The skills of the change master.

The fundamental skills for the rest of the decade and the opening of the new century will be the skills of dealing with change. They are the skills of jazz, not of chamber music, of basketball rather than baseball, of poker rather than chess, skills of dealing with situations that are in constant flux, situations about which you do not know enough to make a decision - yet you must constantly make decisions, and even failing to decide is in itself a decision, irrevocable, the lost time unrecoverable, the opportunity evaporated.

Can you do this? Do you have the skills? Are you ready?

They don't teach these skills in medical school. In fact, I haven't seen a real curriculum for them anywhere. For some people, the skills of dealing with change are difficult, and do not come easily. I am convinced, though, that they can be learned by anybody.

What are these skills? If you ask people to name the skills of change, most would mention a certain openness to new ideas and realities, a certain flexibility, a willingness to try something different, to be different in some way. And they would be right: Openness and flexibility are certainly prerequisites. But they are insufficient. Here we will be looking at what I call the "deep skills" of dealing with change. They include:

1. Anamnesis: The skill of keeping in touch with what is deep and constant in the midst of change. The martial artist would call this "keeping base." We might call it "not forgetting who you really are." This allows you to maintain your balance and keep contact with your true goals. The question, for individuals, families, and organizations, is: What are your deepest values? How do those values inform the way you react to change?

2. Listening: The skill of truly hearing the other: your spouse; the most bitter, dug-in, resistant doctors on your staff; the other half of a racially-divided community; or the part of yourself that you are spending enormous energy trying to ignore. Change often is expressed most directly in your relationships to people around you. All by itself, listening is one of the most powerful tools of change. We are not talking here of listening passively, with an occasional encouraging grunt. We are talking about listening actively, asking questions, telling the other what you think you are hearing and asking them to correct you, with no argument and no agenda, truly no agenda - other than to deeply understand this person. Think of it as being teachable. Think of it as interviewing. How do you know when you have listened enough? When the other person feels that you have heard them, and can say so. This allows you to understand the other, and often to discharge much of the negative energy on the other side. The question here is: What can you do that you have not done to truly understand the other?

3. Joining: The skill of temporarily experiencing the world from die other's point of view. This is expressed in the American proverb, "Walk a mile in my shoes." The martial artist would call it, "blending," moving with the oncoming blow and matching its speed. The psychologist or hypnotherapist might call it "pacing the other's reality," temporarily drawing out and amplifying the client's view of the world. You can do this, even if your world view is completely opposite, and you can do it without ever pretending that you have dropped or forgotten your own truths. It is temporary, but it only has power if it is complete, if for at least that moment you have immersed yourself in the world view of the other. This could be physical: getting into scrubs and assisting in the surgery, or processing forms at the HMO for a day. It might be educational: reading all the literature that the other side reads, studying their arguments and their decisions. It might be purely mental, and it could take mere seconds: As you sit down in a meeting with someone, imagining for a few moments that you are them, coming to meet with you. This allows you not only to understand the change with which you are dealing, but to find a point of leverage, which is often the point of common ground. The question here is: What can you do that is temporary but complete, to become the other, the person or force that represents the change you are facing?

4. Penetrating: The skill of seeing that the presenting symptom is often not the real problem. The presenting symptoms might be a bump on the head, an enlarged pupil, and lethargy indicating possible concussion, the next layer is an abusive husband and alcoholism, the layer under that is that the local factory has closed, people are jobless and despondent. Every change arrives in disguise. The image is one of peeling away the layers of the onion. The martial artist would call this "irimi," or entering: Rather than dealing with the club or sword that is about to crash down on his head, he slips past it to deal directly with the opponent's center. This allows you greater leverage for less energy. The question here is: Is the change facing me the real change? What is behind it? And what's behind that? What is the best level at which I can deal with this?

5. Turning to the outside: The skill of staying out of the way of the change until you can get at it from a better angle. The game is called "whose monkey is this?" The martial artist would call it, "tenkan," or turning to the outside. Confronted with an overwhelming force, he does not try to block it directly, and neither does he run away. Instead, he maintains contact with the attacker, but steps to one side, maneuvering to find a point of greater leverage. Imagine a local group of dermatologists confronting the fact that, as managed care spreads, fewer of their specialty are needed in their city. Confronting this change head-on might mean lobbying with the HMOs to allow patients to self-refer, or to widen the range of DRGs referred to dermatologists, or perhaps even trying to take some marginal DRGs away from other specialties. It might mean attempting to increase public awareness of the seriousness of skin problems. But because the change (less need for dermatologists in this city) is just the local manifestation of a much larger change (a widespread national attempt to force down the cost of health care), these direct tactics probably won't work. To step out of the path of the change, the dermatologists might ask: What skills do dermatologists have that people continue to want? What talents does this particular group have that might allow them to compete in a different way? What customers are there besides HMOs and private patients? What other business models might serve them better? Stepping out of the direct path of the change allows you more options. The question here is: What options do I have besides resisting this change?

6. Big vision: The skill of seeing the forest. The martial artist who keeps his head down, focusing on the technique he is doing at the moment, will likely get clobbered by the next attacker. The health care executive who keeps her nose to the grindstone, focusing all her energy on today's topic - say, a reorganization - is likely to miss the political opposition, change in reimbursement rules, or new competition with the potential to take the whole enterprise out of the game. Wider scanning buys you time. The question here is: What am I missing? What assumptions am I making about the basis of the political and economic support of my organization, about the foundations of my family, or about my health, or the soundness of my job?

7. Hang time: The willingness to stay in the moment of ambiguity. Change is scary. Most people want to get it over with, to get to the end. We experience a tremendous pressure, from our peers and subordinates, and from deep within ourselves, to get to a resolution, to get things settled down. Yet timing is important in everything from souffles to civil rights. President Lyndon Johnson had long held a deep desire to do something about race relations in the United States. But he waited until external events had pushed the public to a fever pitch, demanding action, before he introduced the landmark legislation that became the Civil Rights Act of 1964. Similarly, the new mayor of San Francisco, Willie Brown, is known as the type who can get anything done with amazing speed. He had promised to convene a summit meeting on homelessness. But as the date for the summit approached, he found that everyone - business, neighborhood leaders, homeless activists - expected him to do something about the problem, but it had to be their way. They had no consensus on their definition of "the problem." So he canceled the meeting, and told the public why. He was roundly criticized, yet the tactic will likely succeed - by increasing the pressure on the various groups involved to come up with creative solutions that everyone can back.

Executives are particularly handicapped in their sense of timing by a management culture that equates speed with decisiveness, and delay with increased costs, lost opportunity, and loss of control. As ex-Apple CEO John Sculley put it, "When, most companies are confronted with problems, they try simply to fix them." In that climate, a tremendous advantage accrues to the player who is most willing to just hang out with the problem. The reality is that there is a right time to move, and that time is rarely "as soon as possible." Sometimes the right time to move is "as late as possible." The question here is not "How soon can I get through this?" The question is, "When is the best moment to act?"

8. Wholeness: The ability for an organization, an individual, or a community to move as one. We might call this "integrity." The martial artist might talk about "uprightness" or "balance." This is not typical. More commonly, when we move, we move disjointedly. We make decisions without involving the people affected by the decisions. We leave troublesome people out of the information loop. We make a decision, then look for a magic wand that will get people to "buy in" to it. People react to the change out of fear, since they had no information and no voice. Wholeness allows you to move with tremendous speed when the time comes to move. The question here is, "What would this organization look like if it were more whole? What can I do differently to help that happen? What are the origins of the splits in the organization - between the suits and the clinicians,- between different specialties and departments, different levels of licensed professionals, and so on? What can we do to heal them?"

9. Knowledge: The understanding of how change works. Dealing with change takes training. It takes study, in subjects like chaos theory, family dynamics, communications theory, systems theory, and psychology. And it takes experience-based training aimed at cultivating the abilities of the true change master. You cannot deal with change successfully without changing yourself. The abilities of the change master are not superficial, like a better golf stroke or a new surgical technique. To master change, we must become different at the deepest level. The question here is, "What can I learn that would make me better at dealing with change?" The clue is: choose what is hardest for you - that is your true path.

These nine are just the beginning. In fact, we'll talk about another 10 skills of the change master next month. Together, they form a way of seeing the world, a way of being, that is profoundly different from the conventional skills of a manager in a slow-moving organization in an evolving industry. But they are the same skills that we need to be good parents, mates, citizens - and good humans - in a fluid world of dazzling and frustrating change. Over the coming months, we will play with these ideas and others, showing how they relate to real-world situations, such as competition, price-cutting, motivation, and team-building.

KEY CONCEPTS: Change/"Deep Skills" of Dealing with Change

What are the fundamental skills for dealing with change? Presented here are nine skills that can help you become a change master in an uncertain and turbulent health care environment. These skills range from active listening to seeing the big picture. Managing change - whether solving a problem immediately or knowing that the best decision is to wait - will be fundamental for success.

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 Health care Forum journal and New Scientist, a system host of The Well Computer Conference, and a faculty member of Health Online. 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] the Internet.