Rushing to a Solution?
I was talking with a friend the other day who is trying to change “the way we do things around here” for his organization by creating teams of physicians, nurses and managers to handle operational issues. He has found the process slow to develop in part because the physicians he is asking to participate have little or no training in team leadership. Of course, some will turn out to be uninterested in learning and need to be replaced, but others will engage and try to make it work. However, they may find their training and practice as physicians makes it more challenging than they expect.
I recently became aware of the work of Michael Bungay Stanier, who has developed a thoughtful approach to the challenge. As he noted in an interview,one of the challenges is that the first problem someone brings to the table is usually not the main problem. He calls it a symptom, which seems plausible. The second issue is that one’s advice is almost never as good as the advice giver thinks it is. Thirdly, giving advice too soon may prevent the person receiving the advice from developing the necessary commitment to making it work.
In a TEDx talk quoted by Norris Burkes, he elaborated on what he calls the “advice monster.” He describes three behaviors typical of advice monsters. First, he “tells it.” Stanier notes this person needs to tell you in order to add value to his life. Second, is one who wants to “save it.” Again, the rescuer is trying to add value to his own life. The third type wants to “control it.” As I think about what doctors do, we are prone to all three behaviors. (And I am including myself in this. I have done my share of all three.) After all patients consult doctors for advice and we get in the habit of “telling it,” even though we know the probability of the patient taking the advice is low. Of course, being a rescuer is built into medicine; after all we are trying to save people from the Apocalypse. And doctors, like most other people, have control issues.
So, does this show doctors are hopeless? Stanier would likely reply no, as the challenge is not to avoid giving advice forever, but to spend more time exploring the issues before speaking up. He names it as a call to “stay curious.” Since a person, patient or otherwise, almost never starts with the real issue, the challenge is to avoid rushing to a conclusion. The ten minute patient-encounter, with eight minutes devoted to documentation, seems to be teaching doctors to avoid open-ended questions, but “tell me more” is almost always in order. If the problem has a simple solution, the odds are the individual would have already taken care of the issue without involving you. A maxim I learned years ago is “The obvious simple solution is almost always wrong, because problems are almost never simple or obvious.”
The last suggestion Stanier has is to ask the person what they want. After all, a solution that appeals to them will get more engagement than one that does not. My father, who was a career Army officer, taught me that the military expected comments and suggestions to be offered by the junior officer first, because if the general announced his or her preferred solution, everyone else would say “Yes, Sir.” The medical equivalent is to seek input from the nurse or administrator before “prescribing” a course of action. Even though prescriptive talking is an occupational hazard, giving the other person the opportunity to have meaningful input into the decision making. As Dad taught me, “It isn’t necessary to have all the good ideas yourself, but it sure helps if you can recognize a good one when you hear it.”
So, what “advice” did I give my friend? Since I have experience trying to do the same thing, I reported on my attempts to build trust and to start small projects that were specific and patient-focused. While I still thought that was the best way to begin, I noted my efforts were derailed in part because all parties wanted to jump to the “big issues” like ownership, control, and money, which I know is redundant, without having established a common understanding about the more amorphous issues like culture. My friend responded that lots of people were talking about culture change. I suggested the English language translation of “culture change” was probably “If you would just change, things would be better.” He agreed that seemed to be the case.
Yet culture does matter. Unless doctors recognize both the strengths and weaknesses of “cowboy culture,” or the rough Jacksonian Democracy which characterizes most doctor culture, progress will not happen. Likewise, unless administrators recognize both the strengths and weaknesses of bureaucracy and their innate distaste for Jacksonian Democracy, progress will not happen. For this understanding to occur, frank and candid discussions need to occur and both sides need to avoid becoming defensive. Progress requires changes in both cultures to find a place in the middle that works given the specific circumstances of the community in which the organization operates. And it requires trust. The underlying barrier to progress, then, is the lack of trust, followed by the barriers to understanding that result. Progress is possible, but it takes time, a lot of work, and leadership committed to developing trust. I hope there is enough time and energy, as patient care requires it. Certainly rushing to the answer will fail.
10 March 2020
 https://www.youtube.com/watch?v=oTk0Cz7yRNI. Accessed 10 March 2020
 Burkes N. Not All Advice is Created Equal. The Jackson Sun, Saturday, 7 March 2020, p. 1C.
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