V O LU M E 5 , N U M B E R 3

Reflections
The SoL Journal
on Knowledge, Learning, and Change

FEATURE ARTICLE

Breathing Life
into a Dying System
Katrin Kaeufer, Claus Otto
Scharmer & Ursula Versteegen

Commentary
Dr. Gert Schmidt
ON THE WEB

Response to Pascale
Commentary (5.2)
Shawn Patterson

Emerging Knowledge Forum
Connecting Lean Manufacturingand Organizational Learning
Jamie Flinchbaugh
Leveraging Global Culture
in Our Journey Toward Global
Leadership Development
M.J. Jamal and Nora Hughes
Organizational Culture Change
after a Merger
Rosemarie Livigni
The Rise and Fallof Collective Reflection
Cathrine Pedersen, Karina Aase,and Odd Einar Olsen

Published by The Society for Organizational Learning

ISSN 1524-1734

reflections.solonline.org

V O LU M E 5 , N U M B E R 3

Reflections
The SoL Journal
on Knowledge, Learning, and Change

Published by The Society for Organizational Learningreflections.solonline.org

FEATURE

Breathing Life into a Dying System
Recreating Healthcare from Within
By Katrin Kaeufer, Claus Otto Scharmer & Ursula Versteegen

Often lost in the debate about healthcare reform

sonal and systemic change: the doctor-patient

are the individual patients and caregivers who

relationship. The authors – active participants inmake up the system. However, by engaging in an

this initiative and long-time contributors to the SoL

open dialogue with the community, a restive group

community – describe the promising changesof physicians in rural Germany is reinventing theunfolding in their region and offer a framework that

local healthcare system from the ground up. They

applies to other systems in need of renewal.
— Paul M. Cohen, Senior Editor

Katrin Kaeufer

H
Claus Otto Scharmer

ealthcare systems around the developed world are in crisis. Surging expenses, aging
populations, and growing needs have pushed many systems to the brink. AcrossEurope, especially, where national health systems trace their roots to Bismarck,
Beveridge, and other social reformers of the 19th and early 20th century, citizens havebegun to question the future of the systems that have historically seen to their health andwell-being. Analysts in Germany have warned that their “system will collapse under its
own weight” without massive reform. “The piecemeal reforms enacted to date are hardly
adequate to the task,” they add.1
Against this backdrop of increasing desperation, a promising new approach is taking
shape in Lahn-Dill, a region of 280,000 inhabitants north of Frankfurt. Led by a grassrootscommunity of innovators, including medical professionals, the project has begun to change
fundamentally the local healthcare system.

Roots of Change

Ursula Versteegen

In the fall of 1994, hospital researchers in the town of Giessen surveyed local physicians fortheir views of the practice of medicine and its prospects for the future. The questions strucka deep note for one respondent, Dr. Gert Schmidt. Three weeks after taking the survey, heobtained the results. Many doctors were near despair about their jobs, with little hope thatthings might change. Sixty percent of the physicians surveyed felt “inwardly resigned” to thestress of their jobs. Forty-nine percent said they had at least once thought about suicide.
That day Schmidt left his office and ran into a patient who told him, “You are so stressed.
You don’t have enough time for me.” When Schmidt arrived home, his frustration was compounded when his 10-year-old daughter told him, “Daddy, I don’t ever see you.”reflections.solonline.org

Kaeufer, Scharmer & VersteegenBreathing Life into a Dying System 1

Copyright © 2003, Society for Organizational Learning. All Rights Reserved.

also are discovering a powerful opportunity for per-

He began talking to colleagues about
how things might change. In particular,
doctors viewed the existing emergency
care system as a source of waste and frustration – and, as one put it, a place “where
you begin to sense the region as a whole.”
From these conversations emerged a
network of physicians, patients, andgovernment and other officials committed to large-scale change in the healthcare system, starting with a new emergency care system for the region.
“The most striking development that
I have seen is that the patient complaints from this region dropped virtually to zero,” says Dr. Peter Eckert, thehead of the regional supervisory board.
“That is in stark contrast to otherregions, where we have many, many
complaints and lawsuits.” While quality indicators like complaint rates have
improved, many costs have fallen. For
instance, ambulance usage has declined
slightly (while increasing in comparable
regions) and local hospitals now require just half the number of nighttime emergency physicians deployed under the old system.
As significant, important qualitative shifts are occurring. “My relationship to patients has
become more like a partnership, more a thinking-together,” said one physician. “I am moreable to elicit and reformulate the thinking of patients – to help them to see what they think
and to become aware of what they really want.” Another said, “In my case, I have rediscovered the joy of work. That wasn’t the case earlier. I had lost it.”
None of this says that the innovators in Lahn-Dill have found “the answer.” Indeed, when
one of us visited recently with several of them, their assessment of the overall system was still
dire. While encouraged by their progress locally, many felt they were trying to “fix a dying
system.” One said, “Maybe what’s needed right now is not to keep this system alive artificially, but to perform a controlled, urgent shutdown.” Whatever the path forward, we believethat their process has uncovered a cornerstone for basic innovation: re-inventing the doctorpatient relationship. This key relationship, which has eroded steadily as healthcare systems
have come under growing stress, represents a lever for future change, both for quality careand for maintaining the vigor of the medical profession.

The Lahn-Dill Initiative: A Seven-Year Journey
The emergency medical system in the county of Lahn-Dill includes hospital emergency rooms,
ambulance services, and local physicians. (For more on the German system, see the sidebar
titled “System at a Glance.”) In an emergency, patients could call:

2 Kaeufer, Scharmer & VersteegenBreathing Life into a Dying System

Reflections

Volume 5, Number 3

• a local physician, most of whom are required to provide after-hours coverage (usually
through a group of cooperating physicians);• the hospital emergency room; or• a universal number – 112 – to reach a centralized ambulance dispatch center.
Dr. Schmidt believed that coordinating these three options across the region would savemoney and time, provide better patient care, and make life easier for the doctors. Today,
through the efforts of Dr. Schmidt and his neighbors and colleagues, the region has a new,joint emergency care center called ANR (Arzt-Notruf, or “physician
emergency call”). It features a second phone number, 19292, that allows
patients to consult a physician after hours or on a weekend. This was
inspired by research showing that 70 percent of emergency callers were
simply seeking medical advice – for instance, whether a child’s high fever
warranted a visit to the emergency room. Previously, an ambulance
would be summoned in response to most such calls. Furthermore, one
doctor noted, “When patients were in a panic they might call several
numbers. Sometimes when I would show up the ambulance was alreadythere.” Physicians, working side by side with paramedics in a joint center, now take these 19292 calls and handle the problem over the phoneor send another doctor, rather than an ambulance, to see patients.
Eighty-five percent of patients say they are satisfied with their accessto emergency care, according to an independent survey. Most people in the region now selectthe appropriate option, calling 112 for true emergencies and 19292 for less-urgent needs. By
reducing unnecessary ambulance trips and emergency visits, the system has saved 2.7 million
euros per year – four times the cost of running the program.
But realizing these achievements was anything but easy. The journey began with extensive
and often frustrating negotiations among the key players – local hospitals, physicians, ambulance services, and insurance companies, each with its own interests, constraints, and turf
allegiances. The breakthrough came when the practitioners began to speak about their own
experiences, or those of loved ones, with the emergency system. The group soon realized ashared will and vision for more integrated, coherent patient service. That accord helped allparties stay connected and conclude their negotiations.

The breakthrough camewhen the practitioners
began to speak about
their own experiences,or those of loved ones,
with the emergency
system.

System at a Glance
For more than a century, Germany’s healthcare system
has provided quality healthcare to every citizen. It does
so with a multipayer model that steers a path between
the government-financed systems in most of Europe
and the market-based system of the U.S. Most careis financed by statutory “sickness funds,” to which
employers and employees contribute equally. It is a“solidarity system,” in which everyone pays a percentage of income, regardless of age or health status. Thissolidarity system also covers healthcare costs of theelderly, disabled, or unemployed. Private insurancecompanies provide supplemental coverage, but onlyreflections.solonline.org

10 percent of Germans, generally in high-income
groups, have such coverage.
Everyone has a choice of providers and a full range ofservices. Reimbursement rates and most regulations
are set nationally but administered locally. It is a largely
self-governing, decentralized system. But it also ishighly complex and fragmented. Furthermore, withhealthcare costs growing far faster than the workforce
that funds it, the system is going broke. If current trends
continue, the gap between revenues and expenses
is expected to reach 62 billion euros by 2030.2

Kaeufer, Scharmer & VersteegenBreathing Life into a Dying System 3

The authors began working with the physician network a year into the group’s efforts, in1997. It took another three years to build a new system3 (see Figure 1). Through facilitateddialogue, the practitioners themselves resolved the financial and logistical difficulties of the
new emergency care system. In the process, participants also created more collaborative
working relationships, particularly among physicians from diverse settings (for instance,
hospitals, private practice, and specialty clinics) who previously had had little connection.
In addition to the joint emergency care center, the physicians subsequently created several
other initiatives, including;• agreements for medical groups to share specialized diagnostic equipment;• a new format for transferring information between hospitals and outside physicians,
and a jointly run office to coordinate care for patients moving between the two settings;• quality-improvement groups of physicians and other healthcare providers to discuss
management of specific conditions, such as diabetes and heart disease; andFigure 1: Milestones of Change

1995
Dr. Gert Schmidt
envisions a new
emergency caresystem for
Lahn-Dill

1996
Regional networkof physicians
approaches
potential partners such as
ambulance services, hospitals,
the fire department, and politicians

4 Kaeufer, Scharmer & Versteegen

1997
First formal
meetings heldwith insurancecompanies,
whose financial
support wasessential

1998
75 physicians
found a nonprofit organization; begin
negotiations
with insurancecompanies

Breathing Life into a Dying System

1999
Interviews with
100 patientsand 30 physicians result in
the “PatientPhysician
Dialogue
Forum” (Intervention One);negotiations
continue

2000
Emergency
services system
begins operating

Reflections

2001–02
The initiative
broadens: quarterly regional
strategy meetings of seniorleaders andpractitioners
across sectors(Intervention
Two)

2003
Continuing
studies ofpatient
perspectives
and physician
networkdesignVolume 5, Number 3

• Buergerforum, or “citizen forum”– a citizen/patient-directed platform toeducate patients and support further
reforms.

Figure 2: Levels of Patient-Physician RelationshipPatients
I. RepairPatient-Physician Dialogue

II.Therapy

Physicians

Event

DefectBehavior

Mechanic
Instructor

In 1999, when negotiations between the netIII. Reflection
Coach
Thought
work and the insurance companies stalled, theMidwife for bringing
authors met with the core team and together
IV. Self-Transformation
forth the New
Self
developed plans for a patient-physician forum.
Our goal was to help the system to see itself© 1999 C.O. Scharmer– to enable people from many points of view
I. Repair: The physician is a mechanic who fixes a defectto “sense” collectively how they together had(an illness, a broken bone, etc.). The patient accepts the“fix” but is otherwise disconnected from the process. As
created a system that failed to meet their aspione patient put it:
rations. We hoped that this process would
My health issue is that I have a broken part, a defect.
deepen people’s commitment to change and
The relationship to my physician, then, is that he is amechanic. He fixes that broken part.
open a quality of collective listening and acting
II. Therapy: The physician-patient relationship is one
that could produce fundamental innovation.
of instructor and student, wherein the patient follows a
We focused on what doctors considered therecommended treatment plan. For instance:
weakest link in a broken system: their relaWhen I have a heart attack, it comes from the way I
behave. I want my physician to tell me, “Eat more of this,tionships with patients. “The core axis aroundless of this. Work out a little bit.”which the whole system revolves is the relationIII. Reflection: The physician becomes a coach. When
ship between patient and physician,” says Dr.
behavior or attitudes impair health, a caring physician canhelp the patient step back, reflect, and remember what
Schmidt. “Without an intact patient-physician
is important in life:
relationship, no health system can work.”
One becomes sick in order to think. When you say you
Studies confirm that the quality of the relationdon’t have the time, time will be forced on you by making
you sick. When you don’t consider life as a present, thenship between caregiver and patient is the single
you become sick.
most important determinant of effective mediIV. Self-Transformation: Both patient and physician,cal intervention.4
by working together, become more fully who they are:We interviewed 100 patients and 30 physiI have been someone who never got sick. And then, allof a sudden, I had cancer. I [had always] worked hard . . .
cians to get multiple perspectives on this relaand I just neglected the fact that I was sick. . . . I went
tionship. The interviews revealed four levels ofback to work full-time . . . [but] two years later, I broke
down. After surgery . . . I learned to talk [with my doctor]
patient-physician relationship (see Figure 2).
about my disease. I only learned at the age of 58, to say
All four levels of care are necessary, and“no.” I didn’t even realize that I lost my identity on theway down, and now I’m not concerned about my futureeach is appropriate to different circumstances.
anymore. Today is important to me now.
Routine procedures and the completion of
medical forms operate at levels I and II. However, responding to people’s concerns in urgent circumstances is also about psychology – forexample, helping elderly people feel safe – and therefore includes elements of levels III and
IV. Any new infrastructure must allow all levels to be present as needed.
At a follow-up session in which we presented these findings, we asked patients and physicians
to discuss in small groups the different levels of patient-physician interaction. We asked them tolabel their own experiences with a red dot (to represent the current reality) and to show witha green dot where they’d like to focus their attention going forward (their desired future) as
displayed in Figure 3.

reflections.solonline.org

Kaeufer, Scharmer & VersteegenBreathing Life into a Dying System 5

Figure 3: Reported Experience of the Patient-Physician RelationshipPatients

Physicians

Event

I. Repair

DefectII.Therapy

Behavior

III. Reflection

Thought

IV. Self-Transformation© 1999 C.O. Scharmer

Self
Current Reality

Mechanic
Instructor
Coach
Midwife for bringing
forth the New

Desired Future

Their belief that thesystem is external andimposed gave way to a new
realization – that patient andphysician interactions drive
the behavior of this system.
This was a turning point.

Both the patients and the physicians arrived at the same assessment: the current reality wasat levels I and II, and they wanted to relate to one another at levels III and IV. We reminded
them, “You are the system,” and asked, “Why do you enact a system, or properties of a system,that nobody wants?”
During the silence that followed, we could sense people’s perception shifting. Their belief
that the system is something external and imposed gave way to a new realization – thatpatient and physician interactions drive the behavior of the system. This was a turning point.
Once such a shift occurs, it becomes a source of energy that drives change processes later on.
We were nearing the goal of this intervention: helping the system see itself.
After that, the conversation took a much more reflective turn, and people freely shared theirexperiences and thoughts about what prevented them from operating differently. The mayorof the town stood and equated problems in the local administration with those of the physicians. He said:
All we do is focus all our resources on reacting, on operating on levels I and II,
which is reacting against the issues of the past, and we are unable to structure
politics in a way that we tap into the resources of levels III and IV.

When he sat down, a woman spoke up:
I am a teacher here in the town, and the key issue we have in our schools today
is that we focus all our energy and resources on operating on levels I and II, pouring
into people dead bodies of knowledge that they can’t use once they graduate. And
we are unable to create learning environments of levels III and IV, which help
people to tap into their own sources of knowledge creation. True learning means
to light a flame, not to fill a barrel.

Next, a farmer lamented the “mechanical model” of industrial agriculture in which farmers are “unable to relate to nature and farming in a way that involves these deeper levels, orthat relates to nature and the earth as a living system.” Another turning point came when apatient said, “I don’t want the system to kill the best physicians we have.” The physicians,
many of whom viewed their patients as unreasonably demanding, began to open up after
hearing this patient speak.
Afterward, participants formed several action groups, including a nonprofit patient advocacy organization that could help take the system to levels III and IV where appropriate.

6 Kaeufer, Scharmer & VersteegenBreathing Life into a Dying System

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Volume 5, Number 3

A Second Intervention
In 2000, a year after this patient-physician forum, contracts were signed and the new emergency care system began operating. Incorporating many insights of the forum participants, it
has shown that structured attentiveness to each level of interaction allows for better use oftime and resources. For instance, rather than treating every 112 call as an emergency, physicians now can provide comfort, counseling, or a home visit as needed. At the same time, thesystem reduces the burden on physicians by directing calls to a single center rather than to
100 individual practitioners.
In the fall of 2001, after one year of operation, we were invited to do a qualitative analysis of the system. We interviewed 35 patients, physicians, nurses, and insurance company
representatives. (For an example of the stories we gathered, see the sidebar titled “A Deeper
Level of Care.”) From that process emerged a group of patients, doctors, and insurers readyto further the change effort. At its first quarterly meeting, we presented a summary of what
we heard in our interviews. The table below summarizes responses to the questions, “Where
do you see the problem today,” “Why,” and “What can be done?”
Clearly, different levels of response require different organizing principles. In its current
form, our healthcare system follows principles located primarily on levels I and II of thepatient-physician relationship; the organizing principles for levels III and IV are still emerging. However, we do see a change in perception among both patients and physicians.
Our interviews with patients, for instance, suggest that health and personal responsibility
are closely tied. As patients become more responsible for themselves – for example, by gathering health information from the Internet and other sources – they are challenging thedependencies built into the traditional system. And physicians as well as patients are creating
their own infrastructures for reflection, or what we call Aufwachorte – a “place for awakening.”
Table 1: Responses to Interview Questions
Patient

DoctorInsurance system

Problem“I’m a piece of wood.”“I’m here on a hamster wheeland fighting single-handedly.”“Costs are gettingout of control.”Diagnosis/
Why?

“It’s a file cabinet system.”
They have a system which
they want to stick people
into. And if you have someother problem, or the medicine doesn’t work, the systemstill presses you into thesedrawers. . . . Here’s where you
go in, and tough luck if you
don’t fit.”“There is pressure from above,from politicians and insurancecompanies, and I’m eaten up
from below, by the patients.”“There is a flood ofpractical constraints,
demographic developments, an illness
panorama, new technologies . . .”From clinical reaction to personal encounter: “The doctor
was a human being. In thatmoment he was at my side
no longer as a doctor, but
as a friend . . .”Redefining the physician’s work:“We have to return to the original
intent of medicine – to heal.”

Therapy/
What CanBe Done?

reflections.solonline.org“To liberate ourselves intellectually, we sometimes proceedsuch that up front we write thediagnosis, the case history, get
our facts and figures down, andthen we have time to focus on
the patient. We first satisfy thesystem. Once we’ve done ourpaperwork duties, then we canstart being doctors.”

Quality and efficiency
for everyone: “We wantto ensure quality forour customers.”“Whether a person
has money or not,everyone receives
care.”

Kaeufer, Scharmer & VersteegenBreathing Life into a Dying System 7

That starts when people improve the quality of their listening and connection. We see small
but tangible signs of this across the region. For example:• Some physicians now schedule chronic patients and acute patients in separate blocks oftime, so as to focus their attention on patients’ conditions and provide small-group consultationand education.
• Other physicians hold facilitated meetings with their office staff to examine ways toimprove the patient experience (for example, reducing waiting times).
• Doctors in the emergency care center log the patient’s problem after each call, note how
they responded and what they learned from it, and share that learning with colleagues.
• Women in one rural area have created a “regional kitchen” to teach diabetics and theircaregivers more healthful eating habits and lifestyles.

A Deeper Level of Care
We asked a group of doctors and patients for examplesof new relationships developing in the healthcare system. They pointed us to an administrator who helps
vulnerable patients complete paperwork, interact withphysicians, and navigate the system. Here is her story:An elderly woman patient was here this morning
asking for a patient living will, but I told her we don’t
just hand this form out because it involves a farreaching decision. The woman rolled her eyes andsaid she would just go to the courthouse or town
hall to get the form. She said, “I just want to sign
my name and be done with it.” I told her the form
requires serious consideration. You might write on
the form, “I don’t want any life prolonging measureswhen I am terminally ill,” which might be interpreted
as “I don’t want any infusions,” which could meanthat you would die miserably of thirst. Or this statement could also mean you would not be fed artificially, which would be legitimate while dying.
These are the kinds of examples I give patients, andwhen I’ve managed to get their attention they are all
ears. They then understand the magnitude of what
they are signing. But we have to fight the attitude
of “I just want to fill out the form.” The local courthouse and the town hall have stopped handing out
these forms, because they have realized theimportance of the issue.
In this case, when the woman says simply, “I want theform,” she is acting on Level I: she wants the problem
fixed. But the administrator refuses to play the role of amechanic: she wants to instruct and coach. She initiatesa shared thinking process, a process of reflection thattakes their relationship toward Level III. By the time theclient leaves the office, she has begun to understand

8 Kaeufer, Scharmer & VersteegenBreathing Life into a Dying System

the importance of her decision and can think about
what she really wants. She has awakened.
This administrator then told us another story, andwe understood better why she felt such commitment
to her work.
I had to fulfill the role of guardian for my mother. She
had had a stroke and was on a respirator. I remember
watching three doctors, standing at her bedside . . .
My mother lay there. She couldn’t remember
anything, even though she was still aware. She
was like a babbling child, and she kept asking thesame questions. At the beginning the neurologist
and the senior physician stood there and talked
to each other about her, over her head. But when
I showed them my mother’s living will, they readit and realized what it meant and my mother thenassumed a personality for them. Although she
still wasn’t clear about what was going on, they
respected her because she had appointed someone as her guardian and had given this situation
so much thought. All of a sudden she was there
as a person and I was greeted with a hugeamount of respect. And there was relief on the
doctors’ side.
This really impressed me – this about-face within
15 minutes once the form had been read, thesenior physician’s joining in, and the respect thatthey then showed her.
After the patient’s wishes were understood, shebecame a participant in the decision-making process.
She and the physicians moved to a deeper, Level IVinteraction, which now included the patient herself.

Reflections

Volume 5, Number 3

New Tools for Connection
The redesign of the local emergency healthcare delivery system has not brought level III
or IV care to every doctor-patient encounter– nor was it intended to. Rather, the intent
was to create a shared understanding of theregional healthcare system and thus give doctors and patients new ways to think and act.
In building the new system, physicians haveseen that their relationships with patientsprovide a starting point for reinventing thehealthcare system, a means of assessment,
and moments of meaningful connection.
Physicians and patients now have the formal structures and shared experience to work
differently together. The coordination of careand, more broadly, the communication among
physicians across Lahn-Dill have improved.
But probably the most subtle change is in
how the self connects to the whole system,
and what impact the individual can have onthat system. Though still overloaded, physicians feel less isolated, more engaged, andmore effective. Dr. Schmidt describes theimpact of the initiative to date:
The experience of shaping something gives you power. You also learn to see themeaning of your work in the context of the whole region, and that, too, is empowering. Through better knowledge about how the system in the region works, andthrough getting to know a lot of people, you end up having different access tomaking things work. Today, we are in a different position to make things work
because we are seeing the whole more clearly, and because the whole networkof personal communication relationships flows more smoothly.

This is where we are today, in late 2003. We have gone well beyond restructuring the
emergency care system. We have begun to change relationships and raise awareness of what
is possible. We are discussing the kinds of infrastructures needed for the different levels ofphysician-patient interaction, and how to make provision for them. The financing, structure,and delivery of healthcare remain as enormous challenges. But we know how to name anunderlying, largely overlooked problem, and we have new understandings and aspirations.
These are big first steps in this work in progress.

reflections.solonline.org

Kaeufer, Scharmer & VersteegenBreathing Life into a Dying System 9

Endnotes
1 Jürgen Wettke, “Health Care Reforms in Europe,” Health Europe, McKinsey & Company, September(2003): 5.
2 Alin Adomeit, Georg Nederegger, Rainer Salfeld, and Jürgen Wettke, “Reforming the German HealthCare System: No Room for Compromise,” Health Europe, McKinsey & Company, September (2003).
3 Our work included open-ended interviews with 130 physicians and patients and a community action
research project (Senge and Scharmer, 2001) that included facilitated dialogue and strategy
discussions. These sessions were largely based on the “presencing of the whole” approach toleading change (Scharmer 2004, forthcoming; Senge, et al., forthcoming).
4 Prof. Manfred Spitzer, cited in R. Kahl, “Die wundervolle Welt des Lernens,” Süddeutsche Zeitung
no. 258, p. 11.
References
Fletcher, J., and K. Kaeufer. “Shared Leadership: Paradox and Possibility.” In Shared Leadership:
Reframing the Hows and Whys of Leadership, Craig L. Pearce and Jay A. Conger, eds., 21–47.
(Thousand Oaks, CA: Sage Publications, 2003).
Scharmer, C.O. Theory U: Learning from Future as It Emerges. (Forthcoming).
Senge, P., and C.O. Scharmer. “Community Action Research.” In Handbook of Action Research, Peter
Reason and Hilary Bradbury, eds., 238–249. (Thousand Oaks, CA: Sage Publications. 2001).
Senge, P., C.O. Scharmer, J. Jaworski, and B.S. Flowers. Presence: Human Purpose, and the Fieldof the Future. (Forthcoming).
Versteegen, U., C.O. Scharmer, and K. Kaeufer. “Praxis Pentagon of Organizational Learning.”
Reflections 2, no. 3 (2001): 36–44.

ABOUT THE AUTHORS

Dr. Katrin Kaeufer is a

Dr. Claus Otto Scharmer

Dr. Ursula Versteegen is afounding member of SoL andis co-founder and lecturer of

co-founder of SoL Germany. She

a research affiliate at the MIT

the MIT Leadership Lab foris an independent researcher and

Sloan School. She has earned

Corporate Social Innovation

consultant working on learning-

the German innovation award

and a visiting professor at thebased approaches to knowledge(Stiftung für Industrieforschung)Center for Innovation andcreation, process innovation, andand the 2003 Beckhard Mem-

Knowledge Research, Helsinki.

human network development.

orial Prize for the co-authored

He is author of Theory U:

She has worked extensively withpaper “The Comparative

Learning From the Future as

healthcare, agriculture, corporate

Advantage of X-Teams.”

It Emerges and co-author ofand nonprofit organizations.

kaeufer@mit.edu

Presence: Human Purpose,ursula.versteegen@t-online.de

and the Field of the Future.
scharmer@mit.edu

10 Kaeufer, Scharmer & Versteegen O Breathing
Breathing Life
Life into
into aa Dying
Dying Syste
SystemReflections

Volume 5, Number 3

COMMENTARY

Commentary
By Dr. Gert Schmidt
The article by Katrin Kaeufer, Claus Otto

When I started to see the system in these terms,

Scharmer, and Ursula Versteegen can only

I realized that the relationship between patientsuggest the powerlessness and frustration thatand physician was the key to the system. It is

physicians in Lahn-Dill felt just a few years ago.

in the doctor’s office or at the patient’s bedside

The size and complexity of the system seemedthat individuals can have the greatest impact,

overwhelming. Our 10 hospitals, 400 physician

where we can begin to treat the patient, notpractices, and 8,000 healthcare employees

just the disease. As a result of the dialogue

treated 25,000 patients a day. Together weforum, others in the system, including evengenerated 2 billion data points a year in theinsurance companies, have come to accept thisform of office visits, test results, diagnoses, andview as well. This breakthrough, as the authors

prescriptions. Most healthcare providers andsuggest, was not the result of an imposed solu-

administrators responded in one of two ways

tion but rather of a shared insight developed

to this scale and complexity: we either gavefrom multiple perspectives.

up or imposed a set of fixed rules that madeit possible to steer the system from outside.

These conversations were a remarkable awakening. They generated a lot of inner energy,

However, the Patient-Physician Dialogue Forumamong physicians, that is still present. We

opened my eyes to another way of seeing thelearned to think systemically, to boil questions

system – from within. Suddenly I could reduce

down to the point where our next action be-

the system to its essence. Patient A has healthcomes evident. The difference in our thinking

problem B and wants to regain C, his experienceis evident when we visit colleagues in otherof health. It’s a mathematical formula: A–B=C.

regions. Physicians elsewhere see themselves

This is not an impossible equation to solve.

as cogs in the system. They worry, for instance,

When you talk with Patient A, and apply diag-that “the insurance companies won’t let us”

nostic tools, you can identify health problem

behave differently. But in Lahn-Dill we no longer

B. With the help of the patient, you then canworry about what other parties may or may notco-create C, a healthy outcome. You reduce

think; we ask them directly. And in every instance,

the behavior of complex systems to the rela-

we do what we can locally. We focus our atten-

tionship of three variables. In thinking further

tion where we can make the biggest difference.

about point B in the equation, I realized thatthe answers to a patient’s particular healthissue usually reside within the region. Healthis defined through our genes, our biography,social context, and the structure and processes of the health system in which we operate.
We cannot change our genes, but everythingelse – especially the structures and processesof the system – is enacted locally.

The authors note that all of this work is justa first step. As we gathered feedback from all
sides, one thing became obvious: the only sustainable way to take our system to its next levelis to focus on regional self-governance. This
insight has given us the courage to act. We now
are working with key leaders from across Middle
Hessen, the larger region surrounding Lahn-Dill,

Copyright © 2003, Society for Organizational Learning. All Rights Reserved.

reflections.solonline.org

Schmidt

Commentary 11

to produce a common vision for the future of theDr. Gert Schmidt is a co-founder of SoL Germany

system. We are now planning a regional public-

and a physician, specializing in internal medicine,

private healthcare company that will bring together

in a large group practice. In 1997 he founded ANR,

citizens, physicians, sickness fund adminstratorsand others needed to solve the problems we

a 130-member physician network that he now
heads, in Lahn-Dill, Germany.
anoruf@aol.com

encounter in daily practice. All of this has led
physicians, even in remote areas, to say that theyno longer feel they are alone. In short, our viewof the system has changed. That has given us
something we didn’t have a few years ago:
hope for the future.

O Commentary
12 Schmidt
Kaeufer, Scharmer& VersteegenBreathing Life into a Dying Syste

Reflections

Volume 5, Number 3

Reflections
The SoL Journal
on Knowledge, Learning, and Change
Volume 5, Number 3

Editorial Team
Editors-in-Chief
Karen Ayas and Peter M. Senge
Senior Editor
Paul M. Cohen
Publisher
C. Sherry Immediato

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Kaeufer, Scharmer & VersteegenBreathing Life into a Dying System 13