The water is wide.

Trying to predict what cardiology will look like in 10, 25, or 50 years is an almost absurd act of imagination. Perhaps even more than most branches of medicine, it has been changing so fast that it is hard to recognize from year to year. When we contemplate the changes that cardiology and the rest of health care are facing, we know that none of these changes will ever be "just technical." They will all be deeply human, and each one will be very difficult for some people. As people and organizations, we all come to that point where we have to change. Where we are is not working, we can't go on like this, we have to do something different. After boldly setting off to go someplace new, after some basic work is done to escape the original presenting problem--we reach the Great River. This is a point at which small, incremental changes won't do and we truly need to see ourselves differently. There is no bridge, no easy way across. This is where we must gather our resources and courage, remind ourselves of why we came this far. Yet many of us don't, and settle for something comfortable rather than cross that wide, turbulent river.     

Living in the question

We live in a fast moving-world. Business has accelerated to breathtaking speeds in the 1990s--and in the last few years the afterburner has really kicked in. The speed of change is overwhelming. Especially in health care, who has time to "live in the question?" We need to decide things quickly, get the decision out of the way, and move on, right? Maybe. Biology shows us that you can't plan ahead very far. New things come along that you don't even have a category for, and therefore you don't even see them. Things are going to happen that you literally have no notion are even possible. The key to succeeding in this environment? Don't plan ahead. Stay curious. Make small bets. Build organizational hothouses. Feed the seedlings that grow. The challenge is to remain curious, to live in the question, both personally and organizationally.     

Health care 2015: flight of the butterfly

Projecting out to the year 2015 sounds presumptuous. Who can predict that far ahead? Perhaps no one can. Social and organizational arrangements come slowly. It takes five years or so to implement simple concepts, sometimes decades for more radical changes. Once you have the ideas in tangible form, it can take another five years to get it working right. Early adopters bring others into the movement and, over 15-25 years, new directions dominate. It takes at least a generation of new practitioners to take on the new values and methods so what is likely to dominate in 2015 is beginning to be taken somewhat seriously as the successor movement to our current fad with externally imposed managed care. Put another way, entire generations of people will resist new ideas, making implementation unlikely until their control fades and a new generation takes the helm. The exciting challenge for the observer is to address the issue of where health is and should be going. Both are difficult challenges. Agreeing on what is important and what is not represents a competitive challenge. How do we perceive the world? Surely our value sets will color what we see. Who is not predisposed to select a future where they fit and their pet theories are likely to become reality. For these and other reasons, it is probably easier to agree on what we would like to see happen in the future than on what is happening. Unfortunately, unless we see the world as it is, we are less likely to be able to shift it in a direction we would like to see.     

Preparing to tack: when physicians change careers

Because of the progressive health care revolution that gives all the power to the managed care insurance companies, the usurpation of physician autonomy, and the replacement of the physician-patient relationship with HMO policies, doctors are looking at other career choices. Many doctors have never considered life after medicine and have made no plans for that time in their future. Despite their ample education, some doctors say, "I don't know how to do anything else. I am trapped in this system, and I can't get out. If I knew what else I could do, I would definitely change careers." Many doctors feel that it is too late in their lives to make such a change. However, it is becoming more and more acceptable to switch or modify a medical career. A number of physicians have switched careers successfully without disgrace and have discovered that there is indeed a life after the first career choice. It isn't always easy, but it can be done.     

Treating patients like customers. Just-in-time inventory control for patient-centered care

Managing change in health care is a complex, poorly studied process that's even more poorly understood. We do not have a clear model to visualize as we contemplate just what it is we are changing. Explore how modern hospitals are "warehousing" patients like excess inventory, and examine the changes needed to escape this morass. A strong physician/hospital alliance is the key to establishing more efficient, patient-centered care.     

The Zen of physician initiatives

Many physicians today feel ravaged by the brutal speed with which change has been occurring. They see the beliefs and practices of a lifetime being abandoned and replaced by the flavor of the month, management du jour. But if you are willing and able to take the brave step of approaching your physicians without an agenda, meeting with them to listen to their concerns, and can also avoid hanging a lightning-rod label on every bright new idea that comes out of the sessions, you'll be on the way to effective new management. This new style is a "Zen" approach (but don't give it that label) that lets real collaboration come into the place that is supposed to be all about healing--the health care organization. From "never call it anything" to "stay with them until they get it," ideas on how to be a Zen manager are presented, with the ultimate goal of truly partnering with physicians and infusing them with a desire to move beyond the frustration and disenchantment they are feeling.     

The Efficacy of Different Methods for Informing the Public About the Range Dependency of Magnetic Fields from High Voltage Power Lines

The AC electric and magnetic fields associated with high voltage power lines have become a concern as a possible health risk. In most cases the strength of these fields decreases as the inverse square of the distance from the line. In earlier work, we found that laypeople do not understand how rapidly field strength decreases with distance. Most believe that any high voltage power line they can see is exposing them to strong fields. This paper confirms the earlier finding and explores a number of strategies which might be used in risk communications to correct this misperception. We found it relatively easy to provide subjects with a better understanding of the range-dependency of magnetic field strength. Moreover, the quality of this acquisition was apparently independent of the manner in which they were instructed. Such successful instruction is markedly different from the well-established difficulty of teaching people about many qualitative domains, such as physics or ideas in probability. Clearly, while some erroneous beliefs are highly resistant to change, others can be altered quite readily. We suspect that an important distinction between knowledge about the range-dependency of power-frequency magnetic fields and less tractable topics involves the presence or absence of prior folk-theories or "mental models" of the domain.     

Running toward the roar

How do you embrace paradox, changing and growing without losing your sense of who you are? We talked last time about the paradox of reaching for the new, without losing your ground in the old. Paradox is the place of insight. Accepting paradox, not as a momentary distraction but as a place to live, lies at the heart of dealing successfully with change. We can see this most clearly if we ask ourselves, "What business am I in? What am I about?" In health care, this did not used to be a meaningful question. Today, it is a critical one. But to really develop, we have to seek out the situations that are the most difficult for us, work them through, hang out with them long enough to begin to be at home in the paradoxical, ambiguous, and strange circumstance.     

The microprocessor and medicine

Technology continues to accelerate at an amazing pace. Where have we been, where are we going, and what do these technology enhancements mean to the health care industry? We are entering the era of the personal computer becoming the window to the multimedia digital world of cyberspace. Microprocessors will continue to improve from one generation to the next to make cyberspace as realistic as possible-and with their improving capabilities will come myriad applications for health care services, either not cost-effective, or not even contemplated, until now. As a leader of an organization, one who approves substantial budgets for information technology, you must ask yourself what new products and services these startling technological advances will create. How will they change health and medical care?     

Clinical reengineering. Integrating medical and operational management

In the continuing push for cost containment in health care, many organizations have turned to cost reduction methods that fundamentally change the way care is delivered. As health care organizations continue to make financially-driven staffing changes that impact patient care, medical leadership must take on greater responsibility for operational management. Physician executives are uniquely qualified to take on leadership roles in work redesign, and must do so to ensure excellent and fiscally-responsible patient care. This article presents a proven methodology for work redesign that helps physician executives apply their clinical skills to operational management in designing new health care delivery models.     

Leadership for the next millennium: the physician executive

We continue to muddle through using tourniquets and bandaids on a health care system that is in dire straits. And the future is even less promising. There will be millions without basic health care, let alone basic health care coverage. Rural and inner-city hospitals will close, with progressive public apathy, as we focus on the marvels of expensive technologies that serve only the few. Costs will continue to rise at double digit rates, and our nation's employers will fall further behind in the global marketplace. Preventive care will be uncommonly provided and only more rarely reimbursed, while a couple more children die of measles in Mississippi. It's not a pretty picture, and it simply doesn't have to come to pass. "What we really need is leadership," the public cries. That leadership can and should come from medicine through physician executives.     

What kind of leaders will be successful?

The U.S. health care system is fundamentally changing. The pace of change is swift but will vary, depending on regional market forces and state legislative mandates. This complex change is leading to rapid market consolidation of providers and insurers into organizations called "integrated health care systems." There is, as yet, no proven role model that will guarantee success. The purpose of this article is two-fold: To help individuals who see an expanding role for themselves in integrated health care management decide if they have what it is going to take to be successful. To identify individual management training needs by use of a self-evaluation tool. Some of the needed skills can be enhanced by education and experience. However, some are personality and style characteristics that may not be changeable.     

Adverse Health Experiences,Environmental Attitudes,and Pesticide Usage Behavior of Farm Operators

Water pollution from agricultural pesticides continues to be a public concern. Given that the use of such pesticides on the farm is largely governed by voluntary behavior, it is important to understand what drives farmer behavior. Health belief models in public health and social psychology argue that persons who have adverse health experiences are likely to undertake preventive behavior. An analogous hypothesis set was tested here: farmers who believe they have had adverse health experiences from pesticides are likely to have heightened concerns about pesticides and are more likely to take greater precautions in dealing with pesticides. This work is based on an original survey of a population of 2700 corn and soybean growers in Maryland, New York, and Pennsylvania using the U.S. Department of Agriculture data base. It was designed as a mail survey with telephone follow-up, and resulted in a 60 percent response rate. Farm operators report experiencing adverse health problems they believe are associated with pesticides that is equivalent to an incidence rate that is higher than the reported incidence of occupational pesticide poisonings, but similar to the reported incidence of all pesticide poisonings. Farmers who report experiencing such problems have more heightened concerns about water pollution from fertilizers and pesticides, and illness and injury from mixing, loading, and applying pesticides than farmers who have not experienced such problems. Farmers who report experiencing such problems also are more likely to report using alternative pest management practices than farmers who do not report having such problems. This implies that farmers who have had such experiences do care about the effects of application and do engage in alternative means of pest management, which at least involve the reduction in pesticide use.     

Seven lessons in medical management

In more than 15 years of functioning as a medical director, addressing the needs and wants of patients, physicians, hospitals, and ancillary health care suppliers, I have accumulated pieces of ?wisdom? that I now feel I should share with others in medical management. The concepts are fairly simple, but they are of significant value in the ?real-life? management of people. The seven simple ideas outlined in this article are not meant to be the end-all to management philosophy. Books have been written about each idea, and there are hundreds of good ideas in many sources I do not touch on here. However, I have found these seven items of significant value in dealing with others and hope others find them similarly useful.     

Habits of mind for turbulent times

How do you deal with change--in either personal circumstances or in the turbulent health care environment? Do you rail against the variables that seem to put you in the uncomfortable situation, blame yourself, take it personally? Are there ways to start looking at change differently and more effectively? Here's the key: It's all weather. Whatever you can't control, no matter who does it or why, is just part of the weather--where you are right now. How do we treat weather? We try to find out as much as we can about what's coming, but we keep its unpredictability in mind. We prepare for its extremes as wisely as possible. We grieve any losses it causes us, and celebrate the lovely spring days and quiet summer evenings it gives us. And never once do we take it personally, think that the weather is out to get us, or that lousy weather means that somehow we have failed. We just know that its not personal.     

The next stage of managed care.

Since the turn of the century, we have gone from medicine as a cottage industry, based largely on barter, to the complex entity it is today. What we will see in the coming decade, if not sooner is the emergence of the next level of managed care. As managed care matures, contradictions in the health care system that we have not been able to resolve will be addressed, as well as other value-related issues. The ability to deliver value and then to monitor outcomes will be the nut to crack. The next big movement will be to hone in on outcomes and measurement. This will be the path to increasing the inherent value of the medical care system. This will go hana in hand with accountability, which is where physician-sponsored networks (PSNs) will be an indispensable tool. Centered as they are around accountability and responsibility, PSNs will be a natural starting point for developing the protocols to produce and collect this data. The standardization of care, anchored upon medical evidence, is the objective.     

Providing health care to human beings trapped in the poverty culture

The culture of poverty impacts everything patients in this socioeconomic group think and do. If what poor patients say does not sit well with the way we think, that doesn't mean they are wrong. Physicians have to adjust their mental model and think in different cultural terms. The author recently completed his thirtieth year of a career dedicated to providing health care to people living in poverty. He shares seven concepts important in building a mental model that will enable physicians to successfully provide health care to this patient population: (1) Poverty is the number one health problem; (2) we see same diseases as everyone else; (3) patients are trapped in the poverty culture; (4) patients' behavior is often manipulative; (5) compliance is a unique challenge; (6) patients have limited resources; and (7) the ultimate contributors to poverty are unwanted adolescent pregnancy and substance abuse. These concepts can help physicians to be more effective in providing health care to patients living in poverty. They can help them understand what is happening, so that their experience might be fulfilling rather than demoralizing.     

The new rules of leadership and organizational politics

As the health care industry continues to experience unprecedented change, organizational politics are also evolving. Major changes are underway in the rules of engagement and how management and workers behave on the job. The new rules of the game include: Practice leadership, not management; practice inclusion with a vengeance; practice modesty and consideration and demand both; act on rumor, don't await confirmation; aggressively collect allies; understand the politics of voice mail; and know that position power isn't personal power.     

The pitfalls of managing contingency workers

Contingency workers have proven so cost effective that they may constitute half of the health care industry work force before the end of this century. However, because these workers don't have stakes in the companies and are bitter about losing their full-time jobs, they are often difficult to motivate and even more difficult to manage. In fact, their attitudes negatively affect the morale of their full-time coworkers and poison the overall work environment. The author offers some tips to make contingency workers feel more a part of organizations in hopes that their attitude and performance will improve.     

Physician executives: managers first, clinicians second

The literature is replete, many would say depressingly so, with accounts of the changes that are rocking the health care delivery system. The demands on the system's leadership increases with every change. And the future holds even more changes, with a level of uncertainty that will makes today's demands seem childplay. Physicians, especially physician executives, will surely be key factors in helping the system maintain its fundamental charge of high-quality patient care provided at reasonable cost, but what exactly is expected of them? One point is clear: While their clinical backgrounds will continue to arm them well for reaching the executive suites of health care organizations, physicians who hope to fully succeed in management will have to acquire and master a widening range of management skills. An indication of just how demanding the health care management job will be is provided in this report, based on interviews with physician executives and the people who seek and sell their services.