Dissent and cynicism: Learning from listening to doctors

An excerpt from The Doctor Crisis: How Physicians Can, and Must, Lead the Way to Better Health Care

I just listened. They were very unhappy and angry.

I was elected executive medical director in November 1998 but would not assume the leadership role until January 2000. This was fortunate. I knew that I needed time to prepare for a job that was about as radically different from my twenty-plus years in the operating room as I could imagine. Although I had certainly not drawn a detailed blueprint, I did have an approach. Two priorities topped my list: I wanted to talk face-to-face with as many of the five hundred Kaiser Permanente (KP) Colorado doctors as possible, and I wanted to learn as much as I could about leadership and business, which included attending a Stanford University executive leadership program. Sometimes the most important step that leaders can take is to recognize what they do not know. I was very clear when elected that I did not have extensive business experience. I knew that I would have to work doubly hard to understand how to lead effectively in a complex environment. I needed to learn not only what to change but also—and more important—how to lead change. To do so, I would have to listen and learn.

I hit the road in March 1999 for what I called my Listening Tour. I felt a powerful impulse to get out there and listen to what the doctors had to say. I needed to look them in the eye and feel their frustration; I needed to hear about and understand what they were experiencing. I also sought to send a signal that I cared deeply about what the physicians thought and felt. I could have met with a representative sampling of physicians, but I wanted to hear everybody. I wanted to look all five hundred doctors in their eyes. In this sense, the Listening Tour served as an act of respect for my physician colleagues and an opportunity for me to be as well grounded in their reality as possible. I was very open with doctors that I did not have a specific plan for how to run the place but that I would build such a plan based on what I heard from them, which is precisely what I did.

From March until mid-June 1999, when I would start the Stanford program, I put a few thousand miles on my car visiting doctors. I carried with me nothing but a pad of paper and a pen. I went out to the clinics one after another, typically spending the better part of a day at each one. In advance I would schedule fifty-minute meetings each hour with four to five physicians — thirty to forty doctors per day. I would spend more than 90% of each session listening and taking notes. I heard about frustration with the call center, confusion about scheduling, and irritation at not having the full teams needed to deliver high-quality patient care. I heard and felt frustration with and anger at the group leadership. The messages from each physician at each clinic seemed to be dispiriting echoes of one another. I did not offer solutions to the problems that the physicians raised. I did not commiserate with “yeah, everything sucks.” I just listened. And what I heard at clinic after clinic, from physician after physician, was that they were deeply unhappy and often angry.

At one clinic in particular, I found that the staff was not angry so much as they were infused with a sense of futility. It was as though they were at a dead end and there was nothing they could do. During the Listening Tour, I learned a critical lesson: the difference between cynicism and dissent. Cynics are characterized by a sense of hopelessness and futility and do not present alternative solutions along with their criticism. A dissenter, on the other hand, wanted to work to make the organization more effective.

Thus, I learned a valuable lesson: Dissent has value, while cynicism has none. Dissent can be just as angry as cynicism but comes with engagement: I care enough to be angry about the situation here. Dissent comes with ideas for change and solutions for improvement. Dissent is forward thinking and solution oriented. Cynicism is futile, hopeless, and negative. Challenging futility is an essential component of leadership. Futility doesn’t help me. Can you take that and turn it into a request, a proposal for change, an idea? In a sense, all leadership is change leadership. This requires real understanding of the point of view of those who will be affected by whatever the change might be. Here is where the Listening Tour played an essential role. Instinctively and through experience, I understood that change was not dictatorial in nature but instead was more subtle, more personal. Change required listening and understanding. I had long ago learned to listen actively, that is, to listen to what the person was trying to convey to me. Too often I had seen people pretend to listen, but their version of listening was little more than a break between pronouncements. They appeared to listen while forming the next thought that they would articulate.

I had been drawn to an idea articulated by Randall Root, founder of Root Publishing and a respected thinker concerning strategic engagement work with employees. Root’s notion was that when taking on challenging problems, it was essential that both parties share all their data. If I have your data and you have mine, we can get somewhere. Valuing dissent is saying that I don’t agree with you, but I am working with you. With my data and yours, we’ll meet and find a solution.

Jack Cochran is executive director, the Permanente Federationand the author of The Doctor Crisis: How Physicians Can, and Must, Lead the Way to Better Health Care

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