Time Span Preferences and Physician Leadership
Elliott Jaques’ theories about organizational structure and psychology were largely ignored by the business community until the 1980’s, when interest in “lean” organizations developed. I became aware of his ideas at a Levinson Institute seminar I attended 20 years ago. Today there is an institute dedicated to promoting his ideas about the “requisite organization.” I want to focus on one aspect of his work.
Half a century ago, while advising a UK Metals company, Elliot Jaques had a deep and controversial insight. He noticed workers at different levels of the company had very different time horizons. Line workers focused on tasks that could be completed in a single shift, while managers devoted their energies to tasks requiring six months or more to complete. Meanwhile, their CEO was pursuing goals realizable only over the span of several years.
After several decades of empirical study, Jaques concluded that just as humans differ in intelligence, we differ in our ability to handle time-dependent complexity. We all have a natural time horizon we are comfortable with, what Jaques called “Time span of discretion,” or the length of the longest task an individual can successfully undertake…
In the Jaques model, one can rank discretionary capacity in a tiered system. Level 1 encompasses jobs such as sales associates or line workers handling routine tasks with a time horizon of up to three months. Levels 2 to 4 encompass various managerial positions with time horizons between one and five years. Level 5 crosses over to 5 to 10 years, and is the domain of small company CEO’s and large company executive vice presidents. Beyond level 5 one enters the realm of statesmen and legendary business leaders comfortable with innate time horizons of 20 years, (level 6), 50 years (level 7). Level 8 is the realm of thinkers like Henry Ford, while level 9 is the domain of the Einsteins, Ganhis, and Gallileos, individuals capable of setting grand tasks in motion that continue centuries into the future.
The further into the future one plans, the more uncertain it becomes. Said another way, one’s innate tolerance of ambiguity and uncertainty determine one’s “time span of discretion.” So how does this relate to practicing physicians and their leadership capacity? I want to consider this two ways: the physician perspective and the managerial perspective.
I had a conversation with a pathologist whose daughter was going to medical school and considering a residency in internal medicine. He asked me what I thought, since I knew his daughter, and he could not imagine why she was interested. I suggested that he had been attracted to pathology, because it appeared to be “cut and dried,” and at least in purple and red, if not black and white. He agreed this was so. I also suggested that his current dissatisfaction with his practice stemmed from the fact that as he had learned more, he had discovered his assumptions were not true—pathology has its own share of ambiguities. He agreed this was true, also.
On another occasion, I was talking to a young surgeon who had become disenchanted with her general surgical practice, and had decided to return to the teaching hospital to take a position as a trauma surgeon. When I asked her why she wanted to make this change, she said: “I can’t stand dealing with your patients and their recurrent vascular access problems. I want to deal with problems where the patient either makes or doesn’t, but it is only a one time thing.”
As a third example, I was talking to a young pediatrician who was bored with her practice and had decided she wanted to apply for a management position at the hospital. When I discussed Jaques’ ideas with her, she commented: “I can’t stand ambiguity.” I did not discourage her from applying, but did suggest she pick her projects very carefully.
When I was making specialty choices forty years ago, I was attracted to nephrology because it was a chance to take care of a group of patients who had never been around before—those who lived through kidney failure by dialysis and kidney transplantation. The novelty, the uncertainty if you will, of figuring out what to do was a major attraction to me.
Each of us made a choice of medical specialty based, in part, on our tolerance for ambiguity. To be sure, every specialty has its uncertainties, but the time horizons of those uncertainties do differ. Surgeons and other procedural specialists typically have time horizons of three months to a couple of years, whereas cognitive specialists often have to think about the rest of the patient’s life. The issue is complex, though. A surgical oncologist, for example, is going to be a lot more comfortable with uncertainty than many internists. The point for this discussion— all physicians have to deal with the issues of time-dependent complexity, ambiguity, and uncertainty.
These subtleties are mostly invisible—most observers would say the defining characteristic of physician work is busyness. This leads to a view that physicians are really functioning at Level 1 in Jaques’ scheme—just trying to get through the day. Most managers, though, believe they are operating at level 3 or 4, if not 5. This disconnect is one of the things that leads to the communication gaps that occur in most healthcare organizations. It also hampers management’s ability to use physician skills effectively.
Thinking in terms of “time-span preferences” has implications for the leadership roles physicians should undertake. I have found proceduralists usually are most effective, and happiest, working on projects that are well-defined, they would say specific, and have outcomes that are straightforward. Projects that are hard to bring into focus, or where it may not be clear how to measure the outcome, tend to be the province of those physicians whose practice is mostly “evaluation and management.”
15 June 2014
 Rasky, Susan F. Corporate Psychologist: Elliott Jaques’; His Ideas on Work Take Hold. New York Times 17 February 1985. Located at http://www.nytimes.com/1985/02/17/business/. Accessed 15 June 2014.
 Saffo, Paul. 2011: What Scientific Concept Could Improve Everybody’s Cognitive Toolkit?
http://edge.org/response-detail/11105. Accessed 15 June 2014.
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