Medical Coaching: Don Miguel Ruiz’s “Four Agreements”

In Commentary, Featured, Opinion by Nadim LalaniLeave a Comment

In medicine and medical education, we’re often hyper-focused on medical content, rather than the art of medicine. I recently finished reading Don Miguel Ruiz’s book “The Four Agreements“1, and identified some excellent educational pearls for medical students, residents and practicing physicians; pertaining to self-awareness and belief systems. In his book (albeit with a rather religious theme) Ruiz walks the reader through what he calls the Four Agreements – contracts to make with oneself in order to foster more peace and balance in their everyday lives.

  • Be impeccable with your word
  • Don’t take anything personally
  • Don’t make assumptions
  • Always do your best

Four agreements

Self Awareness and Redirecting our Attention

Ruiz describes how we acquire our personal beliefs through socialization from our parents and mentors. This process (which he calls “domestication”) forms the basis for deeply entrenched beliefs and an inner critic that judges how well we (and others) hold to these ideals. Furthermore, Ruiz outlines that during our formative years, our attention is also focused upon particular objectives. Given that we have a finite attention, we have a tendency to tune out redundant or un-important stimulations. By tuning out things however, we create a false reality (our perception) about the world around us. These two things – socialization through beliefs and focused attention leave us with deeply entrenched and often skewed perception of the world from our own limited point of view. We not only become conformists to these ideas, but also judge ourselves and others harshly when we fail to conform to these expectations. This is certainly an rational conclusion, but how can this help us in medicine?

1. Being self aware

Self awareness is a crucial skill at all levels of our journey. Understanding who we are and how we think enables to change and improve. It also allows us to have locus of control and be proactive rather than reactive to the world around us.

As it applies to emergency medicine, the importance of understanding how you think and behave is paramount to successful practice. Each physician has inherent biases and opinions, and if one is not aware of these, it can result in medical errors or missed diagnoses for patients. For example, if you have a strong counter-transference to patients who are chronically intoxicated and frequently present to the emergency department, your attitude and opinion may result in a critical missed diagnosis. Being cognizant of these biases, allow one to focus their attention upon patients, or conditions where extra caution should be utilized. This is by no means a new concept, as Pat Croskerry has previously suggested that being self aware is an useful method to help eliminate cognitive biases such as premature closure and anchoring2. 

Challenging firmly held beliefs is difficult to do, but is necessary as it enables us to understand why we behave the way we do, but affords us the opportunity to change. In medicine, as in science, we are constantly evolving our understanding and knowledge base. As a result, we are identifying practices or aspects of medicine that were once dogma (i.e.: think bolusing insulin or fluids in children with DKA). If one does not challenge firmly held beliefs, we can not proceed or continue to develop as a profession and a specialty. It is also important to challenge our own socialization and beliefs that have been entrenched as dogma – for example, believing that only specialists have the necessary training to be excellent teachers/medical educators, results in missing out on potential educational opportunities. 

2. Broaden our attention

Broadening our attention enables us to take in “all the facts” before we come to conclusions. It also fosters humility when we understand that our perceptions are not facts and we don’t actually “know it all”.  Taking note of our limitations is a form of mindfulness.

Consider an potentially hostile interaction with an consultant (i.e.: in which there is an disagreement about seeing a particular patient), one should focus on listening to others NOT for the sake of having a rebuttal, but actually listening to what they are saying, their fears and the metamessage behind their words. Broadening our attention to take in things that we do not want to hear allows us to create a shared pool of meaning and greater understanding.

Being impeccable with your word

Ruiz outlines how we develop an inner critic through the process of socialization. This critic judges ourselves and others harshly when they fail to conform to our thoughts and perceptions.  The result is the (very familiar in medicine) culture of criticism and self flagellation. Being impeccable with our word in medicine means three things:

  1. Avoiding all the negative things we say about each other that become folklore [e.g. bashing ER doctors and other parts of the hidden curriculum].
  2. Avoiding negative self-talk and instead being your own best advocate.
  3. Understanding that we are all unknowingly the products of socialization, and we need to go easy on each other in medicine.

Ultimately, this is a manifestation of collegiality, professionalism and managing the ED team efficiency and effectively. We’ve made excellent progress in terms of this representation of collegiality and professionalism in recent years, but there is more work yet to be done. Recognition of the unacceptability of hostile behaviour  is the most important step, and to be mindful that we’re all attempting to act in the patient’s best interests.

Not taking anything personally

Ruiz shows how our beliefs create a perception about the world we live in that doesn’t really reflect the truth. We all essentially live in a perceived reality that we have created for ourselves. In our minds, these perceptions turn into facts about how the world should be. This sets us up for emotional reactions when other’s ideas conflict with ours. This has special importance in medicine:

1. It’s about us, not them

It is important to understand that our emotional reaction to others’ behaviour is the direct result of how we perceive the world. Sadly our perceptions may not even reflect the reality of the situation.

2. It’s about them, not us

On the flip side – the negative things people say are more about themselves than they are about us – as they have created a narrative about how they perceive the world.

Having the mindset that most people are not going to see the world the way you do enables us to shrug things off and move on. It allows us to have the locus of control and continue to be ourselves in spite of others’ perceptions. Similarly, challenging ourselves to examine our personal narrative and how they impact our world view allows self-honesty and creates a habit of taking personal responsibility.

This can also be thought of as resilience – bad things happen in the ED; and sadness and anger is a constant reality of our work. In conjunction with this, each individual has their own set of ‘baggage’ that may skew their judgement and interactions with others, whether this is on a personal, consultant or patient level. It is paramount to ensure that one does not let their emotions dictate their practice – and the ultimate focus should always come down to the patient, and patient advocacy.

Not making assumptions

Ruiz illustrates how an in-born need to explain and understand things, conjoined with the paradoxical fear of questioning things, creates assumptions about the things around us. These assumptions usually conform to our personal narratives because this is far easier than the act of challenging one’s beliefs. There’s a lot of assumptions made in medicine – these form the narrative of the hidden curriculum and it’s past time we stopped making them. Not making assumptions in medicine means encouraging dialogue.

  1. We can do this by training ourselves to ASK and CLARIFY.
  2. We can do this by having those difficult conversations. The other place that we make assumptions is not on the med-side, but on the life-side with those that we love. Understanding how to communicate directly with our loved ones is equally important.
  3. Ultimately, within the CanMEDs spectrum, this idea comes down to communication; whether it is between the physician and the patient, or within the medical community itself.

Always doing your best

Ruiz shows that our “best” is contextual and dependent on many things. In medicine our “best” is not going to always be the same – it varies moment to moment depends upon:

  • Being sick versus healthy
  • Being refreshed versus tired
  • Being happy versus being anxious

Individuals can gain a better understanding of the different biases, teamwork failure and communication gaps in their own setting – and with that knowledge, one can then “do their best” to address those issues explicitly. In doing this, it fosters self acceptance and accountability to oneself.

If we’re all undertaking this self-reflection, we understand that we’re all trying our best and that our best isn’t always perfect, which would foster a less critical culture in medicine. This would free us from the hyper-competitive self-flagellating culture that we work in, and would enhance the educational experience and positivity of the work environment.

“It is not enough to do your best. You must know what to do, and THEN do your best.”
– W. Edwards Deming

Closing thoughts

The above pearls can be summarized into three concepts; self-awareness, transformation and intention.

Within self-awareness, one needs to question why particular things are valued, and why certain beliefs are held – and one may come to surprising conclusions about their inner workings.

Transformation requires one to show more empathy for themselves and others, while maintaining a sense of assertion. Question, clarify and utilize dialogue! This will enable one to ensure they are presenting their best-self.

Intention is simple, by behaving with the best intentions, one will ensure they are being purposeful about the things they do.

Written by Dr. Nadim Lalani, with peer review and editing by Dr. Shahbaz Syed and Dr. Edmund Kwok. 

References

1.
Ruiz DM. Four Agreements: A Practical Guide to Personal Freedom. Amber-Allen Publishing; 1997.
2.
Croskerry P, Abbass A, Wu A. Emotional influences in patient safety. J Patient Saf. 2010;6(4):199-205.[PubMed]
Nadim Lalani

Nadim Lalani

Nadim is an emergency physician at the South Health Campus in Calgary, Alberta. He is passionate about online learning and recently made a transition into human performance coaching. He is currently working on introducing the coaching model into medical education.
Shahbaz Syed

Shahbaz Syed

FRCPC Emergency Medicine Physician at the University of Ottawa, with a fellowship in Digital Scholarship, and an special interest in rational resource utilization. Additionally, holds a role as editor for CanadiEM, and is the junior social media editor for CJEM.