She decides to fix it. She attends all the right meetings. She writes letters and calls important people.
After 6 months, she quits in frustration.
She then shares her experience at medical staff meetings: The system was too corrupt. No one wanted to change. No one would listen.
Farson and Crichton wrote a great little book called, Management of the Absurd. Chapters include: “Big changes are easier to make than small ones”, and “Planning is an ineffective way to bring about change”.
After many attempts, false starts and unexpected successes, I offer the following absurd advice to fight for change.
Experts say, “Start with a vision”. They are right, but we misinterpret what they mean in two ways.
First, we conceive vision to be too kind and beatific. We envisage something noble, attractive.
Change grows from the ugly or painful. Reality causes suffering that drives us to build a vision of something better. We dream of a better future because we cannot stand the present.
We also misunderstand vision as something nice to think about, like a birthday present or tropical vacation.
Visions for change are more like obsessions, that torment us between 2 and 4 AM, leaving us haggard and grumpy at breakfast. True visions consume us.
Tortured change agents feel driven to fix, not because they want to, but because they must.
Absurd change is more like fighting the resistance than designing the future. The resistance is a whole system of people, processes and structures that maintains the status quo.
Some call this culture, but culture is misunderstood almost as often as it is overused.
Culture brings up images of dancers wearing kilts, suspenders and pointy hats at a county fair, while a fat man plays an accordion from the old country.
Organizational culture should bring up images of a snarling Doberman wearing a drool stained spiked collar.
Melodramatic, perhaps? Unless we trigger the right meaning, our efforts fail before we start. We have mangled Drucker’s “Culture eats strategy for breakfast” into something peaceful and tame.
Doctors spend too little time preparing to fight the resistance. They assume logic will rule, but it rarely does.
People think that change is about a project. They think it’s about changing something. This is partly true but mostly wrong.
Change is more about fighting the resistors of change than actually changing process. It’s more about building an alliance to support change than doing the technical work of change.
Changing a light bulb is easy. It is much harder to win agreement to change the bulb, never mind consensus on the type of bulb to use.
Fighting the resistance is not pugilism. Pugilists love to fight, and we need fighters to drive change. But pugilists ruin change.
Fighting the resistance often means taking a beating in public so we can advance in private. Pugilists hate this. If you enlist fighters, make sure to temper their expectations.
Absurd change is slow. People confuse big events and unusual circumstances with change. Events signify turning points, but turning points are discreet and reversible.
Change is continuous and directional. Change occurs over years, like adolescence, and leads to something completely other, new and unknown. One motion passed at a national meeting will not, by itself, create change.
Change takes far more effort than most people expect. If you hope to change one difficult light bulb, plan to put everything else on hold while you focus on that one task.
The committees and meetings and lawsuits and complaints and phone calls and emails will suck all the oxygen out of your schedule. You will struggle to manage regular duties.
Expect to treat change as a second job, an obsession. Double the time you expected to spend on a large change effort.
You can drive absurd change in two ways.
1) Revolution: You create a mob and bulldoze the resistance.
2) Political process: You build a coalition and work to gain support from inside the resistance.
Full support is rare. Someone will always feel like they’ve been bulldozed.
To build an alliance, you must work with people you do not like or trust. You might have to work with people you know have lied and will lie again.
Abandon utopia and get comfortable with good enough. Demanding perfection guarantees failure.
Get comfortable with ambiguity. Crisp plans with colourful Gantt charts rarely capture messy reality. The resistance will demand rigid clarity. It will use your inability to deliver exactly as expected as reason to undermine your whole effort.
Build support for directional change, not positional perfection. Positional perfection does not exist this side of Utopia. Find the essence of what you want to change. Do not confuse details with essence.
Expect lies, heckling, misdirection, misquotation, ad hominem attacks, gossip, slander and just about any muck your opposition thinks might work against you.
Let abuse thicken your skin. That is the easy part. Trying to stay open, humble and kind is much harder. Thick skin can protect soft skills.
But do not confuse scars with thick skin. Scars are wounds poorly managed. Too many physician leaders become rabid anti-doctor doctors after serving in leadership. They have been hurt so deeply by colleagues that they spend the rest of their careers sneering at doctors; working to crush individualism at every turn.
Finally, let others do it. Your success depends on others getting credit for the outcome.
Doctors are an unusual lot. They like hard things. We equate effort with meaning. Hard things have value. Hard things are worth doing, and a life without challenge is empty.
We have a new wave of doctors in medical politics, during one of the most exciting times in Medicare. I hope they have their personal protective equipment on and are hungry for danger. Tomorrow rests on the absurd change they accomplish today.