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Changing perception: an interview with Charles E. Dwyer, PhD. (Part 1--Physician Anger).

Q. WHAT STANDS OUT IN your mind about the state of affairs of physicians in this turbulent environment?

Dwyer: Well I wouldn't want to be one. lam not sure I would recommend that my children go to medical school given what! know about the turbulent environment. One of the nice things about the present situation, from my point of view, is that the people I encounter are very anxious to learn. That may be out of fear and desperation, but they are very open to learning.

The people I encounter are MDs who have some managerial or executive responsibilities. They are really pressed not only to learn something about management, and marketing, human influence, budgeting, planning, and so forth. They have to do it in this really crazy environment where enormous pressures are being put on physicians and particularly on physicians in management positions.

Q. I understand that you have an "answer" to the physicians problems. In other words, how they should accommodate the new environment both organizationally and personally. What do you tell them?

Dwyer: I basically cover three things. One is! try to convince them that what they have been taught about organizations is both false and dysfunctional. Two, that their job is ultimately about influencing people and how to go about doing that more effectively. Three, and these all tie together, if they want to be more effective in dealing with people, as well as with the turbulence, they have to make some fairly significant changes in themselves. We have all been taught to resist changing.

Q. What are those changes?

Dwyer: We have been taught to think certain things about human behavior in organizational settings. One way I put it is their security blanket of belief is unraveling and they are not quite sure what to do. They have been taught that organizations are all about missions and visions and values and ideology and that they are all in it together and that they all believe the same thing. From my point of view, that is absolute counterproductive nonsense. Organizations are about individual human beings taking care of what is important to them. That doesn't mean people aren't altruistic, but that altruism is coming out of them and not out of the institution or organization.

Part of the problem is that we have, for about 100 years, reified and vivified organizations, pretending that they have an Independent existence and that they live, move, breath, think, want, know, and care, decide, plan, take responsibility just like human beings- they don't. They are artifacts. They are conceptual artifacts and inventions of human beings.

The traditional model of organizations creates a great deal of confusion and also a lot of inept attempts to influence people: "Let's do it for the good of the health center." That is a meaningless phrase. "Good for the health center" means good for the person using the phrase "good for the health center." We hear it in all organizations. I hear it in the university Well, what I think of as good for the university may not be the same as the President, the Provost, or the Dean, or the Chairman of the Department. It just isn't the way to influence people. There is a pathology really an intellectual pathology in this country that says get your vision straight and all will follow you. That's not the way it works.

Q. Your comments remind me of HMO executives saying that their mission is to raise the health of the population. A noble thought, but it doesn't move physicians to action, does It?

Dwyer: No it doesn't! So, it's a little shocking when I put this on the table and say organizations aren't about those things. Organizations are about power, seekers, and resources. You are a seeker and you are trying to tap into the resources; often perhaps to do good, but do good as you define it. The only thing that makes a difference is whether you have power. The problem is physicians had power in this country by virtue of their role as physicians for many years, decades. That has eroded and their autonomy is going away and they don't like it. They are not quite sure what to do about it. They are angry and frustrated I think they are fearful. Control over important decisions is being taken away from them. Some 18-year-old kid looking at a CRT tells them that they can't send that patient to the transition unit. Their medical judgement is being overruled by a decision in a computer made by somebody looking to maximize returns. That is not a friendly environment for a physician.

Q. So how do physicians reassert their power and influence?

Dwyer: Well, the difficulty is that you have to work at it now. If you are not used to working at it, you resent the notion that you have to go out and do some things that you haven't been doing before. Physicians have to treat people in ways that maybe they don't feel they ought to have to treat them.

I indicate in my model of human influence that people do what they do to take care of what is important to them, to serve their values. If you want somebody to do something other than what they are doing now, then you must bring them to perceive that what you want them to do is better than what they are doing now in terms of what is important to them. We have been doing it all our lives. That is what sales, marketing, advertising, politics, parenting, religion, and negotiation are all about. They are all about using your behavior to put certain perceptions in other people's heads about the desirability of the behavior you want them to engage in.

What does that mean? This has been around forever and I just try to elucidate It. One common approach is: "I will serve your values if you serve my values." Quid pro quo. Build up chits. That's what organizations are for. The trouble with that is that you have to pay for value satisfaction. You have to pay to get the behavior you want from other people. We would rather not. So we say "we have a problem.' Everybody knows that is nonsense. We don't have a problem, you have a problem and you are trying to dump it on me. We say we have a problem because it is a safe, comfortable thing to say. If a physician really wants to be effective, he turns to a person and says, "I have a problem and I need your help." That is a much more powerful way of trying to get someone to do what you want.

Q. I have run across the effectiveness of physicians' call for help a couple of times in the field. I refer to very successful practices where doctors ask members of their team--nurses, physician assistants, and other office staff-- how they can help the doctor make the practice better. They say their call for assistance works magically.

Dwyer: The reason it works is that if I don't overdo it and ask you for help, how does it make you feel? It makes you feel good, powerful, valuable, worthwhile. If you help me, I owe you. That is all set up in our social relationships. Physicians, in particular, are people who go into medicine to gain high autonomy and prestige and a sense of control. They find it difficult to turn to a nurse or a medical practitioner and ask for help. "How can you help me with this?" Establishing the inferior position at that moment in time, establishing indebtedness, giving recognition for contribution, sharing ownership. All of that is embedded in a simple, "I need your help." Most people find it sticks in their throats.

Q. Just can't quite get it out?

Dwyer: We have been taught since we were three years old that we shouldn't have to do that. Instead of going around and trying to get people to buy into your values or those phantoms called the values of the organization, you should be going around saying, "What are these people already doing that they love to do? How can I help them do it better but in ways that will facilitate what I want?" Nobody has to buy into my values.

Nobody has to get "on board" with respect to my vision for me to influence them. If that was a requirement of influencing people in organizations we would all be living by ourselves in caves. I just have to show you how it is in your best interest to do what I want you to do.

One of my favorite stories is about somebody I thought was extraordinarily effective. He was a former Dean of the Wharton School. I was doing some private programs in Singapore. My client in Singapore wanted to be able to use my Wharton affiliation in advertising. I said I had to check that with the Dean. I asked him if it was all right if we used it. He said sure and he would write a letter to authorize it. He asked if there was anything else he could do for me and I said no, I don't think so. He asked if it would be helpful to me and my client to have an updated list of all Wharton alumni in the Singapore area. I told him it was a great idea and the next day the printout was on my desk. Do you see what he was doing? He was taking something I was already doing, I was already in vested in and had energy behind. He was helping me do it better than I otherwise would have done it. He was helping me in a way that would help his agenda, namely all the alumni in Singapore were now going to hear from somebody at Wha rton at no expense to him.

That is a path of least resistance find out what people are already doing and then help them do it in a way that makes it effective for you as well. That doesn't get you on the cover of People Magazine. That doesn't seem like the person of vision. That just turns out to be a very effective human being who gets things done.

People don't think that way. With most Deans, you walk in and they want you out of the room so they can get back to their important agenda or they want you to sit there and listen to a lecture about their latest notion of cutting-edge issues.

Q. So we are talking about effectiveness. I am reminded of Peter Drucker's famous book The Effective Executive. In that 1956 book, he said, "Look at the future and not the past. Look at opportunities and not the problems. Create your own bandwagon and don't climb on someone else's. Think of something big and make a difference." Are these Drucker reminders on what makes an effective executive what you're talking about?

Dwyer: That's all very good. In fact, a program I ran for Wharton for many years was called 'The Effective Executive." ft was patterned very much after Peter Drucker's title.

You see, each of us is a seeker in our organizational interactions. We are also, simultaneously in the eyes of other people, a resource. They want to tap into us. What happens is some physicians allow other people to gobble them up and tell them what they should be doing and how they should be using their time, energy, and talent. Then they feel harried and never have enough time to do anything that is important to them. They can 't seem to get to the big issues or think the big ideas.

One of the things I talk about from time to time is what I call inactive management; knowing when to do nothing and having the courage to do it. Sometimes, you have to say no. You have to decide what you are going to focus your attention on. Other people are going to try and focus your attention on what they want you to be doing. They flatter you and give you gratitude, indebtedness, all kinds of goodies. You find yourself on their agenda all the time. ft is a fairly safe place to be, but it is not the way to make movement and change in organizations. ft is not the way to get a hold in this turbulent environment.

Q. Let's take something specific. It seems to me there is a growing chasm between hospitals and physician organizations. Suppose you are a physician executive, a medical director of a large group. You want to do something big and something effective to close this gap. What would the effective physician executive do? How would he think?

Dwyer: Obviously it is contextual, so we are not giving a blueprint for people to go out and try to follow in terms of specifics. But, what has happened, of course, is physicians are being put in competition with hospitals. That kind of competition can easily develop into dysfunctional conflict. So, what the physician executive in the hospital (or the medical center) should be thinking is what he wants from the physicians. I am very specific with people. What behavior do you want, what performance do you want, what is it you want that you are not getting? Then, what is it that you have or that you could produce for these people to provide in exchange?

People say they don't have anything the physician wants, but yes, they do. You can make the life of the physician a whole lot easier. You can facilitate things. You can provide supports of various kinds. No, not necessarily to get the physician to come with you instead of the medical group, but to find ways of cooperating with the medical group that make sense to you and to the medical group. Otherwise, the physician shouldn't cooperate with the medical center. As we know, much is being taken out of the hands of the physicians and it is now decided by the HMOs, the third party carriers, the insurance companies, the self-insurers, and all the rest. They are making the key decisions. If physicians and physician executives want to influence them, if they want to influence legislation, government, they have to look to the values of others and imaginatively create ways to use resources in the service of the values of others, as well as those of the physicians, executives, etc.

Again, we have been poisoned to a certain extent by the academic environment that says if you have good reasons, and good statistics, and logic is on your side, right is on your side, you are going to carry the day. That is false.

What is it you have that somebody else wants? How can you make an exchange? How can you show people it is in their best interest to do what you want them to do? ft is always possible to do so. From the first time you cried and mommy fed you, you influenced someone to perceive that doing what you wanted them to do was the best thing they could do to take care of what was important to them. Why does mommy get up at 3:00 in the morning, feeling like a dishrag, to come in and change or feed you? Because it establishes, affirms, validates her as a good mother. She cares about you, she loves you, she believes that in her head, and doing that distasteful task reconfirms she is that kind of a person. There is a huge untapped pool of goodwill among physicians, but adversarial approaches only generate defensiveness and counterproductive conflict.

Getting back to the physician executive, everybody says it is about money. ft is not about money. Money is a means, not an end. People in this country in particular have been so focused on money that they have isolated themselves from intrinsic value satisfactions that are available. They have tended to focus the discussion on income and money. Money is important, but things that are equally if not more important are the things we want money for. What is that? Security, autonomy, acceptance, approval, prestige, sense of success, accomplishment, self worth, respect in the eyes of other people. That's what we want. I can give some of those to you in exchange for the things! want from you.

Physicians are legendary for taking on thankless tasks. Why do they do that? Again, it validates them as a person who does the right things. You do it, I do it, most people do some of that in their daily lives. ft doesn't occur to executives to tap into that in order to get people to make sacrifices. They say that if they are going to lose money, or have to work on Saturday morning, they're not going to do it. Not true. You can get people to do anything you want them to do if you look to what is important to them and tie it to what you want. But you do not influence by saying, "It will be good for the medical center."

Q. Physicians have been taught to think a certain way. They have been conditioned to have a certain social contract. How do you, as a physician executive, recondition them to the new environment?

Dwyer: I don't recondition them. I show them how they can recondition themselves. This gets into an area that! call self design. ft is a particular approach to personal development. We now know, because of the work of research MDs and others (for example, psychologists, psychiatrists, and neurologists), how to go into our brain and override the dysfunctional things we have been taught. I believe that you can actually decide how you are going to respond conceptually, emotionally, and behaviorally to anything that happens in your life.

If you don't want to be angry, if you don't want to be fear-filled, if you don 't want to be frustrated, if you don't want to be anxious, stressed, you don't have to be. Those are all taught responses. We have the potential for those things, but it is accidental and arbitrary that we are taught to use certain triggers to respond in those ways. ft is amazing to see that physicians, who should have some sense of the neurochemical breakthroughs on how the brain functions, just don't know about this. Even when told, they don't believe that they can quickly, simply, painlessly, effectively and safely go into their own brains and after the way in which they respond. You don't have to be stressed. I don't care what the external environment is. You don't have to feel stress, fear, anxiety insecurity any of those things.

Q. How do you make this fundamental attitude shift? How do you give yourself a new mind job, so to speak?

Dwyer: What we know is that you can by conscious, imaginative rehearsal go into your brain and override just about any program that is in there. So, if you don't want to be stressed out in a certain situation, what you can do (and this is a very abbreviated version), is figure out how you do want to feel in those situations. Then, twice a day you imagine a situation that triggers this stress reaction in you. You picture it in your mind. As soon as you "see" that trigger or stimulus, it will start to go down a neurological pathway to your stress response.

What you do is rehearse your brain repeatedly in having that same trigger or stimulus give you a calmness response, a confidence response, a joyful response; whatever you want. You can actually teach your brain to respond in a new behavioral way, cognitive way. and emotional way to anything out there in the world that you want to.

We are taught in our socialization and acculturation processes how we are supposed to process in formation. You can teach your brain a new way to respond to these quite accidental and arbitrary programmatic responses you have been taught. People go around doing Incredibly foolish things. We have all been taught to. I don't do it anymore because now I understand where it came from, how dysfunctional it is, and what to do about it.

For example, we go around all day long saying that someone makes us angry, or drives us up a wall, or when people do things like that my blood boils. People don't seem to understand that they have been taught to say that, they have been taught to feel that way Every time you say that to yourself or another, you are making it true. You are solidifying an arbitrary translation box neurologically in your brain so that when that guy shows up you will feel anger. At that point, you can't help it. You may not express it, but you are going to feel the anger. Why? You have rehearsed It. He is the stimulus and anger is my response. He is the stimulus and anger is my response. You don't have to do that to yourself

We rehearse our negative emotions 100 times more than we do our positive emotions. When you are in a turbulent environment, the temptation to rehearse and justify, rationalize your negative emotions, is overwhelming. You go home and unload on your spouse. Or you talk with your colleagues at a conference about how those nasty lawyers are making your life impossible, or the legislators, or the insurance companies. Now you have a we-they situation. They are the enemy and as soon as you make somebody else the enemy you will have a difficult time influencing them.

Q. Other than going to one of your Physician in Management seminars, is there any reading that you'd recommend to physician executives?

Dwyer: I would recommend a book that I edited for the ACPE based on my course, called The Shifting Sources of Power and Influence. If somebody wanted to get even more serious about self-design, (and this unhappily sounds self-serving), I have put all of this material into three self-instructional seminars built around audio and videotapes, transcripts; workbooks, readings, and evaluation materials. They were recorded at WHY the public television station in Philadelphia. The people who have used them view them six or seven times. They call me and say that every time they view them, they get more out of them. They give it to their spouse, their kids, their colleagues. It lays out in detail the whole concept of organizational mythology the basic approach and principles of human influence, and a much more detailed method and explanation of the technique I refer to as self-design.

I am deeply interested in these issues as they relate to each of us, and physicians more specifically I spend most of my time with these issues. I enjoy applying my concept to real situations that people are concerned about. As I do that, my concepts are challenged and developed. I constantly strive to improve my concepts and techniques. I welcome the help of others in applying and developing them. Anyone who want to contact me is welcome to do so.


Charles E. Dwyer, PhD, has served on the executive education faculty at the Wharton School of the University of Pennsylvania for 32 years. He is the Academic Director of the Managing People Program at the Wharton School, as well as an Associate Professor of Education in the Graduate School of Education. He is also a faculty member of the American College of Physician Executives' Physician in Management program, where he teaches physician executives about understanding organizations, human influence, and personal development. He is facilitating a cyberforum for six weeks that started February 1 on physician anger and resentment (please log onto ACPE's website at to participate n this discussion). Dr. Dwyer will be presenting an overview of how other industries have coped with difficult changes at the Spring Institute's Senior Executive Focus on Dealing with Anger, Fear, and Resentment on May 12-14 in Las Vegas. He is author of The Shifting Sources of Power and Influence, available from ACPE. He ca n be reached by calling 610/328-6328 or via email at

Richard L. Reece, MD, is Editor-in-Chief of Physician Practice Options and Chairman of the National Association of Integrated Health Organizations (NAIHO). He can be reached by calling 888/457-8800 or via email at
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Author:Reece, Richard L.
Publication:Physician Executive
Article Type:Interview
Geographic Code:1USA
Date:Mar 1, 1999
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