The Good Journey at ACPE

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My Ride

More than three years ago I began two projects, one personal and one professional. I started full-time work as ACPE’s first physician CEO, and I began restoring an old Toyota Land Cruiser. As my last day at ACPE approaches, I’m thinking about the similarities between those projects.

Both ACPE (1975) and the old Cruiser (1979) were born about the same time. In geologic time, both came into existence before Mt. Saint Helens erupted. In political history, both were new during the first oil crisis in the US in 1979.

The craftsmen and women who built these legendary entities had pride and vision for the future. The core components of each (physician leadership education; classic 4WD mechanical components and reliability) deserved to be retained. But after more than 30 years of change and progress, each required some remodeling to needs of today.

For the Cruiser, my son and I found a diesel engine to replace the old, inefficient gasoline engine, and decided to repair a few other things that needed attention. Little did we know that a LOT more parts needed an upgrade. The short version of the restoration is the cover story in the Winter Edition 2011 of the magazine 4x4 Garage.

Brake lines needed to be replaced. Damage from boulders hidden under layers of bondo required new sheet metal and welding. The transmission frequently popped out of first gear on steep downhill grades.

We found a Toyota diesel mated to a more modern 5-speed transmission from Australia. That nearly tripled the gas mileage, and the added turbo now makes for a quick old 4 x 4! We found a canvas top made only in Pakistan (by a company owned by Ehsan - a physician) that’s an exact replica of the original Toyota soft top. We had help from several people across the globe with far more expertise than either of us. We shared our mistakes, and admitted what we didn’t know. Actually, it was my son who did most of that on his build thread on the online forum IH8Mud.

The venture into social media meant the world was able to see what was happening in my New Mexico mountain shop. Those connections brought us into contact with many interesting, courageous and creative people.

Meanwhile, at ACPE, we began the process of imagining what a more modern College might look like for physicians with a passion for learning, leading, and innovating. We got rid of some old traditions, such as tuxedos and evening gowns for the Induction Ceremony. We switched from paper ballots to on-line voting for ACPE Board candidates. We made some changes to our board: adding ex-officio members with younger and different perspectives.

Our board, blessed with some very strong Chairs during my tenure, grappled with what author Jim Collins called the Hedgehog Concept: What are we passionate about? What can we be the best in the world at? What drives our economic engine?

On the day I signed my contract to become CEO, Lehman Brothers collapsed. The early months of the recession forced us to develop a more efficient engine. That modification continues to get high miles per gallon since the recession has eased, and will serve the College well in the years to come. Dr. Peter Angood, who will begin on November 15, will be able to install the turbo charger for the next phase at ACPE, and maybe change the sheet metal for the next model years!

Your staff and I had help from many of you in this “resto-mod”. Through the Board Task Forces, expanded networks, and feedback on surveys, we found new curriculum, faculty, and topics that led to lively sessions, and even a new certificate program (HIT).

The Physician Executive Journal of Medical Management became PEJ. The topic of physician leadership made it to the Wall Street Journal, New York Times and NPR, indicating greater relevance for the College and its members.

I’m going to write one more blog for ACPE before I leave for the next phase of my life after our Board meeting at the Fall Institute in Scottsdale next week. For those of you who find yourself in a CEO role someday, I want to share some of the important lessons I learned about the unique challenges inherent in “the corner office” – even though there are no corner offices in the cylindrical building that houses ACPE headquarters here in Tampa.

If you see the sky blue Cruiser with the Pakistani soft top somewhere in the U.S. over these next few years, wave to me and smile.

The Situation at Pumpkin Springs

On day seven of my raft trip down the Colorado River at the bottom of the Grand Canyon last week, our group came to a popular stopping point called Pumpkin Springs. The rocks just above the hot springs was a place to jump into the dangerous and exciting Colorado River for a cool, refreshing diversion from the hot sun of the mid-afternoon.

Our guides noted that the landing here would be difficult because it required landing just above rapids. They told all of us to disembark from the rafts with our life vests on, should we fall into the fast moving river just above the rapids.

No one wanted to go into Pumpkin Springs because of rumored high levels of arsenic. It didn’t smell very good, either. But some wanted to do the jump into the river – including me. What happened next surprised me, and taught me a few lessons about taking chances in a group.

We climbed to the rocks overlooking Pumpkin Springs. The guides pointed out the jumping spot and the water below, noting that the life vests caused you to pop right up out of the water, and the prevailing eddy current would actually pull you back upstream to a nook in the rocks – and a rope to climb back up. One of the guides jumped to demonstrate the deep water below, and the route to the rope.

Then came the question, “Who’s going to jump?” Several people announced quickly that they were not jumpers. I didn’t say anything. I was thinking about it. Then I uttered, “I think I will.”

I watched as my friend and fellow physician Howard leaped off the rock to the muddy water only about 12 feet below. He popped up just as predicted. His nose was bleeding. His fingernail caused a superficial laceration when he grabbed his nose to prevent water from going up his nostrils.

My turn. I’ve jumped before from similar heights – but that was about four decades ago. Standing on that rock, looking down at the swirling water only 12 feet below, I could not make the leap. Step up, look down, back off. Repeat sequence. I have no idea how many times I did that dance. My legs were shaking. I could feel the adrenaline rush that comes from fear.

Of course it didn’t help that others in the group were watching my agony. What if I got hurt on the landing? Hours away from any kind of rescue. One of my friends pointed out that I have good health insurance - the moral hazard reason to do something risky.

Another said he was beginning to question my manhood. That always comes up in a group of men – for just about any issue!

I just could not visualize myself in the air, landing feet first and entering the water straight. Then another member of the group decided she couldn’t wait any longer to jump. Watching her helped me visualize what I must do. I was finally committed. I jumped. Easy. Good landing. The current brought me back upstream to the rope, just as the guides mentioned.

Climbing back up to the rock, I jumped again with no hesitation. The cold water felt very refreshing. My agony of fear and indecision was over. Even my manhood was back!

Then I noticed that the eddy current on the first jump that pulled me back upstream – away from the rapids - was different. It was moving me downstream! I swam hard just to stay in place. Finally I made some headway and was able to get back to the rope. When I got back up to the rock, I asked Howard, who had jumped again, if he had the same problem with the current. Out of breath, he said the same thing happened to him. In the cold water longer than anticipated, he was getting cold. We decided not to jump again.

Commitment is important. If you’re not ready to do something, don’t announce that you’re “thinking about it”. It’s hard enough to understand what’s going on in your own mind when faced with a risky decision, and even harder for the group watching to understand what’s behind the indecision. Rumors and assumptions can be quite interesting! Actions do speak louder than words – to yourself, and to others.

Once you’ve taken that initial risk, sometimes everything goes as predicted – but sometimes it doesn’t. There are often unanticipated challenges and dangers. Don’t be afraid to talk about those unexpected events with others in your group. Base your next decisions on the “current conditions” you’re experiencing. Trust your instincts. Maybe my initial fear was justified after all.

Seeking -- And Finding -- Physician Leaders

One of the more interesting and active discussions in our ACPE Network is about “Why aren’t physicians leading?". You’ll find all sorts of opinions and insight. I want to submit the opposite hypothesis: that physicians ARE leading. And doing it very well!

Here are just some of the recent pieces of evidence that demonstrate the effectiveness of physicians when they are in leadership roles:

1. The New York Times' health blog picked up Amanda Goodall’s newly published research in the journal Social Science and Medicine, in which she looked at the credentials of CEOs at US News and World Report’s Top 100 Hospitals for Cancer, Heart, and GI care. Though the numbers of physician CEOs in American hospitals is low, there was a strong correlation with physician leadership in the top performers. In fact, quality scores were 25-33 percent higher in the physician led hospitals than their non-physician led peers. Like basketball teams and research universities that she’s studied, which show that former players and researchers get the best results when they are in charge, the experience of being a physician adds a powerful dimension to leadership and results in health care organizations. Read about it here.

2. The recent US News and World Report ranking of the nation’s top hospitals was released last week. Of the top ten, nine are led by physician CEOs. Going down the list of Honor Roll hospitals, eleven of the top seventeen are led by physicians.

3.The American Hospital Association recently announced it was forming a leadership forum for physicians. This effort, led by physicians John Combes (a CPE) and Bill Jessee (last year’s ACPE Distinguished Fellow), has twenty other physicians on the Advisory Board. As we read the list of names, we noted that at least 75 percent are ACPE Members, CPEs, former faculty, or use ACPE as partners in their organization’s leadership development programs. Long-time ACPE faculty member and internationally-known leader in quality and safety – David Nash – was the keynote speaker for the physician leadership forum. It’s too early to know where this initiative is heading, but knowing the integrity and experience of the group, their leadership gives me confidence that the right topics, discussions, and recommendations will be made.

4. Anecdotally, we’re hearing from recruiters that health system boards are changing their views of physicians as leaders. Ten years ago, a token physician CEO candidate was requested. Five years ago, a physician candidate would be given serious consideration. Now physicians are preferred.

I have no doubt the growing evidence of physician leaders’ effectiveness will ruffle some feathers in the health care industry. As Dr. Goodall points out in her research, there’s a strongly held belief that doctors can’t manage or lead. I believe it’s true that the vast majority of physicians do not aspire to be in the CEO’s chair of a health system. It’s darn hard work that requires a certain personality and multiple skill sets. But for those who do find themselves attracted to that role, isn’t it time that they be given a chance by governing boards, and/or groomed for the role by their current health system senior leaders?

I heard recently from a highly reliable source that most hospital CEOs do not have an internal succession plan for their replacement. Well-run businesses outside of health care consider promoting internal talent, and grooming potential successors, as a key to the long term success of the enterprise. Does health care fail to do this because the average tenure of a CEO is just under four years? Or because fifty-seven percent of hospital CEOs have been in their jobs less than five years? Do physician leaders at the top performing hospitals view training potential successors as a priority?

As we look more deeply at the characteristics that make physicians particularly good leaders, we’ll be asking questions like these, and searching for metrics to show the differences. We don’t know what we’ll find, but that’s what research is all about!

Disruptive physician or threat to the hierarchy? Watch out for the Kool-Aid

No doubt you’ve been aware of the latest survey on the topic of disruptive behavior in health care. The results of our joint study with QuantiaMD are the same as our ACPE survey nearly two years ago. We physicians still have a lot of work to do in our own house to solve this patient safety issue. We’re making progress. But it’s time to look at another angle of how physicians become labeled as “disruptive”. Sometimes the label is just plain wrong. Like old Hollywood westerns, or Patrick Swayze movies, the hero is often bullied by powerful people and organizations who feel that their authority is threatened, or who perceive that the status quo might change.

Since this latest study was published, I’ve had lots of interesting discussions with physicians, and senior health system leaders. Some senior leaders who come from non-health care industries comment on the odd culture of health care compared to many other industries. They point out (it’s also my experience) that disagreement, rather than being viewed as a strong cultural attribute for innovation and change, is frequently considered a threat to the hierarchy. Sometimes decision-making is highly centralized in the C-suite, and leaders are very uncomfortable with questions or differing opinions. In these health systems, the organizational Kool-Aid demands “loyalty” to the leaders, rather than legitimate, truthful debate about the merits of strategy, policies, or procedures. More about “loyalty” later!

When faced with a physician who voices distaste with the Kool-Aid of mindless agreement, these leaders label her/him “disruptive” – not because of behavior, but because of disagreement! That can lead to all sorts of problems for the physician who must then answer to the official organizational procedures for dealing with the disruptive physician, such as medical staff or legal proceedings.

In my first health system leadership job, I remember asking the senior physician leader of the system what Dr. X thought of the strategy proposed.
“He disagrees with us, so we’ve removed him from the committee.”

Dr. X was a physician who was respected and admired by his peers, by the nurses, technicians, and support staff who dealt with him, and most importantly, loved and respected by his patients. At least he wasn’t officially labeled disruptive, and made to go through counseling or monitoring! His disagreement with the strategy was shown to be correct a few months later.

Another physician with the same excellent clinical and service reputation came to me looking for a job. He’d been fired from another system because he disagreed with administration, sometimes too aggressively and disrespectfully. After listening to my new management colleagues advise against hiring him, and sharing my obvious concerns with him about his behaviors around managers or executives, I hired him. His dedication to patients, and his remarkable creativity were the characteristics my physician group needed. Working with him to change his behavior when he became frustrated or angry, he gradually learned how to use more productive behaviors. He got his 5-year pin, and eventually was named physician of the year by a well known national health care organization.

Both of these physicians were labeled as cynics by those who didn’t appreciate their disagreement. The best definition of a cynic is “a passionate person who doesn’t want to be disappointed again.” (Benjamin Zander, conductor of Boston Philharmomic) I learned that disagreement, when respectful and done in the spirit of innovation and improvement, is good. It’s what I like about working with talented and passionate people. It should not be extinguished. It should be encouraged.

If you hear your senior leader ask for “loyalty” – watch out! It’s just another way to stifle honest disagreement, or can be viewed as bullying.

I’ve never forgotten what I was told by a senior legal counsel in one of my first health care jobs, “Sometimes loyalty is more important than telling the truth.” Not for me.

You can hear the word “loyalty” used when uncomfortable decisions are made without the input of experts, when leaders don’t want to be questioned, or in a complex situation with public relations implications is unfolding. I don’t believe that a leader should ask for loyalty from followers. Loyalty can only be given freely by those who choose to follow, not forced upon them by a leader. Maybe if you run a monarchy or dictatorship it’s OK to ask for loyalty.

This quote from Col. John Boyd helps me put the issue of loyalty in proper perspective:

“If your boss demands loyalty, give him integrity. But if he demands integrity, give him loyalty.”

What do you ask of your team?

The Tyranny of Infallibility

Why is it so hard for we physicians to acknowledge that we’re human, prone to mistakes, misstatements, lapses in judgment, fatigue, or failure? I’ve had a most amazing week criss-crossing the country, doing presentations and having discussions with very interesting people.

One of those people was Jeff Skiles, co-pilot of USAir Flight 1549 that landed on the Hudson River in January 2009. I guess we say “on” instead of “in” because it didn’t sink - for awhile, at least. In the year and a half since I’ve known Jeff, he’s developed a very effective presentation on the impact of moving from autonomy to teamwork in commercial air transport. It’s that teamwork which contributed to the miraculous result for the passengers and crew.

A key point of Jeff’s comments is acknowledging fallibility, and dealing with it by building a team of people who learn how to communicate without “taking it personal” when they’re questioned by a team member. He said authority used to be based on fear or intimidation by the senior pilot. It’s now role-based authority.

When Capt. Sullenberger declared, “my aircraft” after the A320 hit the geese (Jeff was flying the plane), it was clear that the captain was taking responsibility for bringing the aircraft down. Jeff would go through the checklist to start the engines, if possible. Once it was clear that a crisis was occurring, the cabin crew began their respective autonomous actions to secure the cabin.

Jeff says his training in aviation comes in handy in his other roles as general contractor, husband and father. Now that’s a powerful testament to the effectiveness of these concepts!

I joined other ACPE faculty for some on-site teaching last week, and the topic of human error was discussed as a key component of the engineering science of reliability. I don’t know about you, but my instinct from years of being a physician is to believe that “human error” doesn’t apply to me – I’m a physician and not supposed to be fallible like other humans. That’s crazy!

Once we start talking about human error and the physician’s role, whether in full time clinical practice, or in system leadership, typical comments turn to our inability to admit we make mistakes because of the legal system. Are we using the legitimate but separate issue of the tort system to avoid discussion of our own human foibles, and appropriate methods of building safer care? Maybe we could find humor in our foibles, and have some fun with the topic instead of avoiding a necessary discussion!

Like many of you, and like some of the physicians with whom I teach, on certain occasions I’ve deliberately ignored the advice of a malpractice attorney to not admit I made a mistake in diagnosis or treatment. Knowing the truth of what happened and my role in it, withholding that truth from any human being isn’t right, and it eats away at me.

Most studies of physicians conclude that we do not like to be controlled or directed by others. If we don’t like the control that the tort system and lawyers have over us, then why do we exhibit learned helplessness by agreeing with them that we must not admit our fallibility?

Frankly, it’s liberating to discard the illusion that I should be immune from human error and weakness. That holds true for both clinical care, and in leadership or management roles. It’s self-imposed tyranny to think otherwise. Best yet, I believe that the key to improving safety, reliability – and changing the tort system – is in throwing off the chains of infallibility and perfection that we expect of ourselves, and adopting many of the concepts that helped other industries become much safer.

Notes from the San Antonio Annual Meeting

ACPE's Annual Meeting, held in San Antonio, ended this past week. The participants had an energy, enthusiasm and passion to improve health care that was noticeable to me and the ACPE staff. Here are some comments and observations from the meeting, in no particular pattern, that might be helpful in your daily activities. These thoughts might also help you put the current uncertainty of health care in perspective.

• Kevin Fickenscher, long-time ACPE member and editor of Dell's Washington Report, noting in his Vanguard presentation that in 2009, the federal government collected $1.3 trillion in taxes; expenses for Medicaid, Medicare, Social Security and service on the national debt totaled $1.2 trillion. We borrowed the rest.


• David Nash, dean of Jefferson University School of Population Health, who has an uncanny knack for sound bites, shared his new four word summary of Accountable Care Organizations: "No outcome, no income."


• Grace Terrell, CEO of Cornerstone Health Care in High Point, N.C., and Sue Freeman, CMO at Temple University in Philadelphia, both commented on facilitator Francine Gaillor's thought-provoking statement that "leadership is a stage." Everything a leader does is under a spotlight. Your words, actions, body language and moods are constantly on display. How does your performance come across to your audience?


• Chal Nunn, CMO of CentraHealth in Lynchburg, VA, commenting in a break-out session on quality and safety: "A 99-1 vote is considered a tie by the medical staff."


• One of the participants in the same break-out session commenting on the challenges in getting agreement by the medical staff, got a big laugh when he mentioned, "the 'silverback male' on the medical staff can derail the best laid plans."


• John Kenagy -- surgeon, author, advisor and keynote speaker -- outlined his concept of Adaptive Design, which allows front-line workers to rapidly and energetically spot and solve problems on their own. No layers of bureaucracy and hierarchy needed! Several attendees commented on how useful the A3 Problem-Solving Report will be in developing operational plans to resolve problem areas in their workplaces.


• Tom Royer, physician CEO emeritus of Christus Health System, gave a moving address to the new CPEs and Fellows at the Induction ceremony. Relating several poignant moments in his leadership career, he asked all of us to ponder why we're put on the earth, and to appreciate the opportunities we have to help others.

Now we're changing our focus to the Summer Institute in Boston, July 15-19. In addition to our Integrated Health Systems course, which covers everything from strategic considerations to physician engagement to financial integration, we're launching a new course on entrepreneurial thinking. This new course was developed in response to one of our ACPE Board Task Force's recommendations. It will be taught by the director of the Entrepreneur Program at the University of Southern California's School of Business.

Bostonians say the snow has melted and that summer is a great season to visit their historic city. If you haven't ridden the water taxi there, I can highly recommend the experience as a cool summer mode of transportation.

The Bus or the Rope?

How many times have you heard leaders talk about “getting the right people on the bus”?

I find that analogy in health care to be difficult. It just doesn’t resonate with my experiences or my sense of how we should be thinking of our work on behalf of patients. First, let me outline why the “bus” and its occupants makes me uncomfortable. Then I’ll outline a model that makes more sense to me.

Ask a group of physicians or executives where they’ll be sitting on that bus if they’re the leader. The immediate and most common response is, “In the driver’s seat, of course! I know where I want to go and how to get there. I want people on the bus who support my direction.”

A few want to sit in the back and monitor what’s happening as the bus barrels down the freeway. Some are comfortable with rotating drivers.

Are riders on your bus comfortable pointing out problematic strategic, operational, or patient safety-related decisions? What do you do if your riders disagree with you? Usual responses: “They’re asked to get off the bus” or “They’re thrown under the bus!”

Ask about where the patient rides on the bus. That question gets some very interesting responses: “Somewhere behind the driver”; “In the driver’s seat”; “In the baggage compartment.” That last response gets a lot of laughter, and heads nodding in agreement.

Now imagine a different image. Imagine you, your team of health care professionals, and a patient are on a rope, climbing a mountain in the Rockies, Andes, or Himalayas. You are all linked together on that rope, all with the same goal. In health care, it might be evidence-based medical care, highly reliable and safe care with optimal outcomes, or patient centered care. It’s risky work. There might be many ways to get to your collective goals, but it will require input from everyone.

It might also require vigorous disagreement from time to time about the safest and best way to proceed. If you’re the leader of the team, and know how you want to achieve your goal and how fast you want to get there, are you comfortable with agreement, or perceived agreement? No one speaks up. Do you assume everyone agrees? Do you want to encourage disagreement before starting up that dangerous part of the journey?

As you proceed up that mountain, you’re about to step in a crevasse. We’re all prone to mistakes as human beings. How do you want the team member behind you on that rope to respond? I want to hear, “STOP – that’s not safe!” Or feel the sudden tightening of the rope as an ice axe is plunged into the snow. We’re all in this together – each one of us concerned about one another’s personal and professional safety – regardless of our status in the hierarchy of the team. What happens to one of us is likely to happen to everyone else on that rope.

Finally, imagine a situation where the patient is the only person on the rope who isn’t ready, or in shape, for the push to the top. Not strong enough. Circumstances don’t seem auspicious or comfortable. Do we have the courage, compassion, and situational awareness to listen? Do we decide to wait until another day or moment, or do we drag the patient up to the top because the health care team believes it’s the right thing to do?

Put me on a rope with people who aren’t shy about voicing their concerns for patients, and for safety. People who can be counted on to do what’s right, for the right reasons. I don’t mind if those people are a little rough around the edges. If everyone realizes that the most important individual on that team is the patient, we’ve got a great team! Come to think of it, maybe that patient is the true leader of the team.

Physicians and Disruptive Innovation

Last week, ACPE Vice President of Career Services Barbara Linney hosted a webinar on career options that broke previous attendance records. This one was notable for the number of physicians looking outside the hospital sector for new roles. Consulting, insurance, pharma, or entrepreneurial ventures were mentioned as preferred destinations.

I’ve been racking up frequent flyer miles the past few months doing on site training on clinical leadership and moving from autonomy to teamwork in a health care system undergoing stress and change. If energy, enthusiasm, and engagement of the audience is an indicator of most physicians’ state of mind, it appears that many are thinking about what they can do beyond individual patient care to provide remedies for a broken system, and to get more satisfaction from their professional careers.

The topic of disruptive innovation generates the most animated discussion. They’ve been giving thought – when they can steal a few moments from their roles as production workers in the fee for service system – to what they would change, and the technologies or business models that would help them do just that.

Just as we talk of the ACO concept as moving from “volume to value” for consumers and purchasers, clinicians are thinking how they can provide value beyond their role as patient care “volume producers”. Henry Ford’s comment about the people wanting “a faster horse” before his disruptive innovation of the Model T resonates with physicians. Most don’t believe they can be a “faster horse” in their practice situations. They cite patient safety and quality as their first concerns. Our pledge as physicians to “first, do no harm” is jeopardized.

John Agwunobi, a long time ACPE member and Senior Vice President at WalMart, made some very insightful comments last week on a conference call with us here in Tampa. John is using his background as a MD, MBA and MPH to change the status quo through his role at WalMart. The joint announcement by WalMart and First Lady Michele Obama last week about reducing salt, sugar, and fat content of foods sold at WalMart as one step to improve the health of our population is just one example of that.

John (and I) encourage you to think of being a physician as just the start of your lifelong journey of learning, improving health, and making a difference in people’s lives. Your clinical experience is a foundation for adding new competencies that will give you new opportunities to improve health and health care. Imagine what you might be doing if you didn’t view being a physician as your only identity, or the only valid destination for your learning and education!

Would you learn how to incorporate engineering principles of reliability and safety into patient care? How about learning how to lead people from different professional backgrounds? Does disruptive innovation appeal to you? Starting a new business, or improving the business we’re in? Studying behavioral economics to find ways to change our population’s unhealthy lifestyles and habits?

Like you, I’m proud of my path to becoming a physician, and honored to be recognized as such. Paradoxically, recognizing that there are many other people and professionals – besides physicians - who make important contributions in our society and work just as hard, helped me put my “physicianhood” in proper perspective. It was the foundation to build on – not the ultimate destination in my life.

My Day at a Free Clinic: The Truth Behind the Rhetoric

I just got back from a most remarkable experience: volunteering at a free clinic in Charlotte, NC.

Like many of you, each day I read my Daily Digest to be aware of the health care news of the day. The political rhetoric about the work ethic of the unemployed has been awfully harsh lately. Opinions about health policy and the tug of war between the two political parties that appear on the editorial pages of our nation’s newspapers seem very disconnected from the reality on the streets and country roads of the United States.

I had the opportunity to hear the stories of hard-working and proud Americans who have lost their jobs, and with the jobs, their health insurance. It’s these stories that make the policy issues come alive, and drive home the absolute necessity for clinicians to help create a system that is worthy and respectful of the character of these Americans.

Mary, 60, is a well-educated woman whose COBRA coverage expired two months ago. She lost her job as a loan evaluation specialist at a bank 20 months ago. She paid the full cost of coverage for her health insurance under COBRA because she knew the consequences if she developed a serious illness, and couldn’t pay for the costs of care.

With hypertension and thyroid disease, she’s familiar with generic drugs that keep her costs down. She’s not sure what she’ll do to cover the years until Medicare coverage becomes available, because she’s caring for her 87-year-old mother, and helping her son who moved back home when he lost his job. She’s also back in school re-training as a health care billing specialist, because even “dumbing down” her resume to not appear overqualified for many jobs hasn’t helped her land any interviews. She takes care of herself, and relies on her faith that she will make it through her difficult situation.

Susan, 45, is a wife and mother of two elementary school children who stayed behind in New York to continue working at her job when her husband got a new job in North Carolina. Though living apart as a family was difficult, as an accountant she knew it was necessary to get through the recession. She was the first to lose her job. A few months after moving to NC, her husband’s job disappeared. Neither has been successful in finding new work. She told me her children have health care coverage, and that her kids have been very supportive of her as a good mom, even though times are tough for the family.

Those were just two of the nearly 1,200 people who showed up for the free clinic. Not only was I privileged to be part of their lives for a few minutes, but it was an opportunity to work as a team with nurses, other physicians, and volunteers to help others in this season of hope and goodwill. The young physician (six months out of internal medicine residency) working in the cubicle next to me was my lifeline to high quality, current medical thinking. She thought my years of experience were equally as important. We made a good team yesterday. Thank you, Nicole.

Finally, on behalf of other ACPE members who served as volunteers yesterday, we thank Ed Weisbart, one of your ACPE colleagues who is a leader for the National Association of Free Clinics, for letting us know of this opportunity. Included with Ed in making this happen is our own Charisse Jimenez, who helped us get the word out.

Interested in volunteering or making a donation? Visit the National Association of Free Clinics to learn more. In addition to practicing physicians of all specialties, residents and medical students are welcomed to volunteer. The NAFC also needs mid-level practitioners, nurses and everyone else who can help, clinically or nonclinically.

A Good Death

My friends and family must be outliers from what many physicians tell me about patients’ demands for expensive, and often futile, care.

Several friends are facing terminal illnesses. Their concerns are about overtreatment and getting into situations that diminish the quality and dignity of their lives. They tell remarkably similar stories of listening to their oncologists’ recommendations for additional (but debilitating) chemotherapy. Then they decide to forgo the recommendations because it doesn’t fit with how they want to live. Their biggest concern is having a good death, because they already know life will not be long.

My Mom has a debilitating disease. She wanted enough diagnostics to know what the problem is, and then told her doctor that she’d come back when the symptoms got bad enough that she would consider medication. Not yet.

Grandma Winchester, my 93 year old mother-in-law, is another good example of health economist Michael Grossman’s theory of consumers’ demand for health and healthy days – not necessarily health care. Health and healthy days provide us opportunities to do what we love, whether it’s time with family, hobbies, or meaningful work. Time spent in doctor’s offices or hospitals is not a preferred way to spend her days.

Within the past year, she’s chased a bear out of her kitchen and been evacuated twice from her 600 square foot cabin in the Colorado Rockies because of nearby forest fires. She stays in shape by hiking, shoveling gravel on her mile long driveway and walking two miles round trip every day to get the local newspaper and her mail. She gave up driving a few years ago because she wasn’t as sharp as she wanted to be. But she still drives her snow plow truck in the winter to plow that driveway.

Though she loves her doctor and has gotten excellent care, she hates going for a visit because it means she has to impose on one of her children or grandchildren to drive her to town. Instead, she appreciates that her physician answers her questions by email. She’s talking about getting “DNR” tattooed on her chest.

About two years ago, her husband of sixty-seven years died in their cabin – just as he always wanted, sitting by his favorite fireplace. Despite being paraplegic for almost sixty years from the polio epidemic, he never developed a pressure ulcer – even in his final days. His family made sure of that.

Grandma will die in that cabin someday. Her family will make sure of that.

I read somewhere that 80% of Americans say they don’t want to die in a hospital or nursing home. But 80% of Americans do die there. The reasons are undoubtedly complex.

Think about your own wishes and what members of your family want. Lots of expensive care, waiting for the next test result, cooped up in a hospital? Maybe some do, but many other people just want to have healthy days, and realistically know they won’t live forever.

What is a good death for your patients? Have you asked?

Arrogance

The word came up in two separate conversations, from two very different people. Every two weeks, we ask someone associated with ACPE to spend 45 minutes sharing his/her insight on the trends occurring in health care. Both people are nationally known, one a recruiter, the other a physician leader. With the number of physician leadership roles growing rapidly in the past few months, I want to share their comments because they’re important for both job seekers and leaders who plan on staying in their current organizations.

The recruiter said physicians seeking a new position for all the wrong reasons are spotted very quickly in the process. These physicians often say they’ve discovered how talented they are in management and know they would be successful in their first full time management role. They haven’t invested in management training because they possess “natural talent”, are highly critical of the leadership of their current organization and say they no longer enjoy clinical work. The term the recruiter used to describe their demeanor? Arrogant. Further, these doctors are quickly dropped from candidacy.

What does arrogant mean? Here are a few definitions – none of them conducive to effective leadership! “Overbearing pride evidenced by a superior manner toward inferiors.” “Haughtiness.” “Contemptuousness – the manifestation of scorn and contempt: every subordinate sensed his contemptuousness and hated him in return.” “The trait of being imperious and overbearing.”

The other guest, a health system physician CEO, said over the years he had to fire several excellent clinicians who had very poor communication skills and lacked self-awareness. They often had very good analytic abilities, great insight into problems and solutions, but could not manage a civil word with peers, subordinates or superiors. Some were friends. Again, the term arrogant was used to describe their behavior.

With teamwork replacing autonomy and independence, arrogance is a trait that will derail you and your career. It’s OK to be proud of your achievements as a physician, but it should come across as quiet confidence to others on the health care team. Some physicians DO have a natural talent for leadership and business. Most of us, however, must learn new concepts and behaviors we weren’t taught in our medical training. I’ve heard stories from coaches and mentors about successful behavior change in arrogant physicians who recognized how they were being perceived, and sought to change. Some of my most valuable experiences have been helping smart, talented physicians change their behaviors.

If you’re one of the hundreds of physicians who are looking for a rewarding role in leadership or management, be sure your first interview puts you in the best possible light. We want you to be successful. Many people are watching and curious about the impact of more physician leadership in the health care industry.

Notes from the road: An optimistic view of the future

Physicians are preparing to lead health care change across the country. This is perceived by some entrenched interests to be a threat. To patients and their families, and to physicians’ co-workers, this is a very positive development. I think whoever is closest to patients and consumers will be in the best position to impact change.

Crisscrossing the country over the past few weeks, here’s what I’ve seen and heard to justify my optimism. In Iowa, a large predominately rural health system has launched its Physician Leadership Academy. Each of the thirty-seven physicians were enthusiastic about learning how to improve dysfunctional work processes, develop innovative strategies, and find ways to improve patient outcomes of care. The initial class was nearly 50 percent larger than anticipated, and next year’s new class is equally committed and talented.

In South Carolina, the hospital association and medical association held a joint meeting to discuss what health care reform means for their communities. I talked with several ACPE members during that meeting. I learned that South Carolina has been collaborating with Atul Gawande on the surgical checklist project and with IHI on quality initiatives. The sense of common purpose and respectful disagreement on issues (not people or motives) between the medical society and the hospital association was very impressive. When it comes to interdisciplinary teamwork and measuring health care outcomes, I think South Carolina is a special place.

In Nevada, a large physician group has been managing financial risk for a few years, and doing very well. I listened to a sophisticated conversation at breakfast between two of the attendees about the clinical and financial management of heart failure patients across the continuum. I assumed both were physicians. Wrong. One was the CFO. I believe these kinds of conversations will become commonplace in integrated systems, ACOs, and medical homes if health care change continues in that direction.

In Nebraska, a rural community is beginning an important dialogue with its hospital board, independent and employed medical staff, and hospital staff about how to become a “physician led system, managed by business professionals”. Everyone will have to imagine how their roles will change, and what it means for relationships with large tertiary care centers in nearby cities.

In San Antonio, Texas several dynamic young physician leaders from different branches of the military remind me that some of the best teamwork training and practice occurs in our armed forces. When an individual fails, the whole team fails. They hold both individuals and teams accountable for serious safety events. They correct the problems that lead to the adverse outcomes.

If you see a system around you that frustrates you, or isn’t good for safe and reliable patient care, start now to learn what you can do to change it. Your satisfaction in helping to lead change, and see your role as a physician in a new perspective, will give you exciting new options in your career.

Dog Sleds and Teamwork -- Or How a Team of Huskies Made Me a Better Manager

Years ago, before beginning my management career in health care, I trained our four Siberian/Alaskan huskies to pull a dog sled. My motivation was to allow our toddlers to enjoy the winter wilderness with a smile on their faces. Kids love dogs, and a down sleeping bag wrapped around them makes for a nice trip in the back country.

Now this is going to be dangerous: I’m going to share some insights on working with a team of dogs and how that might have some relevance to working with people when you and your team have a goal in mind. We love our dogs, but we should have at least that same love and respect for the people we work with, don’t you think?

There’s always a first time when you and the team get together to try something new. Each one of the huskies individually would instinctively pull on my ski-joring rope when I went cross country skiing. I thought getting each of them to work together would be a piece of cake. But the first time I hooked up the four dogs in their harnesses it was a disaster! The dog I chose for the leader was Junior, the oldest and alpha male of the group. Strong beyond belief, he was always the aggressor in the yard. I assumed that the others would follow his lead. Wrong. Junior would stop pulling to turn around and snap at or fight with the others. Harnesses were tangled, none of the others wanted to pull.

I was quickly growing frustrated -- and so were the dogs. I decided to “punish” Junior by putting him at the back, in the “wheel position” – the first dog immediately in front of the sled. I chose the youngest dog (Togo) with the mellowest personality of the group for the lead. Lo and behold, much to my surprise and delight, the team ran with the characteristic excitement and enthusiasm of a high performing sled dog team! Junior loved being in the wheel position because he could keep an eye on the others, and it was the best position for the strongest dog. The others (Wiley and Lupe) appreciated being able to run faster. The dynamics changed very quickly among the four of them.

Over the years, you learn valuable lessons about teamwork. Don’t expect your team to do something that you wouldn’t do yourself. Got a hill to climb? Get off the runners and run up the hill with them. Lost and unsure about which trail to take in a whiteout? Trust your team. Their instinct is correct and deserves your trust and faith. Praise them for a job well done. Keep the momentum going. Don’t slam on the brake suddenly and stop the forward movement until you’ve crossed the finish line.

I noticed that every time I stood up to use the footbrake to slow the team down, I’d lose my balance, and sometimes fall, bringing the team to a complete stop. “What’s your problem?” they seemed to be saying when they looked back to see why we weren’t moving. One day I asked a veteran sled dog driver how he managed to avoid falling when using his brake.

“I never use it until the race is over. I stay low like the dogs, dragging my feet or knees. Standing up on one leg, and raising the other to stomp on the brake, elevates your center of gravity, and makes you unstable.” I have no idea how that relates to our teams at work, but I thought it was interesting.

McChrystal's Downfall

How have you been perceived as a leader lately?

What’s fascinating about the uproar over General Stanley McChrystal's conduct is that it's not focused on differences over the war strategy in Afghanistan. Instead, it's about a leader’s behaviors. General McChrystal’s situation has a lot to teach us about leadership!

First, it demonstrates the fragility of titles, positions and roles of authority. You are in your position because a more senior member of your organization made a decision that they could trust you to be a valuable part of a team. Once that trust is fractured, your lofty title can disappear in an instant.

Second, like the General, many of us physicians have superiors who are “civilians” – e.g. not clinicians, not doctors. When we find ourselves in disagreement with our non-clinical colleagues, do we state that disagreement face to face, or do we make demeaning comments about them to our subordinates? I suspect that sometimes the stresses of leadership and management make all of us say and do things that don’t reflect well on us. One of my friends who once worked with McChrystal told me that the behavior described in the Rolling Stone article, in which McChrystal openly disparaged other high-ranking U.S. officials -- was out of character from the man he knew a few years ago. Still there’s no excuse to ridicule and disparage the thoughts and ideas of others who may disagree with us.

Third, are you a role model of professional and respectful behaviors for your staff? If your closest staff feel comfortable belittling others, they may be acting that way because you a). exhibit those same behaviors yourself, or b). you haven’t told them it’s unacceptable behavior. Do you routinely attribute not-so-flattering motives to people who disagree with you, or whom you perceive as adversaries? I find my judgments about the motives of others are more often wrong than right. I try to ask them rather than assume I know their motives. I hope my failure rate on fundamental attribution error is decreasing as I get older and more experienced!

It’s hard to imagine how this situation could have ended without McChrystal being replaced. Not only did McChrystal’s comments demonstrate disdain and disrespect for his superiors, but his inner circle of leaders was guilty of the same behaviors!Would you want to work in an organization or unit where these behaviors were the norm?

Ask yourself what you would do if you were the CEO (President Obama). Knowing that our preference as physicians is to avoid confrontation or conflict, would you have fired the general yourself? Asked HR to do it? Found a way to live with the situation while you gave the general another chance? Would you find out how the front line troops felt about their commanding officer before making a decision?

Maya Angelou says, “People will forget what you said. People will forget what you did. But they will never forget how you made them feel.” As leader of your practice, business, unit, or health system, how do your staff and colleagues feel about working with you?

Lessons from ACPE's Annual Meeting

It always takes me a few days to unwind from the intensity and new ideas coming out of our Annual Meeting. This year's meeting in Washington, D.C., and that's me in the picture with my wife, Janet, and an actor who portrayed one of the "founding doctors" during our induction ceremony for Fellows and Certified Physician Executives.

At the meeting, we heard from Dave Snowden about Complexity Theory and how it can be applied to the chaos of health care. He pretty much exploded many of the status quo ideas about a linear, predictable and manageable control mentality when it comes to improving our health care system! His analogy of parents trying to “manage” a 6 year old’s birthday party and all the unexpected twists and turns inherent in such an endeavor was hilarious.

He mentioned that we should be aware of “outliers” from the norm. Thinking about that, I met two medical students who found their way to our Annual Meeting and asked them why they came. Both were curious about physician leadership and system change. At least one has already decided he wants to be involved in system change when he graduates. I want to meet more outliers like these, and like the many young physicians who were attending their first ACPE meeting and are excited about being agents of change.

It feels like a renaissance is occurring among a growing number of physicians. No longer content to watch from the sidelines, or rail against powerful forces with major roles in health care, these physicians are excited and optimistic about the role they can play in shaping the system to better serve patients, and the professionals who work in the system. Many said they’re tired of the “us vs. them” way of thinking. They know that the strategic importance of financial statements, linking quality and safety to the business functions of medicine, and knowing how to influence organizations to change are new knowledge content that will be important.

We heard from David Cutler, a health economist, and from six leaders who gave us updates on what they expect in payment, safety, comparative effectiveness research, IT, medical home, and integration. The innovators among us – probably most of us – were imagining what new ideas can disrupt the status quo, and change the health care landscape.

Finally, I want to thank Harry Leider for his leadership as President of ACPE over this past year. He demonstrated to me, to our Board, and to our members how enlightened and effective leaders work. One of Harry’s greatest achievements was organizing seven Task Forces on key issues. Their reports were given in person to the Board. The analysis and recommendations were insightful, strategic, and very useful. You’ll be seeing more in the months to come about what ACPE is doing to implement those recommendations. Thanks to the more than 200 members who contributed to this vital work.

A Good Friend at CMS

The Obama Administration is set to disclose that Donald M. Berwick is its pick for administrator of the Centers for Medicare & Medicaid Services, according to a report from the Bureau of National Affairs.

Members of ACPE are quite familiar with Don’s work and writing as a physician, CEO of the Institute for Healthcare Improvement, and one of the authors of the Institute of Medicine’s landmark reports calling for greater safety and efficiency in our nation’s health care system. I think Don is a great choice to lead the country’s largest source of funding for health care services. If he survives the confirmation process (never an easy task), here’s what we should expect, and why he’s up to the challenge.

First and foremost, Don knows that the health system should be designed with patients and consumers as the primary focus. He’s written and spoken eloquently about his personal experiences with mistakes and poor communication among members of the health care team during his wife’s serious illness a few years ago. He’s made the impact of errors and poor communication very real to care givers and health care leaders through the voices of Americans who have lost children and spouses from medical error to the attention of the health care industry by allowing them to share their stories with us. Hearing their stories and their determination to prevent similar tragedies from happening to others should make us no less committed to a safer health system. Look for CMS to have a relentless focus on health system safety.

Consistent with his focus on consumers, watch for a spotlight to be shown on the cost of care. These federal funds for Medicare and Medicaid come from our taxes. We have every right to demand that CMS funds are being spent for essential services, delivered efficiently. Recent articles on communities that have BOTH high quality and low cost are worth re-reading. If you haven’t looked at the Dartmouth Atlas recently, you might want to see how your region or community compares to the best cost performers – and ask yourself why. Overuse of medical services will be a hot topic.

Now that insurance reform changes have been passed, I expect the next large change to come in how physicians and hospitals are paid. Many health policy experts have pointed out the flaws in the fee-for-service system when quality, safety, and lower costs are the goal of a nation’s health system. Based on his experience as a pediatrician, IHI’s experiences with promoting greater efficiency , and imagining an idealized design in which a system is perfectly designed to achieve the results it gets, we should be prepared for a transition to bundled payments, and/or capitation for large populations. This means that another wave of integration between physicians and hospitals will occur.

Recent reports suggest discussions have already begun across the country as balance sheets of independent group practices deteriorate in the recessionary economy, and health systems are seeking clinical leadership to deliver lower cost care with high quality. Add to this equation the preference of young physicians for employment by a large organization, and we’ve already got momentum for change in the alignment of hospitals and physicians.

Finally, Don has the characteristics of a “Level 5 Leader”, as described by Jim Collins in this best selling business book, Good to Great. Noting the common leadership traits that make these leaders highly successful, he describes men and women who understand from personal experience what’s happening at the front lines of their businesses or industry, like most physicians in leadership roles. They “turn information into information that cannot be ignored”. They’re ambitious for their enterprise (not themselves). They’re quick to give credit to everyone but themselves when everything is going well, and take personal responsibility when things aren’t going well. They lead with questions, not answers.

Please join me in asking what we can do to help Dr. Berwick transform our health system to one that’s more responsive to patients’ concerns about quality, safety, and cost. This is the time to use what we’ve been learning about leadership, influence, reliability and teamwork. The next few years are going to be exciting ones for all of us!

Physician Leadership: The Next Generation

I’ve had a couple of really great weeks.

I had lunch the other day with several physicians who are here in Tampa for the Certified Physician Executive tutorial. Almost all of them were in their thirties. Last week I was at a meeting with CMIOs, many of whom were in the same age group. This is a very energetic and determined group of physicians who have a whole different set of challenges than many of us have had, or are currently dealing with. I left these two separate meetings with optimism for the future of health care and a determination to make ACPE a place where they can get the help they’re seeking. Here’s what I heard.

Many of these physicians already have advanced degrees in management. They’re very articulate in defining leadership and management challenges in health care. They decided during their medical training, or before, that they wanted to be in leadership or management roles. All of them are familiar and facile with information technology as a means to improve health care. Some of them were tapped for IT roles because of the perception that they’re “technodocs”. Direct, one-on-one patient care is not their preferred career path. They want to maintain both a clinical role, and a significant leadership or management position in whatever organization they’re working with.

They note that the health care industry is extremely hierarchical. Leadership positions are usually given to physicians who are much older than themselves. They’re being pulled into leadership roles primarily because they have IT skills, and because they really enjoy the opportunity to improve a system. Unlike many mid-career or older physicians who describe being pushed into management roles somewhat reluctantly, this group is very excited about shaping the next generation of health care.

They’re interested in learning how to position themselves in the eyes of system leaders and board members as potential senior leaders – even as physicians who are still early in their careers. Because they’re young, many older physicians feel they can use their personal connections with senior leaders or board members to make life difficult for them when change management issues are not to the liking of senior colleagues. Their spouses sometimes ask them if their CMIO role will lead to anything else after the IT implementation is completed, or whether their system leadership opportunity ends with that job. I think that’s a very fair question, and one that deserves an answer.

If you’re in a high level senior leadership role at your organization, would you do anything different if you knew that the youngest physicians making an impact in your organization might be impatient for more significant leadership opportunities? Have you mapped out a career path with them that fills their needs for a satisfying career in health system leadership? What would you tell them about positioning themselves for those higher level roles if they’ve already gotten their MBA or MMM, and if you’ve been noticing how quickly and elegantly they’re able to define a thorny issue in your organization compared to older physician leaders without that leadership and management training? If you thought that one of the youngest physicians on your staff was the best leader for key organizational roles in quality, IT, safety, operations, or even the CMO role, would you discount their suitability because of their age? Can we create organizational structures for the health care systems of the future that are less hierarchical, more teamwork oriented and less age-dependent?

The Blunt End vs. The Sharp End

Clinician leadership. Integrated health system. Accountable Care Organization (ACO). These are the concepts and words being discussed, debated, and defined at our Winter Institute in Naples, FL over the past few days. They’re the same words and issues I heard last week at one of the nation’s premier MHA programs. We’re talking about strategies, structures, compensation methodologies, alignment challenges, and the economics of integration. Why are these topics at the “top of the charts” of what both physicians and non-clinical health system leaders are listening to, and talking about?

First, many health systems and physician groups are anticipating changes in payment that reward quality, outcomes, and safety – regardless of whether any health care legislation emerges from Washington. Clinicians with additional knowledge competencies in integration strategies, compensation methodologies, will be vital to successful implementation of integration strategies.

Second, for medical groups and health systems to be viable economic enterprises, the bottom line must reflect improvements in quality and patient safety. One of the questions discussed in the Advanced Quality course was, “What’s the cost of a Never Event?” The discussion included a financial analysis of Never Events and complications, AND how to mobilize clinicians to develop better communication techniques, and change the culture of the entire organization to address the cost of poor quality and outcomes.

The power and importance of clinician leadership can be summarized using a concept familiar to system safety engineering and accident investigation. It’s called the sharp end-blunt end model(1) of how organizations and the people who work in them interact. Imagine an inverted isosceles triangle representing an organization. The blunt end is where boards and senior organizational leaders develop missions, strategies, and goals for the organization. The sharp end is where the organization’s people, processes, and technology touch its customers (patients). In health care it’s what happens to a patient, in the ED, ICU, lab, radiology, ambulatory care, etc. When an organization’s mission, vision, values, and goals are translated into appropriate specific individual human behaviors and actions at the sharp end consistent with blunt end strategies, it’s performing at a very high level.

Clinicians are intimately familiar with activities and behaviors at the sharp end, because that’s where we’ve spent many years of our lives. We’ve experienced the frustration of inefficient work processes, and understand how harm can occur to our patients. Now imagine a clinician entering strategic and operational discussions at the blunt end. There’s tremendous insight and wisdom that can be contributed to decisions about what to improve, how to improve, and what observable behaviors at the sharp end will indicate that improvement is happening.

Just being a clinician isn’t enough to be effective in a leadership or management role. We have to learn about strategy, influence, basic health care finance, and organizational dynamics to really be effective in making change happen. Just as we have our own language and thinking styles, non-clinical leaders have theirs. Breakthrough change comes when new insight emerges from understanding how solving your problem can solve someone else’s problem at the same time. Ask yourself what value you can bring to an integrated system, ACO, clinic, business, or workplace in the health care sector. Maybe it’s traditional one-on-one patient care at the sharp end. Maybe it’s that, plus helping out at the blunt end to design a system that works first for patients, and secondarily for the professionals – both clinical and non-clinical – who care for them.


(1)Cook RI, Woods DD. Operating at the
Sharp End: The Complexity of Human
Error. In Bogner MS, ed. Human Error
in Medicine. Hillsdale, NJ: Erlbaum and
Associates; 1994:255-310.

Lessons from Tucson

Our Fall Institute in Tucson, Arizona, finished last week. Here are some quick “ahas” from our Board, our members and me that I thought would interest you at this time of chaos and change in health care. Tossed in this mix is a joke from 10-year-old Anastasia, which put a smile on our faces and made us more creative.

• “If you don’t like change, you’ll like irrelevance even less,” Mike Wirth, president of The Governance Institute, quoting General Eric Shinseki at the Innovators’ Panel discussion.


• “There are two types of change. Incremental change is the process applied to making existing products, services or market shares better (doing what you do better). Disruptive change is doing something different,” Eileen McPartland, COO of Allscripts, in remarks shared with our Board.


• “If I had asked people what they wanted, they would have said faster horses,” Jason Hwang, co-author of The Innovator’s Prescription, reminding us of Henry Ford’s famous quote about knowing what your customer wants – and thinking beyond.


• “We should define ourselves by the job to be done. We shouldn’t be in the business of selling ¼ inch drills – we should be in the business of providing ¼ inch holes,” Jason Hwang.


• “Don’t make hypotheses about segments of markets. Look for general themes and find common values. Segment by behaviors and buying patterns.” Bob Lokken, CEO of White Cloud Analytics, a member of the Innovators’ panel.


• “Why did the tomato blush? Because it saw the salad….dressing,” Anastasia, when asked to share her best joke.


• “I’m 100% clinical right now, but might want some other options in two or three years,” a participant, when asked his reason for attending.


• “As soon as you place a negative label on another person or group, you’ve placed a huge psychological obstacle between you and them in terms of human influence,” Charles Dwyer, a professor from the Wharton School, teaching the Physician In Management (PIM) course on influence.


• “Never expect anyone to engage in a behavior that serves your values unless you give that person adequate reason to do so,” Charles Dwyer.


• “No one has to do anything,” Charles McCabe’s Law, as quoted by Charles Dwyer in his influence course.

The attendees in Tucson were focused on getting the skills they need to lead change in their organizations and communities. They asked lots of great questions about how to get that first management opportunity or how to move on to more responsible leadership positions. We had physicians asking about roles in insurance, pharma, and employee health – and we had experienced physicians from those sectors to help answer those questions. I’m optimistic about the future of health care because physicians are learning the leadership, management, and behavioral skills that are needed to innovate and change. Combined with our clinical experiences, it is a powerful combination for change.