The minds of a medical director.

It's 8:30 a.m., and I am limbering my left limbic lobe in anticipation of slogging through the sequence of the day's agenda, reviewing "to do" lists, as well as memos mistakenly sent to me and more properly handled by those designated to be left limbic for a living (accountants, clerical staff, etc.). The CEO calls, and I am catapulted through a paradigm shift as he entices me to share the latest vision of his "pink elephant" hospital contract. I, unfortunately, see only a "blue Edsel" and proceed to disappoint him with the obvious contradictions.

Just as I begin to do some visioning of my own, a call comes from an Associate Director, forcing my attention to a pressing problem in some mundane area of operations. I proceed to "get creative" and encourage some joint problem-solving when he informs me in no uncertain terms that what's really required is a series of sequential steps designed to solve his problem without his "sacrifice" of a single joule of imaginative energy. Frustrated, enervated, but not surprised, I retreat inward, managing a few menial tasks but keeping my powder dry for the next skirmish.

The above should be familiar to most readers. For those still uninitiated to the "whole brain" jargon, the theory, greatly simplified, states that we have a left brain to handle day-to-day written, sequential, logical, mathematical tasks and a right brain to manage visionary, creative, psychological issues. Good managers develop skills in both lobes to maximize effectiveness and work cooperatively with the "quarter-brained" colleagues in our organizations. Those are the unfortunate ones we tend to mislabel simply because they're zigging while we're zagging. At any rate, we're all becoming more comfortable with this "brain duality" idea. And just when we thought that management engineers had exploited the last of the "polarities": good-evil, introvert-extrovert, yin-yang!

Permit me to wax philosophic with an alternative view. I believe there are three "states of brain": left brain, right brain, and no brain. No brain? Think of those times when you just shut down, turn it off, go within in a mindless way. Some of us do it while sleeping; some don't, and have left or right brain dreams. (The best example of the latter is the chemist who allegedly solved the puzzle of the benzene molecule. He dreamed of a snake chasing and catching its tail and awoke with the realization that benzene is not a "linear" compound but rather a "cyclic" one.) Some do it jogging. Some do it meditating. I am known to do it sitting at my desk, mindlessly filing my fingernails. These are the times when significant problem-solving may occur.

Consider Eastern thought. The East has taught the West the concept of "mindlessness," or "thoughtlessness," and the Tao approach of one step back before stepping forward. It has also introduced a more powerful concept - "centering." We see modern examples of centering in the way the Japanese approach business financing. While we in the West are continually thrown off base by vagaries in the marketplace, changes in demand for our products, the Japanese continue to stay "centered" - focused on the long term, spending enormous capital on research and development to find out where tomorrow's center will reside.

Consider another example of centering. I am sure you share with me the experience of subordinates' confronting us with dilemmas. They exert a significant "pull" on us, and they extract from us a response, a position, an opinion. No sooner do we feel the problem is solved than we are confronted with a peer addressing the same problem. The answer given to the subordinate now appears wholly inadequate to our peer. Again, we are pulled off balance. Let's take a real example.

Health Center Administrator: "We need to add $7,000 to each health center capital budget for an Ob/Gyn machine. Without it, patients will be unnecessarily inconvenienced, and we won't be state-of-the-art. Don't you see my vision? (right brain)

Medical Director: "Sounds reasonable to me. Let's put it in the budgets."

Budget Manager: "This is crazy. We've given great service in the past without these machines. It's just another high-tech boondoggle we can do without. Didn't you think through each step?" (left brain)

Medical Director: "I sure see your point."

Medical Director (internally): "I guess I need to make at least one party unhappy. But I really believe both parties. I don't want to appear weak or vacillating."

A balanced approach dictates that you take nothing for granted. Choosing sides early means:

* You are probably wrong.

* You have not taken the time to consider more creative decisions.

* People around you ultimately lose respect for decisions made in haste.

* You've allowed yourself to be knocked off balance.

In fact, the no-brainer here was the realization that one or two machines could be purchased, giving us the necessary patient service gains. This would keep us within our overall capital budget, but the machines could be transported between facilities, and schedules could be arranged that made maximum use of each machine while it was at the local health center.

Through various techniques, we can learn the skill of finding our center, our point of maximum stability. In physical terms, it is the martial arts concept of a neutral stance with a low center of gravity - a position where it is unlikely we can be pulled off balance by an opposing force. In skiing, it is the concept of looking a ways downhill - not concentrating on our ski tips - to maximize performance. Spiritually, it is a calm place where believers feel they are closest to the concept of God. Mentally, it is the point of balance of thinking - what the Greeks call "equinimitas." When we find this center, we are less subject to the winds of change around us. We need not be whipsawed from the routine process of sequential logic to the other extreme of unfocused vision and abstract imagination.

The key area in the Venn diagram (page 42) is, of course, the center - the area common to the three polarities. It is the area through which, the model would suggest, all thought must necessarily flow. This heightens the issue of communication. Not only must we use the center to translate messages from each polarity, but it is the main faculty needed to deal effectively with those around us who are drifting in their own internal polarities. As a practical matter, the model shows the manager that he or she must find smooth transitions between the left-brained, objective processes in his or her work and the right-brained, subjective, abstract ones. And the idea of "flicking one side on and the other side off" is probably unrealistic. Just as those in our micro-environment are not totally polarized to a brain quadrant, neither is the manager. Facile transitions are the key. This should not be new to physicians. We examine one patient who is intellectually limited, requiring detailed, objective instruction on taking medications. We then walk into an examining room where a patient joins us in a philosophical debate on the politics of child rearing. These same smooth transitions are very much a part of management.

I want to take this one step further. Remember that cheap little toy you played with as a child? It was a small, handheld game with a brightly colored scene covered with a see through top. Inside were little metal balls - maybe four to six of them. The colored scene contained a number of depressed "dimples" into which each ball would sit if you manipulated the game with skill.

Now think about my "tripolar" model. If you envision the center as a dimple raised above the surface, imagine the skill needed to get the ball (our conscious state) to land there. It sounds like so much work. A colleague at a recent meeting told me, "I find it so difficult sometimes--I'm surrounded by right and left-brained people, and they all have different opinions. Because I have the |curse' of seeing both sides simultaneously, I'm just frozen. I'm afraid people will see me as vacillating on my principles. I'm afraid I'll misread them - they came to me for specific, objective answers, and I give them philosophical paradigms."

Not necessarily so. Take our three-dimensional model with the center dimple raised up and make a change. Imagine that the center is really a valley with all other polar aspects on higher ground. Now the "ball" in its natural state simply rolls around the landscape until it comes to rest in the center. All we need to do is keep from agitating the ball out of its hole and back toward the poles. This suggests a natural tendency toward centering; all we have to do is develop our skills and then take the opportunity to relax, allowing a flow through the brain landscape.

As medical managers, we face what seems to be the ultimate paradigm shift. On the one hand, we are exhorted to understand, embrace, and fully implement a concept called "medical informatics" - computerization and transition into databases of much of what we do (patient care, financial analysis, quality assurance, etc.). This is viewed by many as the ultimate left-brained experience - hardware, software, sequential logical algorithms, technical mastery of complex electronic systems. Simultaneously, we realize that the psychological well-being of our colleagues and staff must not be underestimated. We must exploit their "values" if we want to influence their behavior. This requires a deeper exploration and enhanced sensitivity to psychic aspects of management that are arcane to some. That is, right-brained people skills are as important as ever. How do we resolve these "polar" extremes?

At the risk of sounding glib, I would suggest that a "center" exists. The technology is not an end in itself but rather a means to achieve a "humane" goal. For example, our group practice in Orlando is large and getting larger, with increased risks that medical care decays, becomes fragmented, and sacrifices continuity of care - loses "high touch" in the substitution of "high tech." But it need not happen. Use the technology to make what is big seem small. Databases and local area networks create the ability to greet Mrs. Jones at the reception counter with the quality of historical knowledge that convinces Mrs. Jones we know her intimately - as if we were "small enough" to know her personally. Hotel switchboards do it - why can't we? Why not use our technical abilities to create elaborate patient notification systems that promote quality while creating an honest, caring, and concerned environment? As we let the "ball" sink slowly to our center, the view of each pole clarifies. The marriage of "high tech" and "high touch" becomes a "no-brainer."

My sense is that the ultimate quest is for the ability to deal flexibly with an external as well as an internal world. The medical director is in a position where communication with the environment as well as maintenance of "equinimitas" present constant challenges. At this basic level, we all find ourselves on a common path.

Edward H. Lowenstein, MD, is Medical Director, Orlando Health Care Group, Maitland, Fla. He is chair of the College's Forum on Medical Informatics and a member of its Society on Managed Health Care Organizations.