the disorienting dilemma

Unless you're an educator, you may not be familiar with the term "transformative learning". The theory of transformative learning was developed by Jack Mezirow, a sociologist and Emeritus Professor of Adult and Continuing Education at Columbia University. It refers to the ways we adjust our thinking based on the acqusition of new information. Nothing special about that, but the thing that sets transformative learning apart from, say, what we learn from reading is the fact that transformative learning always involves what is known as a "disorienting dilemma". 

 "You can't resolve a dilemma

with the very same mind

that made it."

~Albert Einstein~

A disorienting dilemma can be described as an experience that does not fit our expectations or make sense to us without a substantial change in our world view, our conditioned assumptions, our previously held beliefs, or our tightly held convictions. It leaves us stunned. Disoriented. Our dilemma forces us to ask several questions:

• What have I been thinking all this time? Why?
• What am I really committed to?
• What is important for me to accomplish?    
• What is preventing me from accomplishing what I am committed to?
• What path will I take going forward?

While Mezirow's theory was intended to reference learning in adults, it is applicable across a broad spectrum of behavior and experience. And it is especially relevant to health care providers.

A disorienting dilemma for me evolved gradually with the changes in the health care system...the erosion of the physician's authority by self-proclaimed intermediaries who had neither knowledge of nor concern for patients’ well-being...attorneys, auditors, insurers. A system whose number one priority was corporate profit rather than compassionate care. The imperative to see more patients, faster in order to generate more revenue...which I believed put patients at risk. I worried about missing a diagnosis, or bungling a procedure, or prescribing the wrong medication in my rush to stay on schedule...in my efforts to appease corporate administrators, while struggling with an oppositional-defiant electronic medical record system, a baffling coding and reimbursement system, and the ever-present threat of litigation. It scared me.

Medicine was my passion, but my sacred duty was to patient well-being and safety, hence, my dilemma: Should I stay and fight the system? Did I have a duty to engage in that battle? Or should I go? 

"Sometimes you change your mind...

sometimes your mind changes you."

~Binyomin Scheiman~

Long story, short: I abandoned the practice of medicine. After thirty years in Family Medicine, I told my patients and colleagues I was retiring…when I meant I was quitting. I didn’t put it quite that way, of course. It wasn’t as though I simply got fed up with things, turned in my stethoscope and tongue blades, and slammed the door on my way out of the office. I wasn’t impulsive about it at all. I agonized over my dilemma for years. My decision had nothing whatsoever to do with my patients. Caring for them was my passion. Nor was I defeated by the perpetually long hours. Nor was I discouraged by the fact that I’d been running behind schedule all day, every day for thirty years with no chance I’d ever catch up. That wasn't the problem.

I simply deferred to what I considered to be my sacred duty, my true calling...and I did what was necessary to honor it.

"Sacred duty is the thing that

if you do not do it, you will feel

a profound sense of self-betrayal."

~Stephen Cope~

Sooner or later, most of us will come up against a dilemma that requires us to re-evaluate our deeply held beliefs in life, to question our assumptions and opinions, and perhaps, to change our minds. Then we will be confronted with the imperative to act on what we have learned in the process, or to betray ourselves.

The important plot points in our lives tend to involve disorienting dilemmas. They punctuate our professional narratives as well as our personal lives. And they unfold among our patients. For example, whether or not to terminate an unplanned pregnancy. Whether or not to place Mom in an extended care facility. When and if to discontinue life support.

Are you facing a life-changing decision? Are you ready to learn? Are you prepared to act?

"Two roads diverged in a wood

and I--I took the one less travelled..."

~Robert Frost~

jan