, medicine, end-of-life care, and research and teaching: Boston, Bethesda, Los Angeles, Shreveport, Syracuse, more than 15 years

Associate Professor of Neurology at UCLA and LSU; Founding Chief of Neurology Service, of Hospital Based Home Care Outpatient Program, and of Geriatric Outpatient Program, at VAMC Shreveport; Lecturer in Medical Humanities at SUNY Upstate Medical Center, Owner of Neurological Consultations

· Enabled modern State law for the terminally ill by discerning consensus underlying divisive conflict on Bioethics Committee of the Medical Society of the State of New York to create compromise that permitted a unanimous opinion of the Committee for the Legislature and Governor’s office.

· Saved 4-fold ROI annually for medical center by reducing patient re-admission rates on neurology service from 20 per month to almost none, by organizing and directing multi-disciplinary team using modern treatments.

· Authored 89 original medical/scientific communications on genetic and toxic diseases, and on medical ethics; improved quality of practice and patient advocacy by forming >30 aligned teams of physicians, guest scientists; medical, graduate, and college students; and physician extenders: teams doing clinical, educational, and research activities; and especially coaching teams and members to work effectively and humanely.

· Ensured >150 terminal patients got quality of life and treatment they preferred by resolving conflicts with families and healthcare staff over dogma, uncertainty and guilt and by coaching the participants.

· Produced modern, scientifically-based, humane, driving regulations about health in NY State by discerning consensus underlying conflicts on the DMV Medical Advisory Board and coaching Board members.

· Coached and tutored 50 medical students in groups of 10, monthly for 2 years for each group, on improving inter-personal relations and in writing and discussing divisive political and ethical topics compassionately and with respect for opposite opinions, in Medicine and Society programs.

· Inspired effectiveness and quality in more than 20 teams of physicians treating acute illnesses of artists to enable them to perform; and to teach performers to continue their profession by avoiding and reducing stresses that lead to disabling problems.

· Produced first book on pathophysiology and treatment of Inherited Ataxias by organizing International Symposium, raising funds, ensuring all aspects of Symposium ran smoothly, and coaching authors to write clearly and concisely.

and AMA/RWJohnson Foundation/Northwestern University Program in Education for Physicians (Professionals) in End-of-life Care: New York, California, Pennsylvania, New Jersey, New Mexico Trainer of Trainers (Facilitator) (1999-2006)

· Trained 1500 physicians, nurses, social workers, administrators, chaplains and other healthcare workers in effective, compassionate ways to care for dying people so as to maximize quality of remaining life, and themselves to train their own colleagues; by aligning and inspiring 20 faculties from 5 states to facilitate EPEC Program.

· Added to success of 12 NY Programs by writing and facilitating modules on Cultural and Spiritual Diversity and on Stress Reduction for the Practitioner.

Life Loan Foundation, Palo Alto, CA Medical Director 2005-2008

· Created non-profit to loan funds to dying people to improve their quality of life by inspiring team, resolving conflicts, and writing much of business plan. (Market collapse of 2008 blocked further efforts).

Star’s Edge International, Orlando FL and SF Bay Area, CA Licensed Avatar® Master 2005-2011

· Learned and used skills and tools to help others with self-discovery, self-empowerment and enlightenment, and learned to, and forged, aligned and effective teams.

· Guided several hundred people to learn skills and tools to succeed enjoyably in aspects of life which they had not found enjoyable or successful, by guiding (coaching) and working as a member of and aligning numerous groups and teams.

Enterprise Resiliency Group (ERG), Silicon Valley Senior Partner 2009-2011

· Created ERG by bringing 12 experts into cohesive emergency and disaster planning team, and finding non-profit beta-test site;

· Wrote 32-page report of prioritized suggestions to non-profit, by leading core team and 6 others through successful test in minimal time and resolving conflicts among the team so report was unanimous.

· Made the non-profit resilient – able to withstand a broad range of potential emergencies and disasters -- by guiding management and staff to implement our recommendations.

VOLUNTEER WORK IN SILICON VALLEY

Abilities United, Palo Alto, CA Board of Directors 2008-2011

· Assured agency flourished despite loss of 20% of State funding by inspiring and coaching departmental managers of silos to align, to explore viewpoints and methods outside their comfort zone, and to collaborate on social enterprises;

· Resolved 28 health and safety issues for disabled clients by investigating nature and degree of problems, clarifying priorities, and working with Board and departmental managers to create effective solutions.

· Developing living All-Hazards Disaster Plan by inspiring, coaching, and coordinating work of a team representing all silos.

American Red Cross – Silicon Valley Chapter, Santa Clara County CA 2007-2011

Coordinator for Mentoring, DAT Captain, Sheltering Supervisor and Instructor; Health and Safety Instructor.

· Engaged 10-15% more volunteers for new Chapter by organizing and leading a mentoring program: acclaimed by Executive Director and Board as major success for Chapter’s first year.

· Inspired key people to collaborate in new Chapter by resolving conflicts between people from two disparate, culturally-distinct, former chapters during merger.

· Led more than 15 focused teams to aid clients effectively and compassionately in local and national disasters, by coaching members of the team while in action.

Toastmasters District 4, SF Peninsula, CA Club President, Area Governor, Club Coach. 2005-2011

· Motivated a failing club at an IT firm to succeed by coaching and inspiring members to align purpose, mission, and activities.

· Coached and inspired officers and members of 5 individual clubs, 4 of them at IT firms, so as to lead the Area to be Distinguished.

· Used skills as a consultant for dysfunctional teams to coach a club, that had failed with an earlier coach, to achieve in five months the Select Distinguished status, the second highest club award.

ProMatch (Nova/Connect!/EDD), Sunnyvale, CA Facilitation Team; Co-Lead Problem-Solution-Results &Resumes Team; Author and Presenter, Workshops on “Breaking Free When You’re Really Stuck” 2010-2011

· Assured > 100 professionals had effective resumes by re-writing presentation and handouts for Targeting Your Resume Workshop to emphasize importance of T-charts and Result-Solution statements, and using latter to create exciting Summary statements.

· Ensured > 150 professionals created solid Problem-Solution-Result statements and effective resumes by facilitating workshops and coaching one-on-one.

· Trained >150 professionals to facilitate by co-facilitating Facilitation Skills Workshops.

· Trained >100 professionals in mental exercises to reduce stress quickly and effectively.

EDUCATION

· MD cum laude in general studies, Harvard Medical School, Boston.

· BA with Second-Class Honours and MA, Oxford University, Oxford (Medicine and Animal Physiology, largely neurophysiology and biochemistry).

· Multiple courses from American Red Cross.

· Trained to train other trainers (facilitation method), EPEC Program

· Selected to co-facilitate with National Training Team of EPEC Program.

· Facilitation Skills Workshop (ProMatch, Nova/Connect) then Facilitator/Co-Facilitator for 5 Facilitation workshops and multiple PSRR workshops

· Multiple courses in management at VAMC, Shreveport

· Courses in tools of consciousness that improve interactions, reduce stress, support creativity in others, align teams, and inspire groups and individuals to improve, Star’s Edge International, Altamonte, FL

Establishing aligned teams; coaching, mentoring, teaching and tutoring basic science, laboratory research (biochemical, genetic, toxicologic, pharmacological, monoclonal antibodies), basic clinical matters, specialized clinical matters, patient care, medical research and medical ethics for many years at several medical schools. Facilitating open, clear, honest communications to improve end-of-life care for more than 10 years in 20 EPEC programs.

CONSULTING FOR ORGANIZATIONAL DEVELOPMENT and EXECUTIVE COACHING

2011-08-10T08:28:00.001-07:00