27 February 2015
Dear Interested Readers
This Week’s Letter
The letter has only one theme despite the appearance of three sections. If I review everything I have written over the previous seven years (this is the first letter of the eighth year) it all comes down to accepting the need for change and then adapting to the realities that change drives. The Triple Aim is the destination. Lean is a philosophy and an enabling operating system. Leadership and strategy are necessities. In the end we have a choice. Change and accept the work of change or stay the same and accept the shrinking world of opportunity that is the result. Managing our feelings will be a part of either choice.
My Worst Speech Ever
I have enjoyed public speaking since my early adolescence. If you do not count Powerpoint, I have almost always spoken without a pre written speech. Occasionally I will scribble a few notes on a scrap of paper to remind myself of some important point. That done, I rarely look at the note. I think my approach to speaking is in part my attempt to copy my father who never read a sermon and, as far as I am aware, never took a note with him to the pulpit.
When I was a child, Sunday was a full day. It began with Sunday school followed by the church service that was attended by all children at our church so there was a lot of squirming. Then there was the big Sunday dinner that was very much like the one over which Tom Selick’s character in the TV show “Blue Bloods” presides. I know this because my wife is a fan of the show and Sunday dinner was a similar gathering in her home and the representation of the traditional Sunday dinner on the show is something we have both noticed. My guess is that if you were a child in the fifties some similar routine may have existed for you within your family.
The Sunday routine did not end when the table was cleared. The acceptable activities for a Sunday afternoon were not the same as for Saturday. Late in the afternoon we would returned to church for a supper gathering, another educational activity called “Training Union” and then an evening service before a social hour for youth that was held in the recreation hall of the church or at someone’s home.
Training Union is where I became an extemporaneous speaker. The printed lesson was usually related to church polity or our denomination’s position on issues of religious life. With some regularity each member of the class was asked to present an assigned “part” to the group. We would be expected to read the lesson material in preparation and then deliver a little speech to the others. After the material was covered in three or four presentations or “parts”, there was often a broader group discussion of the material. In many ways the whole process was very much like a junior board meeting and my guess is that it was intentional as the name “Training Union” implies. We were in training to become the next generation of church leadership in an environment of church polity that functioned very much like an old New England town meeting.
Some of my success as a leader has come from those skills learned in Training Union. I wish that I had approached the biggest speech of my life the way I learned in Training Union. My worst speech ever is memorialized on YouTube. Not only is it poorly delivered, because I read it, it is also quite long. It is fifty minutes and ten seconds long, to be exact. Imagine me reading two of these epistles back to back, or if you have time to kill, check it out.
This disastrous speech could have been a high point of my administrative career rather than the nadir that it was. I had felt quite honored to be asked to give the 2012 Oration to the Massachusetts Medical Society. The Oration is an annual event going back to 1804. The Orator is charged with speaking about an issue of timely significance to practice in Massachusetts. When I read the list of previous speakers I was surprised to see that there were two gentlemen on the list who bore my mother’s maiden name.
My mother was still alive at the time and her hobby was genealogy. I showed her the names and she was pretty sure these gentlemen were cousins or relatives of some sort of my great, great, great grandfather, Dr. Ebenezer Childs who practiced in Shelburne Falls, Massachusetts in the early 1800s. I am a fourteenth generation descendent of a Richard Childs who came to Brewster on the Cape in 1626. Over the next 150 years the Childs clan had multiplied and moved up to Roxbury and then on out to the Pioneer Valley. The two previous “Childs” speakers, Henry Halsey Childs in 1823 and Timothy Childs in 1859 were from Western Massachusetts.
My mother’s great grandfather Dr. Eben Childs was born in Shelburne Falls, moved to the Finger Lakes Region of New York and then took his family to the mountains of North Carolina in the 1850s as treatment for his own tuberculosis. All of this history was pretty interesting for my mother and in some way may have put even more pressure on me to do a good job. I do not know the totality of the origin of my fears but as I prepared to deliver my oration, “Moving Medicine from a Guild to an Enterprise”, my tension mounted as the date approached. You can review all of the speakers since 1804 and the titles of their presentations.
My failure was not a function of a lack of preparation or practice. I think that I had written a pretty good discussion of the process of change in healthcare that was becoming more and more obvious with each passing day. Ironically, my strikeout may have been a function of my eyesight, or rather my trifocals, the unusual lighting in the room and the fact that the spoken word is not the same as the written word. Some combination of these things led to my frustration. No matter the cause, I knew in the first two or three minutes that I was in trouble. I should have switched to an extemporaneous mode but I just continued to plod along.
My concept was change, or more precisely, the evolution in healthcare driven by the realities of the Triple Aim, the unsustainable nature of the current healthcare economics and the necessity that we, as a society, have to invest in other equally important collective concerns like education, job creation, housing and public infrastructure. I knew that the speech would be published. I felt obligated to stay with the script. I did not trust myself to change my presentation in midstream.
More than two years have passed and many things have changed since the speech, but what has not changed is the importance of how we view and manage change as a process that affects us all, as individuals, as colleagues, as groups, and as enterprises, be they group practices, hospitals or health systems. More importantly we have a continuing obligation to recognize that whatever the impact of change is on our industry, that impact is secondary to the impact on our patients and our communities. Change is real and we should continuously measure our success in terms of our response to the demands for change that are increasing daily. My talk was based on my experience trying to lead change. Now I am even more interested in continuing the conversation about change as the pressures to change become even more obvious and it is clear that no one will escape from the need to change.
Advice About Change Leadership From The Professor
Readers of last week’s letter will remember that I published a letter from Alan Gaynor, emeritus Professor at the Boston University School of Education as part of the introduction to the discussion of how smartphones are an innovation for care delivery in the hands of some. Smartphones are just one part of the “many hydra headed” manifestation of change in healthcare. Smartphones in medicine are a great example though of how technology is part of the change process. Paradoxically, the positive options they produce have a side that many clinicians may fear or experience as a stress of change.
The downside side of all that smartphones can offer is the reality that the rapidly increasing utility of these devices in practice will be experienced as disruptive technology by those who are trapped by the handcuffs of the economics of today’s care process. An important point in the discussion was that many of today’s practitioners are so overwhelmed with change that they fail to notice or understand the changes that are already underway in the totality of the relationship between clinicians and the patients that they have been serving. After the letter came out Alan wrote me again:
…Many thanks for the way you integrated my contribution. Here are a few thoughts (attached) about what it takes when we ask people to change.
Your attachments are powerful, especially Dr. Nancy Snyderman’s interview (with pictures) with Dr. Eric Topol. They covered a lot of what I’ve been reading in two books in a nine-minute video.
But the wellness ads show how much virtual medicine is already available. As they used to say (and sing) in the sixties, “Times, they are a-changin’.”
Here are those comments from Alan about how he (I assume as a thoughtful “everyman”) reacts to change within his work environment. I have read a lot of “change literature”. Those “how to books” are usually written from the point of view of those advocating for change. Unstated but of great importance is the fact that often senior leadership in many organizations is usually just the conduit through which employees experience external pressures from the market and the regulator and payers. Their motivation for change is often “loss avoidance”. Less often the motivation is “aspirational”. Alan has addressed change from the point of view of those being asked to change and require being convinced that they trust the change process. It is a fact that sometimes even when we know that “Times, they are a-changin”, the knowledge is not enough to break the inertia of the status quo.
Here is Alan’s attachment to his letter. It is his take on the personal request or advice to change:
I am going to be very resistant to change unless I have reason to believe that:
1. This is good for me or there is a very compelling reason for me to do it;
2. I know and understand how the changes I am being asked to make contribute to a larger organizational and social vision.
3. My colleagues and clients believe that this is something that we should do;
4. My bosses believe that this is something that we should do—and show it in their behavior and commitment, personally and organizationally;
5. I can do it:
a. I have the physical, mental, and emotional capacity required;
b. I have the knowledge required to do it;
c. I have the technical skills to do it;
6. I can count on getting assistance when I need it;
7. I can see progress along the way;
8. There are personal and structural incentives and facilitators for making this change/changes.
The message in the eight points is concentrated; I think there is much to gain by expanding the discussion of each of his points.
I could not agree more with “point one”: I am going to be very resistant to change unless I have reason to believe that this is good for me or there is a very compelling reason for me to do it.
Many, if not most people, do begin their consideration of a proposal for change with an internal analysis that can be expressed by the personal concern, “What’s to become of me?” I have frequently said that it is inevitable that when we hear that a change is on the way the first thing that almost all of us do is a quick personal risk/personal benefit analysis. If the answer from that analysis raises red flags, we are not very open to further consideration. I think that much of this analysis occurs below levels of our full awareness.
I first focused on the personal audit associated with change when I read Herbert Benson’s mind-body classic The Relaxation Response when it was first published in 1975. Over the years it was probably the book I most frequently recommended to patients. Benson gives a physiologist’s review of the “fight or flight response” before offering meditation as an appropriate therapy. There has probably never been a more popular introduction to mind-body medicine and indeed, no better written argument for self-care.
I was very interested in the book because when Dr. Benson had been a young cardiology fellow he was also my physiology lab instructor during my first year of medical school. The other lab instructor in my section was a very young Sam Thier who would eventually become, among many other important responsibilities in healthcare, the second CEO of Partners. It was clear to even a first year medical student that these two intellects were exceptional in different ways, even among a faculty known for being exceptional.
In the introduction to later editions of his book Dr. Benson recognized that when the book was first published it was heretical for him to suggest a mind-body connection that could be managed by patients. One of the most interesting sections of the book, and also the section that provided me with the most insight that would be useful for my own self care, as well as what I wanted my patients to learn, was the section that tried to quantify the stress associated with change. Change or its contemplation is one of the most potent triggers of the “fight or flight” response.
What was news for me was that even “positive” changes like a promotion to a new job, buying a new house, getting married, and having a child along with many other desired events in life were experienced as being just as stressful as negative changes. Let’s face it, even “good” change makes demands on us that feel like threats and we have evolved reflex attitudes and physical responses to fight threats. Even innovations presented by someone else that would give us a better tool (like smartphone technology) often initially trigger the same sense of stress and the negative reflex of “fight or flight” responses that would be evoked by a new list of regulations from CMS.
Is it a surprise that many clinicians experience “burnout” as external events stoke the flames of change around them and they are consumed by of their daily release catecholamines? With their “fight or flight” responses activated, many clinicians are ready to fight! The CEO with a bright idea should not be surprised when a “positive” strategic move gets translated as a “negative” by the practice and a battle erupts.
Alan is generous when he suggests that professionals would next say, “I am going to be very resistant to change unless I know and understand how the changes I am being asked to make contribute to a larger organizational and social vision.” This is where the CEO with the potent new strategy for change begins the “rational” presentation about the “why” of change. What is not often understood is that if the proposed changes do not pass the “What will happen to me?” test very positively; there will be a huge hill to climb to acceptance. The audience may engage but there will be palpable skepticism expressed in terms of fears of “unintended consequences”, requests for consideration of alternative strategies or the suggestion that the changes be “piloted” or studied.
Alan’s third point: “I am going to be very resistant to change unless I know and understand that my colleagues and clients believe that this is something that we should do” does suggest some strategic considerations. A “guiding coalition” is part of the change formula that John Kotter advocates. We all know that there are “informal” leaders in any group. The influence of these “opinion leaders” on the collective attitude in any group and their ability to either block change or facilitate change cannot be over appreciated. The informal leaders are often the most respected physicians and are highly aligned with the traditions and values of the group.
Alan mentions “clients”. A very effective guiding coalition should include all stakeholders. How often do we include our “clients” in a discussion of the changes that we ponder? The best examples of including patients in a meaningful way in the evolution of change that I have from personal experience come from the inclusion of patients in Lean improvement processes. The work of Dr. Tony DiGioria’s remarkable Institute for Patient and Family Centered Care incorporates patients and families in the most fundamental ways to change how care is delivered. If you are not familiar with this work go to:
Professor Gaynor’s last line of resistance offers a real strategic opportunity for a leader who can communicate and demonstrate “managerial courage”. “I am going to be very resistant to change unless my bosses believe that this is something that we should do—and show it in their behavior and commitment, personally and organizationally.”
The recent book The Lean Prescription, Powerful Medicine for Our Ailing Healthcare System by Dr. Patty Gabow, the retired CEO of Denver Health, is a vivid description of the leadership that Professor Gaynor would want to see before he would drop his resistance to change. Dr. Gabow is the perfect example of the leader who can create meaningful change. She is the prototypical Lean CEO who leads by example, inspires trusts with her presence where care is delivered, and makes change happen by a combination of teaching, coaching, and mentoring. As Alan’s declaration implies, leading change requires much more than just advocating.
What I like most about Alan’s list is that it is perfectly balanced between a description of issues that create resistance and his list of items that will enable him to accept change. I was surprised when he began the second part with, “I can do it if I have the physical, mental, and emotional capacity required; if I have the knowledge required to do it; and, if I have the technical skills to do it.” But, this is the perfect balance to his original condition associated with resistance, the personal impact of change. Together the two questions are core of the interior conversation that so often fills our heads as we struggle with change. “What’s to become of me?” is balanced by “Do I have what it takes to live through the change and prosper?”.
“I can do it if I can count on getting assistance when I need it.” This is the most powerful statement in Alan’s octet of pre conditions for successfully engaging him in the change process. The technical aspects of change are often complicated and difficult but are much less stressful compared with the emotional or “adaptive” aspects of change. The emotional components of change frequently include a sense of loss, the necessity of reinterpreting values, and the reestablishment of trust in an uncertain environment. There is no more demanding task for leaders than the work of guiding an organization through the issues of “adaptive change”. I think that Alan’s request is a plea for assurance that the organization will be there for him as he goes through the stress of change. In the midst of change, leadership often errs by just pushing and pushing without checking the pulse of those who are trying to follow but are falling further behind.
The knowledge of pace and distance is key to success in long distance running. How often did we ask our parents about how much further did we need to ride or how long it would be before we were “there”? Alan’s seventh condition is the corporate equivalent of that understandable desire to know where we stand. Metrics are important in change as reflected by Alan’s affirmation: I can do it if I can see progress along the way. We often forget to ask, “How will we know if…?”
Finally, understandably, and with realistic honesty, motivation is connected to self-interest as expressed by: I can do it if there are personal and structural incentives and facilitators for making this change/changes. Daniel Pink’s impressive book, Drive is a thoughtful review of motivation. Pink is convinced that the greatest motivator is the challenge of a problem and our greatest satisfaction is the heuristic joy gained from successfully accomplishing a difficult task. There is nothing better than the high fives and shouts of “We did it!”.
Pink does acknowledge that there is a role for one-time bonuses and other mundane rewards at moments of inflection in an organization. Perhaps Alan’s request is really an expression for reassurance that on the other side of the change things will be better. Leadership must be clear about expectations. Will the work-life balance be improved? Will the mission be secure? Will I still have a job that satisfies my need for personal security and professional actualization? I frequently say that motivation arises from either loss avoidance or aspiration. In truth it is often both.
Change is hard. Every medical group and health system that I have visited is in the conversation; this was not true just a few years ago. The reality that if something is not sustainable, it will not go on forever is becoming manifestly obvious. We cannot afford to let change separate us into winners and losers. We must hope that every medical professional, every practice, and every health system successfully transitions to the new world of value based reimbursement and population health that is being called “Curve 2”. We have no human assets to waste, and indeed the solutions for the future will be about reclaiming and refocusing non-performing or poorly performing assets. The change process has barely begun. A healthcare environment that is volatile, uncertain, complex and ambiguous requires leadership that navigates the moment of change with a communicated vision that creates understanding and clarity that leads to coordinated action.
I Only Know What I Read in the Papers: The Continuing Saga of Partners Proves that No Organization Will Escape Change
The headline of the Sunday Boston Globe last week read, “Job one for Partners new chief: taming giant’s image.” Rob Weisman, who is one of the senior healthcare reporters for the Globe, writes early in the article, “Partners last week bowed to pressure to abandon its three-year quest to acquire South Shore Hospital in Weymouth, an unprecedented setback for an organization used to getting its way”.
If I ever needed to point to one fact as evidence that we are in the midst of change, what happened to Partners’ plan for expansion is perhaps about as good an example as I could ever hope to offer. You might want to review the article:
Last May when Martha Coakley first announced the deal that she had made with Partners, then led by Dr. Gary Gottlieb, a friend of mine who is an experienced lawyer told me that there was no chance that a judge would ever block an agreement of this sort. He said that it was a “rubber stamp” process and implied that the deal was as good as done. So why did it not happen? Clearly there was well organized and effective opposition to Partners desire to expand. That fact alone is evidence of change.
It is interesting that initially most of the individuals and organizations that should have expressed their dismay and sense of violation were relatively quiet and it took days to weeks for them to recognize, one by one, that they could dare to express their concerns. Once they were talking they organized effectively. I think that it is not a stretch, given Partners size, influence and prior hardball business tactics strategically applied to get their way, that many who should have immediately expressed their outrage were fearful and only began to speak when they realized that their voices were going to be part of a choir singing a protest song.
It has become a reality that Partners reputation has been sullied. Their prior accomplishments, vast resources and effective public relations were inadequate to cover up the fact that at the end of the day it was hard for intelligent people to trust that their ambitions would really lead to a benefit for the community. The facts, their response to the pushback and their prior history were enough to support the logical conclusion that it was a “now or never” time for action for those who wanted a fairer medical market in Massachusetts.
What is happening in Massachusetts is happening all across the land. After years of talk, whether everyone believes it yet or not, the economics of waste in healthcare can no longer be ignored. Everyone has suddenly realized that healthcare takes too much of the pie. Change is inevitable but what we are experiencing is increasingly unsustainable and intolerable. Let me use another Globe article to make my point. The headline on Sunday was about Partners. The headline on Wednesday was about the worsening realities of the state budget: “State shortfall could hit $1.5 billion”.
Not far into the article we read about the causes for this problem facing the new governor after the snow is cleared: “The first is significant increases in costs for items and programs for poor and disabled people, and pensions — just to keep the same level of service next year.
Nobody wants to pay more taxes so we read further and discover: “The group’s projected $1.5 billion shortfall assumes funding for programs considered discretionary, from public safety to aid to cities and towns, stays the same. But to close the gap, it predicts there will be reductions in funding for everything from higher education to services for the needy… The group says the gap could be smaller if the Baker administration is able to reduce the skyrocketing costs of Medicaid, a major driver of budget increases.”
Healthcare spending is $0.42 of every tax dollar in Massachusetts. The economic impact of the cost of care is greater than these numbers. We have been living with the economic impact of the high cost of care for so long that it has become a part of our expectations and is accepted as just the way things are. That has been the position of many in our industry who have said, “This is just the cost of high quality care. You want high quality care, don’t you?”
We have collectively shrugged our shoulders and said, “Sure, I guess so”, and then have paid the bill. The sun is setting on that day in America. The day that dawns will be a day when we use innovation and our sense of mission to accept and manage change, or it will be a day when we say like we do for better education, better public transportation and better social services, “We just can’t pay for it. We will have to make some tough choices on what to cut.” What to cut is not a pleasant consideration. If we end up having to make cuts that hurt people, undermine our collective future because we cannot exercise the collective will to find a way to improve within our resources, then it will be a sad day.
I believe that we will find the better way. We have tools that can help. We have many reasons to be motivated. I hope that Dr. Torchiana finds a way to lead Partners to lead the way for all of us to a lower total cost of care. There is no question that even though Partners did not get what they want, they do have the ability to make things happen.
I Am Getting Used to The Cold
The picture on the header is from my frosty environment. When I come in from my walks I have icicles in my beard. The thermometer read -19 early on Wednesday morning and a pipe was frozen but thawed without a rupture or the need for a plumber. The roof has been shoveled after long negotiations about the price. I am now rooting for more snow so that I can tell my grandson that I survived the winter of ‘14-15, the coldest, snowiest winter in history. I just want it all to be over by Opening Day, April 13.
Take a walk in the single digit air this weekend. It clears your head and it feels so good as the feeling returns to your toes as you warm them by a fire.
GeneDr. Gene Lindsey