Spam, spam, advertisement, spam … wait wait, what’s this? A small envelope, addressed from Maine. I wonder what this is about? Usually, when I get an envelope this size, it’s a letter from someone trying to sell me something or complain about something I have no control over. So imagine my surprise when I found a short letter from Sidney R. Block, DO, referring to a Rheuminations column from the previous month. And it wasn’t hate mail!
The letter read simply, “I enjoyed reading your musings. … One question: Did you ever stop by the farm and ask the person who put up the sign what he or she meant by [Fuel Your Hunger]?”
Appreciative Inquiry has been described as a framework, a process or an orientation based on the principles of positive psychology. Developed by David L. Cooperrider, PhD, and Suresh Srivastava, PhD, in 1987, AI was originally applied in the business world to leverage the strength of employees to engage them in positively impacting the organization. The crux of AI is a focus on identifying what works in, and what gives life to, an organization. By focusing on these positive determinants and expanding on those strengths, an organization can grow in a positive manner and render its weaknesses moot.
While AI was originally met with some skepticism, more than 40 years later, evidence exists that AI may indeed improve such outcomes as productivity, engagement, well-being and employee retention. More recently, AI has been applied to healthcare settings, although a recent systematic review did not demonstrate consistent improvement in outcomes in high-quality studies. Nonetheless, AI has enormous potential to improve our work environment and healthcare delivery as a whole.
A Positive Lens
If this is the first time you’ve heard about Appreciative Inquiry, you may be sharing my initial thoughts: What a load of New Age crock! Everyone gets a trophy! How can we possibly ignore our weaknesses? But slowly, I’ve been convinced that perseverating over the negative is likely counterproductive, and identifying strengths and benefits is a more humanistic way to approach work dynamics.
Of course, I cannot summarize 40 years of research on Appreciative Inquiry into a 2,000-word column, but the pith is that when you orient yourself toward solving problems, you start to see the world as a set of problems, rather than a panoply of potential opportunities—the positive principle. Similarly, when you reframe and reclaim the words around you, you start to construct a reality that feels more aspirational—the constructionist principle. And because words seem to be most powerful when strung together in the form of stories, understanding what animates people through their own narratives may be a fruitful way to promote engagement and meaning in their work—the poetic and simultaneity principles. Altogether, when we reframe our world through positive thoughts and words, we start engaging in positive actions that lead us toward the realization of our goals—the anticipatory principle.
Appreciative Rheumatology
Well, that’s all fine, but how does this relate to rheumatology? In my mind’s eye, it has everything to do with our subspecialty. As rheumatologists, we are expected to be superior diagnosticians, to uncover what is wrong with people and systems. But rarely do we conceive our role as the people who identify what is right and what is correct. Even when we think of the word positive in the clinical context, we rheumatologists mostly use it to refer to the presence of abnormal antibodies that cause disease.
When we start to orient ourselves toward a truly positive lens, we find ourselves becoming better doctors. We begin to conceptualize ourselves as people who are not there to bust inflammation, but to support the patient’s sense of holistic well-being. That is the latent power of rheumatology that Appreciative Rheumatology can uncover: We don’t treat people only for inflammatory diseases. We provide support to enable our patients to find meaning in their health and life journeys.
We are facilitators of hope. We are advocates for joy. We are generators of positive possibilities. We are stewards of human dignity. We are custodians of our own self-care. We are cultivators of critical thinking. And we are a million other things that we choose to be.
An Appreciative Clinic
Appreciative Inquiry is all about dreams. In fact, it is the second step in the 4-D framework that Dr. Cooperrider devised in the 1970s (i.e., discovery, dream, design and deliver). What would my dream clinic look like?
In my dream clinic, I wouldn’t see people for their chief complaints, but rather for their greatest desires. I wouldn’t ask about deficits, such as swelling, pain or stiffness, but start by asking what they dream of doing if their disease were under better control. I would solicit stories of their everyday lives and what gives purpose to their existence—and then co-design a management plan that would get them to where they would want to be.
Of course, that is my dream. It is a dream I am sure is shared by many of you. To be honest, that dream is still far away, but Appreciative Inquiry can help us begin to figure out how to make this into reality.
For example, we can alter our own practices to embrace a more supportive patient model. In fact, I’ve already started to change the way I solicit the review of systems. Instead of inquiring about a laundry list of symptoms, I ask my patients, “If it is applicable, tell me a story about how the symptom I’m asking about has impacted your life.” Yes, it takes a little longer, but the data are so much richer. I find I’m repeating myself less and less because a more comprehensive narrative starts to emerge.
Another, quick way in which I apply Appreciative Rheumatology in the clinic is that I ask patients, just before their assessment and plan, what their dreams are and how I can be of service. I get robust answers to guide what type of pharmacologic and non-pharmacologic approaches I may incorporate to support that patient’s care.
I’ve clocked how much longer it takes to implement these practices, and for each patient, it takes only two extra minutes. The decision is simple: Spending two extra minutes with the patient is a worthwhile endeavor.
Solution to Burnout?
On a similar note, I see Appreciative Rheumatology as a potent tool to address the pervasive and seemingly insurmountable problem of burnout in the rheumatology community. Our current perspective seems to emphasize the features that lead to burnout (e.g., electronic health records, prior authorizations, poor salaries and moral injuries stemming from chronic illness and healthcare disparities). Reducing these through mandatory yoga sessions and online modules simply is not going to be enough.
Instead, let’s focus on what makes us thrive. In an Appreciative Rheumatology mindset, let’s think about what makes us the best people in the hospital to work with. When we are at our best, what inspires us to get up in the morning and have that elusive pep in our step? How can we build on our collective strengths and crowd out all the negativity that seems to inundate us? Instead of emotional exhaustion, let’s talk about emotional elation; instead of depersonalization, let’s talk about dignification; instead of reduced personal accomplishment, let’s talk about raising personal accomplishment.
This may sound utopian to you, but this is a step we can take right now. If we articulate a shared vision—a dream—we can create a destination in our mind and manifest it into reality. We can ask questions and interface with one another to collect and pool our strengths. We can advocate as many people with many dreams but with one goal: a work environment in which we can thrive. Doesn’t this sound like a more fulfilling and sustainable approach to our work?
Research Driver
Moreover, Appreciative Rheumatology can also serve as a driver of research by encouraging us to focus on positive outcomes and strengths-based interventions. This approach can help us move beyond reductionist approaches and focus on promoting overall well-being.
How many times have we seen the next blockbuster drug suddenly fizzle out because it may have met the benchmarks for symptom reduction but did not do its job in improving the quality of life? Arguably, even for relatively simple interventions—masks and vaccines, for example, and our emphasis on preventing death and morbidity instead of focusing on how they empower individuals to regain agency in their lives in the midst of a pandemic—has been counterproductive.
An entire compendium of literature showing the power of placebo exists. It’s been conceptualized as a nebulous concept associated with easy suggestibility. But let’s flip this around, Appreciative Rheumatology style. Consider the placebo effect as an affirmation of the power of human aspiration. It can potentially make a sugar pill as effective as a tumor necrosis factor inhibitor. Perhaps we should study those who possess this alchemical superpower and figure out how we can inculcate it within ourselves.
Advancing Diversity, Equity & Inclusion
I must continue to meditate on one aspect of our practice to see how Appreciative Rheumatology fits with respect to diversity, equity, inclusion and belonging.
Positive thinking has intense power and identifying positive outliers has value, but I am less optimistic that positive thinking by itself can help resolve the long-standing social injustices present in our nation and our world today. Moreover, I fear that by emphasizing positive thinking and upliftment, we enter a zone in which we unintentionally neglect systemic disenfranchisement and inaccessibility to opportunity.
We cannot pat ourselves on the back with the degree of progress we have made because, in many ways, our initiatives continue to be fragile and lack sustainability. Certainly, those of us with privilege have to move away from self-contented allyship, but what, exactly, is the shape of that positive goal? Perhaps we should highlight the doers who continue to fight endlessly for the ideals they embody. Maybe it makes sense to review Martin Luther King Jr.’s dream in the context of today’s era and to brainstorm creative, equitable and inclusive solutions to effectively put into action those cherished ideals and values, instead of treating Dr. King’s words as a historical artifact.
I wonder if we should all take inspiration and imbibe the sense of pride that our friends and colleagues from the LGBTQIA+ community are boldly exhibiting. These are rheuminations for another day—a day I hope will come soon.
We Have the Power
The best thing about Appreciative Rheumatology is that we have the power to institute it here and now. As human beings, we have a nearly infinite ability to dream and an unrivaled capacity to communicate and collaborate. The tools of Appreciative Rheumatology are largely free and easy to use. However, they do require training, vigilant mindfulness and deliberate practice.
Translating Appreciative Rheumatology from the pages of The Rheumatologist into a flesh-and-bone reality in our clinics, labs, classrooms and beyond requires bold leadership, visionary thinking, empathic dispositions, collaborative mindsets and the willingness to embrace uncertainty. I am so grateful to participate in a vibrant community that does not lack any of these qualities. You empower me to dream boldly—and for that, I am a deeply appreciative rheumatologist.
Bharat Kumar, MD, MME, FACP, FAAAAI, RhMSUS, is the associate program director of the rheumatology fellowship training program at the University of Iowa, Iowa City, and the physician editor of The Rheumatologist. Follow him on Twitter @BharatKumarMD.
References
- Merriel A, Wilson A, Decker E, et al. Systematic review and narrative synthesis of the impact of Appreciative Inquiry in healthcare. BMJ Open Quality. 2022;11:e001911.
- Cooperrider DL, Srivastva S. Appreciative inquiry in organizational life. In Woodman RW, Pasmore WA (eds.). Research in Organizational Change and Development. Vol. 1. Stamford, Conn.: JAI Press; 1987.
- Hung L, Phinney A, Chaudhury H, et al. Appreciative Inquiry: Bridging research and practice in a hospital setting. Int J Qual Methods. 2018 Apr 18;17(1).
