When Good People Do Bad Things
Understanding hot and cold ethics helps practitioners recognize why they did what they did and take steps to prevent a recurrence.
Dr. Harold Jones was devastated when the board suspended his medical license. He had always thought of himself as a good person and a good physician. Now the board was telling him he was neither. “I can’t believe this is happening. I feel like my whole career, my whole life, has been a sham,” he said on the first day of the PBI Prescribing Course. “I don’t know who I am anymore.”
Then others in his course began sharing their stories. Several said they felt the same way Dr. Jones did. “I’m not that kind of person,” said one. “The person I am, or thought I was, would never, ever do what I did,” said another, near tears. One physician summed up the feelings of many when she worried aloud about ever returning to medicine. “How can I ask the board to trust me when I don’t even know if I can trust myself?” she asked.
By the end of their PBI Prescribing Course, Dr. Jones and his classmates had gained a new perspective that allowed them to begin making sense of what had happened. They didn’t feel any less responsible for the wrong they had done. But they were able to see now that their transgressions didn’t have to define them. Dr. Jones began to realize he was still the same caring, responsible physician he had been for the past 20 years. And as his self-respect returned, he gradually regained the self-confidence he needed to turn his life around.
Understanding Hot and Cold States
For Dr. Jones the turning point was learning about hot and cold states. It was not really a new idea to him. He remembered reading Dr. Jekyll and Mr. Hyde as a boy. But the old story about a doctor’s dual nature took on new significance as he reflected on what he had been through.
When we are in a cold state, we are rational and analytical, said the instructor. When some combination of forces pushes us into a hot state, our emotions take over. People tend to think of lust and rage when they hear the word “hot,” but any powerful emotion can throw us into a hot state. Once that happens, we lose much of our ability to process our thoughts and feelings. We start doing things we never would in a cold state.
According to Dan Ariely, a professor of psychology and behavioral economics, and the author of the book Predictably Irrational, an older, more primitive part of our brain takes over when we are in a hot state. Instead of processing thoughts and feelings in the neocortex (the “new” part of the brain), our “reptilian brain” or “lizard brain” assumes control. We react quickly, almost reflexively, without thought.
That’s a good thing when you’re confronted by a wild animal. You don’t want to stand around thinking about what the best course of action is in that situation. It’s a dangerous thing, though, when you’re a doctor on rounds.
What Dr. Jones found strangely reassuring about all this was how even brilliant, experienced professionals will behave irrationally in the heat of the moment. As Ariely writes, a person in a hot state “seems to be absolutely and completely divorced from the person he thought he was… He becomes unrecognizable to himself.” That was exactly how Dr. Jones felt.
What Pushes Us Into a Hot State
The more Dr. Jones heard about hot and cold states, the more eager he was to understand what had happened in his case. He wanted to know what had pushed him into a hot state in the first place and what he could do to keep it from happening again.
The instructor in the course described how external situations can combine with internal vulnerabilities (deep-seated, often unconscious feelings) to push people into a hot state. As he listened to the presentation, Dr. Jones began to see his own situation in a new light.
After years of treating patients for chronic pain, he had done the unthinkable: when an elderly patient’s daughter told him her mother was too ill to come in for her regular visits, he had given her the prescription meant for her mother, no questions asked, no follow-up to make sure his patient received her medication. It was only after renewing the prescription that he learned the daughter had never given the medicine to her mother. Instead, she had sold it on the street.
Now as he thought it through rationally, he suddenly realized what had happened. After his own adult daughter had died in a traffic accident the year before, Dr. Jones had buried himself in his work. “I couldn’t do anything about my own pain,” he told others in the Prescribing Course, “but at least I could help ease my patients’ pain.” The long hours he spent at work left his wife feeling abandoned to her own grief, and after months of struggling she had asked for a trial separation.
“I was a mess,” Dr. Jones said. “And then this young woman came in to talk to me about her mother. She was the same age my daughter would have been, and looked just like her. Even dressed like her. When she asked for the prescription, I just said yes without thinking.”
How to Avoid a Repetition
“Once you’re in a hot state, it’s too late to fix things,” says PBI founder, Stephen Schenthal, MD, MSW. “By that point you’re no longer thinking rationally. That’s why professional boundaries are so important. They’re the guardrails that keep you from slipping into a hot state,” he explains.
“Professional Boundaries are the guardrails that keep you from slipping into a hot state.”
To help keep a firm grip on to those guardrails PBI participants create a Protection Plan towards the end of the course based on their own vulnerabilities and risk factors. Dr. Jones wrote in his protection plan that he would go to grief counseling and ask his wife to join him in couples therapy so they could begin working together to ease some of the pain they felt over the loss of their daughter.
The course instructor also explained how accountability worked against the forces pushing you into a hot state. When you know someone is paying attention and holding you accountable, she said, it encourages you to think things through. Dr. Jones realized that his own sense of accountability had steadily declined over the years. As a professor in the medical school and a senior partner in his practice, he no longer thought much about how others might judge him.
Now he took steps to rebuild his sense of accountability. He committed to hiring a practice monitor to work with him and alert him any time he seemed to be ignoring or violating best practices. To heighten his accountability, he would ask the monitor to report any concern to the office manager as well.
When he met with his medical board six months later, Dr. Jones explained what he had learned and the steps he had taken to guard against any recurrence of his violation. He compared the practice monitor he now worked with to being on probation. Both, he said, increased his sense of accountability.
Dr. Jones was happy and grateful that the board agreed to reinstate his license. What pleased him even more, though, was the note the board chair sent him afterwards. “We were all very impressed by how thoughtfully and professionally you handled a very difficult situation,” she wrote. “Good luck.”
- When you are in a cold state you are rational and analytical.
- Any powerful emotion can throw you into a hot state.
- External situations and internal vulnerabilities (deep-seated, often unconscious feelings) combine to provoke such emotions.
- Once we are in a hot state we react quickly, almost reflexively, without thought.
- Even brilliant, experienced professionals will behave irrationally in the heat of the moment.
- Professional boundaries work to keep you from slipping into a hot state.
- Accountability helps counter the vulnerabilities pushing you to cross boundaries.