Absurd change is a high-risk procedure: A doctor gets frustrated with her clinic, hospital or LHIN.
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.
Absurd 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.
Why bother?
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.
Shawn, I am sure that there are others who think as I do but someone has to say it. I have sometimes tried to imagine what you have been going through. This article says so much but trying to flesh out what is between the lines overwhelms me. I am confident that it has not affected your integrity and honesty. I hope that your thickening skin is protecting you.
Thanks, Gerry.
I wasn’t trying to be tricky. I had in mind so many of the docs I see who give leadership or politics a try and then leave early. I hoped to give people a sense of what they were getting into but packaged in a way they might not have seen before. The ideas come from a mixed broth of experiences in a number of organizations and clinical settings.
As for the OMA experience this year, it has been more fun and more challenging than I ever could have expected. We are in the midst of big changes in Ontario. I am looking forward to see what happens next!
Great to hear from you, as always.
Cheers
I am very happy to see the word “fun” in your response. Carry on.
Thanks just what I needed “They assume logic will rule, but it rarely does …. Changing a light bulb is easy. Expect lies, heckling, misdirection, misquotation, ad hominem attacks, gossip, slander and just about any muck your opposition thinks might work against you.”
Shawn you forgot ‘death threats’ too much fun “Suffering fools gladly”
“Ariadne auf Naxos” Opera by Richard Strauss; Libretto Hugo Von Hofmannsthal
Bacchus sings:
Hear me, mortal one who stands before me,
Hear me, you who wish to die.
Ariadne sings:
Does nothing remain of Ariadne but a breath?
Looking for Ariadne’s Thread of Wisdom
My letter ‘Flaws in Toronto’s Opioid Overdose Prevention Program’ EMN 2015; 37(12):31 With hyperlinks to Public Health Ontario’s training literature
http://journals.lww.com/em-news/Fulltext/2015/12000/Letter__Flaws_in_Toronto_s_Opioid_Overdose.14.aspx
Thanks Gary. Great comments!
I have only had death wishes, no threats yet. 🙂
Thanks for sharing your letter, too. Well done.
Cheers
Change is directional? Moving in a particular direction?
Where our health care system is concerned , It has been, the reins have been seized by social justice post modernists and are driving the health care in the sad direction that we have all witnessed over the last several decades and which has accelerated in recent years.
Not all movement is forwards, not all change is good, not all change is necessary , not all change can be described as being an improvement , not all change should be accepted or tolerated.
Our health care system is in the process of being swallowed up by the corrupt and infested swamp with negative consequences for all concerned , in particular for the widgetized providers and those patients that they care for….only the bloated over compensated health care bureaucrats and the overcompensated salaried and pensioned SJ Quislings from our profession will be celebrating.
One has a vision of them as the pigs of Animal farm , clothed celebrating at a sumptuous feast , standing on two feet and drinking whiskey ( the 7 commandments having been: 4 legs good, two legs bad; no animal shall wear clothes, sleep in a bed, shall not drink alcohol, shall not kill another animal; all animals are equal) …rations having been reduced for the rest of the overworked, underfed and miserable widgetized animals at the collective farm…”all animals are equal, but some animals are more equal than others ” .
We need someone Churchillian with the courage, wisdom and judgement to reverse the direction, to lead the drive to drain the swamp….and introduce an evidence based hybrid public/ private health care system as enjoyed by the world’s top rated health care systems!
I can see no such heroic figure on the Canadian horizon …..big changes are coming, the Liberal government has passed all the bills required to impose their ideological nightmare on the citizenry of Ontario, all that is left is the actual imposition of their miserable scheme doomed to failure.
I am also looking forwards to the inevitable calamity , adopting the attitude of, that proverbial Indian who fell asleep in the canoe as it floated towards Niagara Falls, who tried to paddle against the current, who then resigned himself to his fate , took out his pipe and lay down to relax….as he went over the falls.
Andris
Your comments are always so rich and varied that I find it hard to respond! All I can say is that I hope readers take the time to think and debate, in their own minds, what you have said. You should write a book!
Cheers
Feels a little like this was directed at me. I feel a little burned out both in my practice and my political activities. I feel that you are moving in the right direction but are being undermined by the old guard sniping from their perches in the College and other sinecure positions. Its hard to do the contract and re-structure and refocus the organization at the same time. You are right about vision, it can’t be pie in the sky do everything for everyone. Like your own vision, it is useless unless it is focussed. Blurry vision is worse than blindness. The blind know to be focussed and actively look for obstacles. Blurry vision gives you too much confidence and leads you crash around hitting obstacles and misidentifying what you are looking at. In focus vision is sharp, clear and to the point.
Great to hear from you, Ernest. I’ve noticed that you’ve been a bit quieter around medical politics lately. I sure hope you can recharge and get back into the thick of things soon!
No matter where doctors choose to lead change – in their clinics, offices, regions, provinces or elsewhere – change requires a peculiar endurance and perspective. It is hard. But we need more people like you fighting for change.
Thanks for all you do, and have done, for healthcare!
Great to hear from you.
Cheers
Well said, Ernest. I totally agree with you.
Shawn, the only thing constant is change! We already have change, but it is disorganized and therefore absurd. We need to organize targeted change for the sake of the system. I am discouraged at the current state of the system. How long has it been? 10, 20 or 30 years?