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Seven lessons in medical management.

It is said that we can never act any higher toward a situation than our understanding of that situation allows us to act. Thus, a search for understanding before action is critical. This is the basis for the seven ideas in this article. Productive and motivated people have expectations, need goals, need rules for problem solving, need to feel no pain, may need "reality checks," may have baggage they need to shed, and do better when they are treated as responsible adults (by leaders who have the humility of true mastery).

The job of a great manager is to provide a mission, a direction, and motivation. Motivation comes from the importance of the job (meaningfulness), responsibility, and autonomy, and from feedback (knowledge of results). Positive feedback - catching people doing things right - creates a desire to repeat the events.

1 People Buy Expectations.

People, in general, do not seek or accept anything unless they believe they will obtain some personal value by having obtained it. They only seek and accept a thing or an idea on the basis of what they think it can do for them. Therefore, it is important to understand that what anyone is "selling," whether with an idea, a service, or a product, is some "thing" that offers to fulfill the other person's expectations. When you can offer to meet the other person's expectations, he or she will be more likely to "buy" or accept the thing.

The corollary to this is that you have to know what their needs, wants, and expectations are before you can convince them of the value of what you offer. The value may be evident to you, but it is worthless to them until they see the value to them. Until you know what their expectations are, you will have no idea of what you are really trying to "sell" them.

It is evident that people commonly act out a self-interest, and we have to know what their interests are before we can meet them. If we are to be understood, as far as what we are offering selling) as an idea, service, or product, we first have to understand the other person's viewpoint. It doesn't matter what we understand when we try to communicate. What matters is their perception of reality.

The fact that "people buy expectations" is worth considering in any human intercommunication. Telling people to do or believe something may, if they are coerced, force them in a certain direction, but it does not make them believe in what they are doing. Kicking them in a certain direction wastes managerial effort. It is much better for them to have a self-perceived value in heading in a desired direction on their own.

2 Goals Matter.

Goals are critical to getting to the place where one wishes to go. Without goals we have absolutely no idea what our direction is, or when we "got there." General George Patton's "Rule of Goals" was never to tell people how to reach a goal. He would define the goal, aim them in the right direction, and let his men figure out their own best way to get there.[1] In this manner, they owned the method and were fully responsible for the achievement or failure. Everyone in a business must know what the objectives or goals are. Otherwise they are working from day-to-day in a "get by" mode, but never reaching toward what they should be accomplishing.

There are dozens of ways to set goals. My favorite is to pick the top five I personally think are important and make sure I am always working on one of them. When one is completed, it gets replaced by a new one. More than five and there's too much confusion. Less than five is too few to maintain important changes in flow.

Catch yourself doing something not in those five goals and you have to ask yourself, "Is what I am doing more important than my five goals, or should I make this my new goal and discard one of the five I thought were important?" It makes people prioritize what is really important.

When you begin this, you should have your five goals written down. This forces you to prioritize and be true to yourself. Unwritten goals are uncommitted goals, and allow you to make excuses to yourself as to why you "drifted off course." You have to know what the goal is, how to proceed, who can help or hinder you, and when you want to have it completed. The goal list should have what the goal is and a reasonable self-imposed deadline.

Employees should also have lists like this. They should have defined goals and deadlines, and be fully responsible for their implementation and completion. Remember, no goal means no direction. Without a goal (or five), people end up exactly where they are headed - nowhere. The boss's job is to refine the goal so it meets the company's needs, to give support for getting there, and to redirect people when they wander off target. It is not to stand over their shoulders and tell them each step along the way.

An example of how not to set goals comes to mind regarding a subordinate who was asked "to help reduce costs in handing medical referrals." Because her boss had given a rather vague order and she did not have experience setting priorities, she set up 24 subgoals. Within one month about half of the goals were partially done, and she was feeling swamped in work. She was then advised to "get help," but the help, which created seven new subgoals, made things worse.

I was called in by her boss when things hit "panic mode." We sat down for three hours and determined what was critical and urgent, which boiled down to only three subgoals. Now she had something small enough to handle. She agreed to drop the other 28 items and work on those three. The rule was that the instant she caught herself doing anything other than those three things, she'd stop and go back to those three. Within five days they were completed, and resulted in removing more than half of the other subgoals. Of the eight or so critical (but not urgent) items still left, she took them on four at a time and had them done in another week.

3 Problems need to be handled in

the most productive way.

In handling problems, a manager or supervisor may often be tempted to get details of a problem, tell people how to solve it, and send them off to perform the supervisor's version of "the fix." This approach, however, makes people dependent on the supervisor for "the fix." The people who could and should solve the issue don't learn from this approach, and suffer a weakening of their own potential skills to create their own (and sometimes better) solutions.

The rule in handling problems with (not for) others should be what Napoleon called "Completed Staff Work" (CSW). CSW takes a little more time in the beginning, because certain ground rules are set and have to be communicated to staff, but, in the long run, it actually sets up a team that is better able to solve its own situations without depending on the boss.

The Rules for CSW are:

* Anyone can bring a problem to the boss. * Any problem brought to the boss must have at least one viable solution associated with its presentation. Without a solution, the boss has the right and obligation to reject the problem and to send the staffer away until he or she comes up with a reasonable solution. * The boss may not always accept the suggested solution but will at least point out a different approach or help the staffer modify the solution to the problem so that it fits the company's needs. In this way, the staffer learns to think more accurately about the problem and to seek a better right answer.

When working with CSW, or any problem, there are certain steps that may allow a person to better approach the solution. One critical step is to determine the "effects" of the problem. Problems are not marketing problems, management problems, claims problems, or other labels. Problems are what they are based on how they affect the system. One has to identify the affect.

But problems are not defined merely by how they effect. Defining effect is just the first step. After defining the effect, one must look for the "root cause." A good manager (like a good doctor) looks for the cause of the symptom and does not merely treat the symptom. Do not give "a fever pill" for the problem and stop there. Find out why the problem occurred in the first place and deal with the cure at the root cause level. Cure the disease, not the symptom.

4 Competition sometimes warps

rational thought.

People generally act out of self-interest. It is not that managers fail to learn that "their" self-interests may differ from "your" self-interests. This is understood easily. The distortion of rational thinking comes at the next stage, after it is realized that different points of view exist and when people start to take it personally. In reality, most people who disagree with you are not against you; they are merely for themselves. You just happen to be in the way with your own self-interests. When you start taking it personally, conflict accelerates, and win-win solutions become harder to reach.

Many managers, especially ones with little experience in dealing with ambiguity, disagreement, chaos, and uncertainty on a daily basis, approach conflict using WIDOID RICSAS (When In Danger, Or In Doubt, Run In Circles, Scream And Shout). While it's fun to watch this as an outsider, it is a terrible thing to be wrapped up in as a participant.

When the potential for conflict arises, a better way to handle it is to "Ride the tiger in the direction it is going." This does not mean you have to agree with anything, but it does mean you have to get the other person to realize you are listening to and understand his or her views. To do this, the "Carl Rogers Rule 5f Communication" is extremely useful. "Listen well and calmly. Don't interrupt. Let the other person deliver his or her point of view, and repeat it back to them to their satisfaction. Only then should you make your own point."[2]

What being able to repeat their issue "to their satisfaction" does is prove to them you listened and understand. Again, you do not have to agree. You may choose to use phrases like, "I understand" (which is not saying "I agree"). But you have to connect with the partner in your conflict, and sane, calm, understanding connections are what put the power of discourse in your corner.

At the point where any discussion is allowed to become a shouting match, and you join in, you give the message, "It's okay for you to be dysfunctional, and I'll prove it by becoming dysfunctional myself." If the other person wants to be dysfunctional, fine. Just don't allow yourself to condone the dysfunction by playing it back. Being calm when the other person is in WIDOID RICSAS mode is a potent tool and a sign of managerial maturity. Let others warp their minds, but don't get caught in their pain. Accept no pain; give no pain.

5 People sometimes forget issues.

In any dialogue with a colleague, superior, or subordinant, there is an issue. People tend to drift off of the issue and into new territory. Don't allow this. You simply do not have time for all of their issues. Do a "reality check" by reminding them of what you thought the issue was. See if they agree.

Remember to listen well. Most people are too busy formulating their next rebuttal to slow down, think about what they heard, and make a good response. Slow down! Seek to understand first. Only then should you seek to be understood. But keep the person to the original point until it is resolved. You cannot and should not try to handle 10 different points at once. Deal with one thing at a time. Admit confusion if you must. Then get back to the first point and deal with it until it is resolved or set aside to your satisfaction.

6 It is not what we add but what

we discard that gives us


This is a hard concept to accept, because we all want to believe that what we learn and add to our own thinking is more critical than any behaviors or habits we could shed. When we have reached adulthood, it is what we remove from our emotional baggage that gives us real power. An example will help.

A traveler walked down the road with a huge and heavy pumpkin balanced on his head. In his right hand he carried a large stone, and in his left? hand he carried a brick. Around his waist was a heavy vine. On his back was a pack filled with stones.

As he walked toward a near-by village, a passerby said, "Stranger, why do you have such a heavy,, pumpkin on your head?" The traveler had not noticed the load, and thanked the passerby for pointing it out. He bent and unloaded the pumpkin, feeling lighter after he had shed the load.

Another passerby said, "Traveler, why do you carry such a heavy rock in your hand?" The traveler had not realized the rock was there and tossed it aside. Now he felt even better.

As other villagers passed, they pointed out the traveler's loads, and the traveler dropped them one by one until he felt so light and unburdened that his step was as light as he could ever recall. He felt fantastic.

In the end it is not what we carry, but what is really unnecessary and we therefore unload that makes all the difference in this life. An example from medical management will expand the idea:

A subordinate generated a computer list of high-cost patients. He then retyped all the data from the spreadsheet to a new sheet. He passed the sheet on to a medical director to get an opinion on whether patient disorders were resolved or ongoing. The director was to write "Resolved" or "Ongoing" next to each patients name.

"Why do that?" I asked, "Why not print the spreadsheet `as is' and have the director put an `R' or `O' next to each name?" It was done and reduced his work by 20 percent.

7 It is not as important to be serious

as it is to be serious about

what's important.

We have all experienced people who are more impressed with themselves than anyone else is. The common denominator is that they are self-inflated and they have no sense of humor. Buddha pointed out ages ago, "A Master is never haughty; never superior in his behavior."True masters are comfortable with their mastery. and they others comfortable as well. In order to do this, they accept that they have more or different knowledge to share, and they allow themselves to see the humor in life through this sharing process. This is little different from the Judeo-Christian and Muslim "Golden Rule" of treating others as we'd like to be treated. The people on the staff are adults and deserve to be treated like adults, not like dependent children who need a frequent scolding to keep them in line.

It's great to be serious when seriousness is called for, but seriousness does not have to be delivered with pain and haughtiness. Good leaders can be serious and can let people know the situation is serious without making, people feel little. It's hard enough to face a crisis without having, the boss breathing fire.


[1.] Williamson, P. Patton's Principles. New York, N.Y.: Tochstone Books-Simon & Schuster. 1979. [2.] Rogers, C. On Becoming a Person. Boston, Mass.: Houghton Mifflin Co., 1961.

Richard M. Burton, MD, MBA, FACPE, is Medical Director, Qual-Med Health Plan, Albuquerque, N.M. he may be reached at 6100 Uptown Blvd., Suite 480, Albuquerque, N.M. 87110, 505/880-2980, FAX 505/880-2907.
COPYRIGHT 1996 American College of Physician Executives
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1996, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

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Author:Burton, Richard M.
Publication:Physician Executive
Date:Feb 1, 1996
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