Finding the essential difference. (Next!).

The White House, Nowra, New South Wales: It is dawn. The sun is rising out of the Tasman Sea. Across the road, black and white cows trundle slowly through the thick, shoulder-high mist. But my attention is on the borderless cacaphonic screeching emanating from a nearby tree, alive with what must be hundreds of birds. Now and then a brace of birds bursts from the tree and races off, or barrels past me back to the tree.

What is strange to American eyes is that the birds are parrots, rosellas, lories, green and gold, blue and red, flashy tropical birds that I have seen before only in cages, aviaries, and pet stores.

The scene does not quite seem real.

The cars of Australia are jarring in much the same way. Whether home-grown Holdens (from the down-under branch of General Motors), Ford Falcon Futuras, or Daewoo Esperos, they all look quite familiar. But on closer inspection, few of them are quite like any we see in America. Here in this English-speaking, democratic country, our ally in every war since the country was founded, everything is so familiar and ordinary, and yet nothing is--from the flying foxes careening over Darling Harbor in downtown Sydney, to driving on the left, to the double-deck subway cars.

As Antoine de Ste. Exupery put it in the great philosophical tome The Little Prince: "What is essential is in visible to the eye." Which of these differences are essential? Which is, as Gregory Bateson would put it, "The difference that makes a difference?"

Yesterday my wife and I drove down to Jervis Bay National Park to explore the Botanic Gardens and search for kangaroos in the wild. Only it wasn't, as the map said, Jervis Bay National Park. Now it was Booderee National Park. At the park gate--a small surprise--two teenaged Aborigine girls sold us our permits. At the park store, two other teenaged Aborigine girls operate the sandwich shop. I thought these were small, inessential differences, but I discovered that they mask an essential one: the Wreck Bay Aboriginal Community, it turns out, now owns the National Park and Botanic Gardens, leases them back to the government, and runs them jointly with the government.

A bare generation back, Aborigines were not allowed to own any land at all in Australia. Their relationship to the land they held sacred was legally null. Today, they have become the stewards of the nation's sacred places here, at Uluru (Alice Rock), and elsewhere. This is a profound change for them, and for Australia.

This idea--what is essential, and what is peripheral--is basic to all intelligent management of change. At the core of all our resistance to change is the fear that we will lose something of ourselves, something unrecoverable. "Touching ground"--gaining clarity on what we are truly about, and shaping our strategies around that core--is a key skill of the change master.

Two weeks ago, I sat down to dinner in the "old town" of Alexandria, Virginia, with Roger Fritz, President of Leadership by Design, Inc., a St. Louis consulting firm. An architect by training, Fritz' work these days parallels mine: He helps his clients move profitably through major cycles of change. I asked him, in his experience, what was the most important element in helping clients deal with change.

"Helping them recognize what's essential," he said. "There are two kinds of change: Technical change and profound change. A technical change asks you to learn something different, A profound change asks you to be someone different."

Too often, we confuse the two. An apparently technical change can mask a profound shift in attitudes, in working relationships, even In purpose. And what seems a profound shift--a new mission statement, a team-based reorganization, a change in ownership--may turn Out to be merely technical, another set of forms to fill out, a new meeting to attend, while all the real work is done in "work-arounds" that approximate the old way of doing things.

Is it really only technical?

We make technical changes at the drop of a scrub mask--new software, new imaging techniques, new protocols, new flavor-of-the-week organizational techniques.

Many of these changes are, in fact, only technical. They mimic the techniques we had used previously. They change no relationships, redistribute no power. Previously, one thoracic surgeon walked down the hail with an X-ray to show it to another. Today, he attaches it to an email and sends it across the continent. But he is still a medical professional--an MD, a thoracic surgeon-showing the image to a peer and asking for an opinion.

Other changes in technique actually bring with them profound changes in relationship, attitude, mission, or purpose. They change what things mean. Electronic medical records, for instance, are not merely more convenient versions of paper records. When hospital administrators, HMOs, or even chief medical officers of physician groups, can aggregate electronic medical records, find the outliers--those who stray from the golden path of protocol--and confront them with their waywardness, the traditional autonomy of the physician is broken, for better or worse.

Email can flatten organizational relationships, bringing everyone into direct contact with the top. Cross-organizational teams, benchmarking exercises, and other organizational changes cast people in roles they never had before. All these seemingly technical changes shift people into different relationships with each other and change the equations of power, access, control, and accountability. And all of them--temporarily at least--make people less competent.

Change lowers competence

I am driving a rented a car here In Australia, and I have instantly become a beginning driver, bumbling, over-cautious, and klutzy. Driving from the right-hand seat for the first time, when I try to downshift during a turn I reach for the windshield wipers instead of the turn signal, and for the door handle rather than the shift lever. When I want to look behind me, I look up to my right, missing the rear-view mirror on the windshield to my left.

In the language of Sewell Wright, a University of Chicago geneticist in the 1930s, I had reached a local peak" in the landscape of fitness in my competence as a driver of cars with the steering wheel on the left. Looking out across this metaphoric fitness landscape," I could see another peak not far off, a fitness peak in which I would be competent driving on either the left or the right. But in order to get to that new, higher peak of fitness, I have to climb down off of this peak and cross the valley of incompetence.

This is why, as Fritz had pointed out, 'Every change leads to low competency. And the more profound the change, the more profound the incompetence." It's one thing to be incompetent with a new computer program, not knowing the commands. It's far more unsettling to feel incompetent as a physician, as a leader, or even as a human being, not knowing my relationship to the people I work with, what is expected of me, and what will work.

"Any system has two forms of resilience," Fritz said. "One is identity--all the ways that it knows what Is itself and what Is alien. The second is coping strategies--all the ways that it deals with its own inadequacies in the face of change and conflict. Both of these are shattered by large-scale change."

So it's a bad idea, according to Fritz, to try to drag an organization through all kinds of change at the same time. It's far better to "stairstep" technical changes with profound changes, allowing each type to reinforce the other, and building an organization's competence at the skills of change itself.

The stakes, after all, are quite high. An organization facing change and conflict Is unlikely to come through the experience unaltered. It is likely to change, for the better or for the worse. "The system can adjust downward until it finds an acceptable solution," Fritz told me. "Or it can adjust upward to the next level of elegance."

Cumulative change

Every small technical change carries with it some modicum of profound change. These tiny shifts can accumulate until suddenly, It seems, the world turns upside down.

In a remnant rainforest here in New South Wales, we encountered the wonderful "strangler fig." Drop the seed of this plant into the ground and, with the right chances of rainfall, sunlight, and competition, it can grow into a mighty tree towering above the forest canopy. But if the seed falls instead into the branches of the parent tree, far off the ground, it can sprout anyway. It drops a long root to the ground, and turns into a vine, wrapping itself around the parent tree and reaching upward for sunlight. Often many of these vines braid around a tall trunk, growing fatter and stronger year by year. The parent tree will eventually die and rot away, leaving the vines as an enormous vertical hollow braid, now standing on its own, the scaffold for other, newer vines to climb.

Ownership, authorship, followership, service

Over the last few years, one of the most profound changes in organizations ever attempted has arisen--often hidden among the vines and ferns of technical change. We can call it the question of ownership.

"Historically," Fritz pointed out, "there have only been two mindsets in the workplace. One is the 'employee' mindset--wind me up with the promise of a paycheck, point me in the right direction, and I'll go do whatever you tell me to do, no more and no less. The other is the 'employer/entrepreneur/owner' mindset--I'm in charge, I have a larger goal, I have to think creatively to meet those goals as conditions change.

"Now we are asking employees to be more accountable, creative, and involved. We're essentially asking them to be someone different, to act as if they are an owner. Yet we can't give them final say over anything. So a nearly unresolvable internal conflict is buried at a profound level of change. If we ask the question in terms of control--'Am I in control of this or not?'--there is no answer. It works better if we can frame the question, instead, as, 'When is it necessary for me to act as a leader? When is it important that I be of service?'"

What changes are taking place in your own organization? Are they technical or profound? Are there profound changes hidden in the technical changes? When you attempt a small, technical change, and you encounter resistance that seems out of proportion, look for the profound change buried inside the technical change--that's what people are reacting to. The resistance will only disappear when you have addressed those concerns, one way or another.

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 HealthOnline. 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.