Beyond Better, Safer, Cheaper Health Care: What's Ultimately at Stake?

Health care reform continues to be controversial and divisive and takes its toll on physicians, patients, and national unity. An emphasis on efficiency and profit that depersonalizes human interactions hampers building physician-patient relationships grounded in compassion and trust. The authors argue that health care reform will be more effective if it is grounded in and anchored by a physician-patient relationship that is relationally transformative rather than transactionally commercial. This health care paradigm shift, from the "transactional getting" to the "relational giving," must be physician led. The authors propose 3 next steps. First, establishing discourse "ensembles" will foster conversations where new ideas can emerge and percolate and where participants can renew their collective stand for the humanitarian side of the healing relationship. Second, ensemble unity and effectiveness will be enhanced by the so-called inward journey of leadership. Without that journey, we cannot fully connect with the suffering of others, and we lack the wisdom and will to tackle our health care challenges. Third, to begin the process of solidifying this humanistic foundation, transformative leadership becomes essential. In contrast to transactional leadership, which motivates physicians by seducing their self-interests, transformative (relational) leadership connects physicians with their deeply held values that embody what it means to be a physician and what it means to be human. A shared, collective view of what's at stake if we settle for purely transactional medicine would help create the necessary physician alignment and commitment to reposition medicine as a profession that values service above reward.

How Effective Leaders Harness the Future.

Human beings are fundamentally future oriented. Most of our decisions and undertakings are for the sake of a future to which we are committed or obligated. This future orientation is essential to effective leadership in health care, especially during this time of significant reform, when people are at risk of becoming cynical and disengaged. Conventional thinking holds that our effectiveness as leaders is primarily a function of what we have learned in the past-our knowledge, expertise, and experience. In contrast, the emerging model contends that our effectiveness is also a function of how the future (outcome) of our leadership challenges "shows up" for us. If, despite daunting circumstances, we can "see" an aspired future ahead, we are more likely to commit and engage. Our story of the future becomes the "narrative frame" through which we see and tackle leadership challenges today. Because organizations are fundamentally networks of conversations, an organization's ability to create new language practices is tantamount to its ability to evolve. What makes the future compelling is the embodiment of our deepest convictions and ideals in our image of the future. Because health care reform has challenged the medical profession along the entire spectrum of its traditional values and roles, working toward a unifying vision of the future has been difficult. To enroll others in creating a better future, effective leaders must underscore the purpose and importance of their work and motivate them with inspiring stories.

Hittability: The Leader's Edge.

Mastery of any discipline entails both the requisite skills and the ability to see things as "hittable." However, the concept of "hittability," which, in the context of leadership, refers to whether or not a specific leadership challenge shows up as hittable (or solvable) for those who are responsible for taking it on, is consistently overlooked. Nevertheless, it is a critical determinant of leadership effectiveness. Hittability is a function of the framing lenses-a person's beliefs, values, and worldviews-which frame the way a person "sees" a leadership challenge. Additionally, the future a person is "living into" is the framing lens for the present. In other words, a person's view of the future shapes his or her view of the present and his or her actions within it. Because the beliefs, values, and worldviews that constitute our framing lenses are constituted in and accessible through language (i.e., in the day-to-day stories, or narratives, a person tells him- or herself), reframing them to create a new future requires a new narrative. The ability to shift the previously unhittable to the hittable won't be, primarily, due to some newly acquired knowledge. Rather, it will be the result of reframing our challenges so they show up as hittable.

Health care transformation begins with you.

Most health care transformation efforts are unsuccessful because they overlook the importance of personal transformation in enabling major systemic change. Personal transformation is about creating access to a broader range of ways of being, thinking, and acting in order to be more effective in dealing with those challenges for which conventional strategies are inadequate. As many of the changes that are taking place in health care are inevitable, mastering context is critical to transformation. In moving the organization forward, key thought leaders who embrace new ways of working together can help others recontextualize their challenges, thereby serving as important catalysts for diffusing these innovations into the culture. The ensuing improvement in performance is less the result of having learned some new concept or theory and more a function of having altered the context through which one's challenges are understood. When individual transformation parallels organizational transformation, a tipping point is reached where there is a visible increase in organizational members' effectiveness, a marked increase in organizational members' impact on others' performance, and a collective experience that work is more fulfilling.

Game theory: applications for surgeons and the operating room environment.

BACKGROUND: Game theory is an economic system of strategic behavior, often referred to as the "theory of social situations." Very little has been written in the medical literature about game theory or its applications, yet the practice of surgery and the operating room environment clearly involves multiple social situations with both cooperative and non-cooperative behaviors. METHODS: A comprehensive review was performed of the medical literature on game theory and its medical applications. Definitive resources on the subject were also examined and applied to surgery and the operating room whenever possible. RESULTS: Applications of game theory and its proposed dilemmas abound in the practicing surgeon's world, especially in the operating room environment. CONCLUSION: The surgeon with a basic understanding of game theory principles is better prepared for understanding and navigating the complex Operating Room system and optimizing cooperative behaviors for the benefit all stakeholders.

Elephants in academic medicine.

PURPOSE: To study the types, causes, and consequences of academic health center (AHC) "elephants," which the authors define as obvious problems that impair performance but which the community collectively does not discuss or confront. METHOD: Between April and June 2010, the authors polled all the chairs of departments of medicine and of surgery at the then 127 U.S. medical-degree-granting medical schools, using a combination of Web and postal surveys. RESULTS: Of the 254 chairs polled, 139 (55%) responded. Of 137 chairs, 95 (69%) reported that elephants in their organizations were common or widespread. The most common elephant reported was misalignment between goals and available resources. Chairs felt that the main reason faculty are silent is their perception that speaking up will be ignored and that the consequences of elephants include impaired organizational learning, flawed information resulting in poor decisions, and negative effects on morale. Chairs felt elephants were more problematic among deans and hospital leaders than in their own departments. Of 139 chairs, 87 (63%) said that elephants were discussed inappropriately, and of 137 chairs, 92 (67%) believed that creating a culture that dealt with elephants would be difficult. Chairs felt the best antidote for elephants was having senior leaders lead by example, yet 77 of 139 (55%) reported that the actions of top leaders fed, rather than dispelled, elephants. CONCLUSIONS: AHC elephants are prevalent and detrimental to learning, organizational decision making, and morale, yet the academic medicine community, particularly its leadership, insufficiently confronts them.

Perspective: A new model of leadership performance in health care.

Current leadership models are based largely on concepts and explanations, which provide limited access to the being and actions of an effective leader in health care. Rather than teaching leadership from a theoretical vantage point, the ontological perspective teaches leadership as it is lived and experienced. When one exercises leadership "as lived," concurrently informed by theories, one performs at one's best. A distinctive feature of the ontological approach resides in its capacity to disclose human ways of being and acting that limit our freedom to lead effectively as our natural self-expression. Ontological leadership maintains that our worldviews and mental maps affect the way we lead and are shaped by and accessible through language--hence, to lead more effectively, mastery of a new conversational domain of leadership is required. This emerging model of leadership performance reveals that (1) our actions as leaders are correlated with the way in which the leadership situation we are dealing with occurs for us, and (2) this "occurring" is shaped by the context we bring to that situation. Master leaders use language to recontextualize their leadership challenges so that their naturally correlated ways of being and acting can emerge, resulting in effective leadership. When leaders linguistically unveil limiting contexts, they are freed up to create new contexts that shift the way leadership challenges occur for them. This provides leaders--physicians, scientists, educators, executives--with new opportunity sets (previously unavailable) for exercising exemplary leadership. The ontological approach to leadership offers a powerful framework for tackling health care's toughest challenges.

The language of discovery.

Discovery, as a public attribution, and discovering, the act of conducting research, are experiences that entail "languaging" the unknown. This distinguishing property of language - its ability to bring forth, out of the unspoken realm, new knowledge, original ideas, and novel thinking - is essential to the discovery process. In sharing their ideas and views, scientists create co-negotiated linguistic distinctions that prompt the revision of established mental maps and the adoption of new ones. While scientific mastery entails command of the conversational domain unique to a specific discipline, there is an emerging conversational domain that must be mastered that goes beyond the language unique to any particular specialty. Mastery of this new conversational domain gives researchers access to their hidden mental maps that limit their ways of thinking about and doing science. The most effective scientists use language to recontextualize their approach to problem-solving, which triggers new insights (previously unavailable) that result in new discoveries. While language is not a replacement for intuition and other means of knowing, when we try to understand what's outside of language we have to use language to do so.

Do deans and teaching hospital CEOs agree on what it takes to be a successful clinical department chair?

PURPOSE: To compare perceptions and perspectives of medical school deans and hospital chief executive officers (CEOs) regarding roles, responsibilities, and attributes of effective clinical department chairs. METHOD: In 2009, the authors surveyed the deans of 126 U.S. medical schools and the CEOs of the primary teaching hospitals in the schools' academic health centers. All were queried on 34 items about clinical department chair performance in six categories (mission prioritization, leadership responsibilities, leadership values, skill sets, barriers to success, and competitive differentiators). RESULTS: Eighty-four deans (67%) and 57 CEOs (45%) responded. Both groups ranked ensuring good patient care as the chair's primary responsibility; agreement between CEOs on that responsibility was much stronger than among deans (P < .01). CEOs placed greater emphasis on getting results (P < .01), whereas mentoring was a higher priority for deans (P < .01). CEOs identified the inability to work within budgeted resources as a barrier to chair success more than did deans (P < .01). CEOs reported that high-quality care and cutting-edge hospital technologies were keys to competitive distinction, whereas deans put more weight on clinical and translational research and educating future physicians. The majority of deans and CEOs rated the alignment and relationship between themselves and their counterpart as "excellent" or "good." CONCLUSIONS: Deans and their "partner" hospital CEOs agreed on most of the attributes, skills, and responsibilities characterizing the successful clinical department chair. CEOs were biased toward patient care, clinical quality, and results, whereas deans placed more emphasis on research, education, and mentoring.

The being of leadership.

The ethical foundation of the medical profession, which values service above reward and holds the doctor-patient relationship as inviolable, continues to be challenged by the commercialization of health care. This article contends that a realigned leadership framework - one that distinguishes being a leader as the ontological basis for what leaders know, have, and do - is central to safeguarding medicine's ethical foundation. Four ontological pillars of leadership - awareness, commitment, integrity, and authenticity - are proposed as fundamental elements that anchor this foundation and the basic tenets of professionalism. Ontological leadership is shaped by and accessible through language; what health care leaders create in language "uses" them by providing a point of view (a context) within and from which they orient their conversations, decisions, and conduct such that they are ethically aligned and grounded. This contextual leadership framework exposes for us the limitations imposed by our mental maps, creating new opportunity sets for being and action (previously unavailable) that embody medicine's charter on professionalism. While this leadership methodology contrasts with the conventional results-oriented model where leading is generally equated with a successful clinical practice, a distinguished research program, or a promotion, it is not a replacement for it; indeed, results are essential for performance. Rather, being and action are interrelated and their correlated nature equips leaders with a framework for tackling health care's most complex problems in a manner that preserves medicine's venerable ethical heritage.

Rock stars in academic medicine.

PURPOSE: To investigate the prevalence and characteristics of faculty rock stars, a subset of academic health center faculty who greatly enhance the reputation and/or success of their home institution, oftentimes at the expense of a disproportionate share of institutional resources. METHOD: In 2008, the authors surveyed the deans of 126 U.S. medical schools accredited by the Liaison Committee for Medical Education, using a 13-item instrument consisting of Likert scales, pick lists, and open-ended questions. RESULTS: Sixty-four (51%) surveyed deans responded. Respondents were more representative of public than private institutions (P < .001) but were proportionately representative of institutions of varying faculty size, U.S. New & World Report research rankings, and geographic location. The prevalence of rock stars was 1.42% (range 0.07%-6.42%) of full-time faculty. Over 74% (46/62) of deans felt that these talented faculty contributed to institutional prominence. Most deans were usually willing to offer greater resources to recruit or retain these faculty stars, and 39/62 (63%) believed that these individuals were a good investment. Although 53/64 (82.8%) of deans believed that other faculty are often or almost always aware that these individuals receive preferential treatment, only 37/64 (57.8%) believed that other faculty agree with that treatment. Fifty percent or more of deans (depending on the characteristic) selected self-promotion, a strong work ethic, opportunism, charisma, and political savvy as characteristics that were more common in rock stars. CONCLUSIONS: Deans appreciated both the value and the leadership challenges associated with the academic medical center rock star.

The 3 essential responsibilities: a leadership story.

The 3 fundamental and essential responsibilities of leadership--setting a compelling and appealing direction (vision), selecting the right people (talent), and creating and embracing the right set of guiding core values (culture)--are reviewed in the context of the many contributions and leadership legacy of Dr Stanley J. Dudrick, one of the giants of American surgery. Critical success factors which enable the development of leadership as an organizational capacity in any department or unit are emphasized. They include building a team of faculty and residents who are aligned on mission, vision, and values; forging a climate where people are willing to have difficult conversations rather than avoiding complex problems; and the establishment of an esprit d'corps where people experience that they are contributing to a purpose larger than themselves.

Perspective: the problem with the problem of professionalism.

Enhancing professionalism is an important goal of all physicians, both as individuals and as members of educational and institutional communities of practice. Despite a great deal of dialogue and discourse, the medical profession struggles to ensure that all physicians are able to embrace and live the values of professionalism, notwithstanding the myriad stressors present in today's evolving health care environment. The authors suggest a move beyond the traditional educational paradigms focused on reinforcing rules, providing role models, rewarding right behavior, and removing those who falter, and that we instead view the problem of professionalism as a complex adaptive challenge requiring new learning. Approaching lapses in professionalism as a form of medical error may provide a fresh outlook and may lead to the development of successful strategies to help physicians realize their commitment to the values of professionalism, despite the inevitable challenges that arise throughout their careers.

MicroRNA-29a regulates intestinal membrane permeability in patients with irritable bowel syndrome.

BACKGROUND: The molecular mechanisms underlying the pathophysiology of irritable bowel syndrome (IBS) are poorly understood. One mechanism may involve increased intestinal permeability that is reversed with glutamine supplementation. Our goal was to evaluate the expression of glutamine synthetase and its complementary miRNA in blood microvesicles and gut tissues of IBS patients with increased intestinal membrane permeability. METHODS: We evaluated 19 diarrhoea-predominant IBS patients and 10 controls for intestinal membrane permeability using the lactulose/mannitol method. miRNA expression was evaluated in blood microvesicles and gut tissue. To further confirm the relationship between miRNA and glutamine synthetase expression, cell culture experiments were conducted. Glutamine synthetase was also evaluated in the gut tissues of patients. RESULTS: A subset of patients with IBS (8/19, 42%) had increased intestinal membrane permeability and decreased glutamine synthetase expression compared to patients with IBS normal membrane permeability, and to controls. Expression of miR-29a was increased in blood microvesicles, small bowel and colon tissues of IBS patients with increased intestinal membrane permeability. Increased intestinal permeability was modulated by miR-29a which has a complementary site in the 3'-UTR of the GLUL gene. CONCLUSIONS: The results support the conclusion that GLUL regulates intestinal membrane permeability and miR-29a regulates both GLUL and intestinal membrane permeability. The data suggests that miR-29a effects on intestinal membrane permeability may be due to its regulation of GLUL. Targeting this signalling pathway could lead to a new therapeutic approach to the treatment of patients with IBS, especially because small molecules that mimic or inhibit miRNA-based mechanisms are readily available.