For several years after I moved into administration I was a regular attendee of the twice yearly meetings of the Group Practice Improvement Network. GPIN’s description of itself is straight forward:
GPIN is a nonprofit organization created in 1993 by the founders of the Institute for Healthcare Improvement to provide a vehicle through which medical groups achieve and sustain performance excellence by sharing knowledge of best practices.
In my opinion those two meetings a year were the most valuable time I spent away from my day to day responsibilities as the leader of a practice that tried to adopt the message and insights of Crossing the Quality Chasm as the core of its operational principles. The meetings were most valuable to me when the subject was the mind and attitudes of physicians. In one meeting I discovered that my Myers-Briggs personality type, ENFP, was rare, about 1%, among physicians. That discovery explained why it always seemed like I was talking to myself! In another presentation I became aware of the obvious, the reality of different generational points of view in practice. A baby boomer doc does not work or see the world or face the challenges of the day in the same way or use the same “tools” that a Gen X, or Millennial generation doctor uses. That should be obvious, but how often is the reality considered, or the implications used, to improve how we deliver care? The most frequent and the most important discussions were about compensation and managing the multiplicity of differences between front line physicians, physician managers, and non physician managers and executives.
The highlight of my first GPIN meeting in 2008 was my reintroduction to the wisdom of Jack Silversin, a dentist turned consultant who understands the minds of physicians. I had first met Jack in 1995 in the turmoil that followed the merger of Harvard Community Health Plan and Pilgrim Health Care. Harvard Vanguard Medical Associates, then composed of fourteen health centers with about 350,000 patients and professionally populated by 500 physicians who had previously been the staff of the original Harvard Community Health Plan, separated from Harvard Pilgrim Healthcare on January 1, 1998. The split came after a three year process that had begun in the aftermath of physician concerns that evolved not long after Harvard Community Health Plan merged with Pilgrim Health Care on January 19, 1995.
As the Chairman of the Physicians Council of the Health Centers Division of Harvard Community Health Plan, I had been part of the team that had negotiated the merger. I have a piece of glassware to prove it. I learned a lot about mergers and consolidations during the negotiations, but that was just the beginning. The real learning occurred as the merger went forward with the attempt to “deconstruct,” and then “reconstruct,” the physicians practicing in the legacy organizations into one delivery system.
The health centers of HCHP, the suburban Medical Groups affiliated with either HCHP or Pilgrim, and the small group practice and independent practitioners of Pilgrim represented at least four, if not more, cultures that were often operating in competition in multiple “micro environments” with different hospitals and established referral systems. It did not take long to realize the painful and frequently conflicting interests between insuring care and delivering care. It was not until we began to try to figure out how to realign practices by regions rather than affiliations that we were able to understand just how different and incompatible the cultures were. After realizing that “the blending” was not going to work, it took a year to convince the board that the relationship between the practice and the insurer should change. In 1997 Harvard Vanguard did a “trial run” as an independent physician organization, and then in January of 1998 we were suddenly independent although all of our contracts were exclusive to Harvard Pilgrim.
It was during the early efforts to make the merger work that I met Jack Silversin who had been hired to help manage the conflicts and concerns of the merger. Jack had a clear message. Doctors and the organizations within which they work have evolved in different directions, and need to renegotiate their “contracts” with one another. Doctors believe their “implicit contract” gives them:
- Autonomy
- Protection
- Entitlement.
These concepts often collide with the challenges that face healthcare organizations like:
- Coordinate care across intra- and inter- organizational boundaries
- Reduce cost
- Eliminate waste
- Deliver evidence-based medicine following protocols
- Implement medical records
- Move care to less expensive settings
I think that some of what I learned from Jack in 1995, at GPIN in 2008, and later as a client of his partnership is worth reviewing now, particularly since burnout and the state of professional fulfillment are increasingly significant concerns that must be addressed effectively if we are ever going to achieve the Triple Aim.
In a forward to the excellent “how to” guide to evolving “compacts” between physicians and organizations, Aligning Physician-Organization Expectations to Transform Patient Care that was written by Mary Jane Kornacki with Jack Silverstein in 2015, Edgar Schein, an imminent scholar in the philosophy of organizational culture from the MIT Sloan School wrote:
Healthcare in today’s world is a complex system of independent parts. Whether we are talking about the overall political system with its government agencies, lobbies, unions, insurance companies, malpractice lawyers, and suppliers of equipment and drugs; about a given regional health delivery system including hospitals and clinics; or about a given hospital with its multiple microsystems through which patients move, we always reach the same discouraging answer: It is horrendously complicated and interdependent. One frequently encounters the view that fixing the system is hopeless because it has so many interdependent players, each of whom is motivated to pursue his or her own economic and vocational interests.
Schein’s description of the state of healthcare is a pretty good argument that healthcare is a “wicked problem.” His analysis of the challenges facing healthcare leaves us feeling like we are beyond workable solutions as he describes all the organizational complexity and the conflicting motivations of physicians and institutions. It seems like we can’t discern the way around the individual concerns of physicians and the conflicting institutional concerns of administrators. Everyone is focused on their own interests as their priority while never mentioning patients or issues like quality, safety, access, and health equity.
As I wrote last week, in the effort to understand “burnout” so that we can begin to address it more effectively, Stanford researchers have expanded their research by connecting questionnaires about burnout to measurement of professional fulfillment. The work of Silversin and Kornacki coupled with some recent reading has my mind churning with the idea that “burnout” and its related concept of diminishing professional fulfillment are examples of “wicked problems.” Others have described healthcare in general as a wicked problem. If you are not sure of the definition of a wicked problem, and did not click on the last link about healthcare being a wicked problem, here is the introduction of the piece with a definition:
In 1973 Horst Rittel and Melvin Webber, two U.C., Berkeley professors, published a paper describing Wicked Problems. They said that the traditional scientific approach doesn’t work in solving social problems. Problem solving in the industrial age focused on efficiency, and the challenges our scientists and engineers address are similar. They all focus on “tame” or “benign” problems such as solving a mathematical equation or analyzing the chemical structure of an organic compound. For these, they say, “the mission is clear. It’s clear, in turn, whether or not the problems have been solved.”
A wicked problem is one that’s not easy to describe, it has many causes, it’s hard or impossible to “solve.” It’s occurs in a social context where diverse stakeholders understand it differently.
The tensions that Silversin and Kornacki describe that exist between physicians and the administrators of the organizations within which they work do play out in a way that contributes to burnout and diminished professional fulfillment. Improving those relationships through the negotiation of a new relationship, “contract,” or “compact” between physicians and administrators is a great place to start and is necessary, but it is also insufficient as a complete solution to the problems of burnout and deteriorating professional fulfillment. Many of the organizations, including Harvard Vanguard, that have gone through the compact process have simultaneously adopted Lean which fits perfectly with the “compact” process. Virginia Mason and ThedaCare have proven that it is possible to create better operational systems using Lean engineering and philosophy on the foundation of a “compact.” Lean and a “compact” are a powerful combination, but as “wicked problems” physician burnout and diminished professional fulfillment need even more attention.
Wicked problem “theory” deserves a closer look and characterization. The website wickedproblems.com offers us a detailed description from Horst Rittel, one of the originators of the term.
- Wicked problems have no definitive formulation. The problem of poverty in Texas is grossly similar but discretely different from poverty in Nairobi, so no practical characteristics describe “poverty.”
- It’s hard, maybe impossible, to measure or claim success with wicked problems because they bleed into one another, unlike the boundaries of traditional design problems that can be articulated or defined.
- Solutions to wicked problems can be only good or bad, not true or false. There is no idealized end state to arrive at, and so approaches to wicked problems should be tractable ways to improve a situation rather than solve it.
- There is no template to follow when tackling a wicked problem, although history may provide a guide. Teams that approach wicked problems must literally make things up as they go along.
- There is always more than one explanation for a wicked problem, with the appropriateness of the explanation depending greatly on the individual perspective of the designer.
- Every wicked problem is a symptom of another problem. The interconnected quality of socio-economic political systems illustrates how, for example, a change in education will cause new behavior in nutrition.
- No mitigation strategy for a wicked problem has a definitive scientific test because humans invented wicked problems and science exists to understand natural phenomena.
- Offering a “solution” to a wicked problem frequently is a “one shot” design effort because a significant intervention changes the design space enough to minimize the ability for trial and error.
- Every wicked problem is unique.
- Designers attempting to address a wicked problem must be fully responsible for their actions.
Based on these characteristics, not all hard-to-solve problems are wicked, only those with an indeterminate scope and scale. So most social problems—such as inequality, political instability, death, disease, or famine—are wicked. They can’t be “fixed.” But because of the role of design in developing infrastructure, designers can play a central role in mitigating the negative consequences of wicked problems and positioning the broad trajectory of culture in new and more desirable directions. This mitigation is not an easy, quick, or solitary exercise. While traditional circles of entrepreneurship focus on speed and agility, designing for impact is about staying the course through methodical, rigorous iteration. Due to the system qualities of these large problems, knowledge of science, economics, statistics, technology, medicine, politics, and more are necessary for effective change. This demands interdisciplinary collaboration, and most importantly, perseverance.
Solutions that work for “wicked problems” require understanding, redesign, pragmatism, culture change and perseverance. It is also true that just as a patient with a chronic medical issue that wants to live “normally” with their disease must learn enough to be participatory in the management of the problem, physicians who want professional fulfillment and an improvement in burnout among their colleagues must be a part of the solution. I believe that through participation in “compact” work and Lean or other activities that improve care many physicians do achieve professional fulfillment and renew their enthusiasm for practice. I know that working to improve the delivery of care by our practice was a powerful antidote to my frustration and burnout and was the source of significant professional fulfillment.
