Healthcare professionals charged with the responsibility of supporting those in need of healing find themselves at a unique place in human history. A large percentage of practitioners are faced with the dilemma of whether to continue to practice under the old model of health care or transform their practice to reflect current knowledge. As a healthcare practitioner, I will share my story of coming to terms with this dilemma of change utilizing a casual interview format. Tracing the history and context of my experience offers insight into the healthcare profession's position in general. The questions include basic self-reflections such as, "Who am I/are we?", "How did I/we get here?", "What can, shall, and would I/we like to do?", and, "What aren't I/we?" I conclude the interview suggesting possible scenarios for creative choices for future healthcare practice.

Healthcare professionals find themselves at a unique place in human history. Never before have so many humans had the ability to reflect on such a volume of emerging information and theory suggesting the need for a transformation of their worldview, while at the same time continuing to practice in a contrary manner. Historically knowledge of such profound changes was limited to an isolated few, while the remainder would continue on in their practice un-informed. However, in this day and age of abundant information flow, one must ask why our practice is so slow to follow the changes in theory?

What follows is a format for answering that question by sharing my personal experience in this transitional phase of healthcare. I will narrate my story in a casual environment employing an interview format. My intention is to create a tool that will be an accessible platform for engaging other healthcare professionals in reflecting on their respective questions of meaning within their practice.

The interview is divided into the four topic sections as outlined in Table 1 below. Feel free to browse topics or specific questions of interest.

While the primary orientation of this interview reflects my experience as a physical medicine rehabilitation professional and yoga therapist, the issues examined apply to all health care professionals as we stand poised at this figurative fork in the road of practice. Do we continue down the familiar beaten path, or choose to blaze the new trail with all of its uncertainty and promise? The path we healthcare professionals take, both individually and collectively, as a group will alter forever the collective story of healthcare. By our choices, the stories of the individual patients' lives will also be inexorably rewritten.

What is the dilemma healthcare faces today at the fork in the road?

Healthcare faces a dilemma. On the one hand, healthcare is practiced in a manner that reflects an outdated, limited worldview. On the other hand, healthcare is confronted by evidence that the foundations of certainty that the old worldview rested on are crumbling under the increasing weight of evidence to the contrary. This creates the figurative fork in the road... do we continue down the wide, comfortable road with our well worn map of familiar practice? …Albeit, with the sinking feeling that we're making good time but suspect we are headed in the wrong direction! Or, do we veer at the fork in the road that suggests "the right direction," but is unfamiliar and uncertain based on limited traffic and no map or experience to guide us? This is the dilemma.
Healthcare is not alone in this dilemma. What seemed a foundation of certainty in the old worldview in which to operate and plan, is daily being discovered to be inadequate to the task of enabling individuals and organizations to deal effectively in a complex world. Healthcare is merely a microcosm of the need for change that is present in every other aspect of human interaction, e.g. business, government, services, and society. The adoption of this new emerging worldview will require changing or transforming every facet of individual and organizational life.

What is the old worldview? Presently healthcare providers find themselves attempting to support human health utilizing the old worldview of simplification. By simplification, I mean the dominant paradigm of the last 300 years that can be summarized as operating in the world under a mechanical metaphor. If one can take some whole machine composed of numerous parts (i.e.. the human body) and examine each of the composite parts to discover "what" each part is composed of, then one would understand the larger whole having simplified the composition. I don't wish to discount that this process has provided important understanding of the parts that has led to the incredible advances in medicine in the last century. Unfortunately as the last century drew to a close, the professions and society also found themselves frustrated with the outcomes of the simplification worldview. The growing mountain of parts of evidence found our system of healthcare in the paradox of offering both the best and the worst aspects of care. Western science through the simplification worldview developed incredible procedures and technology unparalleled anywhere else in the world. The isolating, reductionistic simplification of the worldview also wrought a dispassionate, dehumanizing delivery system of healthcare. Both those who delivered the service, and the increasingly smaller number of consumers who could access the system have experienced this sense of being dehumanized.

What I hope to share in this forum is both an insight into how we got to this dilemma and, based on emerging theories, what creative choices we as healthcare workers might seize to deliver both the patients and ourselves from this dilemma. The point I hope to underscore is that there is no simple way out of the dilemma. Complexity is inherent in the dilemma, and it is only by adopting complex thought that we can hope to begin to untangle the complex knot we find ourselves in as healthcare professionals.

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How could this happen?

Appropriately since I am arguing against the simplification worldview, there is no simple answer.

I would like comment on several of the factors that have influenced my transformation from the old worldview. I believe these comments will at the same time mirror how we as a group find ourselves in the dilemma. In my experience, the 4 primary factors include:

1.) the blinding aspect of paradigms;

2.) a penchant for control;

3.) organizational power;

4.) fear.

The blinding aspects of paradigms
Worldview and paradigms are often used synonymously, and will be used as such in this discussion. The word "paradigm" has been used so frequently in the past decade that people tend to gloss over it or fail to appreciate the full depth of the concept. Morin (In press) describes paradigms as, " 'supralogical' principles of organization of thought, or paradigms: the hidden principles that govern our perception of things and of the world, without our being conscious of them." The "hidden" aspect of paradigms is what creates my blindness to my organizing principles of thought.

I continue to be "surprised" during self-reflection when I notice how readily I blindly accept the word of authority figures as "reality" without critically examining the underlying assumptions carried by the authority. This tendency to accept as valid and the "truth" merely reveals a deeper layer of how ingrained the deterministic, linear and mechanical paradigm is woven into our culture and our view of the world. For a more in-depth discussion of the philosophical description and arguments of this mechanical paradigm, click here. Enter www.yogatherapy.com/epistemology.pdf into your web browser is this does not link directly.

My experience has been that through both undergraduate and graduate school training, as well as numerous continuing education courses, the empirical paradigm was always presumed valid and never critically examined. This presumption creates such a momentum that I never stopped to question the premises of my inherited worldview. Rather, a false sense of unexamined certainty arose over time.

Eventually, an internal conflict developed when all of the "parts" were not adding up to my experience of healing with my patients in the clinic. Despite the stack of continuing education manuals (appropriately named for fixing equipment), I "knew" there was something beyond just mechanical body parts alignment required for healing to occur. My "blind spot" wasn't a lack of data or information. After all, I fancied myself as an amateur theologian (spirit parts). I have an undergraduate science degree in psychology and am a confessed self-help junkie (mind parts). Coupled with the anatomical and biomechanical informational parts of a dedicated physical therapist, I should have had plenty of parts. In reflection, I think I did, but I had never been taught the relationships between all of these parts. That is, how are all of the parts related and how do they interact to produce health or the absence of it? How does spirit influence mind? How does the mind influence the body? How does the body affect the spirit and mind? These are but a few of the multiple, complex interactions which had never been the focus of my knowledge base. All of these subjective relationships required my being able to "see" the complex ways that these aspects interrelate to create either health or dysfunction. The old worldview spent little, if any time examining how the quantifiable physical nature interacts with the increasingly subtle, ephemeral facets of mind and spirit.

My view of the world was dramatically altered when the blinders of the linear, "either/or" mechanical parts paradigm were lifted during my discovery of the complex yogic model of health. Not that the yoga model contained truth with a capital "T", but it demanded a multi-perspective considering body, mind and spirit of the patient and how they are interrelated. The model requires the yoga therapist to consider every possible relationship in an amazing tapestry of interrelated interactions, e.g. how emotions guide thinking, how movement reflects spirit, and how breathing affect thinking. To this day, despite 8 years of diligent effort to foster complex thinking, I often catch myself stuck in the ruts of the old paradigm. There are certain efficiencies, mental sloth, and momentum of habit which seem to pull these blinders back down.

A penchant for control
In addition to the episodes of blindness, I have experienced an attraction for the alluring appeal of the old paradigm and its promised "certainty." If I only discovered the right parts of "A & B" for condition "C", then I could be certain to attain outcome "D." I wonder if this desire for control through "certainty" is related to the ancient human archetype of seeking mastery or sovereignty over one's own destiny? Throughout history there is something about being a human that contains a desire for control over events, possibly even genetically linked to survival? The tempting beckoning of the linear, determined approach of just putting all the right ingredients together to reach the whole or health is difficult to resist!

A cooking analogy may help to illustrate my point. Clinically, over and over experience has confirmed that merely assembling the ingredients (techniques and procedures), does not guarantee a soufflé (healing). For only an experienced chef who can marry the ingredients (by having discovered relationships amongst all the ingredients and procedures) produces a culinary masterpiece (the clinical outcome). So often, without understanding relationships, the final product is a disappointing flop, if not a disaster. So, in the end, in the parts paradigm control (read: outcomes) has an illusion because of the absence of relational knowledge. Just as in this amateur's kitchen, the tendency towards disorder and chaos as acknowledged in the new worldview, would have their way. At the end of the day, I was disappointed in my practice results and in a larger sense, contributed to the national outcomes of overall increased expenditure with declining national health.

Organizational power
The old paradigm of simplification proposes the illusion of oneself as an isolated, dispassionate entity working on unrelated, broken objects. I did not realize how by maintaining that worldview of me being "separate," I was in fact blind to the relational power of the various organizations all around which are woven into my identity and reality.

Organizational power or influence, whether from my nuclear family or the larger organizations of society and Western medicine, has a very real effect on my knowledge and view of reality. My identity and values are not created in isolation, but are dependent on my relationships with others. In some cases this power would be exerted as, power over, such as regulatory statutes, professional standards, or office procedures... "This is reality and this is how you practice, or else." At other times, the effect of my interactions with organizational powers was more subtle.

Organizations can wield their influence by limiting alternative viewpoints from being introduced or discussed in journals, conferences, classrooms or other sites of legitimacy. Since the individual does not see or hear those alternative voices of others in official communications, then the implication can be, "It must not be real, because no one is addressing or talking about the topic". Even more subtle than controlling what knowledge was communicated, was the tendency for organizations to market a certain contentment with the status quo. The upbeat spin of publications and conferences in blatant self-promotion reinforce messages such as, "There are plenty of jobs, regular raises and unlimited opportunity; in other words, why rock the boat looking at that?"

Organizational power is an insidious, invisible force that is difficult for the individual to become aware of its incredible influence. Again, the paradigm of parts never suggests that we examine the influence and relationships our various environments and organizations have on our view of reality. Hence in the end, like a fish in the sea lacking awareness of the water surrounding it, we are unaware of the presence of organizational influences all around us. Just as it takes the sudden change of being "out of water" to alert the fish to the importance of its surroundings, for us it seems to take some drama to raise our awareness of organizational influence. Only in flopping around on the shore of limited visits, denied services and increasing productivity demands do we appreciate the importance our environmental relationships has on our practice "reality."

Fear
There are, by the definition of complexity, a myriad of influences that support the complex development of this dilemma of practicing in a manner that defies emerging evidence. I believe the raw, primal emotion of fear is often overlooked and quite possibly a primary influence. I know for myself, fear becomes the dragon I have to contend with most often as I disassemble my old paradigm. The nagging and haunting questions of, "What then?", "Who says?", "Who will pay?", "Are you sure?" and on and on, all are voiced by a pervasive fear response.

Who wants to talk about fear? Notice… that old controlling, deterministic paradigm scorns the subjective, casts it aside, and calls for more object-ive evidence. Such vulnerability, uncertainty, and messiness literally have no place in the old worldview. Emotions and relations are merely "noise" or "error," so how can those variables influence reality? Who wants to be "out" of the organization, questioning, causing trouble and acting "unprofessional?" What attractor to the new worldview would be strong enough to motivate one to move beyond such a paradigmatic prison of fear?

So today, most of us, as both individuals and entire professions, march down the more familiar road of the old worldview, but all the while experiencing that annoying feeling that we are headed in the wrong direction!

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How did you become a spokesperson for change in the practice of healthcare?

At the risk of sounding vain, I ask this question of myself because by responding to a call for a new worldview beyond the fear of the old, this is the position I find myself in today.

Seven and one-half years ago I had not yet completed my yoga therapy training and was still seeing a full, traditional physical therapy daily patient load. Now I present at state conferences, write professional articles, have contributed to the first textbook on complementary methods in rehabilitation, and have completed candidacy portion of my doctoral studies in integral philosophy of transformational learning and change. I am also preparing to host the first ever symposium of dynamic systems oriented rehab professionals. All of this from the guy who used to resist having to phone in a delivery pizza order! Did I arrive here by following some linear, rational five-year plan? Am I achieving my objectives? Will I reach my goal on time? The answer is to "no" to all three questions. There is no plan, I have no measurable objectives, and I literally have no clue where this whole process will take me.

In reflection, I would equate this process to being a gradual disassembly of my old mechanistic paradigm. As I search for the words to describe the process, I am experiencing firsthand the complexity of this story. I want to begin by saying it all started when a yoga class healed my chronic back pain... but that only happened because a patient asked me to offer the class... but that only happened because we canceled our building expansion... but,…can you see the circularity and interrelatedness of the events of life? Oddly, we can all appreciate a well written novel that reveals all of the intricacies of tangled relationships and events, but deny such a world when we step into the clinic or laboratory. Suffice it to say, the complex interrelationship of events and experiences gradually eroded the facade of the old paradigm, loosening my need for control, exposing the influences of the power of organizations, and addressing and overcoming old fears.

While blinding, dramatic Paulian conversions of worldviews can occur, my experience has been for most of us changing paradigms is a process rather than an event. Only a committed, gradual immersion with a focused dedication into a deeper inquiry has held this process together. Strangely, despite the uncertainty, and yes, messiness of this new reality, there is the paradox of order and security as well. If that doesn't make sense, then your paradigm has just confronted mine! Allow me to share a few of the unique influences that have contributed to my story, in hopes that it may allow you to recognize hidden or latent characters within your own story.

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What were some of the key influences in your experience?

Each person's unique story of transformation has its own cast of leading and supporting characters. Mine is no different. I didn't win the lottery, I am not rich, and I am one of two breadwinners for a family of five. Not claiming to be an isolated hero playing out the archetype, I can now appreciate being carried along in a sea of relationships that has resulted in my current circumstances.

My intention is that by sharing my "typical" cast, the reader may better be able to recognize and appreciate their own interwoven relationships of support.

The critical element, I believe, is my stable, growing relationship with my wife of 24 years. Both her challenging me to do my best and her unflagging support have been the primary source of energy for my transformation. Having that one person who shares the vision has carried me through many low points. She has many times effectively been my one island of certainty negotiating this sea of complex uncertainty. Granted that certainty is an illusion... our certain relationship has been my reality!

Secondary influences include a love for reading from my mother; a dedication and devotion to doing what is right from my father; and, a tireless work ethic from both of them. A rekindling of curiosity and discovery during this process has also fueled my ambitions. Fears are no longer seen as impenetrable barriers, but as doorways behind which lie new adventure and discovery. Please understand those fears are still very much present, only now there is an attractor that motivates me to look through or beyond the fears.

One other character (in all respects of the word) and critical influence has been the development of my learning community in my doctoral program. Hardly "heaven on earth," still this diverse, sincere bunch we call a cohort has offered me a home where my perspectives and experiences are supported and validated. Without this web of support, I am uncertain how, or if, I would have continued this process of transformation from my old worldview to that of the new complexity paradigm with all of its relational demands. Historically I have been a loner in the sense of being introverted, a sole proprietor, and preferring a good book to a party. In retrospect, my personality was such a nice fit and so self-reinforcing within the isolated observer framework of the old paradigm! How easy it was to stay comfortably in that paradigm with controlled, superficial relationships. I now believe it is only possible to "know" about complexity on all levels by being immersed in one or more communities with all their complex interactions, upsets and unpredictabilities.

I am now very suspect of someone who claims to see the world in a complex/relational view but remains aloof or isolated from deep, messy relationships. As imperfect as the formal learning community I belong to is, its presence goads and demands of me ever deeper levels of inquiry. I would be surprised if any individual could ever see or identify all of their own blind spots. It is only through engaged communities where others will risk by inviting one to go deeper in their inquiry that most individuals can move from the old isolated view to the new paradigm of relationship. Hence the relationships of intersubjectivity create the connections and relations. Paradoxically, in an "and/both" reality of relations, AND intersubjectivity threatens the very fabric of the community by the tensions arising out of deep relationships.

In coming to find myself a spokesperson for change in the practice of healthcare, I can now appreciate the benefits of chance and the uncertainty of letting go by engaging in deeper levels of relationship. My experience suggests that it is only in this complex weave of interaction that the individual AND the organization can hope to find wholeness or health.

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What have been some of the surprises for you?

Brian Swimme writes of how the universe delights in surprise. I would say "surprise" is one of the better words for characterizing this whole process of transformation. I have been surprised by how many generous and caring people I have made friends with along the way. I am surprised at the power of technology to bring people together, as well as leave them isolated. I am surprised how frightened so many people are. I am surprised how strange it feels to experience both certainty and uncertainty simultaneously. I am surprised at the deep potential every individual holds.

I am also surprised… at how easy it is to lose focus. How uncompassionate I can be with myself. How pervasive fear is every day in my experience. How hungry others are for a new message or worldview. How difficult critical self-reflection is to maintain. What a different world exists through a different paradigm. How anyone could be bored. And, what incredible beauty lies awaiting every breath.

The biggest surprise is to wonder why it seems so many people resist or avoid inquiring more deeply into their reality? What kind of attractor would it take to overcome the inertia of the present dominant mindset? It is my opinion that by retelling our story from the perspective of the emerging worldview there is a very real hope that the next big "surprise" will be how quickly the transformation of the old worldview to the emerging relational worldview takes place.

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What is the emerging worldview/paradigm?

Well it is just that, emerging.

Exactly how it might be described or what name it may go by has not been determined. Some of the names bantered about are: Quantum view; relational view; complexity thinking; dynamic systems view, etc.

Possibly the most significant factor is what it won't be. It won't be a single, universal truth in any sense of the words. Rather, the new paradigm is thought to encompass a continual unfolding of diverse, complex relationships with multiple perspectives and ongoing development. We, as humans, are limited in our epistemology (understanding of what there is to be known), and consequently will never know the "Truth" in a final, complete realist form. This is significant, because in the past attempts have been made to articulate a paradigm that would encompass all of reality, or a positivist worldview. (For more details on the philosophical development, click here. Enter www.yogatherapy.com/epistemology.pdf into your web browser is this does not link directly.)

This emerging worldview invites, in fact necessitates, a continual, critical intersubjective questioning into itself as a paradigm. No falling asleep at the paradigmatic wheel, so to speak, allowed. See Table 2 below for comparison of the two worldviews.

Table 2: Worldview Properties Chart

While the past positivist, mechanical paradigm emphasized reduction, abstraction and disjunction for the pursuit of knowledge, the new complexity paradigm inclusively maintains the value of the old paradigm, rather than exclude it outright in a disjunctive fashion. This complex thinking then goes beyond the old paradigm to bring balance by reconstructing relationships, noting conjunctions and exploring ecological interactions. A simple way (oh no, an abstraction!) to summarize the differing worldviews is to compare aspects of both. The old paradigm preferred linear, binary and Aristotelian "either/or" answers to reality. The new worldview is circular (recursive), hologrammatic (the whole is contained within the part) and favors a dialogic answer of "both/and" when considering reality.

What are the implications of the new paradigm in healthcare? How is the human to be supported in their quest for health? No longer considered a "dispassionate object to be fixed," the patient is suddenly allowed to express their full complexity. Moving beyond the fashionable "Body, Mind and Spirit" logos, health-care professionals will need to see the patient as a part of their larger whole. The complex interweavings will require flexibility, compassion, and creativity to fully support the patient. Exactly how these healthcare relationships might look and the challenges adopting the new paradigm represent are discussed in a later section. For now, suffice it to say almost every relationship will have to undergo change, e.g. patient to healthcare professional, patient to ancillary staff, and professional to financial intermediary.

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What are the scientific and philosophical underpinnings for such a view?

Interestingly enough, the old paradigm's parts are responsible for bringing us to this new view. As science explored both macro and microphysics it discovered what Morin (In press) calls "cracks" in its own foundation. Astrophysics revealed rather than a linear or static universe, our universe appears to be one that continues in a dialogic process of order/disorder, with continual degeneration and regeneration intimately linked in an unending creative process. No fixed sky overhead serving as a backdrop or the Earth as static stage for the human drama underway. The same has occurred in microphysics as we discover what appears to be a very uncertain and nebulous reality rather than some ultimate basic building blocks or objects of reality on the subparticle level. So it is this peering in and peering out by science, which has brought science to be what Swimme defined as "the yoga of the west." This process of the parts giving a way to uncertainty and unpredictability at all levels of life is gradually bringing to light or enlightenment, a new reality in the west.

I find a sense of awe in exploring the relational impact of these parts discoveries on what have been considered the "unscientific" aspects of knowledge to include religion, the humanities, and spirituality. Wading through biologic complexity and chaos theories has brought me to a deeper understanding and knowing of not only my personal, ethereal spirituality, but how it is intimately interconnected with my love of physical health and healing. This understanding is not some grand, rose-colored glasses "everything is in harmony" New Ageism, but reveals the incredible creativity behind the harmony/disharmony, order/disorder and all of the other paradoxes and dichotomies the universe delights in crafting to create surprises. I experience that hologrammatic sense of the surprises within my small part of the story and simultaneously, how I get to participate in so many others' ongoing stories in the larger, whole story.

What a rich and vibrant world of emotions, reason, curiosity, and awe this new paradigm liberates for those who dare to inquire at deeper levels.

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What are the barriers to adopting such a view?

I commented on this briefly when I described the factors that seem to generate the momentum of the old paradigm. Those factors were the blinding aspect of paradigms, a penchant for control, organizational power, and fear. Additional barriers include our systems prevailing political structures, economics, educational system, the effects of mass media, and so many other subtle and not so subtle barriers.

Again we are met with the complexity and circularity of relationships where there is no simple answer, rather multiple intertwined causal factors, all of which continue to operate within the old paradigm. I therefore fall back to what for me personally has created an opportunity to move from one paradigm toward this new paradigm in hopes that there are shared elements to help the reader identify their own barriers.

Further expanding on the blinding aspect of paradigms as it relates to what our culture defines as knowing is a factor I found helpful. The old paradigm equated knowing to be that which one can construct a rational, linear, symbolic argument based on logic. If reality appeared to offer a paradox with inherent illogical conflicts, that would be relegated to the definition of a mystery, or more likely be ignored completely and delegated to the "soft" sciences of psychology, religion or philosophy. Consequently, because complexity and relational knowledge so often falls outside of that linear manner of knowing, our culture and view of other ways of knowing was labeled invalid or mistaken. This leaves both the culture and the individual in that previously stated dilemma of following the limited way of knowing of the old paradigm, and yet "knowing" there is something lacking or some other direction that needs to be considered. It is this other "knowing" that suggests a way through this immense barrier to paradigm change. The emerging paradigm of complexity offers an expanded epistemology that includes multiple ways of knowing, only one of which is the old logical, conceptual-linguistic framework.

The other ways of "knowing" allowed by the new paradigm include experiential (that which we know through experience but may lack language or expressive capabilities), presentational (our ability to express knowing through nonverbal forms of understanding such as art, music, movement, etc.), and practical (skills and abilities of action/movement). These ways of knowing offered by Reason as might be expected, are all interrelated. He argues that all of our knowing is grounded in action, from which flows experience, then subsequent presentation of the experience, to propositional linguistic construction of meaning of that experience, which is then tested again in action.

The clinician can identify with this pattern within practice where one collects history and signs, runs tests, tries procedures and interventions, develops assessments, refines history, adjusts procedures, etc. in the cycle of healthcare practice. There it is... the word practice... how could our practice become so entrapped by theory, that we had thrown out social interaction, intuition, affect and patient's presentational knowledge that are so much apart of our daily patient relationships? The old paradigm restricted our practice to a cold, impersonal observer-object interaction, denying the richness of knowing offered in these other three ways of knowing. But, we "know" that our actual experience and action involves a circular, recursive flow of the art of healthcare, not some "by the book" program. We are told one story and live another, producing that nagging sense or feeling of conflict, but lacking the language to articulate the disconnect of the old disjunctive paradigm.

I believe the transformation in paradigm views can only begin when we individually and collectively honor that feeling of misdirection and begin to explore through all four levels of knowing in a cyclical, reflective manner of practice based on action. Such a transformation will require reevaluating how we communicate and inquire our pursuits of knowledge. For more on how this might look, click here. As a practical application and reflection, we will move ahead to consider the creative implications of such a transformation.

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Where do you/we need to grow the most?

If by "grow the most" I mean change in order to adopt the relational/complexity paradigm, I think there are number of areas that I need to develop, and not by chance, so do most healthcare practitioners. I will build my answers on the conceptual framework of the four ways of knowing.

Conceptually/linguistically I need to find a voice for not only clearer linear construction of concepts in my verbal and written communication, but I must also find a way to describe circular and "less objective" ways of knowing. We as a culture lack experience and clarity in sharing non-quantifiable concepts, and therefore we risk being lost in endless circles of clarifying symbolic and linguistic meaning. I will need to develop the patience and engagement of reiterations of communication that will be required in formulating conceptual knowing through dialog and new vocabulary.

Experientially I need to enhance my level of awareness and honor the experiences of the moment. The challenge in being present to the moment and not heading off into some conceptual reorganization or labeling process is a full-time job in itself and an ancient problem of the mystical traditions. The old paradigm represses or disregards these ways of knowing, forfeiting intuition, the wisdom of subtle awareness, and all of the other in their view "noise" of messy, human interrelationships.

Tied into this process of awareness is also a need to develop the skill of critical self-reflection. Our practice is a race headlong into maintaining productivity without cause for recursive reflection and integration of the subtle aspects of practice. This is what led to my chronic back pain condition, and it was only in creating space for reflection that I came to "know" the effect of unremitting stress and striving. I believe this absence of self-reflection is mirrored in our profession at large by the high incidences of burnout, job-hopping, and diminished personal care amongst healthcare professionals.

The area I need to improve most on is my presentational knowing. I enjoy drawing and creative writing, but rarely do so. I also utilize my yoga asana as a form of movement expression for what I am experiencing internally. I have a sense that more time spent in expression would offer deeper personal insights as well as the nuances of cultural experience. The same can be said about the rat race pace of the typical healthcare practice lifestyle. What if the healers spent a couple hours a week turning inside to draw out their experience of their practice through the various media of presentational knowing? My sense is that it could only lead to a more present, compassionate practice in the clinic.

The final way of knowing, practical, would be augmented by my altering my perspective during patient care. Formerly my perspective was one of "doing to the patient" during my action as a therapist…I knew what they needed and "did it for them." Now, less certain and appreciating their input as part of the clinical wisdom, my perspective is one of "exploration or inquiry" with (in relationship with) the patient. This form of discovery has required my mind shift from "knowing the truth" to a playful curiosity of, "Let's see what might work here?" The amount of pressure relieved by such an attitude, combined with a keener level of observation by continuing to inquire seems like it would be better for my health, and increase the number of subtle relationships I could identify. This would also seem to make patient interactions more compassionate and understanding for both parties, enhancing the health of the individuals and the organization!

So how does one go about making such shifts? I would suggest one step at a time and taking very tiny bites! This is another of those paradoxes... the old paradigm says, "big steps and big bites lead to big change." The new paradigm embraces tiny changes, or perturbations, as the key to big change, or as they say in yoga, "It is not how far you go, but how you go far." This is the process we explore in the next question.

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How are you/we creating your/ourselves in this process of self-eco-organizing?

First of all, what is self-eco-organizing? That is a term Morin (In press) uses to describe the complex processes by which life organizes. It can be applied to the individual, species, or the entire ecosystem. The term embraces the autopoetic (self creating) properties of living systems not as an isolated, sealed off event, but within the living system's greater environment (eco or ecology). This is a fine example of the need to construct new linguistic symbols to communicate within the new paradigm. All of the words bring together a concept that literally did not exist within the old paradigm.

For myself, I am attempting to stay engaged in all four ways of knowing throughout each of my daily experiences. This includes family life, business interactions, community service and school. It involves a moment-to-moment reconnection to as many of the different relationships as I can discover. At times this process is overwhelming, while at other times being quite satisfying. I have tried to honor my experiences, particularly trying to note when my physical experience reveals a sense of stress through shallow breathing, muscular construction or mental discomfort. The foundation for me is my personal practice of yoga which utilizes all four ways of knowing. There are multiple other practices of self-development, but all of them hinge on the discipline of a personal practice. Honoring the insights gained in my practice leads me to inquire where my misperceptions or sense of loss of relationship might exist. When I'm able to "catch" myself stressed and then look deeper, I am pleasantly surprised by the clarity and number of creative options that I have available for me to choose from in my environment.

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How would healthcare be creatively affected by such a choice?

I believe health is a matter of both individual and collective choices made in such a manner that they lead to the greatest level of diversity and opportunity in the future. Constraints or limitations on those choices narrow the potential interrelationships and consequently the opportunities for creative/innovative choice. Can you see how seeking multiple perspectives flies in the face of the old paradigm, seeking the one right answer?

It is not to be confused with a call for random, relativistic "anything goes... all choices are the same", but a sense that there is always a spectrum of choices, each of which could lead to multiple scenarios. Therefore the new paradigm requires careful study and multiple interpretations of the present assumptions underlying current circumstances, as well the assumptions carried forward by the respective choices in any type of decision process.

In a healthcare setting this would require a more thorough engagement with the patient, to understand their assumptions, their ecology, and how those factors may interact with any treatment intervention. Furthermore, in the healthcare professional would be aware of their own underlying assumptions as a practitioner, remaining conscious of how such assumptions will bias their interactions with the patients, and that the patient may in fact know more about what they need than the professional! Can you begin to see why a subset of complexity is complication?

No one said this choice was either easy or simple, only more reflective of our present understanding of reality. There are multiple other perspectives or meta-perspectives to maintain, for instance the interaction of the office environment, the side effects of the treatment intervention, and the individual's experience of the moment. The healthcare professional of the future will need to be flexible, well-informed, open to change and dedicated to the emergent process of healing rather than some linear immediacy of outcome.

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How might you allow your creativity to express itself more?

The old paradigm might be rearing its ugly head here, but in the realm of healthcare there are some ethical considerations that go beyond "free, abandoned, artistic" practice. There are very real life-and-death considerations, and we are aware of certain signs and symptoms that in the new language "point to high tendencies" for the need of specific, life-saving protocols. I say this in the spirit of taking the "middle way," rather than the tendency to exclude the old way of limited creativity in favor of unbridled creativity. So under this disclaimer, allow me to share some of the ways others and I might express our creativity.

I believe the adoption of a self-caring, disciplined personal health/wellness practice that nourishes, challenges and stretches the individual's perceptual framework is a critical first step. Exactly what this practice is dependent on the individual's personal preferences, but it must meet all of the criteria listed. For me it is my yoga practice. If we, as proponents of health, fail to nourish and make creative choices for our well-being, how can we expect anything but the same from our clients?

This new paradigm requires moving from an egocentric perspective toward a community oriented, relationship view. I am finding in the groups I am involved in, that by being open to a deeper inquiry and increased risk taking that such self-disclosure invites reciprocal disclosure leading to a diversity of options that did not exist before. The "AND" is that I also have to maintain a higher level awareness of my own emotional state and avoid my historical reactive patterns of shutting down. Before, I would wall off that experience as something outside myself and presume it was a defect of the "other." Now, when things don't go well in a group setting, I try to make that the focus of my personal reflection, identifying what fears or other barriers are surfacing at the moment. This creates a circular pattern of weaving my group experiences to my personal and back, which serves as a conjunction rather than a disjunction of two "parts" of my life.

I wonder if we established small groups of learning communities within the present healthcare practices, if that might not facilitate both the community of the practice and the personal development of individuals? Immediately the old paradigm sends up a long list of barriers and excuses why establishing small groups would not work. Past experiences with groups, time constraints, avoidance of group dynamics, who is going "pay for it", etc. Despite these initial objections, this seems to be an area where the whole process of healing could hinge. In fact, this is my area of investigation in my dissertation... creating small inquiry communities of healthcare professionals and patients in inclusive attempt to create healing for the healer and the patient.

In summary, I believe a personal practice of integrity, honoring and acknowledging all four ways of knowing is critical to allowing the creative aspects of living to be fully expressed. This practice must be engaged both privately and in community, as it is only in relationship that we come to know ourselves and consequently our role in community. Then it will be a matter of each of us expressing our specific role through action that will allow the creativity of chaos and disorder to be expressed in higher levels of order, relationship and health.

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What do you see as the integral issues facing healthcare?

To be honest, at times it seems healthcare is so deeply imbedded in the current system that it will only be out of the ashes of the old system that a new system could arise. But this position seems to me to be rather polarized in itself. Certainly the tangled web of insurance companies and government, mixed with the power of pharmaceutical companies and the AMA seems a formidable force. This is where the power of leverage points and small perturbations of living systems offers a hope for internal transformation despite the apparent odds.

I believe that many of the conditions heralded by the press as the ominous shortcomings of the current system contain the potential for such a dramatic change. The increasing shift of financial responsibility to the individual, the widely available level of health information, the increasing levels of stress and loss of community, and the oncoming tidal wave of aging baby boomers all contain both the best and worse possibilities for the future. Let's look at some of the future practice scenarios to appreciate the opportunity, as well as the danger each presents.

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How do you address the "head AND heart" issue of compassionate care?
By "head AND heart" I refer to a manner practice that reflects a relational worldview. Rather than a computer program model of processing evidence and executing interventions, the new model would be one of sharp, well-informed intellectual wisdom coupled with a sensitive, compassionate awareness of the whole ecology of the patient. To repeat, this new model builds on the work of the past and continues to discover increasing levels of refinement (head) in reduction, abstraction and disjunction. AND, the other ways of knowing are integrated and enrich the conceptual knowing by delineating relationships and the interactions of the whole.

Presently for myself, I find that my greatest area of need is when there is an issue that requires confrontation or acknowledgment of "heart-level" knowing. Again, the lack of language and experience in this process presents as a new and sometimes intimidating process. I have found that by taking small bites and practicing in as gentle a manner as I can, I gradually seem to be developing some practical knowledge as well! The level of heart connection or intimacy in the healing experience then becomes that much deeper and self-reinforcing. From a pragmatic, business standpoint engaging at this heart level also becomes the ultimate in relationship marketing. Definitely a win-win experience in all directions. All of which amounts to an increasingly positive spiral of relationships and opportunities within my practice and the lives of my patients. So think small changes, regularly engaged…this is work around your heart and theirs, so be gentle and be patient…with both of you!

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Who are healthcare professionals? Who are you? What are your capacities?

I now see myself much more a member of a community than I ever have before. Rather than the lone savior in any one of my various communities, I now recognize that I have a critical role to play in each of the communities. So here we are at another AND. I am an individual AND I am a community. Within this level of knowing, I experience a sense of relief, support and purpose. What I "do" has meaning and great potential, but only within the context of community. If I can through my actions offer family members, co-workers, professional peers and others the opportunity to experience, express, and act in more creative ways, then I have served my purpose in life.

This is a completely different self-understanding then the old, needing to be the expert, the primary cause, and the inerrant savior of every situation. This new viewpoint has created a very positive cycle of action, creative choices, and reflection that I find each month offers increased opportunities to be of service. The word "bored" no longer exists and the list of areas I want to learn more about and projects that intrigue me grows longer by the day.

Seven years ago there is almost no aspect of my present definition of "self" I could possibly have predicted. I "know" that I will continue through a process of deep transformation and change, and consequently have no idea who "I" will be in the future. Incredibly, there is a very deep sense of peace and security in this new definition of self that I never experienced in the old, certain self-identity.

It is my hope that healthcare professionals can engage in a similar process of transformation, which would lead to a creative change in healthcare that no one today can reasonably predict. If we take ourselves less seriously, restore a little of that childlike curiosity, and meet our patients at the heart level, such a transformation could be quite rapid, deep, and nonviolent. We as healthcare professionals can only create such healing and safe environments to the extent we develop our own awareness through personal practice and community building. I believe that in the end, it is only the degree to which we are able to enhance the awareness level of our patients who come to us for support and relief of suffering that will dictate the successful outcomes of a more compassionate, comprehensive practice.

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Where do you see yourself/the practice going?

Personally I see myself becoming increasingly engaged in community and group processes of various levels of inquiry and action. I cannot imagine becoming reclusive or withdrawn from my communities. I hope that this would take place on both the local and national level. In the past, my quest for national participation was driven out of a security-based desire for financial return. I now recognize that as misdirected fear and am experiencing a freedom and liberation of that energy moving toward an authentic spirit of service.

I also anticipate the opportunity to be involved in the education of integral health professionals. Whether this remains limited to the rehabilitation and yoga communities, or expands to a more generalized population I cannot say at this time. I also suspect more of my focus will be on the subtler aspects of the human condition, especially the spiritual. My passion burns the brightest when I experience the integral relationships between spiritual practices and healthcare. What this will look like, I have no idea other than I am sure I will be surprised!

In healthcare, I see practice moving toward a more primary based care. The care will involve group interaction, small group inquiry, and preventive practice in fact rather than theory (consider the current HMO). Integration of such health practices will beyond sterile, isolated clinics into the school systems, religious organizations and community centers. Healthcare will be directed specifically at local needs, with accessible pricing and personal responsibility. Of course such integral system will also require dramatic overhauls in economics, agriculture, and the current political structure. This is no short-term scenario, and yet as I said at the outset, I would not be too surprised if this radical transformation occurred in the next two decades. Consider the changes in information systems since the advent of the PC in 1980. Whole industries have died, been reinvented and been born in that brief period of time. The future will only move faster according to dynamic systems theory.

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What practical skills are the result of such a choice?
Such changes will require a whole host of additional skills, primarily focused on relationship building and maintenance. Individual and group dynamic training, communication skills, and presentational ability will need to be enhanced. The ability to confront and remain persistent has to be honed in the face of a significant momentum that will work to block such changes. Networking capability within the various communities and print media will have to be developed to more rapidly "spread the word." A system of staying abreast of the emerging informational developments within healthcare will require both skill and discipline.

For the individual interested in practicing in such a manner, which includes myself, these additional skills will also need to be developed or improved:

Emotional intelligence
Multidimensional perspectives
Personal ease with uncertainty and ambiguity
Multi-variable analysis of both narrative/subjective data and quantitative measurements
The ability to acknowledge diversity and maintain coherence
Be open to others, engage them, seek out and attend to their observations, discoveries, and criticisms
Accountability and a criticism-seeking manner,
Interpretative reading…with multiple perspectives and deconstructions,
Understanding and living under heterarchies (operating under multiple hierarchies),
The ability to narrate rather than dictate,
An increased sense of playfulness and curiosity,
And a deep sense of humor!

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What are some of the challenges ahead?

If you cite the negation of the above listed skills you are off to a good start, e.g. no sense of humor, perpetual deadpan seriousness, and, dictatorial rather than narrative...

Couple that with what I discussed as my personal challenges and the barriers to creative choices and it all seems an uphill battle!

I keep returning to the principles of living systems that demonstrate how out of the chaos of our current healthcare system there exists the potential for a new level of increased complexity and efficiency not presently manifested. What is required for this new level to emerge is the ongoing input of free energy from the participants (us) with a collective intention for the development of a kinder, more compassionate system. Somehow, as one of life's truly great mysteries, the essence, or a spirit of causality, lies within the chance and uncertainty of the new paradigm. Pregnant with potential and expectation, we as self-conscious parts of the universe will continue to groan and labor in the delivery of this new system of health. We can be sure it will be messy, noisy, full of surprises and tears, but in the end well worth the effort.

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