The "Finally"

“And if one of the common people sins unintentionally and does what is prohibited by any of the LORD’s commandments, he incurs guilt.” 

Lev 4:27, from the ESV

Every healthcare provider worth their wages wants to be the “finally” for a patient. In other words, every practitioner wants to be the one to solve your problem. These days, the American medical industry is unfortunately plagued with the same problem that has hollowed out churches - 1) the institutional trust has evaporated due to institutional betrayal and 2) the sentiment that “I can always go somewhere else to find the answer I want to hear.” Dealt a death blow from the both directions.

That being the case, it is not at all uncommon for the patient walking through your door to be on therapist number four, five, ten. As a therapist, you will hear parents say “We didn’t like the last one,” or “She just didn’t seem to understand my child,” or “I don’t think she really knew what to do.” And when the family that said this eventually says to you “you actually understand” or “no one has ever explained that to us before” or “you changed our lives,” it is like a concentrated drug coursing directly through your brainstem. I did it where all others failed! I was understanding, compassionate, empathetic when no one else was! My diagnostic skill, my bedside manner, my therapeutic technique are superior! What better feeling than that?

• I solved a problem for a suffering child which alleviated difficulty for the whole family unit
• I did it via application of trained skill
• I used virtues to complete this action
• I managed this after the many failed attempts of others

Intoxicating. 

Now, even the most arrogant, prideful person can see the potential danger here. What a fantastic set up to ensnare someone in self-righteous pride. “But,” you say, “just because this could lead someone to pride doesn’t negate the actual good they do/did. They can and should be happy with their good works.”

Yes, this is true in so far as it reaches. Chew on this tautology for a moment: It is good to do good things. Sadly, it does not explain the whole picture of morality.

The Thief that Never Bothers

There is an old phenomenon referred to as “survivorship bias” most commonly illustrated by the image of WW2 aircraft shot full of bullet holes. The idea is rather straight forward: if you only sample from the surviving [data samples], then you are liable to misunderstand the cause that killed the other [data samples]. Because you don’t have the data that killed those [data samples]!

Look at the image of the returning aircraft. That’s a lot of bullet strikes in those red areas. If that is where the planes are being hit, we should increase the armor in those areas right? No. The data shows the opposite. The airplanes with these strike patterns are the ones that survived. Meaning, they can be turned to swiss cheese in these parts of their frames but still make it back. Hits here are actually preferred. Now invert the logic. If they are struck in the areas not shown in red (the blank areas), they do not make it back. A single shot to the cockpit will down a plane while 30 shots to the tail do not. So the conclusion is to armor the spots not showing bullet strikes. 

Another example: You’ve had 0 break-ins since installing security around your home (beware of dog, gun-owner lives here, ADP monitored, etc.). You look at the map of reported burglaries and see red dots scattered across the city, with pockets of peace, including your neighborhood. The conclusion is not that you live in a safe neighborhood and therefore don’t actually need the security, it is the opposite. Neighborhoods that exclude criminality and have wide-spread adoption of security systems (socially/culturally, alert systems, police presence, physical protection means, etc.) have more incentive to add deterrent systems because they’ve been shown to work.

What has that to do with speech therapy? This: you don’t know how many patients you have failed. You don’t know how many times you’ve been a disappointing step, a barrier, on the long road to health. You don’t know how many times a patient has said “he was just no good” about you. Just as you can never examine the planes that never make it back, you can never hear from the patients that never come back. Somewhere out there, a previous patient of yours is talking negatively about you to their new therapist. The new therapist that is succeeding where you failed.

The tough reality in healthcare is that this is unavoidable. You will damage, impede, annoy, frustrate, hurt, and fail already suffering people. And it is because of your lack. You are to blame. You had a headache/cold/hangover and were not operating at full capability. You found this family/parent especially frustrating and are kind of happy they stopped showing up. You were tired because you forgot your coffee. And a thousand other simple day-to-day realities. Of course, there are also the capability failings. You just aren’t very good at this or that treatment. Sure you could study more, take a course, but you could also just muddle your way through. Everyone has limitations in time, money, and scope, after all.* 

The sooner you can accept the idea that you are unintentionally harming families that come to you for help, the faster you can get to work 1) reducing that dreadful number and 2) dealing with that feeling of guilt/failure.

Start offering this failure to God in repentance, genuine contrition around something you did that caused another’s suffering. In doing so, you are freed of that burden. 

All Bad News?

That’s all pretty dour. But there is good news. Just, bare with me for a moment more.

When I became a therapist, no one told me how to know if I were doing a good job or not. Therapists often work solo. Just you and the patient. So how do I know if I am doing a good job if my boss only ever looks at billables, my co-workers only ever see my sessions in passing, and the only feedback I get is from the occasional out-spoken parent? Well, many therapists latch onto that last one. 

“The parent tells me I’m doing a good job with their son/daughter, say they love me, and, since patient-centered care revolves around reported satisfaction, that must mean I’m doing a good job.”

Wrong. 

99% of the time, we (all of us, me included) go to specialists because they have information we don’t have. I go to a mechanic because I don’t know anything about repairing a transmission. That’s ok. And it is ok for me to thank the mechanic after the repair and tell him he did a good job. Did he? I can only know by seeing if my car runs properly now. Which is information he already has. He doesn’t need me to relay to him “hey my car works now” because that is the very reason he released it back to me. He knows the job was done well, which is why the job ended.

I’m not saying parent feedback is worthless (it isn’t; it is very important). What I am saying is that many therapists weigh the feedback too highly and in the wrong way. Take the compliment for what it is - a show of appreciation. Work hard to fit your treatment to each person, making them feel at ease and cared for. That is crucial. But let your work be its own proof of competency. Most lay-people don’t know enough to tell specialists whether or not they are doing a good job. Think about construction work. It looks like a total mess until it suddenly coalesces into the final state. You know that the process is a little messy. But you also know the outcome. Don’t let a person who has never seen a blueprint tell you how it should go. And don’t believe the praise when you know you cut corners. 

If they don’t know, don’t add their words to your metric.

Do all Things as unto Jesus

“The Christian shoemaker does his duty not by putting little crosses on the shoes, but by making good shoes, because God is interested in good craftsmanship.”**

Paul writes in the letter to the Colossians to do all things as labors for the Lord. Imagine Jesus came into your shoe shop and asked you to make him a pair of shoes. Would you take a pre-made pair off the shelf and stamp them with a religious charm? Or would you spend every waking moment diligently pouring your heart into making the best pair of shoes you’ve ever made? 

The evidence of a job well done would be visible in your shoes. If you saw him wearing them 5, 10 years later and they are still holding up, what better proof do you need? Does it feel great to hear him say “I love these shoes?” Absolutely! Still, that compliment is best received when it is not accompanied by a secret guilt that you skimped on materials, hid errors, or could have done better.

What is your “shoe making?” What ways do you cut corners? What ways do you waste other people’s time, money, and trust? Offer those failings to God. Allow Christ to be the sin sacrifice for the unintentional sins of your life as well as the intentional. In what way can you labor for God in excellence? How can you keep your eyes fixed on the proper scales of good labor? Where do you seek out validation that is actually just platitudes or empty words? Do all things unto the Lord, not for the praise of man, knowing that your Father in heaven sees your deeds and will reward you.

*Obviously every patient that leaves isn’t your fault. Some people are genuinely crazy. Misunderstandings happen, personalities don’t match, they want a male/female therapist instead, etc. etc. There are plenty of innocuous reasons patients move on. I’m not talking about those reasons here.

**This quote is oft-attributed to Martin Luther, though there seems to be dispute over whether he ever said it. The sentiment is true regardless of who spoke it first.