And to be honest, it made my life a bit simpler.  Far from being able to create a beautiful painting, I was unable to even paint a wall or draw a stick figure without significant stress, and likely an initial poor outcome.   So I’d leave the creativity to that individual genius—bless his/her soul—and dream about what it would be like to be that creative sort.

In the past 10 years, I’ve had the wondrous of experience of working at ICSI, an organization dedicated to collaboratively addressing issues of evidence-based medicine, quality improvement, and working together to create innovative approaches to solving our problems.  Being a voracious reader, I encountered many a tome addressing the power of collaborative approaches, in dealing with the issues confronting us.

In the spirit of transparency, being someone who had felt “creativity challenged” I likely came to this journey with a particular heuristic, and saw ideas which resonated with me, with which I could identify.  Whether it was Group Genius by Keith Sawyer, or The Wisdom of Crowds by James Surowiecki, I saw examples of how the use of a group could solve problems and create outcomes that supposedly would never have been achieved by a sole person.  Even someone as pithy as Scott Berkun, in his book The Myth of Innovation, provided reinforcement by articulating the story of J. R. Tolkien (The Lord of the Rings) and C. S. Lewis (The Narnia Chronicles) and how they were part of a “group” that met weekly in creating their masterpieces.  Since it reinforced my belief from my personal experiences, this example further supported my commitment to the collaborative approach.

“All of us together is smarter than anyone of us alone” was a motto seen in many areas, and easy to accept as a driver in my work.  And we see this everywhere today—working in teams, in offices without walls, the emphasis on people skills and working interactively—collaboration is the answer, off with the lone genius.

A recent article in the NY Times has raised an interesting perspective, and one that will draw my attention and cause a bit of reflection.  In “The Rise of the New Groupthink,”  (http://nyti.ms/xU7m0w ) Susan Cain calls for a return to a balanced approach.  While there is much to benefit from collaboration, especially if done in the proper environment, and with the application of certain principles, it may at times have an inhibitory effect on the individual creativity which we should still value, and support.

In a typically American way, we have swung from an adoration of the individual genius to the power of the group.  But not every great idea comes from a group, and Ms. Cain uses the Jobs/Wozniak comparison as a great example.  For often the true creative genius is an introverted, often uncomfortable individual in public venues, but a remarkable fount for ideas and new products when given solitude, isolation, and time without interruption to create their product.

As I reflected on this, I realize that I use my own perceived lack of individual creativity to bring others to the table, where upon hearing of a new thought or approach, my brain explodes with ideas of how to improve, expand, or edit that creation—usually to the delight of the “creative genius” who had the initial idea, and now sees it exploded by a different lens in the discussion.

Don’t get me wrong, I’m still a fan of collaboration.  The problems we are confronting in this world cannot be solved by one individual or one group.  The world is too complex for such a thought.  But that doesn’t mean that the nugget of a new method, product, or approach can’t come from the individual genius working madly in his/her study/laboratory.  Not all wisdom and creativity comes from a collaborative approach.  I now realize that there’s a reason I sometimes hide in a corner, shut out the outside world, and let my internal thoughts run amok—it frees up my ability to allow that often dormant creative part of my brain time to cogitate, and surprise me at the most unusual times with a solution for the problem I’m addressing.  Then I take it to others, and allow the collaborative process to improve it in ways I’d never imagined.

I’m sure some of you see yourself in this description.  It can be difficult being the “lone genius” craving silence, uninterrupted time to contemplate, and constantly thrust into a bustling, restless, talkative, opinionated group.  There is value in the wisdom of crowds, but there’s also value in avoiding a total movement to Groupthink, as comfortable as that may be to many of us.  After all, Newton, a profound introvert, had to have time alone under an apple tree, to be hit with his ultimate solution to the problem with which he was wrestling.  We all need time for that “apple to the forehead” moment, or at least I do.

I’ve recently written a short piece for The Minnesota Physician, addressing the need to continue our efforts in furthering patient engagement.  (http://bit.ly/teOcxo )  I drew on the work of Jessie Gruman from the Center for Advancing Health, and others who have been strong advocates in this area.  Her story, both as a patient with multiple serious cancer episodes, and as a “scientist” in the area, have given me much to think about.  Adding in my appreciation for the work of Judy Hibbard and the Patient Activation Measure, Bev Johnson and the wonderful work of the Institute for Patient and Family Centered Care, and having engaged in lively discussions with Jennifer Sweeney from the National Partnerships for Women and Families, has stretched and stressed my physician-trained brain in a good way, or so I’d like to believe.

It is critical we continue to move toward a model which engages our patients, families and communities as active and equal partners in addressing the crisis which is confronting us in our present disjointed, disconnected and fragmented health care system.

So, as is my wont, let’s add another perspective that has struck me as potentially useful in helping us understand how and why this engagement is critical.  And it comes to me from my work in culture change and leadership in which I gained an understanding of the importance of “fair process” in working within our health care system in changing our culture to one focused on patient-centered care.

Fair process is a term derived from a Harvard Business Review article written by Kim and Associates, initially published in 1998, and republished in 2003.  It addresses the need to manage differently in the evolving knowledge economy in which we live.  It has become an intrinsic part of our collaborative work at ICSI, and has been of great value in our efforts to bring together multiple stakeholders to work on complex topics.

It addresses the need humans have to be involved and feel part of the change that is swirling around us.  Basically, it concludes that as a leader/manager, there is a greater likelihood your staff will go along with a new process  if they felt they were part of the effort, even if they don’t agree with the outcome than if a smaller group of well intentioned, dedicated colleagues come up with a change suggestion they agree with, but weren’t involved in the development of that process.  Consider the impact of that for a minute—it’s the need to be involved and feel part of the process that in many cases has more importance than the actual outcome.

In their article, Kim and Associates address that there are three elements critical in fair process:  Engagement, Explanation, and Expectation Clarity.  First, engagement is exactly what I’ve mentioned—including and involving those affected in the decision making, allowing opportunity to voice opposition, raise questions, contribute to the discussion.  Second, explanation—ensuring that the rationale and reason for the decision is clear and understandable.  That includes a discussion of the various perspectives and opinions that were considered and a clearly communicated message as to why the decision was made.  And last, but certainly not least, there is a need for expectation clarity—a clear statement of what the new “rules of the game” are, what the behavior expectations will be, what the penalties for failure to become accountable to this new change are.  This creates a clarity that allows the employee to focus on the task immediately at hand after this decision has been reached—using fair process.

It strikes me that this same type of “fair process” should and must be a part of any effort to engage patients and their families as active partners in their health care efforts.  Consider the idea of engagement as described by Kim—doesn’t this totally crosswalk with the need for shared decision making, consideration of values, provision of choices, and consideration of the patient’s perspective?  Explanation is critical, but needs to be more than the provision of printed patient education materials, a paternalistic set of “physician orders” or directives to “change what you’re doing if you want to improve.”  It’s a very different type of explanation than the often times confusing terminology used by many in the medical profession to communicate their recommendations, equating silence on the part of the patient as acceptance rather than what it truly might represent—disbelief and confusion.

Lastly, as Jessie Gruman and others in their work on patient engagement articulate, we need to create an expectation clarity—or terms of engagement as it’s often called.  Patients need to clearly hear and understand what is needed of them, no, in fact is expected of them, if we’re to work as a team.

There are other complicating factors, and perhaps this is just another way of saying the same thing, an unnecessary redundancy, but I find it another useful contextual framework on which to build our efforts in this critical area.  As we move forward in “co-creating” our health care system, it reinforces the importance of our efforts, but through a different terminology.  That’s only “fair” don’t you think?  Would your patients feel they’re experiencing the fair process which seems a critical part of any type of change effort in which we ask them to engage as a part of their “partnership” in maintaining and improving their health?

While it’s seductive to think about how much better we’d all be if there was a reliance on “common sense,” I’d suggest that it is exactly that dependence on common sense that contributes to the problems around us. Or at least, that’s what my common sense says.

In a recently published book, Everything is Obvious, Once You Know the Answers, Duncan Watts, of Six Degrees of Separation fame, addresses the infatuation with and reliance on common sense, and, in so doing, made a lot of sense to me (but hopefully uncommon in nature). However, he also created another schism in my belief system, upset my sense of equilibrium, and lessened my certainty about many issues in life that I’d taken for granted. I guess that’s just common sense.

But what is common sense, and why am I suddenly peering suspiciously over my shoulder when a discussion regarding the need for common sense arises. I’m sure we’ve all been in a discussion where someone emphatically and convincingly calls for the need for “common sense” in solving a problem. Nodding our heads sagely, stroking our chins (at least that’s what I do) in contemplation, we reflect on the potential such a reasonable action might have in solving our problems. I mean, take health care, it certainly is in need of repair (or so my common sense tells me) and how much easier it would be if we just applied a little common sense to solving the problems.

Common sense is accepted principally when we can’t specifically pinpoint the underlying principles or evidence for why a specific fact is correct, it’s just common sense. It is a loosely organized set of observations, insights, and wisdom we accumulate over a lifetime, in response to reactions to everyday situations.

Try explaining why some of the things you think of as common sense are labeled as such. We are convinced we’re all above average drivers, in spite of the mathematical fact that that is not possible. It’s just common sense that it’s right to hold open doors for others at times, be respectful of other’s space in conversations, not stand face to face and stare at someone in an elevator. We just know based on our experience those behaviors make sense. It’s precisely because while they sound logical, seem reasonable, and make sense, when in reality, we don’t really have underlying evidence to support exactly why it is….common sense. I mean, that’s just common sense, isn’t it?

But there is a danger in relying on common sense as a basis for a decision, especially one that has significant implications in predicting future outcomes. The decision may be a great strategy, be well designed, and well intentioned, but if it’s based on a bad idea, it’s not going to get us where we need to go. And unfortunately, all too often what sounds like good common sense to us intuitively is based solely on our existing belief system, and not any underlying hard evidence or facts. Because that’s exactly what common sense is—a conclusion based on anecdotes, beliefs, but not able to be proven.

In ancient Greece, the wisest and most respected scholars gave much time to considering the cause of lightning and thunder. Because of their underlying beliefs in the existence of mythologic gods and goddesses, after great contemplation, likely accompanied with the intake of significant amounts of a grape extract, thought leaders concluded that lightning and thunder were the result of arguments and disagreements between the gods—Zeus particularly perturbed with Athena perhaps. It just made good common sense—at the time. Today we laugh at that and are astonished that they could make so foolhardy a conclusion.

But what belief, common sense concept that we hold dear today will in a matter of decades or centuries be equally foolish by the standards of knowledge that will then exist? What basic assumption that we accept as common sense will turn out to be as fanciful as the alchemists’ conviction they could turn lead into gold?

I’ve been intrigued and impressed in health care with the continued efforts to incentivize behavior change in health care providers through different permutations of a pay for performance program. While there have been incidences of mild improvement in isolated locations, it has been less than a stellar success. But it is “common sense” that if we pay someone differently, provide a financial incentive of some sort, we will see a significant change in behavior. With that underlying assumption, we see increases in the amount paid, differences in to who it’s paid, complex new mathematical models to either include or exclude risk stratification to engage participants. Surely, if we just find the correct model, apply the appropriate mathematics, identify the critical area of focus, behavior change will be accomplished through pay for performance.

But then we have people like Daniel Pink (Drive), David Eagleman (Incognito), Jonah Lehrer (How We Decide) and others point out extrinsic vs. intrinsic motivation. Extrinsic motivation, as manifested by attempting to motivate behavior change by external incentives—like pay for performance or performance incentives as a part of my annual salary—from a neuroscience behavior standpoint are not sustainable and do not lead to long-term change in behavior.

Yet because “common sense” tells us that if we just figured out how to pay people differently, we’d incent behavior change, we keep tinkering around with the concept, but not consider that perhaps the basic principle—strongly based on common sense—is flawed.

I know this is too simplistic, and there are many nuances which need to be introduced into the discussion, but it seems that a reliance on common sense, which is often called upon in a time of uncertainty or ambiguity, should be questioned and investigated as we attempt to make a predictive decision about our future. After all, doesn’t that seem like common sense?

But I’m not patient, and within a short time, even less time than physicians allow a patient to talk before we interrupt them, I find my finger moving to the “close door” button and push it—speeding up the door closing process. And then just to ensure the elevator was aware of my intention, I often push it once again, or perhaps even twice. Admit it, we’ve all done it.

In our rush to reach a destination, make a deadline, get to a meeting on time, we take an action to accelerate the process. It makes us feel we’ve done something, been an instigator, made a difference.

But I have a theory, and I’m quite sure Otis Elevator is quaking in their boots with what I’m about to suggest. I’m here to suggest that in reality that button, the one we seek out to accelerate the door closing, often has no direct connection to the mechanism which instigates the closure of the door. What if it’s there as a “dummy” button, not a reference to my mental capacity, but itself non-functional in all regards except to create in us a sense that we’ve made a difference, and accelerated the closure.

Really, think about it, and in true quality improvement methodology, try an experiment. I know you’ve got more important things to do with your life, but my hypothesis is that irrespective of when or how often, or even IF you push that “close door” button, the difference in “closure time” (an outcomes measure if ever I saw one) is statistically insignificant. In fact, the more likely intervention affecting door closure which you’ll see have an impact is someone rushing up and stuffing their arm, leg or head between the closing doors—disrupting my PDSA cycle, and also slowing down the process.

Why does my mind conjure up such trivial ideas on which to ponder? Perhaps in our efforts in life, and including my work as a physician and quality improvement leader, we’re often pushing the “close door” button, by adding a new role, putting in a step in a process, introducing a technology that we think will accelerate our improvement efforts. We want the proverbial “elevator door” to close quicker, give us a result which we can celebrate, allow us to claim success.

I constantly hear the need to “move to action” and to accelerate the rate of improvement. But I often wonder, as I begin to understand more and more about the vagaries of human behavior, and the challenges we face in trying to change the status quo, whether we’re at times pushing proverbial “close door” buttons, which give us the illusion we’ve speeded up the process, when in reality, if we’d waited just a tad bit longer, the process initially triggered (whatever that first button we’re pushing identified) would have been as successful without an added “close door” effort.

A silly analogy, a foolish comparison, but I just can’t stop wondering how often I push the “close door” button, think I’m making a difference, when in reality, I’m just satisfying my need to feel I’ve accelerated a process over which I’ve got very little control. Hmmm, seems a bit like life at times, but excuse me, this door seems not to be responding to my initial effort. Where’s that darn button???

What is the responsibility and challenge for the individual who lives near the “commons” who has a vested interest in ensuring the commons is sustained, but also has a personal need which may supersede any altruistic commitment to the betterment of the whole?

Again, I admit that as compared to being an expert in this field, I’m really a “dangerous student” but one who’s interested in how concepts, especially one as this, can be the framework for a larger dialogue.  And I use the term dialogue deliberately, because it will require an openness and willingness to consider different perspectives than those inherently comfortable to me.  Guess what, it will require that from each of us, irrespective of how intelligent, intellectual, logical, or thoughtful we are.

It is perhaps self evident to many, but as we consider the commons dilemma which I addressed previously ( http://bit.ly/r0RlIj ), it seems to have potential in our discussions on patient engagement, empowerment, health care home, or whatever becomes the principle which drives health care reform.  In a nutshell, a patient is being pulled in the same way we as health care providers are as we address the dilemma of sustaining the commons as it exists in our health care arena.

As a “patient” (quotations deliberate), if I’m confronted with a life-threatening or life- changing situation, my thinking becomes an “I” discussion in which I’m likely going to consider only what is needed for my own benefit–selfish as that may seem.  For that’s a human trait, buried beneath all the platitudes about the good of society, the betterment of man, the need for social good.  When confronted with a threat to personal longevity, or health, I shift to the thinking of the individual herder–I’m going to feed my herd, provide them with whatever they need, ensure they’re hale and healthy–and the heck with the rest of you.  As an individual, I’m going to seek out the help I need, and usually, during that type of acute situation, I’m not inclined to be concerned about the impact on others who live around that “commons.”  It indeed becomes all about me, and providing me with the resources that will maximize my health.  After all, I only have one life, it’s not fungible, and during a time of personal crisis, I focus on the immediate impact on me as an individual.

But counter that to the time when we’re in a reflective, analytical phase of our thinking–usually when healthy and life is going well.  It is during those times of relative serenity that our concern for those around us and the recognition we need to do all that we can to conserve that commons leads us to thoughtfully consider how we can be part of a social solution–”going green”, recycling, exercising, etc.–in an effort to ensure there’s a commons still viable for the generations to follow.

It’s likely too simplistic, and maybe already well understood by others, but as I reflect on our work in RARE in Minnesota and future opportunities, and begin to contemplate how we as the “health care industry” need to consider the commons dilemma, I believe the issue will require an equal amount of debate and dialogue from the individual perspective.

It’s not clear cut, it’s not universally agreed upon as a basic premise for discussion. There is controversy regarding the validity of applying this concept to the area of health care, but isn’t it worth considering what it will be required of us as individuals when confronted by this dilemma?  I’ve been in health care for more than 35 years, and have a strong intellectual understanding of the challenges of overuse and misuse and the threat this poses to our industry.  But I wonder what will happen when my intellectual understanding is confronted by a real, personal threat to my longevity and lifestyle.  Will I be ready to engage in actions that will recognize the need for preserving the commons, or will the personal need preclude and supersede all the intellectual and analytical support I’ve given it for years?  It seems like common sense, but then that’s a topic for a whole other discussion, isn’t it?

In 1833, in medieval Europe, William Lloyd produced a pamphlet addressing how best to ensure that a limited amount of pasture land, shared by individual herders, could successfully be shared, both to maximize their individual ability to “fatten” their livestock, but also to ensure that their personal needs did not lead to a destruction of a limited resource.  It was in the herder’s individual interest to maximize their own livestock’s grazing time (personal benefit), but at the risk of destroying the pasture through overuse (the resource)–where the danger was shared by the entire group.

And thus was born a topic around which discussion, disagreement, and multiple interpretations have raged for almost 200 years–and which I believe is worth considering in the context of the work of health care transformation which consumes many of our efforts in today’s complex environment.  For the initial pasture issue became a “commons dilemma” to be revisited by Garrett Hardin in 1968 as the “tragedy of the commons” and subsequently became the framework for Nobel Prize winning work by economist Elinor Ostrom, who used this as a context for addressing many issues challenging the world of limited resources but an associated exponential demand for products and services.

In fact, for those of us in health care, it is possible that we might still be relatively unaware of this concept, had it not been for Dr. Donald Berwick using the “tragedy of the commons” as a framework for one of his legendary keynote presentations as the former leader of the Institute for Healthcare Improvement.  Subsequent to that talk, we often hear of the need to consider the “tragedy of the commons” as a framework which could contribute to a better understanding of the challenges we face in trying to implement change in our health care system.

The “tragedy of the commons” refers to a dilemma which arises from a situation in which multiple individuals, acting independently, and seemingly rationally considering their own self interest ultimately deplete a shared limited resource in the face of recognized knowledge that this is not in the long-term interest of any of those involved.  But perhaps in considering health care we can step back from resorting to language suggesting “tragedy” and address the more fundamental issue–the “commons dilemma.”

The term “commons dilemma” refers to a social situation in which people’s short-term selfish interests are at odds with the long-term interests and the common good.  Many academicians have created careers by relabeling and flagellating the concept–resource dilemma, take-some dilemma, and common pool resource to name a few.  I’m a simple person who looks for simplification in the face of overwhelming complexity, and I believe that while not a perfect overlay, it is of value to consider how these concepts may drive and influence our health care reform efforts.

More specifically, I believe I’m personally involved and experiencing an effort, which may be a concrete example of how we can both apply this concept, and how we need to avoid overstating the synergies–the RARE (Reducing Avoidable Readmissions Effectively) campaign in Minnesota.  It’s important because while I’m fascinated by learning more about principles and concepts, they serve little value unless we have something concrete and real around which to engage in a lively debate and discussion.  And as a non-academic, non-economist, non-policy person, I expect I’m misinterpreting or extrapolating on some of the principles, but am interested in catalyzing a conversation.

RARE is a multi-stakeholder campaign being developed to reduce avoidable readmissions in hospitals across Minnesota.  It is a collaborative effort of multiple organizations, many of whom previously worked on this topic independently, coming together to make a dramatic impact. (I refer you to the web site– http://www.rarereadmissions.org/–for more details)  As this effort evolves, there are many attributes which I believe are worthy of considering in the context of our social need to address the  “commons dilemma” which permeates our communities.

What has caused me to consider how the work of Lloyd, Hardin, Ostrom, and many others as an opportunity to consider this linkage?  One must look at them in the context of how this issue reflects the principles described as fundamental to a “commons dilemma.”   First, with the present health care payment system, the short-term advantages and benefits for health care providers, hospitals, and others involved as individual organizations is best served by maximizing our services, admissions, readmissions today—the first component of the “commons dilemma.”  However, it is clear that in the long term, the resources and finances available to us will become more limited and potentially lead to potentially devastating consequences—perhaps that “tragedy” which many of the economists expound upon in their discussions.

I believe that in Minnesota the RARE campaign is driving an effort that is asking each of those organizations committing to this project, be it hospital, clinic, long-term facility, home care, specialist/generalist, patient, etc. to look at the common long-term good to protect what is becoming an increasingly fragile resource–both from a human resources and financial perspective.

What are some critical factors that will drive this effort and are significant in considering the “commons dilemma” which I believe RARE is in part addressing.  First, research in this area shows that some are more motivated than others to manage this common resource.  It is critical to engage those who demonstrate a more “pro-social” perspective in the initial efforts, and begin to apply social pressures on other similar facilities not demonstrating those characteristics.  In RARE, the commitment from a large number of organizations recognizing the need to work together on this is a powerful recognition of that element.

Second, the ability to conserve a common resource (protect the commons) is promoted by a group’s ties.  If people have an identity with a group, they are more likely to exercise personal/organizational restraint.   The ability to build social ties is imperative in creating an increased force with which to address those who are seen as a threat to the good of the community through their personal interests.   The structure supporting the RARE campaign is focused on building those essential ties as a part of the community being developed.

We also need to better understand the state of the common resource to shape those motivations mentioned above.  Many of us in health care have functioned solely with our own personal interests in mind.  This is not a condemnation, but a reflection of the reaction to the environment, and the uncertainty we see there.  One element of the “commons dilemma” is that much of the short-term individual activity is driven by an uncertainty about the future.  We see this in RARE in addressing the readmissions issue.  In addition, while not in total harmony with this element of thinking, the potential for punishment, either economically or personally, can be a unifying factor for those who have concerns about the long-term good.  Many conversations regarding our RARE campaign reference the impending and anticipated “penalties” to be imposed by the Center for Medicare and Medicaid Services if certain readmissions are not reduced—increasing the potential for a group to attempt to protect the “commons” which is threatened.

Strategic factors also come to play in addressing this extremely complex situation—it wouldn’t be a dilemma if it wasn’t convoluted and uncertain. In addressing the threat to the commons, the order in which one can extract their individual value from that resource is important.  If it is seen as a sequential situation, individuals adopt a first come-first served rule, whereas with simultaneous collaborative activity, people adopt an equality rule.   In a fundamental way, that is an underpinning of the RARE effort—together on a similar time line.

Another but equally important consideration is the impact on one’s reputation.  Research has demonstrated that if there is transparency, and not anonymity among those involved, one will take much less from the common pool—whatever that pool might be.  Those who are seen as part of an equalitarian and public- minded process gain greater prestige.  While it is not clear how this will be manifested by RARE, the commitment by almost all the major hospital systems in the state to this campaign thus far can only reinforce that element of addressing the “commons dilemma” which might be seen as part of the problem but also the potential solution for our RARE efforts.

It is perhaps a stretch to relate our readmissions work to the “commons dilemma” and to the potential of a “tragedy of the commons” situation but it  does serve as a trigger to us in thinking about how we need to work differently.   I’m well aware that this is an extreme oversimplification of many of the attributes and controversies surrounding this socio-economic principle that in reality has been around since the time of Thucydides and Aristotle, and has been both modified and attacked.   But in many ways, the health care issues in this country truly have become a “commons” issue, where we have limited resources (both financially and access wise) but a seemingly infinitely increasing demand for these services.

At this time, with a few exceptions, health care seems to more closely resemble those individual herders, concerned only over their own part of the herd, and insensitive or perhaps unaware of the impact on the common resources they all need in the long term.  In addition to the items mentioned above, there are many nuances and inconsistencies which are deserving of further conversation.  But that is precisely the opportunity I see.  Using the “commons dilemma”, cross walking it with our efforts in health care (specifically as I’ve briefly outlined in the evolving Minnesota effort on the RARE campaign), may allow us to gain a better understanding of the challenges we face and the opportunities we have in working together in co-creating the health care system which will avoid that social tragedy staring us in the face today.  That’s my dilemma, what’s yours?  Do we have anything in “commons” to talk about?

I’ve spoken in the past about our rush to solutions, which often times runs roughshod over the ability to gain an understanding of exactly what or how we’re going to come to any shared perception and common purpose in redesigning our care systems?  ( http://bit.ly/egepts ).  In addition, we’ve really not engaged our patients and their families in understanding exactly what is going to be expected and actually required of them to make this work.   For goodness sakes, we can’t even all agree on operational definitions and roles as we create the “team-based approach” required.

But I’m an optimist, or perhaps naïve, and believe we do have the capacity and capability to pull this off—if there’s enough time, enough will, and impassioned commitment.   But then I open up my most recent Health Affairs and have the opportunity to read an article by Diane Rittenhouse, et. al, (http://bit.ly/quB9bT ) addressing the use of PCMH  processes in small- and medium-sized practices, and once again—check, please?

The article addresses the use of medical home processes (using the seven fundamental principles created by the professional medical associations– http://bit.ly/9WcPtI ) in 1,344 small- and medium-sized physician practices across the country.   Information was collected in an effort to see how successfully the principles were able to be recognized as being in place.  While I recognize that it takes time and significant effort for major changes such as those proposed to be implemented, one would hope we would see a fairly significant movement toward full deployment.  The authors noted that practices evaluated had earned only 21.7% of the possible points available in achieving medical home status.  Check, please?

But some would say that’s encouraging, especially since we’re only a few years into this effort.  Perhaps, but on looking at that 21.7% number, it’s likely artificially elevated.  Why?  While the authors acknowledge the need for all seven items recommended, for methodology reasons, they chose to focus on evaluation of only the last four of the principles.  The principles requiring a personal physician, a whole-person approach, and payment reform were not included in the review.  I would suggest that if we looked at the first two of those and included them in the evaluation, the percentage would be even lower.  Check, please?

I would encourage you to read the article, and consider the implications therein.  I’m not trying to be sarcastic, negative, or cynical, although it may sound that way.  But as those of you who’ve read my posts in the past know, I’m concerned we’ve not recognized the need to address the adaptive (cultural, value, belief) work needed, have not agreed upon the functions essential vs. focusing on the structures and processes, or begun to understand the challenges of engaging patients/families as active partners.

We’re “rushing” toward the development of ACOs, yet from the Rittenhouse article it is apparent we have much to do to even provide the elements of a medical home—which in many minds is the foundation for a successful ACO.  Presently, consultants are making fortunes by assisting organizations in creating the contracting and finances for success, but in most cases, not addressing the significant work needed to create the professional and organizational cultures which will be critical in moving toward this type of longitudinal, population-based approach.  Check, please?

It’s an exciting time, from many perspectives, in that we recognize that we have an opportunity to truly transform our health care system.  But in the face of an apparently intransigent legislative process, dramatically worsening polarization of political beliefs, and an unwillingness to compromise politically, it is uncertain if any of our efforts to work collaboratively in health care, challenging as that is, can survive the political process in which we’re all embroiled.  Check, please?  Oh, and about that tip…..

But what if we’re wrong?  What if we’re basing our work on a set of principles and guidelines that while well intended, have basic flaws, fail to consider the nuances of human behavior, and in fact may have perverse unintended consequences to what was intended.  I’m one who’s often been struck by the naivete of many efforts in health care to improve our processes, limited by our significant lack of understanding of the neuroscience of human behavior.   I believe this is a question that needs to be considered—what if we’re wrong?

In a recent exemplary book, Practical Wisdom by Barry Schwartz and Kenneth Sharpe, I  was formally introduced to the concept named in the title.  Anticipating another self help book, but intrigued because of my experience in reading his previous book, The Paradox of Choice, I plunged into what is often a verbose (I can identify with that), but extremely thought-provoking book.

What is practical wisdom?  According to the authors, it starts with phronesis, based on the work of Aristotle who described a specific set of practical ethics, not a theoretical system of moral rules as being critical in understanding human behavior.  In his approach, Aristotle proposed that doing the right thing (which we’d like to see happen in our delivery of health care) is not just a matter of knowing the right rules, but knowing if it is the right thing to do, in the right circumstances, with the right person, at the right time.  It resonates with the underlying principles of patient-centered care.  To do this takes practice, experience, and making mistakes and learning from them.   One can not truly demonstrate phronesis (practical wisdom) by merely following the rules, by filling out a checklist, by completing a form.

As originally postulated by Aristotle and developed more fully by others, this involves having integrity, honor, and the ability to consider the context and environment in which a decision is made.  It places a value on using the experiences and sense of morals we as individuals have been infused with to demonstrate our capacity to deal with life’s many challenging situations.  My 26+ years of practicing internal medicine were but an example of that “infusion.”  Without this missing ingredient (phronesis) neither rules (no matter how well articulated and detailed) nor incentives (no matter how clever) will be able to solve the problems we face.

As we tackle the challenge of improving our health care systems, he would suggest, and I would support, that we have at times moved toward the use of rules (guidelines, checklists, protocols, care plans, etc.) and incentives (pay for performance, risk sharing, bonuses) as a potential solution to the variation and fragmentation which pervades our system.

But, if we consider the impact of these well intentioned efforts, history and an understanding of human behavior tells us that in reality, often times the outcome is the opposite of what is desired—the unintended consequences referred to above.  For it is a part of human nature that when presented with a set of “rules” or exposed to a financial incentive, the ability and interest in applying practical wisdom is in many cases eliminated, and the more routinized an activity becomes, the more disengaged a person is from actively paying attention to the social and emotional context in which the situation exists.

How often do we hear about the loss of joy from the practice of medicine?  How often do teachers bemoan the present teaching environment, and loss of enthusiasm and passion that used to drive their efforts?  While there are many potentially causative factors, it strikes me that we should attend to the value that being able to use our practical wisdom brings to our jobs, and how, while not intending to, a complex, lengthy set of “rules” can drive that out—and with it much of the reason many of us came into this vocation.

It’s simplistic, I know, and only one of many issues to consider.  In addition, I’ve only touched the surface of the topic, but even with such a superficial exposure, there is a resonance with what I’ve experienced, and what I’ve heard from others.  If centuries ago Aristotle could expound on the value of phronesis, which has now been translated into the concept of practical wisdom, he tapped onto a characteristic of human behavior that transcends the ages—our recognition and need for the use of emotions and insights in creating value in our work and in our lives.

So as we progress in our efforts to transform the health care system, both by engaging our medical providers, as well as the patients and families with whom we interact, we need to be wary of too many rules, not enough rules, too much logic, not enough logic, too much control, too little control.  The list could go on.  But would we frame our discussions differently if we had a more complete understanding of the need and role for practical wisdom.  In our urgency to transform the system to one which is truly patient centered, and provides the high quality care our citizens deserve, does our drive to rules based  programs in reality portend a loss of practical wisdom, and with it the loss of joy and enthusiasm many of us desired in making health care our profession.  You know me, I’m just wondering, it’s the practical part of me.  Or is that my phronesis acting up?

I cannot profess to have read all the rules.  Migraine tendencies and a narcoleptic trend when confronted with excessive verbiage prohibited such an effort on my part.  However, I’ve spent considerable time attempting to experience the epiphany I’ll need to understand how ACOs will be structured and function.  But if I’m to believe the many comments, lengthy formal responses, politically correct alternative opinions, those who created the document were WRONG.  Irrespective of the direction from which the responses came, after a polite acknowledgment of the good intentions of those at CMS who crafted the document, there was a transition to rather strongly worded criticisms and suggested alternatives to the rules as proposed.

And we all know that it’s desirable to be right, correct, and certainly not a good thing to be wrong.  We need to think about this in the  context of how we were brought up.  It was important to get the answer right the first time, to have the highest score on a test, to be 1-2 seconds faster than those around you, to have the right solution before anyone else did—and if not, the shame of being WRONG weighed heavily upon our shoulders, and even worse, our psyches.  So didn’t these people from CMS understand what was expected, and how could they have been so WRONG, in so many different areas.

But after reading Kathryn Schulz’s great book, Being Wrong, and then watching her on a fabulous TED video (http://bit.ly/exwOCl ), perhaps we need to take a different tack.  While we live in the present tense in all that we do—work, shop, play, plan, vote—it is only in the past tense that we acknowledge that we were WRONG.  In fact, there is no shame in being wrong, but there is a shame from our past experiences when we recognize we were WRONG.  But if we look at it differently, isn’t a major way we learn based on our ability to recognize what didn’t work and adjust?  Isn’t it a major part of innovation and invention to discover that where we thought we were going was WRONG and find something even more valuable because we were WRONG in the first place.

In fact, Schulz suggests that it is our attachment to a sense of rightness, and the need to be right that limits our ability to consider alternatives.  It is our persistence to holding onto our beliefs because they must be correct that leads to an intolerance of those who differ.  As she describes, it leads to a series of unfortunate assumptions regarding those who don’t agree with us—who would suggest we’re WRONG.  First, we assume they’re ignorant—we just need to educate them.  When that doesn’t work, we acknowledge they must be idiots, just not able to understand—certainly an approach that limits our willingness to carry on further conversation.  And at the end of our series of assumptions is that they must be inherently evil or subversive if they don’t see it our way—because we’re certainly not WRONG.

Now I know it’s a stretch, and believe me, I’m one of those extremely suspicious of how a centrally created guidebook consisting of over 429 pages of “rules and regulations” can address all the variability from region to region, and yet allow the diversity and innovation which many suggest is imperative if we’re to have any hope of transforming our health care system.   But as I read the initial rules, and as I subsequently review the responses and comments, I reflect on the fact that while they appear to be WRONG, we can take a different approach on how to view the initial efforts.

With regard to the series of assumptions I mentioned above, I think it’s likely safe to say that those who constructed this report were neither ignorant, idiots, or evil.  (Please, all you cynics, hold your tomatoes!).  They are well intentioned, committed, and desirous of creating a venue for change that may rescue our failing, nearly bankrupt health care system.  But if we look at this from the perspective of Kathryn Schulz, they had an idea of which direction was the correct one to take, based on their collective lens on the world they saw, and they put it forward.  It so happened that many thought they were going in the wrong direction.   But by doing that, they have allowed each of us individually, professionally, and organizationally, to look at the idea through different lenses.   Much like in eyewitness accounts, we all see the event in a different light.  So who is WRONG?

In reality, I don’t think any of us have that answer, at least not yet.  In a situation as complex and convoluted as the ACO concept, there is a great opportunity to be WRONG.  And indeed, I think they were—but—rather than a condemnatory response, we can take the Kathryn Schulz approach—perhaps even applauding the effort, acknowledging there are significant differences, recognizing we’ve got much more work to do—and take the comments which suggest CMS was WRONG and work together to make them RIGHT.

I’ve undoubtedly been WRONG many more times than I realized.  We don’t learn from our mistakes if we don’t recognize them.  In the case of the ACO report, many have suggested in mostly polite respectful terms that CMS needs to “recognize” that they were WRONG.  It is that recognition, but also our own, that will lead to the creation of an environment that allows us to gracefully and openly consider different perspectives, opinions, and viewpoints—and being WRONG becomes a precursor for being right.  Am I right, or am I WRONG?

When we first started our discussions in 2006, we were hopeful, but realistically were expecting limited success. As we look back from our present position, it’s been a dramatic, challenging, and personally extremely rewarding experience. It’s enough to know that more than 8,000 patients have been enrolled in the program, that more than 70 clinics remain committed to the effort, and that patient outcomes are exceeding our hopes and aspirations. But beyond that, the development of a collaborative approach to deliver care for patients with depression in the primary sector, based on the brilliant research from Dr. Jurgen Unutzer, has become a template for moving toward a medical/health care home for those clinics with the foresight and capacity for recognizing the potential greater value of this intense effort.

There have been many rocky, often extremely challenging moments, and many of them persist–and with the freight train called medical/health care home coming down the track, some ongoing questions about how and where DIAMOND will leave its legacy. But from a very personal perspective, having more than 35 years of experience in health care, the DIAMOND program has provided valuable knowledge, evolving relationships, and opportunities for both me and ICSI that would have been impossible to anticipate five years ago.

The details about DIAMOND itself are worthy of sharing, and I’d refer you to our web site for further details.

This reflection on DIAMOND stems from attending a conference in Seattle sponsored by the AIMS Center of the University of Washington and led by Dr. Unutzer. I am still in a bit of awe because of my involvement in DIAMOND, along with other ICSI staff, and the commitment of hundreds from our membership, we have created a model that is held in the highest esteem by leaders and experts from across the country. Whether from a policy, government, measurement, behavioral health, primary care, or research perspective, the DIAMOND work was touted by multiple speakers from all venues as THE premier example of what needs to be and can be done to begin to eliminate the duality of our health care system, and begin to integrate mental/behavioral health into the physical/medical model.

Close to home and based on the experience of DIAMOND clinics, we understand the strengths and limitations of the program. Yet it’s refreshing and energizing to get another lens on our reality. Our success in engaging both primary care and mental providers, creating a new role for many psychiatrists, identifying a payment model which has provided a hope for sustainability, moving measurement from process to outcomes, engaging patients as a critical part of our success, translating a research model into a statewide implementation effort–each alone would have been praiseworthy. But as I was approached by people from across the land, it struck me how transformational our work is being viewed, and how valuable it is in identifying both the challenges but also the opportunities to improve our care delivery and payment system, not to mention beginning to address the chasm which has existed between the medical model in which I live and the behavioral health model of my psychiatric colleagues.

Don’t get me wrong–DIAMOND is not the “solution” to our problems. But it’s apparent that to many it’s a gigantic first step in beginning to tackle the massive challenges facing us. There are more questions in my mind than answers stemming from DIAMOND, but at least now we have a basis and experience for those questions, and a reference point. Our work has helped us determine the value of taking a single disease approach to address a tough primary care challenge, and whether DIAMOND’s care manager-based model can extend to other behavioral health or chronic diseases. We have knowledge to consider just exactly how DIAMOND will fit in the evolving ACO world. And while we continue to confront past assumptions about the nature of our work, we have an experience, a story, and data to share.

The two days at the AIMS Center were both exhausting and exhilarating. And what a great feeling that is–to know that in some small way, we’ve been a part of something which is regarded as quite special, unparalleled anywhere else in the country, and valued for what it can offer. I came away with an energy and increased passion for the work of ICSI, and all of us in Minnesota. We truly have a DIAMOND in the rough—let’s learn from it, both from what was successful, and what can be improved. Thanks to all who helped me with a refraction on my lens on reality–it was greatly appreciated.