Last week in part 1of this series, I introduced the topic of perception, as discussed by Dr. Edward Racht, EMS medical director for Austin/Travis County, Texas, during the 2004 CHANGES Conference in Augusta, Ga. For me, Dr. Racht's key point was that to be considered as prehospital care professionals, we must be perceived as professionals by the public. The difference may seem semantic, but I think there's a crucial root issue here.
The process of evaluating a person, thing or situation really has three phases. In the first phase, you simply gather data about the object with all your sensory resources. You then perceive the object, running your sensations through your database of experience and placing the object into an appropriate cognitive and affective context. Finally, you see the object for what it is, discovering its true nature and substance. The roadblock in this process comes between the second and third step, for if the perception is associated with negative feelings or associations, there is little incentive to seek the actual truth. Why go someplace that looks unpleasant?
It's the fact that perception often becomes reality (or masks it, depending on your view) that makes it more incumbent upon the EMS provider to "play to the audience," as it were. No doubt the vast majority of us in EMS are in it to help others, and are committed to developing ourselves personally and professionally to provide better patient care. But although we may think of ourselves as health-care professionals, our tone of voice, our mannerisms and our interactions with both patients and one another may yield a totally different perception to the outside world. That perception effectively prevents anyone from seeing what we see when we look at ourselves. Well-seasoned and hard-edged "I've seen it all" EMS staff may be seen as cavalier and uncaring in the eyes of the world at large. The danger is that if EMS does not cater to what the public wishes to see, no great value will be linked to EMS care. Not only will we lose the battle for professionalism, but also the battle for funding, resources and autonomy.
As I've reflected on this topic, I've come to think there are really three realms of perception. One is internal, the way we view ourselves. For example, I perceive myself as having a lot of hair for my age. Tommy Shaw of Styx or anyone from ZZ Top would probably argue my contention. It's intimately tied to self-esteem and other issues of personal growth. A second group of perceptions originates from our peers. We all belong to a host of peer groups, and each has their own culture dictating what behaviors and attitudes are perceived as "good." We may be very kind and caring, but we know our EMS colleagues will snicker behind our backs if we miss three intubations in a row.
The last set of perceptions are those shared by a society, and this is where Dr. Racht focused his comments. He argues that to some extent, it doesn't matter how good we think we are. What matters is what the public thinks. Given that the layman wouldn't recognize a slick intubation if it hit them in the face, the public perception of competence is tied to response times, client communication and personal empathy. Excellent clinical care registers very low on the scale of public opinion.
Dr. Racht used multiple examples from the editorial pages in his hometown paper to make his point. I was recently reminded of this on a far more personal scale. A few weeks ago, I walked into a new Men's Wearhouse store here in Daytona Beach. The manager and his wife, both of whom worked at the store, were more than friendly and helpful. In the course of conversation, I found that they already knew who I was. About a year before, their next-door neighbor had suffered from cardiac arrest while out working in the yard. These folks had called 9-1-1 and had come with the patient to the hospital. I was the ED physician who ran the code, and who told the family and friends of the patient's death. They remembered me as compassionate, kind and respectful. They knew absolutely nothing about the technical care I provided, nor did they care to ask. What they needed was not clinical brilliance, but emotional support. That is exactly the care we downplay in EMS training, and the attitudes we consider as "soft." Our technician culture overwhelms our caregiver ethic.
In the end, your peers know if you provide good care, and you certainly know if you did the right thing. It's difficult to accept that the public just doesn't, and likely won't ever, "get it" like you do. But to be frank, they really don't care if you're having a rotten day, hate your boss, are overworked and underpaid, and are concurrently juggling 18 other flaming bowling pins. All this may well be true, but if these factors influence your attitude toward the patient you are undermining the drive toward the professional status EMS demands.
The trick, of course, is to find a way for all these realms of desirable perceptions to harmonize. It's finding a way to make your own actions fit your own expectations for thought and behavior, building confidence, security and self-esteem. It's excelling in your technical capabilities and organizational competence to excel in the minds of your peers. It's demonstrating patient care attitudes that meet the public's demand for help, compassion, and clinical acumen. It is certainly possible to exist in multiple cultures, each with varying perceptions. For example, someone who is intensely religious in their own life may function quite well within a peer organization that is religiously neutral and a general society that may be frankly secular.
The larger question is if you can't meld all of these realms of perception into a coherent whole, which take priority? That one is nearly impossible to answer. I would never argue that it's better to just look good than to be good, although I suppose that this is what many in life do. By way of contrast, I suspect that the attitude and ethos of many organizations, both public and private, are driven more by peer perception of competence and status than by the actual needs of the consumer. I think that the current generation of public service professionals is being raised in a culture of customer service. But, fortunately, I heard the music starting in the ballroom just as I began to seriously ponder the question. Saved again.
Once the seriousness of the conference was over, the party commenced. The CHANGES gang had commandeered a hotel ballroom and stocked it with a band known as The Swinging Medallions. They were actually pretty good musically. But like most smaller city bands, you knew they had to compromise somewhere. Apparently they ran out of funds when it came to choreography. The best way to describe them is as the Lawrence Welk orchestra pretending to be Earth, Wind and Fire, with all the lack of rhythm possible in such a scheme, especially when they opted to play ... and no, I'm not making this up ... "Play That Funky Music, White Boy." (Actually, I always kind of wanted Lawrence Welk to do a funk show. "You've seen Bobby and Cissy dance-a the hustle. My, how they can move and shake their boo-tee. Ahn now, our lovely Champagne Lady Norma Zimmer and all the boys and girls will-a groove to that young people's favorite, "She's a-Built a-Like a Brick House.")
For some reason, I don't do well at parties. Put me in front of an audience and give me a job to do, and I'm just fine. Put me in a room with a zillion other people and ask me to sit down and make friends, and I just can't do it. So I stood in a corner, smiling quite happily and noting with Dr. Racht how wonderful it was that EMS folks were engaging each other in many educational and productive fashions despite the obvious corrupting influence of music, alcohol, scanty clothing and gold medallions. Which, I suppose, is actually a closet plea for some immensely attractive woman to pay attention to me at the next party I attend. Oh, me of fragile ego.
I took a few hours after my last talk the following day to walk around Augusta. It's kind of an interesting city, and you can't quite figure out if it's trying to be a copycat of Savannah, an antebellum industrial powerhouse, or a modern center of business and learning. For example, there's a wonderful park along the Savannah River known as the Riverwalk. The development extends for a mile or so and includes many romantic overlooks and historical markers. Along the Riverwalk are luxury hotels, art museums, a science center, playgrounds and a marina. But once you get 20 yards inland, the amenities one would usually associate with this kind of waterfront rejuvenation, such as restaurants, boutiques and clubs, are strangely absent.
Of course, it might just be me. Our local paper just did a two-page feature on the joys of an Augusta weekend. Maybe if I had seen the article in time, it would have changed my perception. Next time, it'll be a longer stay. Georgia's already Gentle on My Mind.(My many thanks to the folks at Georgia State EMS Region 6, and especially to Lawanna Mercer-Cobb, for the kind invitation to speak at this meeting. Hope to see you again.)