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So, what's the problem? (Conflict Management).


School in Boston, one gray building bears an inscription, in Latin and in concrete: Ars Longa, Vita Brevis,"1 Roughly that means that the "art" of medicine takes a long time to master, and lifetimes are short. That was true when Hippocrates chiseled out the phrase and since then the "art" has gotten longah. And even if life expectancy has doubled, it is still too brief Imagine these pieces of a day's agenda for a busy physician executive:

1. Morning- Management Committee. Update on Status of Clinical Information System

2. Afternoon- Vendor Selection Committee: Selection of Disease Management Company for Diabetes

3. Evening- Physician Compensation Committee: Restructuring Financial Incentives for Staff Physicians

Behind each of these colorless labels, there is a story to be told and some 'problem to solve. Each of the Issues has a history that we are more or less aware of It could even be that each of the issues is related to the others.

Medical care presents complex problems to physician executives-thoughtful problem definition is a critical management task. Without understanding the context, cultures, bottom line implications, and personal relevance, problem definition is incomplete and problem resolution may be inadequate or inappropriate. Physicians and other executives often push to action before a problem is understood. At other times, the nature of an issue is intuitively grasped and unnecessary formal analysis may delay vital intervention.

1. join the Management Committee discussion

As the meeting unfolds, we're reminded that the clinical information system has been under development in a partnership with an outside vendor. Originally we specified that the system have operational capabilities (among others) to link hospital lab and radiology data to outpatient clinical offices and, on an annual basis, to supply data for several HEDIS measurements that are required by the HMOs that we contract with.

Today, we hear first that the vendor cannot deliver both elements on the original timeline without a major increase in our resources. Without much warning, there are difficult choices to make. Before the opening presenter finishes speaking, we are thinking: Can we change vendors at this point? Did we change the scope of work after the contract was signed? If we did, why? Failing to deliver HEDIS results to our HMO contractors will mean that we didn't meet part of our contract and either financial penalties, a poor showing on their report card" to our patients, or a decrease in their business with us. Or all three. We know also that failing to deliver daily lab and radiology data to the outpatient practices will mean that we don't meet our commitment to supply data to those practices so that they can manage their subcapitation more effectively. They will want to renegotiate the deal, So, what's the problem?

Do we understand the problem?

If our choices are complex, some of the difficulty may lie in our understanding of the problem. First we listen to the story told by the vendor and the in-house managers. They're saying that our original specifications were incomplete and caused an underestimation of resources. Further, they tell us that the HEDIS specifications delivered by our HMOs have changed five times in the last eight months and that their complexity and scope has morphed from a simple reporting of claims-based findings about immunization to requiring a continuous scan of several pharmacy databases as well. We hear that our laboratory is now contracting to do the basic lab work for the outpatient practices, that their volume has tripled, and that the systems developers have seriously underestimated the complexity of reporting data to multiple practices that have differing technological competence. None of this is a new tune.

We also "listen" to the financial implications of our predicament. We hear what it might cost to bring the project in on its original timeline and what it might cost to lose HMO business. We hear the potential lost savings that may occur in the outpatient practices if we delay the delivery of lab and radiology data.

Do we understand the problem? What we really understand is the situation. If all we "fix" is the situation, the problem will reappear in a short time. Part of the story will come out if we listen to our reactions to the situation. Suppose that the physician executive quickly feels that this is just what he expected from this project, as in "I knew this would happen!" Or, suppose that the executive committee starts to play the "blame game," going around the table citing the failures of contingency planning by the contracting staff, or the changing of specifications on the part of the medical staff. "But we all agreed to this contract, didn't we?"

Step back

If we step back and ask, "What is the problem, anyway?" we might be able to construct a better response. Stepping back enables us to ask whether, in light of our organization and its direction and limitations, this "problem" makes sense to us. Until it makes sense, we can't say we've grasped the problem well enough to plan any action. In other words, until we have properly defined the problem, we can't act to resolve it.

Let's assume that our physician executive leaves the meeting when the committee has decided to ask its staff to analyze the financial implications of the problem along each arm of possible action. Perhaps someone on the committee really believes that a financial array will make a decision for the group. More likely, everyone in the room feels they need more time for all these issues to settle out and everyone knows that it's the week needed for staff analysis that is desired. What will happen in that week? Sure, there will be a financial analysis. But there will also be a series of conversations among the participants and each will have a chance for reflection.

2. Join the Vendor Selection Committee..

After lunch and checking email, the executive proceeds to the Vendor Selection Committee where two companies present their "Disease Management Programs for Diabetes" in answer to an RFP. Both offer a comprehensive program, including major efforts to educate patients. Both companies are arms-length subsidiaries of pharmaceutical companies. Both project decreased hospitalization for diabetic patients after two years. One has several other clients who report high satisfaction. The other has fewer clients, but offers a state-of-the-art web-based reporting system to keep patients' physicians informed of progress.

The committee takes a straw vote and is evenly split. Discussion goes nowhere for an hour. At the break, in the hallway outside the meeting room, three members of the six-person committee huddle and are overheard saying they just don't have time to learn another new technology. When the meeting reconvenes, it takes the second vendor five minutes to teach the old dogs a few tricks and the vote is unanimous.


The Vendor Selection meeting wasted an hour in discussion because no one asked themselves or the other committee members what the disagreement was about. The formal discussion, with its four-by-four tables and lists of pros and cons, missed the point. When a group discussion becomes a grid-locked standoff, a break can destabilize the discussion, allow a conversation, and uncover "facts" that provide quicker answers. The point is the destabilization, not just taking a break.

To change the "frame" of the discussion usually requires an assertive act that allows everyone's consciousness to shift temporarily from the formal debate. Even when the resulting new picture is not exhaustively filled in, the meaning will become clear. In fact, people in such situations often say things like "I see" or "I get the picture now." Any time a discussion is gridlocked, there is a good chance that there is a failure of problem definition. Not every problem can be redefined by eavesdropping at the coffee break, but the technique of refraining is critical.

There are subjective signs of a need for refraining in a group discussion. Boredom, a wandering mind, or even anger and depression signal gridlock. In a Harvard Business Review article, "The Hidden Traps in Decision Making," Hammond et al describe the importance of challenging the initial framing of a question. (2) The authors relate framing issues to many of the other "mind traps" that can ensnare executives, including "anchoring" (the prejudicial importance of the first bit of information), the "status quo" (the comfort of holding the present course), and others.

In framing problems. it is important to be alert to the emotional and behavioral signals of misunderstanding and incomplete framing. Objective analysis is a powerful tool for decision-making, but uncertainty and curiosity are better suited to the framing of problems. This is especially true in the intensely interpersonal context of a physician executive's day, where an intellectual challenge is often coupled to an interpersonal one. For the physician executive, problems are often framed in group discussions not in solitary thought.

3. The Physician Compensation Committee's proposal

The evening meeting on the physician executive's schedule is the Physician Compensation Committee's proposal for restructuring physician incentives. A group of older physicians who were among the busiest of the subspecialists had demanded a "fairer allocation" in the incentive payment methodology. The "proposal" was that a national consulting company be hired to conduct a complete review of the incentive structure using national and local benchmarks. Each physician's actual compensation would be noted in relation to his or her peers in the group. The proposed consultation was specified in great detail and the subcommittee had already had preliminary discussions with several outside firms. The proposal was so complete, in fact, that it was accepted and the meeting was adjourned after 45 minutes.

Ask: does it feel right?

But on the drive home, the physician executive noticed that he kept thinking about what would happen next. He "knew" that the consultants would array their findings in a couple of months, but that would not be the end...only the beginning. It did not feel right. He started imagining the different directions the compensation discussion might take, until he let himself be distracted by the basketball game on the radio.

When a planned resolution doesn't "feel right," it means that something is missing, not aligned, or contradictory about the plan. It is shortsighted to be seduced by temporary relief. The Compensation Committee's "story" had at first seemed coherent, complete, and detailed. But it was clear afterwards that it wouldn't solve the "problem." In fact, on the way home, the physician executive might have said to himself, "Why are we doing this anyway?" if he hadn't been distracted. If he had tried to explain the meeting to a curious friend, both would have seen and felt that the story did not quite make sense.

Incomplete diagnosis

If he had questioned himself about the problem they were trying to solve, he might have realized that neither he nor any of the committee members had done much work on defining the problem. Everyone had a theory, of course, even though most of them were held quietly behind each person's eyes. One theorized that there were more specialists than the group needed and the incomes of that subgroup were threatened. Another thought that the incentives were a problem because they rewarded practices that adhered to medical society protocols and pathways and discouraged practice idiosyncrasies. Still another saw the problem as growing from the dependence of the groups finances on managed care and Its utilization review and case management programs.

There were probably other theories and reactions. If the specialists changed the incentive system in their favor, the increasingly prepaid reimbursement system would require disadvantaging some other group. For each formulation of the problem," a "solution" would have unpleasant and/or unexpected side effects.

When different theories come out, there can be conflict. When physicians have opinions about the right action, we speak them with authority, which may foreclose debate among those around us, or, worse, may prevent our internal questioning. When opinions seem to be fixed worldviews, we risk forgetting that others' assumptions can be disrupted in the interest of turning a debating standoff into a conversation. Resistance is mobilized when the diagnosis is incomplete and the approach incoherent. Increasingly, physician and other executives turn to consultants and their companies for help. Too often, this appeal precedes an adequate understanding of the problem at hand and does not attend to the process of problem definition.

Conflict avoidance

Why do we fail to understand management problems well enough? One reason is that we see or feel conflict and difficulty down the road. We wish to avoid it or put it off. With the flux and change in medical care today, everyone is wary. It is hard to be sure that the name on the building will be the same tomorrow.

Very often, managing problems has unpleasant effects. Sometimes, we avoid this risk by denying the problem altogether. At other times, we forgo the risk of side effects in our zeal to show a "bias for action." If unresolved Issues are not recognized or if they are "denied," paralysis may result.

In the second meeting of the day, this might have resulted, for example, in putting off the vendor decision until other competitors could be found. Or it might have resulted in a decision that no one felt enthusiastic about, but which simply represented the lowest common denominator of opinion. On the other hand, if the leader of that group had taken the bull by the horns and made the decision, covert resistance would follow the committee out of the room. Leadership, according to the old surgeons' motto--Sometimes right.

Sometimes wrong. But never in doubt!"--is particularly dangerous when a complex problem hasn't been understood.

The why and wherefore

Problems begin before they are sensed or felt. The asteroid that will hit the Earth is out there somewhere, but we haven't seen or sensed it yet. In the physician executive's first session of the day, he might have sensed that this "problem" had been traveling towards the medical center for a long time before it was noticed. When executives sense such a problem, they want to know "who, what, where, when, and how much?" They pay less attention to "why? and wherefore?" Sometimes they hire a consultant to deal with the problem. The "who, what, where, when, and how much?" are important. They can be comparatively straightforward to describe and analyze. But. by themselves, they are incomplete and seduce us into imagining we understand what we are doing.

The most effective test of whether a problem has been adequately defined is whether It is coherent, has a direction, includes the major themes, has explored the main possible outcomes, and has accounted for the major intersections with other issues. To define a problem requires both concentrated focus and its opposite: free, open speculation and association. This Is sometimes caricatured as "thinking outside the box." Others describe the process as alternating between "convergent" and "divergent" thinking. Still others work in alternation between "brainstorming" and "multivoting." Too much "divergent" thinking, especially in a management group, is often derided as a time wasting avoidance of decision-making. Yet "divergent thinking," "thinking outside the box," and "guided speculation" can be the process that reveals the "why and wherefore" and discloses the underlying story.

To define a problem means describing the elements and their surroundings or context. Characterizing the issues fully means looking at their points of attachment to the workings of the organization and the people in it. This process has some similarities to the case-based education system used at Harvard and other business schools. The difference is that the objective problem lives in the real world and has consequences--it Is not a rehearsal or an educational tool.

Building a coherent story

Listing the elements, describing the contexts, and understanding financial personal, and organizational dynamics often happens best in the presence of an interested outsider. Such a pre-consultant and a physician executive need to exercise certain skills if a coherent story is to be built.. .or a complete picture drawn. The technical skills that must be brought to bear are listening, talking, organizing our understanding, and planning our actions. But we can't afford to imagine that listening and talking are things that we know how to do effectively or with sophistication. And we can't expect that we can put together a story and design a plan without them.

1. The third ear

One of the skills that physician executives need to hone involves what psychiatrists call "listening with the third ear." which means hearing the context and the backdrop of problems as we formulate them. It requires focus, prioritization, analytic dissection, pattern recognition, and logical construction. But it also requires the opposite-objective withdrawal, seeing or hearing from a distance, "guessing" in the mind's eye, and resisting premature closure. Physician executives have exercised many of these skills in clinical practice and leadership positions.

2. The art of true conversation

Talking is not simply reactive babble. Questions can be closed or open, direct or indirect. They can seek "reactions" or information. They almost always reveal the questioner-so the questioner must know who they are, how they think, and what their reactions are, Questions are always answered...the skill is to understand the response.

Discussions in groups are frequently paralyzed, repetitive, and boring-they are rarely conversations between people. They are often set pieces or presentations designed to coerce a logical thought pathway without entertaining questions. The discussion presentation is most effective when its content, clarity, speed, and direction effectively mirrors what its audience expects and the way it thinks. This mirroring supports the conclusions that are baked into the material and the way it is organized. When Ross Perot presented his charts on television, he confirmed the conclusions his supporters expected. The set-piece presentation is not an Invitation to reframe the core questions. Even when It appears to pose a question, it is entirely predicated on original assumption sets.

True conversation in a committee means a simultaneous focus on the persons involved, their reference frames, and the strength of their 'theories" of the world. It involves sensing when and how to disrupt others' assumptions and how to overcome resistance. The skill of group disruption is a particularly important one- pressing the group's 'reset" button can quickly get to new perspectives and speed the process of problem organization.

When effective, what may first sound like conversation is, In fact, the construction of a problem formulation. Such a construction is the polar opposite of a formal set-piece presentation. Rather than mirroring a set of established ideas, the construction of a story can be a new synthesis. The problem is a "story" that is constructed among people. It is not a story until It Is "told." In the example of the Disease Management Vendor Selection Committee, the elements of the new "story" lay in the experiences of three older physicians who were wary of automated technologies and uncertain of their abilities to learn them-until the individual concerns were described, the story could not be constructed.

The first condition for problem definition is the presence of other interested people. The second is that the story is important. The third is "open conversation." It is common to see posted on the walls of a meeting room a set of mottoes describing the conduct expected of participants. All of us have seen the preprinted tent cards that have one's name on the side facing away and a set of bullets on the back that encourage us to be open and contributory. This exhortation underscores the known value of open dialog, but achieving openness is regularly under cut by the closed process of a meeting.

Open dialog must proceed associatively: it cannot be achieved by taking turns in alphabetic (or any other) order. That dialog must be actively facilitated and when this is done, the conditions for story development will be present. The facilitator's role will be to catalyze the connections, get more detail, and continuously feedback observations about the story as it develops. To be most effective, such an open dialog will be explicitly bounded by a time limit and the participants will know what they are supposed to do. The facilitator will directly elicit discussion from the participants.

Most meetings are not open dialogs-and they should not be because they serve other purposes. A meeting designed to gather input, for example, into the development of a new physician incentive or compensation system will need to provide a structured opportunity for each of the stakeholder groups to present their position or case in a prescribed manner. In this fashion, the stakeholder "theories" will be more completely obvious. When the discussion leader is a powerful organizational figure, the discussion itself will be naturally constrained by the participants' understanding of their organizational role and their desire to mirror the thinking pattern (though not necessarily the specific conclusions) of higher authority. If, for example, the leader prefers to analyze using a four-fold table (hi-b; hi-to), the participants will organize their discussion points in that structure.

3. Elements of an organized story

To complete the process of problem definition, the problem must be "organized" and the story told. The tests of an organized story are coherence, direction, meaning, and implication. These should be perceptible both as individual attributes and as a whole.

* Coherence means that the driving forces and the major players should have clear connections to each other. Coherence would establish, for instance, that the reason for joining laboratory and radiology reporting to HEDIS reporting was a desire on the part of the IT department to avoid the perils of interfacing separate information systems and the attendant costs.

* Direction would take into account the major and minor missions of the organization. In this way, it might become clear that the organizational goal was to become a major integrated health care company and that integrating systems capacity was perceived by all to be crucial for such a development. Any misgivings about direction should be obvious. Often these will derive from the debates and discussions that went before. Since the specific story is likely to be much more concrete and immediate than the mission's abstractions, anything that was papered over will emerge in misunderstanding and disagreement.

From the standpoint of the problem definition or story, the existence of enduring misunderstanding is an important theme or symptom. Recognizing the theme creates tension, which makes the direction of the story more complex. Resolving tension Is not likely if its source lies outside the immediate issue. The immediate and concrete illuminate the complex organizational history and make the specific direction understandable.

The meaning of an organized story should be clear and connected to the forces and players. An organized business story can have more than one level of meaning. The Clinical Information System story, when it is organized, might mean that we have overestimated our capacity for rapid change and underestimated our resources. And, it might mean that we need to educate ourselves about how an IT function should be managed by senior management. And, it might mean that the state-of-the-art in IT is less than that which we were sold." With those meanings in hand, we could respond with frustration or see clearly that we need a more sanguine view and to have more modest goals. We could see that innovations in IT show us what could be done, not necessarily what can be done.

As the story is completed, the implications can be evaluated. An organized story should make the implications fairly obvious, but they will not often answer the question or solve the problem. The object of the problem definition is to pose the problem so that steps can be taken to solve it. If, for example, we conclude that we thought we knew more about clinical information systems than we actually did, we can look for the expertise we need. If we conclude, by contrast, that no one knows enough about clinical information systems, we'll seek a consultant very carefully.

The purpose of such a story is not the resolution of the problem, but a coherent understanding of the direction to be taken. When the diagnostic work-up is complete, the next steps can begin.


(1.) Hippocrates, Life is short. the art long, opportunity fleeting. experiment treacherous, judgement difficult." Aphorisms, sec. 1.

(2.) Hammond. John S., Ralph L Keeney, and Howard Ralffa, "The Hidden Traps in Decision Making," Harvard Business Review, September/October 1998. 3-9.

(3.) O'Shea. James and Charles Madigan. Dangerous Company, Now York: Penguin Books, 1997.


One of the great values of consultants is that they provide an interested "audience" and they are generally an outsider to the enterprise. It is not possible for "insiders" to provide perspective. This is true for at least two reasons. First, insiders largely share the enterprise's worldview, mission, values, or paradigm. Second, power and political relationships inevitably supervene to affect both what is said and what is thought.

It is evident, however, that there are major problems with the use of consultants. There's an old joke about the definition of a consultant." A consultant is someone you pay to borrow your watch so they can tell you the time." The key "outsider" value of the consultant takes place when the executive figuratively takes off the watch and hands it to the consultant. That is when the consulting task is settled, because that is when and how the story is told, When the consultant is used by management as a means to avoid a problem--or worse still, to avoid understanding a problem--the result is very likely to be unsatisfactory

Working with consultants is described in O'Shea and Madigan's book Dangerous Company. (3) This book chronicles a series of consulting engagements between established companies and a wide variety of consulting houses. The book is especially concerned with the opportunity for error that can develop in major engagements. The mutual seduction of consultant and consultee can result in enormous costs and can contribute to the downfall of companies. An executive who does not take the time to understand what they are trying to accomplish and why will often engage the wrong consultant for the wrong task at great cost. The major consulting "styles" differ significantly, but the role of personal relationships in establishing the consultative relationship...and a major hazard in its use...stands as an important subtext in the book.

Consultants often summarize findings and recommendations in a set-piece presentation designed to mirror the consultee's thinking style. Their stories must be tested critically, as they are delivered. If they are not evaluated as stories, they will inevitably derive directly from the way the original problem was presented to them, If the original problem wasn't told as a "story." no story will emerge from a consulting engagement.

John Ludden, MD, CPE, FACPE


Problem definition is a central piece of work for physician executives.

1.One effective means for improving problem definition is to deploy the skills of listening, talking, and concurrent self-examination. While executives possess these skills, they are not often developed into sophisticated tools. Developing these skills takes coaching and practice.

2. Problem definition in business and medicine is not an individual task. "Others" are important in constructing a definition. The "others" can be colleagues, advisors, or (sometimes) consultants. Each "other" has his or her own characteristics and business needs and should be enlisted with these in mind.

3. A problem is defined when it is "organized" into an understandable whole. As such a "whole," it will be a "story" that can be told to an active listener. Bulleted points are not a story Evaluating whether a story is understandable is an objective exercise, though it employs some subjective tools.

4. Sometimes, defining the problem's story will make the solution obvious. But more often, it will not. Defined problems will be solved by the use of expert knowledge and this is a key role for consultants.

John M. Ludden, MD, CPE, FACPE, is Associate Clinical Professor in the Department of Ambulatory Care and Prevention at Harvard Medical School in Cambridge, Massachusetts. He serves on the board of the National Committee for Quality Assurance and is President of the American College of Physician Executives. He can be reached by calling 617/421- 6219 or via email at
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Author:Ludden, John
Publication:Physician Executive
Geographic Code:1USA
Date:Jul 1, 1999
Previous Article:Renegotiating health care: an interview with Leonard Marcus, PhD. (Conflict Management).
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