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Problem solving: not good medicine for health care.

As he waited for the photographer's cue to smile at their 25th medical school reunion, Brian Campion learned that he and his classmate Joseph Johnson were at similar points in their professional careers.

For many years they had enjoyed both their medical practices and administrative duties. However, the overwhelming demands of delivering both high-quality medical care and attending to the leadership needs of their organizations caused both men to feel the need to limit their roles.

Johnson decided to devote his career solely to medical practice. Campion reluctantly decided to give up patient care and become a full-time physician executive. Both men believed that while their choices simplified their lives in the short term, the compromise had required them to sacrifice something that was of great value to them. Indeed, health care leaders and professionals face many such dilemmas disguised as win/lose situations that appear to demand a solution, choices that require them to sacrifice something of great value. They wrestle with many questions:

* Do they devote precious time to professional practices or to their private lives?

* Should they focus on the needs of patients or devote their attention to the needs of the organization?

* Do they view their work as the practice of medicine or the satisfaction of business requirements?

* Do they focus on what is best for the community or the organization?

Every day thousands of practitioners, administrators, insurance executives and policy makers face similar dilemmas. Few find suitable ways to make choices that are both personally satisfying and best for the patients they treat and the institutions they serve.

The road to improved health care is littered with unsuccessful attempts to resolve such issues. In retrospect it is apparent that most of the intransigent issues in health care cannot be solved by using traditional problem-solving methods. Rather, such either/or issues require a new language, new processes and more helpful tools.

There is a more productive way of addressing these issues. If Campion and Johnson had addressed their situations differently, they might have created even more satisfying alternatives for their careers and their lives. There is an alternative and more productive approach.

The problem

From early childhood through their professional careers, health care professionals have perfected their problem-solving skills. They are trained to believe that most of life's challenges have solutions.

Should they fail to find an appropriate result, they believe that they must have employed the wrong problem-solving method. And if their attempt to solve a particular problem fails, they assign blame and often assume that not finding a solution is the result of some personal limitations.

What is more, if others around them appear to be unsuccessful in overcoming their challenges, they quickly judge these others to be less-than-competent.

Typical problem solving approaches involve a process similar to that found in Figure 1.

The process assumes there is a solution. Either the problem is resolved--or it remains a problem. What if it were thought of not as a problem, but a process to be examined and a set of choices to be pondered?



Is there day, or is there night? Is there life or is there death? Do I focus on me or on my family? Do I focus on the short-term or the long-term? If I do what is right for the short-term, I might not have the resources for the long-term. If I focus on the long-term, I might miss the opportunities before me.

For all of these issues there are no simple solutions. Treating them as problems to be solved only creates added complication and frustration. Furthermore, such dilemmas are never completely resolved; they challenge us throughout our lives.

The paradox

What keeps health care leaders up at night and the country from moving toward improving health care is not their ability to solve problems--it is their inability to effectively deal with paradoxes, which are seen as issues that appear to resist solution.

When repeated attempts at problem-solving fail to deliver effective solutions, health care professionals must learn to view them through a different lens. They must apply alternative processes, not the problem-solving methods that have failed them so resolutely.

A paradox or dilemma is a situation or proposition that appears as a contradiction. By definition, a paradox has at least two competing aspects, which are called polarities. Focus on either side, and the other side becomes problematic. Why do we feel compelled to choose one side over the other? Why can't we choose both?

Well that takes us to the heart of paradox--the deep seated and often erroneous belief that we can't possibly have our cake and eat it too. But we can! We must find a way to provide low-cost quality care; we must find a way to work with the short-term and toward the long-term; we must find a way to be a physician and an administrator.


The success of any business, and the professionals who work in it, depends on the ability of decision makers to sort through and manage the competing interests of critical stakeholders. Do we meet the needs of customers or those of shareholders? Do we invest in the future or harvest the profits today? Do we focus on creating stability for employees or seek to expand organizational capabilities that may or may not result in improved ability to compete in the health care field?

When facing an issue we must determine whether it is a problem to be solved which requires the familiar either/or thinking or whether it is a paradox to be balanced which requires both/and thinking. Applying the wrong methodology to our issue exacerbates the presenting issue.

Figure 2: Is your issue a problem or a paradox?

Positive answers to the following questions indicate that a decision maker faces a paradox to be balanced, not a problem to be solved.

* Has this issue existed for a long time?

* Are there at least two opposing and valid points of view?

* Have we tried a number of "fixes" that have not seemed to work over the long term?

* Is this issue important to us? (1)

Let's explore three kinds of paradoxes:

1. Organization: The diversity of skills, the competing interests of government, employees, and patients, and the complexity of functions that are required to produce and deliver a product and/or service creates commonly experienced organizational paradoxes.

2. Role: People in similar professions and interests face similar paradoxes.

3. Health care system: The structures and policies within the U.S. health care system create unique paradoxes for those companies operating in this marketplace.

Organization paradoxes

Employees from different functions often necessarily play competing roles.

For example, while physicians seek to maximize the quality of care, finance people seek to minimize the cost of care. As a result, employees from different functions often view each other with distrust and suspicion. Neither personalities nor competencies are questioned. Rather, their efforts are being viewed from the opposite side of a polarity.

Opposing parties often believe that the others' solutions will lead to nothing short of doom. They therefore demand that their points of view prevail. The more committed and concerned people are, the louder their voices become. Health care leaders consequently find themselves negotiating sides.

Indeed, at the end of the day, leaders are judged on their ability to tread carefully through arguments that result from competing points of view--clearly a formidable challenge. Leaders may unwittingly favor one polarity over the other, treating dilemmas as problems to be solved, not as paradoxes to be balanced.

If either side of a paradox does in fact prevail, the leaders' decisions are likely to diminish the capacity of the organization over the long term.

The decision to treat a paradox as a problem is typically not a conscious one. Unfortunately, leaders are often truly unaware that they are dealing with a different kind of animal ... one for which their education and experience has not prepared them. Indeed few managers and leaders know the definition of the word paradox or recognize one--let alone the alternate methodology needed to address them.

Professionals within an organization experience paradoxes as unique to them or their departments. In reality, these individuals are players within a larger organizational paradox over which they have limited influence.

Because of the scope and depth of organization paradoxes, only the senior leadership group can successfully address them. Only they have access to the broadest perspective. Only they can determine how to accommodate and balance polarities in ways that are healthy for the organization over the long term.


The Organization Paradox Minefield, as illustrated in Figure 2, is a model for clearly assessing the paradoxes an organization is experiencing. (2) The senior leadership group of an organization comes together to identify and model the most important organizational paradoxes. They assess where their organization is on the continuum of each, noting the place with an X.

Experience shows that an X close to one end of the polarity, e.g., margin, causes problems for the organization now or will in the future. The leadership group can then decide which polarities appear to be out of balance and develop one or more strategies to rebalance them.

The result of the polarity-modeling exercise in Figure 2 indicates that the organization is too focused on profitability and stability, which will impede its ability to operate in a competitive environment in the future.

In a study of more than 1,000 companies between 1983 and 2006, Dodd and Favaro found that only 38 percent of companies were able to achieve both profitability and real revenue growth (short-term/long-term paradox) in the same year.

Only 44 percent of the companies grew earnings and achieved growth (profit/invest paradox) in the same year. A similar percentage of companies were able to add value in their divisions and in their stand alone business (part/whole paradox).

Those companies that were able to balance these polarities more often were significantly more financially successful. The researchers found that evaluating these three paradoxes was a better indicator of total shareholder value than other often used measures, such as EBITDA, economic profits, return on capital, or price-to-earnings multiple. (3)

Role paradoxes

Many individual employees experience paradoxes that appear to be unique to their profession or their position in the organization hierarchy. Unfortunately, few of these individuals are conscious of or understand how significantly paradoxes shape their points of view and their relationships with peers.

Even colleagues in the same profession may become estranged from one another when they hold opposite perspectives on a polarity and neither is able to find constructive value in the point of view of the other.

High-achieving professionals feel intensely the double-binds of trying to deal with competing polarities. Example paradoxes include conflicts between specialist vs. generalist, focus on the needs of patients or the needs of the business, and administrative practice vs. medical practice.

Health care leadership paradoxes include focus on the mission of the organization by providing the highest quality of care for all people or focus on the maintaining the organization's financial health. They also entail standing up for the needs of their own organizations or meet the many needs of the communities they serve.

Role paradoxes can cause people a great deal of stress. The more committed people are to their professions or their organizations, the more likely they are to experience these feelings. The inclination of most people who experience professional paradoxes will be to develop a deep sense of personal inadequacy, seek commiseration from those who share their point of view, or blame others for failing to understand their circumstance.

Though these responses may ameliorate some of their immediate feelings, they are not constructive. The competency to balance opposing polarities of critical paradoxes is a significant factor in determining the degree of professional success.

Fueling the difficulty is the conviction that each person's point of view--based on education, experience, and beliefs--is correct and that others' points of view are not. This underlying black-and-white thinking prevents people from working together in a more productive manner.

People who hold strong opinions toward the extreme end of a polarity are often viewed by others as having personality issues and being exceedingly difficult to collaborate with. This response creates yet another barrier to effectively managing the paradox.

In retrospect, Johnson and Campion realized that their clinical experience made them better administrators; their administrative experience made them better clinicians. At the time, however, their colleagues were somewhat suspicious of their intentions and expected them to play one role or the other. Unconsciously, both men accepted that distinction.

Overcoming role paradoxes typically requires an expansion of self-perception of the role one can play. This realization creates a new set of possibilities of what could be achieved.

Continuing in both roles would have required the two physician executives to more carefully allocate their time by letting go of work they had been accustomed to doing, but would add less value in the future.

To acquire the necessary support for the transition, they would also have had to reshape the expectations and relationships of those around them--to help them see the possibilities offered by a new paradigm.

Health system paradoxes

Each of the many players within the health care delivery system relies on other companies to use and promote their products and services; each wants to be as successful as possible. Forced dependence versus desired independence creates a unique double-bind where everyone evaluates potential changes to the system with a careful calculus with an eye toward their own success.

Further, the central roles played by the government, special interest groups and insurance companies tend to dampen the potential positive effects of a competitive marketplace. The resulting responses to proposals for change create a gridlock that reduces the system's collective ability to provide optimum service at the best price for patients and the best returns for those providing them.

The result is a health care system which many perceive as far too expensive given the benefits derived. A significant number of system stakeholders seem dissatisfied with the status quo, yet no one is powerful enough to change it.

Examples of system-wide paradoxes include providing greater access to all patients or restricting access to those who can pay for it; encouraging free access to specialty care or controlling access through the use of primary care providers as gatekeepers; promoting individual or small group practices or developing large multi-specialty practices; delivering high-touch or high-tech patient care. Who wins these apparent competitions--doctors, insurance companies, government, suppliers, patients?

Within the current health care system constituencies frequently meet as adversaries. In hearings before Congress and in courtrooms issues of care are explored and adjudicated. Often in a more personal sense there are disagreements between how patients want to be treated and the care and approach that is actually delivered.

Attempts by any player or faction, even the federal government, to change the status quo can cause the other parties to respond defensively. Treating the health care system in such venues as a problem to be solved rather than a process to be discovered only exacerbates the perception that there will be winners and losers. Rather than focus on who is or may be to blame for the ills of the current system, significant, meaningful, sustainable change requires otherwise competitive parties to come together within a new collaborative forum.

Improving the health care system will be realized only when a microcosm of significant players come face-to-face and agree to listen to one another. They will be obliged to determine their common interests and a shared vision. The resulting common ground provides the foundation for trust and effective action.

Rather than uncovering what is broken, the parties must discover what they want to create. Common ground, a shared vision, and increasing trust among the parties are the basis for building an agenda in which the stakeholders actively participate to plan and achieve an improved health care system.

The methodology known as Appreciative Inquiry, has been successfully used in business, community building, and complex relationships between foreign governmental entities. It is uniquely suited to address the complex health care issues.

The National Institute for Health Policy (NIHP) provides such an example. Both authors worked with NIHP to develop a neutral forum for multi-stakeholder collaboration on complex health care policy issues. Several years ago NIHP convened a diverse group of 80 stakeholders involved in many facets of the Minneapolis and St. Paul emergency and acute care system.

Historically, hospitals in the region--despite occasional overcrowding in their emergency rooms--were reluctant to share real-time utilization information. Within an environment that honored both competition and cooperation, the stakeholders were able to break through their mistrust of one another and determined that it was in the best interests of the community and their organizations to openly share emergency care availability with one another.


Overcoming the downside of a polarity held too strongly requires significant personal and organizational introspection. It is helpful to take the counterintuitive step of bringing those who hold opposing points of view into the room.

We begin by establishing the common ground proposition that we are here to provide excellent patient care within the framework of optimizing the available resources. We then ask the following questions and listen carefully to the responses to discover what is best for the care of the patient:

* What is the strength of the other's point of view?

* What are the deficiencies of my own point of view?

* How can we accommodate both points of view simultaneously?

* What are we going to do to ensure both sides prevail?

Paradoxes are a natural consequence of living in a complex world. Paradoxes are pervasive in all aspects of human affairs. Accepting the probability that both polarities of a paradox can co-exist allows all parties to construct more wholesome and successful personal and professional lives and more fully functioning organizations.

People who are open to the possibility that their own and others' points of view are valid will break through the barriers that all have experienced and work together to make a difference. It is not compromise that people ought to be seeking--it is the vitality that comes from wholeheartedly embracing and realizing the benefits that can be derived from fully embracing and achieving the positives that are available at both polarities of a paradox.

Ralph Jacobson

Ralph Jacobson helps organizations accelerate and make change as easy as possible. He is Principal of The Leader's Toolbox, Inc., and the author of Leading for a Change: How to Master the Five Challenges Faced by Every Leader. He is an adjunct faculty member of the Physician Leadership College, University Leadership College, University of St. Thomas. He can be reached at


Brian Campion MD, MPA

Brian Campian, MD, MPA is a Fellow in Healthcare Leadership at the University of St. Thomas's Opus College of Business. Until recently he was the founding lead faculty of the University's Physician Leadership College and director of the Center for Health and Medical Affairs. He can be reached at



1. Johnson B Ph.D. Polarity Management: Identifying and Managing Unsolvable Problems, HRD Press, 1996

2. Jacobson R. Leading for a Change: How to Master the Five Challenges Faced by Every Leader, Butterworth Heinemann, 2000.

3. Dodd, Dominic and Favaro, Ken, Managing the Right Tension, Harvard Business Review, December 2006, 84(12), pp. 62-74

By Ralph Jacobson and Brian Campion, MD
COPYRIGHT 2008 American College of Physician Executives
No portion of this article can be reproduced without the express written permission from the copyright holder.
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Title Annotation:Leadership
Author:Jacobson, Ralph; Campion, Brian
Publication:Physician Executive
Geographic Code:1USA
Date:Jan 1, 2008
Previous Article:Using real-time simulations to make medical technology decisions.
Next Article:ACPE Spring Institute and Annual Meeting.

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