I signed up for yet another program in my relentless quest for self-improvement (and perhaps recovery from decades of physician hood). This one features Dr. Lisa Lahey, co-author of Immunity to Change.
This is my second encounter with the book (when the student is ready the master will re-appear?) in which she and her co-author, Robert Kegan, lay out a model to uncover “the disjunction between understanding the need for change and the lack of understanding what prevents it.”
In other words: Why, even when we know that something must change, even when the stakes are high, and even when we know what change is required, we cannot make (much less sustain) the change. Think of the number of resolutions falling by the wayside, the diets, exercise equipment, and aspirations languishing in our corners.
The immunity to change (ITC) model is based on earlier work by Dr. Ron Heifetz, a Harvard medical graduate who developed an “adaptive leadership” framework. The ITC model assertion is that challenges fall into two basic categories: technical and adaptive. Technical challenges have known solutions that can be tested or solved. Adaptive challenges do not have known solutions and require shifts in beliefs and priorities.
For technical challenges, fixes are relatively easy, requiring only technical solutions – a combination of skills and knowledge. As an oversimplified example, an orthopedic surgeon (having skills and knowledge) can perform a hip replacement (the technical fix) to alleviate the pain of severe osteoarthritis (the technical challenge), and the patient will have increased mobility.
On the other hand, if the patient wants to recover but doesn’t walk post-op, s/he may be worrying about re-injury, recurrence of pain, or falling. Anyone telling the patient to get up and walk (the technical solution for the technical problem of not walking) isn’t dealing with the underlying adaptive challenge. The patient may be afraid of recurring pain or of causing re-injury by walking too soon. Until the mindset is challenged, s/he will not walk voluntarily.
How is this relevant to the larger health care situation? I spend a lot of time pondering the problems in the current U.S. health care ecosystem. I have been disappointed in the nature of, and lack of success of, many of the interventions which have been attempted to relieve burnout (ice cream sundaes at midnight in the ER, really?) and by my lack of ability to develop ingenious solutions. Beyond supporting individuals and groups and sounding the alarm bell – I haven’t developed a system-level cure. I have merely uncovered more causes for the almost universal despair felt by many parties involved – especially the patients and providers (nurses, physicians, APPs- all groups).
Dr. Lahey quoted Dr. Heifetz (and his collaborator Linksy) in the program: “The single biggest failure of leadership is to treat adaptive challenges like technical problems.” As soon as I heard that, I knew this was a (if not the) fundamental problem with how we have approached health care. We have attempted multiple technical fixes: the medical home, team-based care, value-based care, evidence-based medicine, and scribes (to name a few) to deal with a fundamentally adaptive challenge. None of these were terrible ideas, but all were technical solutions to a problem that is clearly, momentously adaptive. Access, cost, population health, health equity, worsening health outcomes, substance use, and mental health are all problems far too complex to expect their solutions to be neat technical fixes. Similarly, the increasing cognitive task loads and expectations on physicians, decreased autonomy and time per visit, looming productivity expectations, and overflowing inboxes are bound to fail if we all look for technical fixes.
The increased industrialization of medicine has created many of the current problems. My bias is that certain institutions (health, education, and prisons, among them) should not be “for profit.” Even the theoretically “not-for-profit” health systems increasingly operate under a for-profit business model. Another challenge for which a shift in mindset is required.
So far, multiple failed technical changes and an industrial medical model have not gotten us where we’d like to go in terms of the health of our population. The time is ripe to unearth the hidden competing commitments that keep us stuck and challenge the assumptions underlying how we operate. My post on cognitive dissonance outlines some of these (not-so-hidden) commitments. It’s time to rethink our actual goals (along the lines of addressing factors influencing health, including poverty, racism, food deserts, and education) and to examine what assumptions get in the way (there is not enough for everyone, they didn’t work for it, etc.) This will likely make many of us uncomfortable. It will require a reallocation of funds and effort. It will be hard. It may be the only way to improve the health and well-being of our population.
Claudia Finkelstein is an internal medicine physician.
