Hey everyone, I'm Brandon Odo.
And I'm Brian Bowling.
And this is Critical Care Scenarios, the podcast where we use clinical cases, narrative storytelling
and expert guests to impact how critical care is practiced in the real world.
Hey everyone, welcome back.
It's Brandon Odo.
Let's chat today about I'm going to call it the mobile locus of control.
Sounds fancy, but it's not so complicated.
The question that we're trying to sort out is when are things that happen, your fault,
or I suppose if they're good, you're doing your achievement or success.
And I'm talking about in the medical context, so what I'm really talking about is patient
outcomes.
A patient does well, you can save their life.
Did you do that or did it just happen?
Is it more a matter of luck or fate or circumstance or was it you?
Did you achieve that?
Was that your success?
Did you save a life?
What about if a patient doesn't do well?
Patient dies, patient suffers.
Did you do that?
You were taking care of them.
Your goal was presumably for that to not happen, but it did.
Did you mess up?
Was that your error?
You could see how these things kind of go together.
If you believe one, it seems like you'd have to believe the other.
And you can also see how, to some extent, this is just a matter of your perspective because
with so many other things in life, you probably have some responsibility for patient outcomes
and to some extent, they are also due to circumstances outside your control.
To tackle this, I am pulling in a term from psychology called the locus of control, because
this same question arises in many other circumstances.
And the question that psychologists ask is, when you're looking at a person and how
they view the world, do they tend to think about it?
And to view the things that happen in their life as being something they were responsible
for, or do they tend to view them as things that befell them due to outside, uncontrollable
circumstances?
In other words, the kind of driving motivator for the events around you, are they within
you?
Or is it outside of you?
Where is the locus of control?
And where people tend to place that locus, tends to determine how they view a lot of things.
For example, people who tend to have an internal locus of control may feel more empowered,
but they also may feel more guilty when things go wrong because they feel like they did
it.
People with an external locus of control are more of the opposite.
They may feel more at the mercy of events around them, but perhaps that can also be liberating
when things go wrong.
So when it comes to patient outcomes, what's the right answer?
You might say it should be a very external locus of control because, well, when patients
don't do well, you don't want to think that was your fault.
And of course, there is a lot of truth to that.
On the other hand, if patients do well, you'd also have to say that was not your doing.
You are really just a cog in the machine, kind of a leaf blown around on the winds of
fate here.
And I don't know if that is really the right answer either.
And of course, we're talking about this as if it's something you can decide.
But I think that is correct.
Like I said, there is not really one true way to look at this because it is a mix.
So it's more a matter of perspective.
And when it's a matter of perspective, I think that means we can choose the most useful
way of looking at things.
There's a whole school of thought and philosophy called pragmatism espoused by the American
William James.
And one of the tenets essentially says that that which is true is really that which is
most useful to believe is true.
And from the pragmatist perspective, I think the locus of control that benefits us best
as far as making us happy, satisfied practitioners of medicine is the truest one because there's
no other truth that really matters here.
You can't put it on the table and look at it.
It's whatever makes the most sense.
So what I would propose is that the locus of control that is most useful to us as clinicians
is a mobile one.
You can't fix it in one place because that's going to make it wrong in the pragmatic sense
of wrong a lot of the time.
When a patient does well, you should feel that you played a part in that.
That's going to be the most rewarding thing for you and that is the kind of belief that's
going to help you have longevity in this field feeling like you you made a difference.
You helped people.
You made a mark on the world in a positive way.
People are alive and well because of you that otherwise would not be.
On the other hand, when patients don't do well, you really should believe the opposite.
You should believe that that was just essentially their fate.
What that means is some combination of luck and a million circumstances, the vast majority
of which are not in your control is just something that happened even though you did the
best you possibly could.
Now, of course, I'm not saying that you should not try to learn from bad outcomes both personally
and as a system, all those things are true, but that's very different from saying that
it was your fault.
So are these contradictory ways of looking at things?
No, I don't think so.
They're both true or false in equal portions, but that's what I'm saying.
You get to choose which one you use and I think you need to be able to hold both of those
beliefs simultaneously because that will be the most useful and pragmatically correct
way of viewing things, having that mental flexibility to say things went well and I did that,
things went poorly and that's just life.
That's just how it is.
If that sounds weird to you, I don't know what I can say except maybe work on it.
Practice it in Orwell's 1984, they talked about a double think, the art of believing
to contradictory things simultaneously.
Of course, that was in a very negative context, but I think it can be useful in this sense
because it is useful to be able to do this and if it's useful, then it's true.
And I think that's correct.
If you're getting it wrong in either direction, see if you can work on this.
See if you can practice moving around your locus of control and really believing that
it is true.
You helped the patient who did well and the patient who didn't do well, that wasn't your
fault.
Talk to you next time.