Thinking Outside the Healthcare Box: Systems Theory Discussion with Guest Dr Shelly Smith-Acuña – Part 2

Feb 22, 2022 | Podcast

This is the second part of a two part interview with Dr. Shelly Smith-Acuña on Systems Theory. You can read about, or listen to, the first part of this conversation here. I highly recommend tuning in to part one first.

For both parts of this interview, I’ve proposed that Dr. Smith-Acuña and I take a unique look at the health care system. We are blending her background in Psychology and Systems Theory with my own experience of the healthcare system as a doctor. We set the scene for this discussion by having all of the “family members” of the healthcare family attend an intensive psychotherapeutic session together. We are sending all the players of healthcare to get therapy because, let’s face it, healthcare systems are really dysfunctional.

As we have seen in part one of this interview, the healthcare family unit arrives at this session very unhappy. Of course, we assume that it is just the patient in the family that is unhappy. But, through the course of our session, we see that no one in this healthcare family unit is feeling good about their role or about how the family unit is functioning. Many doctors, nurses, and administrators are all discouraged and fed up with how the system is working right now. In the second part of this interview, we will look at the remaining principles of systems theory (structure, history, and the social-cultural narratives) and offer some insights on how to improve the dysfunction of the healthcare family unit.

Systems Theory Discussion with Guest Dr. Shelly Smith-Acuña

In parts one and two of this interview, Dr. Shelly Smith-Acuña and I take a look at our healthcare system through the lens of systems theory. Specifically, we are looking at the six members of the health care “family”: the server (healthcare workers), the bureaucrat (administrators), the patient, the guard (insurance companies), the dealer (pharmaceutical industry, or Big Pharma), and the judge (state medical boards). Dr. Smith-Acuña and I will structure this therapy session to help unpack the principles of systems theory, which are: context, causality, communication, change, structure, history, and the social-cultural narratives.

In this second half of the interview, we are talking about the three remaining aspects of Systems Theory, which are structure, history, and the social-cultural narratives.

Impact on Your Third Opinion

In rounding out this conversation, I find myself deeply inspired by the suggestion from Dr. Smith-Acuña that everyone in the healthcare family can be better serviced by approaching health care by being “calm and connected and curious all at the same time.”

This is at the heart of what I want to help my clients do: become an active participant in their own care, and act as an advocate for themselves within whatever healthcare system they are a part of. Stepping into this new role may feel a bit rebellious because “calm, connected, and curious” are not currently the mantra of the existing healthcare system. But, when you understand that you’re working within an existing system with its unspoken and unchallenged “rules,” you can better understand why it’s imperative for you to become your own advocate, trust your gut, and speak up for yourself.

As a patient, or someone working within the healthcare system, you have a choice about how you approach your own care or the care of others. If you are frustrated or feel stuck in your own role within the system, trusting your own third opinion as a patient, doctor, or administrator can shift the way that situation plays out. One way to do this is to approach your care, or the care you are giving, with an attitude of calm, connection, and curiosity.

To make this shift, Dr. Smith-Acuña and I offer a few questions for you to ponder as you reflect on your care, or on the care that you’re giving:

Around care:

What are you seeing that we’re not seeing here?

What are other possibilities?

Why are you doing things this way?

Around the system and training:

When was a time when you were treated differently?

What is a time that you had the opportunity to challenge conventional authority and it actually went well?

 In this episode, Dr. Shelly Smith-Acuña and I discuss:

  • Structure as the fifth principle, and the hierarchy that comes into play within the healthcare system. Structure encompasses sharing power and sharing responsibility, along with good communication.
    • How definition and clarity around the structure of a system give everyone working within it a better sense of how to interact and work.
  • History and development is the sixth principle of Systems Theory. This involves understanding both the history of the doctor’s profession, or health history of an individual patient. Events such as trauma are not always considered when approaching care, and they have an impact on outcomes.
    • The role of transference and countertransference: unconsciously patients and doctors experience and react to one another based on their past personal experiences and what they encountered in their families of origin.
  • Social and cultural narratives is the seventh principle of Systems Theory. Each of us has encountered both social and cultural experiences that inform who we are now, and how we understand any given situation. These narratives also impact language shaping experience and form dominant narratives.
    • One example of this is a dominant narrative around passive-aggressive care. Within a healthcare system, the patient is often expected to be a passive recipient of care, with doctors using aggressive approaches and language around care.


Systems Theory in Action: Applications to Individual, Couples, and Family Therapy by Dr. Shelly Smith-Acuña, 2011.

Wise Mind, as explained by the founder of DBT (Dialectical Behavioral Therapy), Marsha Linehan in this short YouTube video. This Venn diagram is an amazing summary of where two people can be in healthcare interactions, from successful to polarized.

Correction and more information on the 20th-century physician, William Osler. Dr. Osler was actually one of the four founders of The Johns Hopkins Hospital rather than Johns Hopkins University as explained in the episode. For more information about William Osler, click here.


Barbara:  Welcome to Third Opinion MD Podcast. I’m your host Barbara de la Torre. I am delighted to bring you part two of the interview with Dr. Shelly Smith-Acuña. She is the dean at the Graduate School of Professional Psychology at the University of Denver. What we’re doing is we’re focusing on a conversation based on what she writes about for systems theory, and that is seven principles where you can understand how systems function and how they are dysfunctional. In this case, we’re really focusing on healthcare.

For those of you who missed the previous episode, part one of the interview with Dr. Smith-Acuña, you should go listen to it, but let me fill you in. I’m going to take you back to part one where I ask her the question in the beginning.

I imagine healthcare undergoing this intensive psychotherapeutic session, that we’d have these players that we can call a healthcare family unit. They’re so unhappy. We assume it’s patients that are unhappy, but it’s really doctors, nurses, administrators, it seems like everybody is unhappy with the way the system is working right now. Would you consider, as a part of our conversation today, applying your seven systems theory principles to these groups as if they’re in a family therapy session?

Dr. Shelly Smith-Acuña:  Sure. That sounds great.

Barbara:  What we’ve gone over so far are what we can even just abbreviate as the four Cs: context, causality, communication, and change. Those are four of the seven principles related to systems frameworks, and they’re really important to know so that we don’t fall into the trap of blaming one thing for the problem, or falling into communication traps, or taking things out of context, or even being confused about whether change is good or bad.

We go over the first four principles in part one. Let’s now turn our attention back to the interview, part two.

Structure, that’s number five. The first example that comes to mind is healthcare organizations. There’s really no need to name any names here, because there are a lot of similarities. Even though they’re different, they operate quite similarly. Most people are members of some hospital health organization since the era of doctors and private practice is largely over. It existed probably in the ‘80s, but it was starting to wane with HMOs and managed care.

Let me start with a couple of examples.

As a physician who worked in corporate medical environments, I noticed many layers of management, many so-called changes to policies, protocols, schedules. They would change formularies for medications. So, if you could get this med, then suddenly you couldn’t get this med. Also, along with decreasing physician autonomy. Most physicians are no longer decision makers anymore, but they’ve been trained to be that way in the structure in their medical training. They’re trained to be that way, they’re trying to make decisions, but the structure is not allowing for that.

Another example would be maybe worsening tension between these classes of healthcare workers. Doctors, nurses, physician assistants, these are probably the top three groups at odds with one another. It’s not really talked about, but occasionally it is. It’s taboo for the physicians to talk about it, but it’s okay for other groups to talk about it. I think it has to do with hierarchy. I think that’s where you mention that in structure.

How would you approach these issues from a systems perspective?

Dr. Smith-Acuña:  I love this question. I think understanding human nature, how hard it is to share power, and how often we set up systems that are really competitive as opposed to truly collaborative. If we’re really thinking of a broader goal, which is functional healthcare that really serves patients and also creates a system that is good for people to work in, then we could try to envision these rules, roles, and boundaries in a way that is empowering to everybody in the system. That’s not easy to do, but I think the idea of understanding what people are empowered to do as opposed to creating those turf wars.

When you say the different levels of training, how could we really envision a system that acknowledges that higher level of expertise and when it’s essential, and what the essential duties are and how responsibility could be shared throughout the system? If you’re sharing power and sharing responsibility, it weaves in some of those other systems constructs. You have to have good communication to do that.

With good communication, we don’t all have to have the same roles. Different roles don’t have to be disempowering to folks in other roles. We can talk about multiple empowerments.

Barbara:  That is really interesting about the good communication piece, because there is a huge breakdown in communication, especially in the large organizations. There are two things I think about that might disrupt the hierarchy, too, the existing groups.

One is the entrance of women into the physician role. That was a game changer. But the names and the responsibilities didn’t change as much. You have now 50%+ women are physicians today in medical school. But you have the origin of the nurse and the doctor that had clear gender roles. Now you have women in the role of a supervisor over what was traditionally a woman’s role to be a nurse, that’s in the past, but still predominantly women. There is some tension there.

It’s something that women physicians really cannot talk about. I’m saying it, I’m getting this out there, but I’m only saying this because it’s not something that we want. We want to work together. We want to collaborate together. Let’s start with that.

Dr. Smith-Acuña:  I love that example. If you think of hierarchy meaning that it inherently disempowers people at each lower level of the hierarchy, as opposed to there is some kind of a function in the hierarchy, and that a healthy hierarchy is really designed to empower everyone at each level of the hierarchy, that’s a different way of looking at systems structure. It’s easy to see that in families. When kids are misbehaving, often they feel very disempowered, and often parents feel disempowered.

So, the idea of working with a family and helping everyone feel their power in a way that is not hostile or aggressive at someone else’s expense but really is good for the whole is almost always a really worthwhile exercise. I wonder about what it would look like to try that level of analysis and that level of clarity about how power exists and how power could be shared throughout the system.

What your question reminds me of, if we get back to these roles in your medical care family, one exercise in structural therapy is to have everyone in the system take on the role of somebody else in the system and articulate what they believe. Your doctor and nurse example, how would they articulate taking that different role? What are their challenges? What are their pain points? What are their victories? All of a sudden, you can often expose a lot of, as you say, unspoken beliefs, rules, roles, and it can be transformed.

Barbara:  I thought of the other example that kind of coincides with that tension between those two groups. That is the formation of unions with nurses, and no unions with doctors. It sounds like it’s a compensatory response to that differential of power. It’s not something that people have to face directly, except there are some institutions that do have that in place. You have either nurses or sometimes physician assistants that are unionized and they have their form of communication through the union, which is very different from how doctors, who are not unionized, are communicating. So, it adds another layer of complexity. I think it’s a great idea that you mentioned the role reversal. We’ll have to do that in therapy for these guys.

With structure, we then move into the sixth principle, history and development. Most health professionals, in my opinion, don’t spend as much time as they should on understanding the history of their profession, their legacy, the mistakes made. They look at all of the victories, but there are a lot of lessons learned with every profession. Or how they’re perceived by patients, unless they’ve studied human behavior more closely.

I had almost three years of psychiatry training; so, I look at these things a lot more. But, I imagine that’s not something that happens. When I observe colleagues who haven’t had a lot of behavioral or mental health training, they look at patients and don’t really see that the background does inform their behavior and how their history of their development, as well as the history of the development of that physician, not just the profession, but personally.

I guess I think, also, of how patients with a history of trauma are also very much at risk for being retraumatized in the healthcare setting without this attention to history and development. I’ll introduce the term, countertransference, is common, but it’s implicit. I’m going to have you explain countertransference to the audience. How can the key concepts of history and development help patients in healthcare settings?

Dr. Smith-Acuña:  I think, first of all, that transference idea came, of course, from Freud and early psychiatry practice, basically saying that unconsciously we can’t help but not only experience others as reenacting what we saw in our family of origin, but part of what happens when we have that transference and experience people treating us the way that we thought our parents treated us is that suddenly our behavior starts to almost elicit that kind of reaction.

When you think about transference and countertransference, you, of course, get that bidirectional causality again. That the physician, or the provider, in any way is going to be reacting to the stimuli of the way that the patient is treating them. So, you have that transference and countertransference in a very elaborate dance at all times.

Barbara:  The countertransference, just to clarify for the audience, is the reaction from the physician or the therapist, the server in this family unit here. The transference comes from the patient, traditionally. But they’re really not different, because the countertransference is really just transference.

One of the most difficult patient groups to deal with for healthcare providers are Borderline Personality Disorder patients, but that’s a whole other topic. I have concerns about the way people are diagnosed, the bias towards women in some cases in diagnosing that, and the manner in which we manage it. I think it was Linehan who came up with the Wise Mind and Dialectical Behavioral Therapy, which is a way of managing the crisis modes that Borderline patients have, or people with Borderline features, there’s a whole spectrum.

It was just the simplest Venn diagram and it was the coolest thing to see that a lot of times doctors who are trained to be very rational and not emotional, because it interferes with objectivity, in their linear training and cause and effect training, reductionist thinking, then you have the patient who is having an emotional crisis and they’re on the far end of the spectrum, and then the Wise Mind is that blending of both. I’m going into what you have talked about in your book, differentiation I believe, where you’re able to separate the thought and the feelings but utilize them in the best way possible. Right?

Dr. Smith-Acuña:  Yes.

Barbara:  I would love it if every single person working in healthcare took psychology classes.

Dr. Smith-Acuña:  The beauty of that would be that life would be better not just for patients, of course, but for providers as well. That’s where you get at that intent versus impact and a lot of not really understanding the problem. It’s not that a physician wants to be really impatient, or ultimately punitive with someone who is eliciting that kind of impatient reaction. To have some perspective on what’s my countertransference, what’s being elicited in me, what am I feeling as well as what am I thinking, and how can use those two reactions together to go down deeper and find my Wise Mind and think what’s the best way to react in this situation, what would be most helpful.

Barbara:  It goes also back to that idea of ‘and’ and ‘both’ again, because it’s okay to be a physician with an analytical mind and to have the emotional compassion to be where the patient is at. Not yelling like they are in some cases, but just that presence. There’s a way of being, and I can’t describe it, I try to cultivate in myself when I see patients. The idea of really just holding that space for them. That’s what feels like the Wise Mind, staying calm and maybe really listening. It’s okay to do both.

Dr. Smith-Acuña:  Yes. And to be calm and connected and curious all at the same time in terms of that kind of engagement. It’s funny, though, if we talk about history and development and then we think the history of the medical profession and basically the way that’s evolved, this moment in history. Like when you’re saying to make space, to listen in that way, to have that kind of engagement, that’s really not the way the system has evolved.

When we think about what kind of change could take place, the other thing with development that I love thinking about is generational change. Can we envision what’s the next generation of healthcare? Not necessarily how is it broken and how can we fix it, because while that might need to be acknowledged, that can put people on the defensive. But to envision what could be a new generation. Sometimes that literally means listening to the next generation, age wise, and saying, “What are you seeing that we’re not seeing here?”

That of course is the beauty that I see of working with families, that there is always wisdom in that next generation and saying, “Why are you doing things this way? They could be different.”

Barbara:  I think that Monica McGoldrick in her book on genograms did a genogram of family medicine. I think they’re one of the coolest tools. I love using them with my clients. How would you describe genograms to the audience?

Dr. Smith-Acuña:  It’s just a pictural representation where you draw out each generation – parent, child, the lines. We probably have all seen them. Mentioning each individual, having their own representation.

What’s powerful about a genogram is visually seeing all of this on paper in one place. If we talk about systems and parts and wholes, it’s hard to wrap your head around that whole of a system. When you see a genogram, you get that relationship just there in black and white of the parts and wholes together. It’s really powerful.

Barbara:  I have a background as an artist, so I actually really love drawing all of the little symbols and everything. It is so cool to see your whole family on one page. It just makes it easier to look at, like you said, to take a step back and look at everything because you don’t have that perspective when you’re too close to one thing or one generation.

I agree, I think it’s going to take the next generation to engender a new type of healthcare.

Our last principle, number seven, social and cultural narratives. Each of us has had something in our lives that has informed who we are now. This topic is really interesting. I was wondering if you could go into a little further the importance of language shaping experience, dominant narratives, those two concepts.

Dr. Smith-Acuña:  Yes. I think just recognizing what we all know, that human beings are meaning-making creatures, and like it or not, we’re always constantly telling stories about our experience. Those are often either not conscious or they’re just part of the dominant narrative and we take them for granted. Understanding the ways that narratives shape our experience and that we need them, they can be helpful, but also the ways that they hold us back with the stories that we tell.

One thing that I’m pretty open about is that I’m adopted. You can tell an adoption story, you can have a narrative about that. The conscious narrative that I grew up with was that I was so deeply wanted by my parents that I was a chosen baby, so instead of being their biological child, I was the chosen child, so it was really special to be adopted. There were parts of that story that actually were quite helpful for my self-esteem. I knew very much that I was wanted by my parents.

But the other part of that narrative is somebody gave me away, there was somebody that didn’t want me. Kind of exploring the impact of both the dominant or stated narrative and then the other cultural narratives. I had lots of stories about friends’ parents that would say negative things about being adopted or other things. Being able to explore both of those stories and then ultimately to make it my own story, to do the exploration of how that turns into my story, which of course is what lots of people do in psychotherapy because that’s where ultimately you rework your story.

Barbara:  You’re rewriting what you want to be the dominant narrative.

Dr. Smith-Acuña:  Yes. And understanding that authorship, that we are all the authors of our own stories. So, to take ownership of authoring our stories.

Barbara:  There are actually quite a few narratives in healthcare that I’m deeply disturbed by that are in existence right now, that it’s the way we practice medicine with patients.

There’s a culture of passive-aggressive type care, to be a passive recipient of care, and we are the aggressors. I’m saying this in a way that it becomes an expected scenario. That’s why often when patients would come in to urgent care, if they didn’t leave with something – that was the narrative, “I’m going to get something to take care of my illness,” like a pill for example – that becomes a dominant narrative in itself, that “I can’t get better unless…” We have to change that to, “What are other possibilities?”

I grew up with a mother who was a physician, fiercely independent, trailblazer. We come from generations from different countries that had either totalitarian government or there was war. I was born in Argentina, but I ended up here in the United States as a young child. I grew up with these stories, and at the same time I grew up with a physician who had an integrative medicine background.

Even before medical school, the dominant narrative was there is a way to think independently and you have to look at these things, don’t take this at face value. I’ve always had that going in. What I was not prepared for is that’s not the dominant narrative in medical school and it’s not the dominant narrative in residency and beyond. The narrative is actually you learn it this way. It’s a very military style organization, if you don’t do as you’re told and sort of stay in your place, it goes up against that. Rewriting is quite difficult.

What do you think it would take to change that? I don’t know if that fits into this one or not.

Dr. Smith-Acuña:  I think where it fits really well is along this whole line of thought about the importance of language and dominant narratives is looking for exceptions in experiences and telling the stories of exceptions. Because what we do with the dominant narratives is we reinforce them, and exceptions instead of being opportunities for change are just outliers.

Part of what you’re saying is to try to look at medical training and try to encourage medical students perhaps, or residents, or whatever it is, to say, “When is a time that you were treated differently? What is a time that you had the opportunity to challenge conventional authority and it actually went well?” Where could there be a culture of saying if we know we want to change the system, we’re going to have to start looking for exceptions and amplifying those exceptions?

Barbara:  Another interesting thing, now that I think of it, is that there was a definite difference among the three areas of medical life. Medical school was my best experience. Residency was not. Being an attending, or life after residency, was similar to residency in some ways, in terms of that narrative.

In medical school, I went to one that I have to tell you is very unique, because when I speak to other colleagues, they didn’t have the same experience. I chose the school partly because it had a center for humanities, it had a medical humanities department, so they’re already thinking outside multiple systems. They are on an island, so I’ll just give it away, it’s University of Texas Medical Branch at Galveston [UTMB]. I absolutely loved going there. I had an art opening there, they let me do that.

There was a group called the Osler Student Scholars, based on a physician named William Osler. I’m going to bring him back on the podcast. He is like the Albert Schweitzer of the early 20th Century, but in a different legacy. He was one of the founders of John Hopkins University, he’s from Canada, he went to McGill in Montreal, and he was also a professor at Oxford; so, a very accomplished physician. He was known for his bedside manner. He changed the face of medical education, he was just part of that. He was part of change, he was just a very interesting physician. He was a funny person, he was also very well respected, and he just was innovative. He gave a lot of speeches about that. I always turn back to history.

There was a lot of that at UTMB. They had a society where they opened a scholarship for students, and I was one of the first student scholars. In that, I had that space, and again, probably more systems, to create things. I created a Spanish speaking medical café so that people would come and listen to music and learn medical Spanish and eat food. Or  just [me] giving a talk about designing therapeutic spaces. It was just a lot of permission to look broadly at health education and wellness.

When I left medical school, no. I think that was the real world. The real world in residency and medical school is usually not that way. I think that was an outlier. But, I think it was the most amazing education, and if only we could have that kind of broad, more encompassing circular way of thinking, it would be amazing.

Going even further back, pre-med, that’s where it gets locked in.

Dr. Smith-Acuña:  I will say even hearing you tell that story, those are the stories that I know you’re looking for, which is wonderful. We need to keep finding more of those stories. Maybe it’s not changing the whole system, but maybe not just the individual. Maybe there’s a residency program that you’ll find through your podcast that really is saying we’re going to do this differently, someone who is willing to experiment to say the next generation should look different.

Barbara:  I love that.

Dr. Smith-Acuña:  The timing, the reckoning that our world is in, in so many different ways right now, is a powerful opportunity. Obviously discouraging in many ways to see all of the things that are broken, but also the chance to address that feels really interesting. I appreciate your thinking along those lines.

Barbara:  Shelly, thank you so much for taking time to talk about these topics.

Dr. Smith-Acuña:  Thank you. It was a real pleasure.

Barbara:  For the audience, you can find more information on the website and on the show notes for this episode. There you can click on the links to the articles and books. I urge you to get the book Systems Theory, which you can find in my list of resources.

I am currently taking new clients. If you want to take a deeper dive into understanding your health and strategizing how to navigate through this healthcare system, go to the website to find out about the services. There is also an opportunity to meet with me for a free consultation to find out more about the service.

If you want to be the change in this world, you need to become a systems thinker. When you gain a broader perspective on the world around you, you’re in a much better position to change it. From this point forward, you are no longer just a patient, you’re an informed consumer, you’re your best doctor, and you can make decisions in a more balanced way between your thoughts and feelings.


Third Opinion MD Podcast is produced by me, Barbara de la Torre, and is generously funded in part by a grant from the Regional Arts and Culture Council. Music is licensed through AudioJungle.

I’d love to hear from you. Please send me your comments, questions, or suggestions for future topics and guests you’d like to have on the show. You can find the contact form under the podcast tab at the website

Any comments made by the host or guests on Third Opinion MD reflect opinions about healthcare and self-care. Please consult with your physician for any medical issues that you may be having.

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