Finding a new path. (Next!).

A young man seeking wisdom traveled far in his search, and one day he came to a Guru seated at the base of a mountain, and said, "I have been told by many and sundry that you know the path up the Mountain of Wisdom. Is this true?"

"Yes, It is," said the Guru, who had a flowing white beard and bushy eyebrows that curled up at the tips. He was wearing nothing of any consequence, save for some beads around his neck and a dhoti wrapped modestly about his loins.

"Is this the mountain?" asked the Seeker.

"Yes it is," said the Guru. "There is only one mountain. I am the guardian of the path."

"Can you take me up the path?"

The Guru great curling eyebrows scrunched together in a furrow of doubt. He was silent for a long time, gazing at the Seeker as if he could see deeply into him. Finally he said, "I can take you up the path, but can you follow? The way is long and arduous, the difficulties many, the temptations to turn aside are legion. Many attempt the path, few succeed."

"I would like to try."

"Your will have to serve as my chela, my disciple, and do whatever! ask, no matter how difficult, until we get to the top."

"I promise," said the Seeker.

So they set off up the path, the Guru moving with amazing speed for so old a man, the Seeker puffing to keep up. The path was, in deed, long. Hours became days, days turned into weeks. The Seeker would have become lost many times without the Guru. At various points, the Guru stopped and made the Seeker perform some task or learn some skill, often what seemed to the Seeker a senseless one. The Guru would go no further until the Seeker had learned the skill Months went by. Further and further up the mountain they tolled, through brambles and deep canyons, over rocks and through caves. They never met anyone else on the path.

After some time (the Seeker had long lost track, but! will tell you that it was, to be precise, one year, one day, four hours, and seven minutes since they had started), they reached the summit of the Mountain of Wisdom. ft was broad and flat and, to the Seeker's enormous surprise, crowded. The Guru seemed to know who everyone was and, standing on a small prominence, he pointed them out for the Seeker- the milling crowds of Hindus, Jews, Muslims, Buddhist monks, Catholic nuns and priests, as well as badminton players, rock stars, stockbrokers, mothers with babies, grandmothers, a woman Prime Minister, four astronomers, and at least one rodeo clown. As they watched, what looked like a tour bus drove up onto the mountain from the other side.

The Seeker sat down, speechless. Finally he looked at the Guru, struggling to get out the words. "But... you said ... one path."

"No," said the Guru gently. "I said, 'One mountain.' There are many paths."

"But... your way was so difficult. And we never met anyone."

"That was not my way That was your way Everyone has their own. That was the easiest path you could have taken. The path to wisdom is always exactly hard enough- that is, it is excruciatingly difficult. You must trust me on this."

The making of a physician

So, how has your path been so far? What have you trained for? How does that training fit with what you are doing now? Every physician goes through a long and grueling process of selection, self-selection, and training. That training is built on a foundation of learning, by rote, an enormous amount of information about the human body, about diseases, symptoms and therapies, about tests and diagnostics. Add to that base the skills of gathering more information, plus certain physical skills, such as finding a vein with a hypodermic, or intubating an air passage, along with the mental skills of coming rapidly to a logical judgment based on that information--and you have a basic medical education. The process selects (and the trainees self-select), for people who find this approach congenial. The process is based on the powers of memory, observation, and logic. Though doctors are trained to consult, it is at root an individual process. And it is reactive--the doctor responds to the presenting situation.

And there is a meta-training as well, a set of assumptions, postures, and beliefs that is often unspoken, but is in its consequences as powerful as anything a physician learns. In his rounds, the intern learns not only that he must know everything, but also that he must appear to know everything. For the patient to have confidence, the physician must seem an Olympian. The fledgling physician learns to hide his ignorance, to dissemble his fear, to elide his vulnerability.

Today, out on the floor, in the clinic, in the executive suite at the health care center, things are changing. Medicine is changing, health care is changing, even the patients are changing. Increasingly, you are being asked to exercise skills that run against the grain of your training. Patients are demanding more information and taking more responsibility. Some of them are going on the Internet and researching their particular condition more deeply than you would ever have the time to do. Managed care is pushing at the edges of ethical practice, demanding that physicians operate in ways that may not be in the best interests of the patient. At the same time, outcomes management and other new ways of improving quality increasingly demand that physicians collaborate with each other, with care managers, and with patients.

Medical knowledge is expanding faster than any physician can keep up with--and the means to search for and process that information are improving almost as rapidly. Genetic markers, polymerase chain reactors, and other early detection techniques will increasingly allow physicians to get involved in the disease process far earlier, often In a preventive rather than reactive mode, turning some of the practice of medicine into a kind of individualized public health. And as these techniques become widely available and their cost efficiencies become obvious, care managers will Increasingly insist that they be used.

So, where the old medicine was reactive, the new medicine increasingly will be preventive. Where the old medicine was based on memory, the new medicine increasingly will be based on an expanded ability to gather information. Where the old medicine was, at root, a matter of an individual physician's judgment, the new medicine increasingly will be collaborative, based on care guidelines, teamwork, consultation, handing over some of the power of judgment, logic, and information-searching to colleagues, to technological tools, and even to the patient and the patient's family. Where the old medicine was authoritative and hierarchical, the new medicine increasingly will be advisory.

The troubles of the hyphen 

When a physician becomes a physician-executive, the shift is similar, but even more abrupt, more confusing, less marked by signposts. To be an organizational leader--especially in the 1990s, in health care more than in any other industry--is to be a master of teamwork, a maven of process, at home with ambiguity, comfortable with change, a nurturer of consensus, yet decisive, ready to move in the face of all the ambiguity.

Suddenly the patient, the passive recipient of care, becomes the "customer" and, as Gail Warden, CEO of Henry Ford In Detroit, puts It, "The customer is the boss."

Suddenly, decisiveness, a quality very familiar to a physician, has to blend with collaboration. After 11 years as a health care CEO, James Reinertsen, MD, of Health System Minnesota told me, "At first I was under the impression that people looked to me to decide. Now I rarely come to a meeting thinking that It is my job to decide. It's far more important for me to elicit the best decisions from the group, and to see that a decision is made. Now I realize that I do not always know the best course.

Pat Hays, former CEO of Sutter Health In California and now CEO of Blue Cross/Blue Shield, echoed Reinertsen almost exactly: "In the earlier part of my career, I felt that I had to be the center of all answers. Now it Is more a matter of shaping the philosophy and the dialog, setting the basic strategic directions, and then getting out of their way."

So did Stephanie S. McCutcheon, CEO of St. Louis Health Care Network: "I was raised to see a leader as the person with all the answers. When I was younger, often I would go into a meeting with an answer ready to go. Now I walk into meetings without answers and craft the answers at the meeting. My experience as a leader is that it's my job to facilitate the development of the vision, to get the team around the table to find the answers, to pose the proper questions, to look creatively for solutions."

Facilitating the vision, eliciting the group decision, shaping the dialogue, and getting out of the way: these don't sound like skills taught in medical school, or learned in clinical practice.

The physician is used to rapid, relatively clear feedback--the patient gets better or worse or dies. The executive is used to feedback from the marketplace, the industry, her colleagues, and her subordinates that is subtle, mercurial, and easy to misinterpret. Communicating a sense of vulnerability, which could be a problem in a physician, is occasionally a necessity in a leader. The ability to communicate a vision, rarely called for in a physician, is a basic job skill for a leader. The Olympian aura of authority, knowledge, and judgment that the physician has so carefully cultivated would be a stone around the neck of the executive.

Finding the new path

The hyphenated physician-executive lives in a state of culture shock. If she does not understand what this shock means, and where it comes from, she will forever be questioning her fellow executives' motivations and competence. Every transaction will seem odd, every meeting interminable, and most processes unnecessary. If she wants to stop feeling weird and start being more productive as a hyphenate, she has to take two major steps.

The first major step is to recognize that the traits of the true organizational leader are, in fact, skills. The skills of the leader who shows up at a meeting without a pre-made decision, who "facilitates consensus," who helps the group "look creatively for solutions" may seem so soft and fuzzy as to be invisible to the medical mind. The physician may find himself saying, That's a skill set? What's to learn here?" The physician may find himself wondering how these people manage to hold down a job at all, let alone become a major suit in the front office, without any noticeable skills. This way of thinking does not make for fruitful, efficient relationships.

But anyone who has actually run a major health care organization for a significant period of time can attest that these skills are real, that they are powerful, that you can't run a health care organization today without them. These skills do not represent a better or worse way of thinking and acting. Rather, they are the right skills for their context. They are a different path up the Mountain of Wisdom.

The second major step is to learn these skills, to set out deliberately, this far along in life, on a new kind of training, a new path. It will take time. As these are significant skills, learning them is a non-trivial task. No one book or seminar will give them to you, no single class or training course. Executives I have interviewed consistently talk about many years, even decades, of experience shaping their style.

Once more with feeling

The Guru turned to the young Seeker and said, "Well, that's enough rest, Let's start down."

The Seeker was startled all over again. "Head down? Whatever for?"

"Why, so that we can try another path."

"What?" cried the Seeker. "I wanted to stay here. Wasn't that the whole point?"

"Oh, no." The Guru seemed shocked. "No one is allowed to stay here. Do you see any houses up here? Oh, no no no no. If wisdom is what you seek, it is here, on this mountain--and you must ascend the mountain over and over again, by one path and then by another. That is how we attain wisdom. That's how I became a guru--and that's why I scoot up the mountain so easily. Come along!"

And with that, he hopped off the rock and vanished back the way they had come.

Joe Flower is Principal of The Change Project, in Larkspur, California. He has written about change in health care for over a decade. Author of hundreds of articles, he is a Contributing Editor for the Healthcare Forum Journal and New Scientist, a system host of The Well Computer Conference, and a faculty member of Health On line. If any of the ideas presented in this column resonate with your experience, drop Joe a line at The Physician Executive, or at [e-mail] on the Internet.