Running toward the roar.

I am writing this in a hotel room in Sydney, Australia, near the Sydney Opera House, in the historic district called "The Rocks." The room is a modern one, perhaps 10 years old at most, with everything from cable TV to modem ports. Yet, parts of the hotel date back a century and a quarter, with the modern facade neatly dovetailed between the stone foundations and brick walls of two older buildings, new and old, forming a pleasing aesthetic whole. This turns out to be a common method of building, not only throughout The Rocks, but all through the nearby downtown district of this thriving city of over three million people--old facades are hollowed out, with a high-rise reinterpreting the architecture of the old building, rising above and behind it. New buildings sprout from the old. Other buildings soar over or nestle around the old ones that preceded them, and many old buildings have been renovated, expanded, and given new uses.

It is as if the city refuses to choose between change and staying the same, but embraces the paradox, changing and growing without losing its sense of what it is--what land and history and people it has grown from.

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.

The art and science of business management has fads and fashions as seductive and compelling as children's taste in toys. The cry of the '70s was "diversify." Harold Geneen's ITT swallowed the Sheraton Hotel chain, American cake-maker Sara Lee bought an Australian sportswear company, Sears bought the Coldwell Banker real estate company, a tobacco company engorged a food company and transmogrified into RJR Nabisco, all in search of spreading risk across different industries and sectors and searching for magical "synergies" that would make the whole more than its constituent parts.

The underlying assumption was that all businesses are fundamentally alike, that the skill of running one business is the skill to run any business. It was an assumption much touted by people who learned their business skills in business schools.

Sometimes it worked. More often, the synergies turned out to be more mythical than magical, and people expended enormous amounts of energy, and made huge mistakes, trying to manage businesses that they knew nothing about. It turned out that there are some things about real estate that are inescapably different from retail or arbitrage, or publishing elementary school texts--and the differences, the localness of each business, the instincts of each trade, were not things you could learn in school. You had to learn them from experience. Time in the field mattered. Health care, in many ways the most local and special of businesses, was the clearest example: it seemed utterly unlike any other business.

So American business dropped the diversification fad, and a new cry arose: "Stick to your knitting," that is, put your bets on doing what you really know how to do better than anyone else. Leave the rest to someone else. In the mid-1980s, Marriott, for instance, realized that it was very good at running hotels, but it also owned and managed billions of dollars of real estate around the world--so it sold most of its properties and leased them back from the new owners. It pulled its money out of real estate equity and put it into expanding its hotel business--what it does best. At the same time, hospitals began to "unbundle," contracting for such ancillary services as laundry and security, and concentrating their capital on broadening their health care services.

So "stick to your knitting," turns out to be a useful thought for dealing with change--don't get seduced by novelty into attempting to do things for which you have no skill.

And yet ... and yet. Let's search for the paradoxical insight here. At the core of every truth is a fallacy, a route to a deeper truth. The fallacy at the core of "stick to your knitting" is the invitation not to change, to stay satisfied with the way we are.

Many of us have a grudging acceptance of the need to change. As one friend expressed it, "If it turns out I really have to change, I'll change." This seems a comforting thought, and it seems sufficient. But the reality is that every change is a new skill, one that takes time and attention to learn. If I wait to change until I am forced to do it, I will be too late. To wait until change is forced on me is to stay perpetually behind on the learning curve.

On the other hand, if I change with every passing breeze, take up every fad, I exhaust my energies. I am perpetually the beginner, never the master of anything. This is the mistake of diversifying for its own sake.

In which direction do I change?

So, I know I need to change. But how do I know in what direction?

There are many ways to find out the answer to that question: assessing the marketplace, surveying new technologies, following industry trends, running competitive scenarios. But let me suggest another way to the answer, a way rooted in paradox.

Wendy Palmer, one of my senseis (teachers) in Aikido, expressed it this way one evening: "What is hard for you," she said, "is your path." It struck me that I had heard the same thing a few nights before from a writer whose fiction I greatly admire, Thaisa Frank: "You find your craft by doing the things that are the most difficult." You might be great at characterization, say, but have little feel for plot. Exploring the mechanics of building great plots would not only be good discipline, it would be the most powerful thing you could do to develop the craft that is truly your own.

As Palmer explained it, we all have our favorite moves, the ones that really work for us. The temptation is to play it safe by repeating those moves over and over, and seeking out the situations where they work best. But to really develop, we have to do the opposite--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.

This is much like the dilemma of the antelope. When lions hunt antelopes, the pride's dominant male stays where he is, while the female lions--the real hunters, swifter than the male--sneak around to the far side of the herd, fan out in a wide semi-circle, and lie down in the grass. The dominant male, bigger but slower, really incapable of catching the antelope by himself, takes on the job of suddenly leaping up and roaring at the antelope. He's good at it. The antelopes bolt from him--and run straight into the trap laid by the waiting females.

For the antelope, salvation would lie in running toward the roar, in deliberately picking out the thing that is most terrifying, and moving toward the source of the fear. No antelope has ever been known to do that. Very few humans can, either--but they are the only ones who can learn to deal with the change that they fear.

In this way, what you fear--what you, your family, or your organization instinctually avoid--becomes a useful marker of the direction of the most powerful change that you could encounter.

Perhaps your organization, as a whole, has a great bedside manner, a reputation for caring. Perhaps at the same time you know that your quality statistics are not the best, that your medical practices must improve. In today's competition, you must lead with your competitive advantage--your reputation for caring. But if you want to last more than the present quarter and the present year, you must pour energy into your weakest point, the arduous task of improving quality through researching outcomes and forming sound practice guidelines.

Perhaps your greatest competitive strength is a relatively strong financial situation, with good margins and sizable reserves--but your greatest weakness is an information infrastructure that is 10 years old, that does not meet the demands of integration, cost-cutting, outcomes management, and new styles of medical decision-making. For you and your organization, this is a place of fear and confusion, and you naturally turn from it and put your energy into what you are good at. In the short run, the safest tactic would be to save your reserves to defend against competitive attack. But to survive in the long term, you can't hold back the reserves. You must use your strong financial position to rebuild your infrastructure. You must run toward the roar.

This paradox--my fears as a guide to change--is at least as vivid at home. What do I fear most? Deeply committing myself to my mate? Expressing my emotions, even the graceless ones? Learning to hear without judgment? That's the direction in which I will find the most powerful engine of change.

Whom in my family do I fear most? With whom do I fear having the deep conversation? Whether they know it or not, they will be my most powerful teachers of change.

If there is any urge that can be called a true "instinct," it is the instinct for order, for imposing patterns on the sensory chaos that confronts us at every turn. We have a deep and strong desire to make sense of the world--indeed, we have to if we hope to survive. People who have chosen to become physicians are particularly good at imposing patterns, at generating order from chaos.

Medical training sharpens this ability still further--the foundation of diagnosis and treatment is a focused, orderly mind, making sense of an overwhelming sea of information. Both diagnosis and designing a plan of treatment are stochastic processes that narrow the possibilities and collapse paradox until we can arrive at a judgment: This patient is or is not a candidate for a bypass graft, does or does not have a chance of regaining consciousness, can safely leave the tumor alone or must have it removed.

Logic and mental order are the power tools of medical decision-making. But they are less useful in dealing with change. Confronted with new circumstances, we must do more than narrow the possibilities. We must generate new thoughts. We must be creative. And we must do that not just once, but repeatedly and continually. We must live in the paradox. l

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.