Volume 12, Number 3

Reflections
The SoL Journal

on Knowledge, Learning, and Change

Understanding Your Medical
Mind: Decision Making
Through Patient-Doctor
Dialogue
Pamela Hartzband and Jerome
Groopman, with Deborah Wallace

Seeing the System Inside-Out
Hugo Sax

Commentary
Manoj Pawar

I Have Never Been Here
Before: The Nonlinear Worldof Cancer
Marilyn Herasymowych
and Henry Senko

Commentary
Emily Tilton

Change on the Scale ofthe Whole: Health, Peace,and Prosperity for All
Victor Garcia© Thinkstock

Published by The Society for Organizational Learning
www.solonline.org
ISSN 1524-1734

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PUBLISHER’S NOTE 12.3

T

he current state of healthand healthcare aroundthe world threatens our
economy, our quality of life,and perhaps even the futureof humankind. This situation isof great concern not only to the
SoL community, but to all ofFrank Schneider
us who at one time or anotherhave been subject to the frustrations of schedulingappointments and sitting in waiting rooms, misdiagnoses,
or operating room errors that result in poor outcomes
and lack of confidence in the medical systems with which
we have entrusted our lives. Likewise, as global citizens
we are affected by social trends that have led to spiraling
rates of obesity, type 2 diabetes, and inner-city poverty
and violence. The articles in this issue offer intimate
stories of patient-doctor relationships, of navigating
personal medical crises, and of grassroots efforts toimprove the overall health of local communities. We
believe that these personal stories are an appropriate
starting point for conversations about ways to renew
and revitalize this critical system.
The first article, “Understanding Your Medical Mind:
Decision Making Through Patient-Doctor Dialogue,” isan interview with Dr. Pamela Hartzband and Dr. Jerome
Groopman, both nationally recognized experts in theirrespective fields. Based on recent research, Doctors
Hartzband and Groopman have concluded that patientsmake decisions concerning their medical treatment
partially based on their individual mindsets – theirmental models. Further, their research shows that patientdoctor dialogue is a determining factor in whether
patients regret or are comfortable with the course oftreatment they chose, irrespective of the outcome.
In “Seeing the System Inside-Out,” Dr. Hugo Sax, head of
the infection control program at the University Hospitalof Zurich, describes his unexpected and disconcerting
experience as a patient undergoing surgery. He sharesin detail the physical and psychological aspects of histreatment as well as the insights he gained into someof the systemic barriers to change in the complex and
uncertain environment of a hospital.
The practical application of systems thinking continues
in “I Have Never Been Here Before: The Nonlinear Worldof Cancer,” an intimate portrait of how a serious healthcrisis forced learning and leadership consultants Marilyn
Herasymowych and Henry Senko to surrender their
fixed ideas of truth and accept that complexity requires
us to rethink everything we thought we knew, including
our definitions of success. They describe how by giving
us a way to simultaneously observe and participate
in a system, systems thinking can provide us with asense of calmness and control in the most challenging
circumstances.
The final feature, “Change on the Scale of the Whole:
Health, Peace, and Prosperity for All,” describes one
city’s efforts to answer the question, “How do we makean unhealthy neighborhood healthy?” In this piece by
Dr. Victor Garcia, a pediatric surgeon at Cincinnati Ohio’s
Children’s Hospital Medical Center, we learn about abold grassroots effort to interrupt a debilitating cycle
in which social inequities feed an epidemic of violenceand poor health. Through what Garcia calls a “brilliant
accident,” he was introduced to systems thinking andAppreciative Inquiry, which have become the basis
for an ongoing initiative to bring about large-scalechange in Cincinnati’s “inner core.”
The current state of overall health and the effectivenessand cost of our healthcare systems concern us all. The
articles in this issue highlight that the future of healthand healthcare may be more promising when grounded
in a personalized, systems-oriented, community-based
approach focused as much on maintaining health as on
restoring it.

Frank Schneider, Publisher

EXECUTIVE DIGESTEXECUTIVE DIGEST 12.3

Understanding Your Medical Mind:
Decision Making Through Patient-Doctor
Dialogue
Pamela Hartzband and Jerome Groopman,with Deborah Wallace
The push over the last decade to standardize medicalcare has resulted in an increased use of metrics andregulatory guidelines – but not necessarily an improvement in patient satisfaction or overall health. In thisinterview, Dr. Pamela Hartzband and Dr. Jerome Groopman look at how current trends in healthcare tend todepersonalize care and reduce the time physicians haveto talk with patients about their health. With little time
for real dialogue, doctors often anchor their diagnoses
on probabilities and initial impressions, while patientscan feel “unseen” and even railroaded into making decisions. Pamela and Jerome propose a three-part decisionmaking framework that helps patients make difficult
choices. This approach also supports patients anddoctors in weighing the risks and benefits of treatment options together – an example of true patientcentered care.

I Have Never Been Here Before:
The Nonlinear World of Cancer
Marilyn Herasymowych and Henry Senko
When consultant Marilyn Herasymowych was diagnosed with non-Hodgkin’s lymphoma, her world wasturned upside down. But rather than become paralyzed
by fear, she and her husband Henry Senko did what
they had always done when facing uncertainty – they
applied the learning system they previously designed
to help people in organizations think and act more
effectively in highly complex situations. Marilyn andHenry share their reflections on how Marilyn’s cancer
diagnosis and treatment forced them to surrender their
fixed ideas of truth and accept that complexity requires
us to rethink everything we thought we knew, including our definitions of success. They find that by giving
us a way to simultaneously observe and participate
in a system, systems thinking can provide us with asense of calmness and control in the most challenging
circumstances.

Seeing the System Inside-Out

Change on the Scale of the Whole:Creating Health, Peace, and Prosperity
for All

Hugo Sax

Victor Garcia

When Dr. Hugo Sax, a physician and the head of infection control for a hospital in Switzerland, entered thehospital as a patient, he had the rare opportunity to seea healthcare system from the other side. His experience
brought into sharp relief the communication gaps andbarriers to change that exist in most medical settings
despite the best intentions of the staff. Equally surprising to Hugo was the ease with which he found himself
falling into a dependent role, reluctant to question
those responsible for his medical care or point out
lapses in protocol that he witnessed. While his surgery
was successful, Dr. Sax came away with more questions
than answers about the ability of healthcare professionals and patients to navigate the complexities of caring
for the individual as a whole.

As a pediatric surgeon at one of the world’s mostprestigious children’s hospitals, Dr. Victor Garcia wasdeeply disturbed by the growing number of children
being admitted with intentional gunshot wounds.
Determined to find a fundamental solution to the cycleof poverty and violence that plagued the city’s “innercore,” Garcia turned to Peter Senge’s work on systems
thinking and David Cooperrider’s Appreciative Inquiry
methodology for guidance in creating sustained“change on the scale of the whole.” Victor gives an overview of the worsening trends buffeting many of our inner cities and the steps a group in Cincinnati has taken
to begin to turn the tide in a more positive direction.
By building on the community’s inner strengths, thisgroup seeks to promote true health and prosperity
for all of the city’s residents and stakeholders.

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reflections.solonline.org

F E AT U R E | H A R T Z B A N D, G R O O P M A N , A N D WA L L A C E

F E AT U R E 12.3

Understanding Your Medical Mind:
Decision Making ThroughPatient-Doctor Dialogue
PA M E L A H A R T Z B A N D A N D J E R O M E G R O O P M A N , W I T H D E B O R A H WA L L A C E
The push over the last decade to standardize medical care has resulted in an increased use of metrics andregulatory guidelines – but not necessarily an improvement in patient satisfaction or overall health. In thisinterview, Dr. Pamela Hartzband and Dr. Jerome Groopman look at how current trends in healthcare tend
to depersonalize care and reduce the time physicians have to talk with patients about their health. With
little time for real dialogue, doctors often anchor their diagnoses on probabilities and initial impressions,while patients can feel “unseen” and even railroaded into making decisions. Pamela and Jerome propose
a three-part decision-making framework that helps patients make difficult choices. This approach also
supports patients and doctors in weighing the risks and benefits of treatment options together – an exampleof true patient-centered care.
© Shelly Harrison Photography

Deborah Wallace: We are always hearing ads andreading brochures assuring us that a particular hospitalor clinic focuses on patient-centered care. It’s theirguiding principle, and it’s what they strive for. How do
you define patient-centered care and why do you thinkit’s attracting so much attention now?
Pamela Hartzband: We think of patient-centered careas care that is customized to the particular individual.
Not only is it specific to your particular medical conditions and your age and gender and so on, but also to
your preferences – how you weigh risk and benefit.
Jerome Groopman: There has been a tremendous
movement to standardize medical care over thelast decade. This has resulted in mandatory guidelinesthat are based on averages of populations and really don’t center on the individual patient. Many people have multiple medical conditions that are not encompassed or covered by these standardized guidelines. Nonetheless, these guidelines are mandated. There is a history over the last decade of repeated failure
and, indeed, harm to patients caused by such mandates.

Pamela Hartzband and Jerome Groopman

Deborah Wallace

The other issue is that medicine is becoming industrialized. We are constantly
hearing metaphors about healthcare as a factory, that your doctor’s office and1

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hospital are assembly lines. We are called “providers” who basically give prefabricated treatment.
And this is supposedly all in service of saving
money. But it depersonalizes care.
Wallace: How much progress do you think we’ve
made toward really delivering patient-centeredcare as opposed to delivering medicine in what
Jerry termed a more industrialized fashion?
Groopman: Well, you know, it’s ironic because wewere trained 35 to 40 years ago to focus on theindividual patient. Now it’s been renamed “patientcentered care.” Back then, we certainly discussed

A lot of lip service is now being
given to patient-centered care, but
in terms of the track record over thelast decade, the reality is that theshift has been to standardization.
evidence, clinical trials, clinical experience, andso on and how they applied or did not apply toindividuals. A recent piece in the New England
Journal of Medicine noted that not a single quality
measure mandated by Medicare from the Center
for Medicare and Medicaid Services is responsive
to patient preferences. A lot of lip service is now
being given to patient-centered care, but in termsof the track record over the last decade, the reality
is that the shift has been to standardization. Quality measures do not address patient preferences.
Hartzband: There are metrics and guidelines thatare specifically targeted to what happens in thehospital. Some of these are extremely helpful, likeguidelines regarding ways to avoid infections in
the hospital and prevent errors in the operatingroom. Both are very important, and standardizing
the approach to procedures has been successful
in these areas. But guidelines are less helpful when
we are talking about decisions with individual
patients about their treatment.

One problem is that there are many different
guidelines and different expert opinions. For
example, the guidelines regarding the treatmentof high blood pressure are different in the UnitedStates than they are in Europe. But even more
importantly, people are different. They weigh risk
and benefit differently. In medicine, we are always
balancing potential risks with potential benefits,
and the ways people do that can be quite different. After all, it is the patient, the individual, who
ultimately accepts the risk of harm associated withtaking a medication or having a procedure or test,
so clearly patients should have a say in what theychoose to do or not do.
Groopman: As Pam said, our concern is not thedomain of medicine where everyone agrees. No
one wants to have an unnecessary infection; noone wants to have a scissor left in his or her belly
after an operation. But once you move out of thatdomain, it’s a gray zone. It is not black or white.
If you are 75 years old and your blood pressure ismoderately elevated and you take a blood pressure medication that can either dehydrate you ormake you dizzy, the benefit to you can be verysmall in terms of preventing a stroke or heart attack compared to the fact that it will make you feelmiserable and you could fall and break your hip.
Our concern is that the really important workthat’s done in the domain of safety is now being
extended to other domains where choices are
not black and white. And as Pam said, experts disagree. They are looking at the same informationand data but they disagree because they value
it differently. So why should their values besuperimposed on a patient?
Wallace: Can you give us an overview of theprocess that you use when you are working withpatients who have to make difficult decisions?
Hartzband: Although patients are obviously individual in how they make their decisions, we foundin our field research that there are common
threads. Some people are what we call maximalists– when it comes to medical treatment, they wantF E AT U R E | H A R T Z B A N D, G R O O P M A N , A N D WA L L A C E

3© Thinkstock

everything and more. At the other end of thespectrum are the minimalists – to them, less ismore. We found that some people have a technology orientation. They want the latest, greatest
high-tech breakthrough. Others have a naturalism
orientation. They prefer natural healing, such as
supplements, herbal treatments, or acupuncture.
Finally, some people are what we term believers.
Believers are certain that there is a good solution
to their problem, and once they find it, they gofor it. At the other end of that spectrum are the
doubters who worry that the treatment will beworse than the disease.
People develop these mindsets in part becauseof their own prior medical experiences, but mindsets are also shaped by their family’s health andthe medical experiences – both good and bad –of family and friends. Your medical mindset isyour starting point. It is your initial approach to a
medical problem. But you can change. You wantto consider whether your initial approach is theright one for the particular problem you are facing.

Your medical mindset is yourstarting point. It is your initialapproach to a medical problem.
The next step is to consider numbers and statistics. You need to understand if the numbers apply
to you as an individual or not. And you need to beaware of how numbers are presented. Are theypresented or framed in a positive way or a negative way? This can influence how you react tothose numbers.
Finally, you need to consider stories. We are allvery much affected by stories. If your Aunt Sue
took a medication and had a side effect, you are
not going to want that medication. But it is not

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only the stories from your family and friends. It
can be a story in the newspaper or on the Internet.
Psychologists call the effect of stories “availability,”
because the powerful story stays in your mind
and is readily available. These stories cause you
to overestimate the likelihood or probabilityof that same thing happening to you.

The stepwise process is to firststart with your medical mind.
Second, look at the data, how itapplies or does not apply. And
third, see how stories sway you.
Groopman: So the stepwise process, as Pam said,
is to first start with your mindset, your medical
mind. Second, look at the data, the information,
how it applies or does not apply. And third, see
how stories sway you one way or another. Most
scientists and decision analysts dismiss stories.
They say, “Oh, they are just anecdotes.” But Daniel
Gilbert at Harvard and other psychologists see
stories differently. Gilbert published a terrificpaper in Science called “The Surprising Power of
Neighborly Advice.”1 In that paper, he says thatit’s impossible to try to forecast or imagine whata certain experience might mean for you as anindividual. Gilbert found that talking to people,
particularly people who are similar to you inbackground and sensibility who have alreadyexperienced the same situation that you will be
experiencing, can help give you a concrete, palpable sense of what your life may be like in the
future. This conversation can help inform yourdecision.
For example, we found this was particularly helpful for several men struggling with their choices
after PSA test results showed up positive for prostate cancer. Should they just be watched, so-called“active surveillance”? Should they have surgery?
Should they have radiation? This is a gray zone.
Talking to other men who made different choices
greatly helped them come to a decision.

© Thinkstock

Wallace: It would be interesting to hear about
each of your medical mindsets, because I know
they are not the same.
Groopman: I’ll start. I was raised in a traditional,
Eastern European Jewish family where the doctor
was on a pedestal. Everything that the doctor said
you did – and you did it to the maximum. I wasraised with a maximalist mindset. I also was raisedwith a believer mindset that everything had asolution. The solution came from the doctor,
and it meant better health.
I also was raised with a very strong technology
orientation. In our family, the pioneers in polio– like Jonas Salk and Albert Sabin – were ranked ashigh as Winston Churchill and FDR in World War II.
Finally, anything that was natural, as Pam talked

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about, the naturalism orientation, was seen as being an ignorant throwback to the European village
life and discounted. This informed my choice tobecome a hematologist and an oncologist, particularly at a time when bone marrow transplant,
which is the most extreme and intensive kind oftreatment, was being developed. It would save
lives of people with leukemia and lymphoma
who otherwise would have died.
Hartzband: I had a different kind of upbringing.
When I was born, the doctor explained to my parents that the new, scientific way to feed babies
was to feed them every four hours by the clock.
I was the first baby in the family, and my dad wasan engineer and very enthusiastic about applying
scientific principles to child rearing. He made achart for my mother so she could check off thebox after she fed me every four hours. Dad went
off to work, and my mother had a very stressful
day with a lot of screaming from me, the baby.
She finally took matters into her own hands anddecided to feed me when she thought I was hungry. When my dad came home he was appalled.
He asked my mother, “How could you not follow
the advice of the doctor, the experts?” And likea true doubter, her response was, “Well, doctors
don’t know everything.” The doubter mentality
was how I was brought up.
My parents were ahead of their time with respect
to a healthy lifestyle. We had to eat whole-wheat
bread, which was not a particularly tasty item in
the 1950s, and we were not allowed to have soda.
My dad used to get my sisters and me up early inthe morning to do the Royal Canadian Air Forceexercises with him. By virtue of their lifestyle and/or their genetics, my parents have had long andhealthy lives without much medical intervention.
My dad is 88 this year and still goes out and runs,
works out in the gym every day, and then works
on his computer. My mom plays golf and is active.
All that contributed to my minimalist, doubter
point of view.
Wallace: In listening to you, I’m wondering whether
you see these frameworks as mutually exclusive.

Hartzband: As a minimalist and a doubter, myfirst reaction to a screening test like a colonoscopy
is that I don’t want to have it. I think about all thepotential problems that can happen during thiskind of procedure, the risks, the complications. Of
course, that doesn’t mean I won’t do it. But I havedoubts, and this influences how I go about making my decisions. I’m not willing to accept thateveryone must have this or that test or procedure.
I think to myself, is this really right for me? I’m notsure. I have to think about it. That is my process.
Groopman: I’m sort of a “maximalist in recovery,”because as I said, my starting point was verystrong that way. I should also add that my father
had a massive heart attack and died in his early
fifties and didn’t get intensive cardiac intervention
in the small community hospital in Queens, New
York. That reinforced my maximalist mindset. I applied that mindset to back pain that didn’t have aclear cause; it wasn’t a huge ruptured disk. I went
ahead with back surgery, and it was a catastrophe.

It’s important to realize that yourdoctor also has these mindsets. So
not only do you need to consider
your mindset, but also yourdoctor’s mindset.
What I learned from that was to temper my inclinations. As we said, in the three-step process, yourmindset is your starting point. It’s important tofirst recognize how you generally approach problems, then to move along the spectrum one way
or another, given the situation. I still believe thatfor many people with acute leukemia, bone marrow transplant is curative. For most people, thealternative is death. Some people say, “I don’t wantto take the risk and end up with potential complications,” and they make the choice not to be transplanted. Sometimes they are at the end of thebell-shaped curve and may go for months to years
without the typical downhill course. They are staying with their initial mindset, but a lot of doubters

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and minimalists realize that they need to shift
their mindset.
Hartzband: It’s important to realize that yourdoctor also has these mindsets. So not only do
you need to consider your mindset, but also yourdoctor’s mindset. Often we hear patients say, “I
went to a specialist and he told me one thing. And
then I went to another specialist and he told me
something completely different. Why?” We believe
this happens because of different mindsets. The
specialists have access to the same data, they arereading the same studies, but they value themdifferently.

The mantra now in healthcare
is about systems solutions
and efficiency.
Groopman: Look at the controversy over mammograms. The government panel, the United States
Preventative Services Task Force, recommended
against routine mammograms for women between
the ages of 40 and 49. Other expert groups like theAmerican Society of Clinical Oncology, composedof medical oncologists, disagreed. It’s not because
they are corrupt or looking to make a buck – which
is sometimes the way they are portrayed – it isbecause they weigh risk and benefit differently.
Hartzband: I’ll give you an example from my own
practice as an endocrinologist. I often see patientswith thyroid nodules, lumps in the thyroid gland.
Most of these are benign, but some of them are
malignant. We generally evaluate these nodules
by doing a needle biopsy, but sometimes, evenwith the best technique and repeated needle aspirations, you can’t get enough cells. Then you needto decide if you are going to just live with thisnodule or if you are going to take it out surgically.
The risk of malignancy in a situation like this is low,less than 10 percent.
I recently had a patient in just this situation, awoman who had multiple biopsies without

enough cells to make a diagnosis, and she asked
me, “What would you do?” Now that’s an interesting question. Doctors are asked it all the time:“What would you do for yourself or your motheror your sister?” My answer was, “Well, given yourparticular situation and the way your nodule looks
on ultrasound, I would watch and wait. But myhusband (Jerry) would have had surgery yesterday.”
So that’s the difference between the maximalist
and minimalist mindset.
Wallace: Jerry, in an interview in US News & World
Report, you made a powerful statement about theimportance of listening and language. You said,“The errors that we make in our thinking often
come about because we cut off dialogue. Most
physicians interrupt a patient 18 seconds after
they start talking.” This was so interesting to me,
the whole notion of the fundamental importanceof language and listening and the consequences
when it is missing from patient-doctor conversations where decision making is so critical. How
did you arrive at this as a fundamental principlethat you rely on so heavily?
Groopman: Let me make a distinction between
two things. The first is making the correct diagnosis,
and the second, which is what we discuss in our
book Your Medical Mind, involves treatment. Bothare relevant to dialogue.
The finding of interruptions every 18 seconds
was shocking to me, too. We found this numberin studies: from the University of Rochester; from
Judith Hall, a psychologist at Northeastern University; and from Debra Roter, who is at Johns Hopkins.
The mantra now in healthcare is about systems
solutions and efficiency. In a 12- to 15-minute visit,
the doctor, nurse practitioner, and physician assistant are required to fulfill certain quality measuresby checking items off a list or they don’t get paid.
They have to ask patients if they wear bike helmets, if they wear seat belts, and if they smoke,even when they know that that person doesn’t
smoke. Every single visit, you have to check thesethings off, and you have very little time left forreal dialogue.

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In England, for example, where these kinds ofquality metrics have been mandated as they are
now in the United States, studies have found that
often patients go to the doctor and their primary
problem, why they scheduled the visit, was neverreally addressed because time was consumed
with all of these efficiency and quality measures.
With regard to diagnosis, the “anchoring error,”where a doctor will immediately grab one of thefirst things a patient says and anchor onto it, is aclassic cognitive error defined by Kahneman andTversky.2 When people stop on the first data point
and then move in a linear way without allowing
other information to be adequately considered,
the result is often misdiagnosis.
In terms of what Pam and I were talking about
earlier, patients weighing risk and benefit, studies
from the University of Michigan show that incommon medical problems, such as hypertension
treatment or high cholesterol treatment, or choices
about orthopedic procedures, in a half to twothirds of cases, doctors do not explore with patients
their own preferences and how they weigh risk
and benefit. The result is that the doctor puts out
his or her own preference and recommendation,and the dialogue becomes centered around what
the doctor thinks about risk and benefit.
So we could not agree more that open dialogue
and time to think, so-called “cognitive work” with apatient, is essential, and that the system is moving
to snuff it out. We are returning to a paternalistic
system where little time is given for dialogue.
Rather, we have top-down management, where“we know” what is right for everyone. Here is themetric that you have to meet. Here is the guidelinethat you have to adhere to or the doctor is not
paid, the hospital is not paid, and the reportcard shows a bad grade.
Again, this is not related to safety or emergency
measures like giving an aspirin for a heart attack.
It has to do with the gray zone. When you bring up
organizational principles, it’s ironic that all of thesepeople who come out of organizational thinking

are now promoting efficiency in healthcare delivery,
as if it’s like producing cars on an assembly line.
That’s not what medicine is.
Hartzband: In the interest of efficiency, someelectronic records have replaced the patient narrative, the description of the patient’s symptoms,
with a series of check boxes. But this limits thelanguage used to describe the symptoms andcan easily lead to an incorrect diagnosis andtreatment plan.
We interviewed a doctor who told us the story ofa patient who complained that he was losing his
stamina. His doctors put him through a big workup, first a cardiac work-up and then a pulmonary
work-up, both negative, and nobody could figureout why he was losing his stamina. Finally, one ofhis doctors asked him to describe exactly what
he meant by “losing his stamina.”

We are returning to apaternalistic system where little
time is given for dialogue.
Rather, we have top-down
management, where “we know”
what is right for everyone.
He said, “When I am walking on the golf course, allof a sudden, I lose my stamina, right here in mycalf.” So what he was talking about was a classic
symptom of intermittent claudication, where theblood supply to the leg is partially obstructed.
When you exercise, there is an increase in the demand for blood, so you get fatigue and cramping
in the leg. That’s what he meant by stamina. Thisdiagnosis was confirmed through additional testing, and he was treated in the appropriate fashion.
That big expensive work-up he had gone throughbefore was unnecessary, and it happened because
there had not been enough exploration into thelanguage.

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Wallace: So it took that whole series of tests, allthat money, all that time before somebody asked
the right question.

but they don’t see it that way. Their assumption is
if you can’t measure something, you can’t manage
it. So they want to manage everything, and theyignore the things they can’t measure.

Hartzband: Yes, exactly.

What people don’t realize with
top-down management is that bysnuffing out open-ended discussion
and having everything in templates,
doctors don’t think or talk in realdialogue. What they are doing is
fitting the patient into the box.
Groopman: What people don’t realize with topdown management is that by snuffing out openended discussion and having everything in templates to fit into an electronic record, doctors don’t
think or talk in real dialogue. What they are doing
is fitting the patient into the box. There are unintended consequences, and many of these organizational reform measures actually work against
patient-centered care.
Wallace: Interesting. So we’re moving toward
Taylorism?
Groopman: That is it. It is Taylorism. I read a piece
about the history of Frederick Taylor. It showedthat most of the research results that he proposed
turned out to be illusory. He found one big, strapping guy who could shovel coal or whatever it
was ferociously.
Hartzband: But the guy couldn’t move the nextday. He couldn’t do it two days in a row. Nevertheless, that became the target work level foreveryone.
Groopman: People who rely heavily on quality
measures believe in Taylorism. The other thing isthey believe we can measure everything important. And we can’t. There are dimensions in medicine that cannot be reduced to simple numbers,

Pam and I have a piece in The New England Journalof Medicine on this subject called, “There is More toLife than Death.”3 The bottom line is that experts
ignore vital dimensions and vital issues that can’t
be measured but that patients find important.
Wallace: When your patients experience poor outcomes, what is that conversation like? How doesthat shift the relationship with the patient andmake it more difficult for both parties?
Hartzband: In our book, we tell the story of twopatients who had elective orthopedic surgery forchronic pain. In both cases, the surgery did not
resolve the problem. Both patients still had pain
after the surgery. Both of them were disappointed,
but one had regret, a heavy burden to carry, while
the other did not. We found that the process of
how the two patients made their decisions madea significant difference in how satisfied they felt.
The first patient was a man who had knee pain
due to degenerative changes in his joint. Before
surgery, he considered his mindset. He reviewed
the numbers. He felt that he made the best decision he could at the time. Of course, as with allthings in medicine, there is no guarantee that you
are going to have a good outcome. You acknowledge this when you sign a consent form for surgery. He was able to accept the outcome andmove past it.
The second patient was a woman who had footsurgery, also for degenerative changes. She feltthat she had been pushed into doing somethingthat didn’t fit with her mindset, and she was filledwith regret that she made the choice that she did.
From the doctor’s perspective, understanding
what the patient wants and why he or she wants
it, and being sure that everyone agrees that this isright thing for this individual can help ameliorate

F E AT U R E | H A R T Z B A N D, G R O O P M A N , A N D WA L L A C E

9© Thinkstock

disappointment and prevent regret. Obviously,
no one wants to have a bad result, but even withthe best care, it can happen. Ideally, you and yourphysician face the bad outcome together rather
than becoming adversaries.
Groopman: Your doctor is not a rubber stamp.
A patient may come with a certain mindset, andoften it’s good to challenge that. The process
involves your mindset and the numbers and thestories. What shared decision making really means
and what patient-centered care really means, tobring the discussion back to the first issue, is that
there is a give and take and a consideration of
the opposite point of view.
We are dedicated to preventing preventable errors
and ensuring safety, but in much of medicine, you
can do everything right in a procedure or you cangive someone a correct medication, and a complication still occurs. And yet, as Pam emphasized, if
you went through the kind of process that we pro-

It’s ironic that all of these people
who come out of organizational
thinking are now promoting
efficiency in healthcare delivery,
as if it’s like producing cars on an
assembly line. That’s not what
medicine is.
pose, we believe that you can feel you did everything you could. That’s a very different feeling, forexample, than feeling you were railroaded into
something or as in my own case with my back surgery where with my sort of unbridled maximalism,
I didn’t get strong pushback, which might havehelped me. This is the art of decision making.
Wallace: What has to happen in the healthcare
system or with individual patients and physicians

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R E F L E C T I O N S | V O LU M E 12, N U M B E R 3

so that the greatest good is served and there ismutual benefit to all the stakeholders?
Hartzband: Of course, we think that everyone isentitled to good healthcare. What concerns us isthat some of the most important dimensions of
medicine are being lost in the push to cut costs.
In particular, time is being devalued. The time thatpatients spend talking to their doctors is being
limited in the name of efficiency, but this timeis needed for accurate diagnoses and patientcentered decision making about tests andtreatments.

What shared decision making
really means and patient-centeredcare really means is that there is agive and take and a considerationof the opposite point of view.
We object to the new language of medicine
where the doctor is a “provider” of standardizedcare and the patient is a “consumer.” This does adisservice to both doctor and patient. We thinkit’s a problem to equate standardization with improved quality. They are not the same. Improving
quality will not always cut costs. We never hear
about cutting costs without also hearing that thiswill improve quality. The mantra is that we aregoing to improve quality and cut costs, but anumber of recent studies about congestive heart
failure, for example, indicate that spending more
results in higher-quality care.
There is waste and fraud in our medical system,
and we need to work on eliminating it. While attempting to do so, we also need to preserve thecore of what good medicine really is.
Groopman: We’re not ignorant of or ignoring thecost problem. Theodore Marmor, who is a professor of policy at Yale, and Jonathan Oberlander, who
is at the University of North Carolina, have written
pieces in the New England Journal of Medicine andother publications that say it’s a mistake to equate
cost with quality of care. Look at countries like
Germany, where there is a private not a socialized
system like England. The way Germany controls
costs is by very strict regulation of the insurance
industry and their profit margins, and by having
uniform and transparent pricing. Germans do not
micromanage the care of individual patients. They
don’t have the Taylorist approach of standardizing
everything and seeing people as cars coming off
an assembly line.
Insurance companies compete for customers inGermany based on perks and other services they
offer, but that’s not what’s going on here in the
U.S. You have two extremes. You have top-down
management from the government, which is theAffordable Care Act, then you have top-down
management from insurance companies, whose
primary aim is profit. The idea that a single government panel is like the Vatican or the Sanhedrin– infallible, with divine wisdom that can standardize care for everyone all the time – is justan illusion.
If the safety issues are all addressed, large sumsof money and lives will be saved. But there is noevidence from all these evidence-based policy
people that strict standardization of other domainsof care either saves money or helps people. In
fact, it doesn’t.
We believe in universal coverage. There should be
no discrimination on preexisting conditions, andwe believe there should be very strict measures toprotect patients with regard to safety, preventableerrors, and emergency protocols. But we think it’sa big mistake to standardize everything. What’s
driving it also, frankly, is enormous profits that are
being made by insurance companies that now
assert that they are the ones who can tell you
which doctor to pick, which procedure to have,as though they are your advocate – and in truth
they are not.
There are also experts jumping in and making
fortunes by generating metric after metric afterF E AT U R E | H A R T Z B A N D, G R O O P M A N , A N D WA L L A C E

11Ideally, you and your physician
face the bad outcome together
rather than becoming
adversaries.
metric. It’s a self-sustaining bureaucracy. Because
if you said, let’s just focus and take care of catheter
infections or operating room errors and things
like that, the consultants wouldn’t have muchwork to do.
Hartzband: We are doctors but also sometimes
we are patients. And when we are patients, wewant our doctors to be thinking of us as individuals – to do what is best for us individuals.

ENDNOTES
1 Gilbert, D.T., Killingsworth, M.A., Eyre, R.N., & Wilson T.D. (2009). “The surprising power of neighborly advice,”
Science 323 (5921): 1617–1619.
2 Tversky, A., & Kahneman, D. (1974). “Judgment under uncertainty: Heuristics and biases,” Science 185: 1124–1130.
3 Hartzband, P., & Groopman, J. (2012). “There is more to life than death,” New England Journal of Medicine 367:
987–989.
ABOUT THE AUTHORS
Jerome Groopman, MD, holds the Dina and Raphael Recanati Chair of Medicine at the Harvard Medical
School and is chief of Experimental Medicine at the Beth Israel Deaconess Medical Center.
Pamela Hartzband, MD, is an assistant professor at the Harvard Medical School and attending
physician in the Division of Endocrinology at the Beth Israel Deaconess Medical Center in Boston.
Dr. Groopman and Dr. Hartzband are coauthors of Your Medical Mind: How to Decide What is Right for
You (Penguin Books, 2012). yourmedicalmind@gmail.com
Deborah Wallace is senior editor of Reflections, and is founder and principal of BrinkPoint Consulting.
deborah@solonline.org© Thinkstock

Groopman: You often hear that you have to be“population-centered.” Well, there is no “population”; no average person exists. It’s a statisticalartifact, and to ignore the gray zone and thetradeoffs that every patient makes in coming to
a decision is really a disservice to patients andto the profession. !

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F E AT U R E 12.3

Seeing the System Inside-Out
HUGO SAX
When Dr. Hugo Sax, a physician and the head of infection control for a hospital in Switzerland, entered
the hospital as a patient, he had the rare opportunity to see a healthcare system from the other side. His
experience brought into sharp relief the communication gaps and barriers to change that exist in mostmedical settings despite the best intentions of the staff. Equally surprising to Hugo was the ease withwhich he found himself falling into a dependent role, reluctant to question those responsible for his
medical care or point out lapses in protocol that he witnessed. While his surgery was successful, Dr. Sax
came away with more questions than answers about the ability of healthcare professionals and patientsto navigate the complexities of caring for the individual as a whole.

The Story
For years, I had a tumor at the angle of the right side of my jaw, about the sizeof an olive pit or even smaller. It always stayed the same size, too small andstable to be worrisome. But recently it had grown, or so it seemed. When thingschange slowly they are difficult to judge. It didn’t hurt, but I was sure I had notseen it in the mirror like this before. No one else seemed to notice.
I had just changed my workplace and had to go to the staff doctor’s office for a
tuberculosis skin test. A nurse greeted me and did the test. I told her about thetumor and that I was not sure what it meant. She suggested I talk to the physician
about it. The physician thought I should have the tumor removed for histological examination. It seemedsimple. We agreed that I should consult with an internist, which meant I was going to be seen by thechief of internal medicine at the same hospital where I worked.
Hugo Sax

The appointment was two weeks from then. After a few days, I got really worried about having to disclose all of my medical history to a colleague with whom I would probably have to wrangle over sometough political issues in the future. More days went by. Finally, I canceled the appointment and rang myinternist in private practice in another town. Physicians are reluctant to have physicians as patients. My
internist is a really good doctor with a practical approach to problems. She relies on a basic inventoryof readily citable causes for specific symptoms based on the principle of “What is frequent is frequent.”
We don’t generally work this way at the hospital, where a patient’s true diagnosis is usually buried
somewhere among a long list of alternative diagnoses, each of which is associated with only a very
low probability of actually being the right one.
I sat in the waiting room for some time. After examining me, my empathetic doctor suggested that I see
an ear-nose-throat specialist for my parotid gland problem. He was young, she said, but excellent. He
performed surgery at a public hospital, which to my internist was proof of his high level of skills. I was
glad she pointed me in the right direction. The illusion that the quality of healthcare is consistent fromF E AT U R E | S A X

hospital to hospital seems to be a mental modelthat I’m still hesitant to challenge, even if I should
know better.
The surgeon focused intently on my problem andalways looked me straight in the eye. He smiled
but never laughed. I had to sit on an examination
chair a bit higher up than his. After examining me
and listening to my story about the tumor getting
bigger over the last few months, the surgeon
readily offered a presumptive diagnosis.
The surgeon donned gloves to perform a needle
biopsy, but I noticed that he didn’t use an alcoholbased hand sanitizer to first clean his hands. I currently head the Infection Control Program at the
University Hospital of Zurich and serve on theWorld Health Organization’s First Global Patient
Safety Challenge. We had just issued guidelines
for hand hygiene procedures in an ambulatory
setting.1
What did I think of an excellent surgeon who was
not following the rules? To tell the truth, although

he did not follow the guidelines, I did not reallyworry about getting an infection.
The excellent young surgeon found another tumor in my thyroid and verified by ultrasound that
it was a cyst. He suggested doing a needle biopsy
to exclude malignancy there, too. Age must haveadded some equanimity to my emotional repertoire, since I did not faint or really panic. The surgeon told me that if the parotid tumor was what
he thought, I would need surgery in the next six
months. Otherwise, it would grow and become
malignant at some time, making surgery moredifficult. I went home, looked through my planner,

What did I think of an excellent
surgeon who was not following therules? To tell the truth, although he
did not follow the guidelines, I did
not really worry about getting an
infection.

13© Thinkstock

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and decided to cancel a trip to the U.S. I scheduled
the surgery for two weeks from that day.
Now I went back to my internist where I had aphysical and lab tests done for the surgery. Simple
medicine. Then I had to see the anesthesiologist
in the hospital I was going to be operated in. She
gave me choices I did not want, more choices
probably than she would have given to a nonphysician. I worked as an anesthesiologist at the
beginning of my career, and some of the drugs
she offered sounded familiar, others not. Whenit comes to your own health, there is something
about choice that is uncomfortable. Too often,
too much data is missing.

When it comes to your own health,there is something about choicesthat is uncomfortable.
Finally, back at the surgeon’s office to sign theinformed consent form, what was in my mind asimple inch-long cut became a three-hour highprecision surgery. Three surgeons would attempt
to avoid cutting the motor nerves that run throughthe parotid gland. If they happened to sever them,
one side of my face would permanently droop,and eating would be difficult. My surgeon alsoannounced that he would have to cut some
sensory nerves, and my right ear would become
numb in most parts. Other nerves that originally
told the parotid to produce saliva would ultimately
find their way to glands in the skin and produce
sweat whenever I thought of or ate delicious food.
He warned me that the remaining parotid tissue
would still produce saliva and that for a short timeafter the surgery, drool might run down my facewhenever I ate.
By then I had learned that the tumor was notmalignant. But these potential side effects were
unexpected and impressive. My meeting with thesurgeon was on a Wednesday. The surgery wasscheduled for the following Monday. On Thursday,my throat was sore, and by Friday, I was coughing

badly. My body seemed to be trying to avoid theinevitable. On Sunday, my symptoms were worse,and I called the anesthesiologist to discuss theoptions. He made the decision to proceed withthe surgery on schedule.
I was still not sure this was the right decision when
I got to the hospital the next morning. I had nofever but a slight numbness to my skin, and a fog
surrounding my head made everything seem a
bit unreal. Everyone was exceptionally nice. Soon,
what started out feeling like a trip to a hotel room
ended up as everyday medical procedure, a sharp
contrast to the idea of being deprived of the innerconnection to a part of my body (my ear).
Scheduled aggression.
Being in a cotton cloud somehow helped. Ichanged into the hospital gown, was pushed
through the corridors on a gurney, and then had
to shift to the hard operating table, the warm
drapes contrasting sharply with the cold air andstainless steel surfaces in the anesthesia induction
room. The anesthesiologist had a beard and afriendly face. I watched my heartbeat on themonitor, spotted some premature beats, felt the
medication run up the vein in my left arm, andfell into an intimate nothingness.
I woke up in the intensive care unit with lots ofcommotion flying in from far away. I was in an exceptionally bright mood and immediately started
to talk with an intern about her career prospects,
purposely using open questions. Then I began tomonitor hand hygiene activity. Everyone seemed
to walk up to me without cleaning his or her
hands. Clearly, I felt no risk of getting an infection;
it was about the protocol. I forced myself to saysomething, but doing so was not easy. Here I was,having just survived a visit to the other side andback, dependent on the staff to know the routine,
the medication, my case, and each other. Why
should I dare to be critical about a protocol item?
The system might fall out of its routine.
I remembered the findings of our focus groupstudy, where participating nurses made sugges-

F E AT U R E | S A X

tions on how to solve the hygiene problem. In theinterview transcripts, we saw an array of options
ranging from boldly confronting non-compliers
on one end to placing hand-sanitizer dispensers
in front of patients’ beds on the other. Flooded by
opioids, I was in a daring mood but still chose asoft approach. I asked the next nurse who cameinto my room whether the hand-rub dispenser

was close enough to my bed for staff to think ofhand hygiene when approaching me. We then got
into a discussion about the importance of handhygiene while caring for patients, she beingsquarely in favor.
These were beaten paths, somehow disjointed
from current reality. The anesthesiologist came byEfforts to Improve Patient Safety
In October 2004, the World Health Organization (WHO) launched a patient safety program
in response to a World Health Assembly
Resolution (2002) urging WHO and member
states to pay the closest possible attention
to the topic of patient safety. The program,
WHO Patient Safety, aims to coordinate,
disseminate, and accelerate improvementsin patient safety worldwide. It provides avehicle for international collaboration andaction among WHO member states, WHO’ssecretariat, technical experts, and consumers,
as well as professionals and industry groups.
In 2005, WHO Patient Safety initiated its first
patient safety challenge under the slogan“Clean Care Is Safer Care,” led by Professor
Didier Pittet and Dr. Benedetta Allegranzi.
Subsequently, many more programs weredeveloped to help countries, regions, andhealthcare institutions tackle the issue ofpatient safety around the world.
As part of “Clean Care Is Safer Care,” an international panel of experts developed the WHO
Guidelines on Hand Hygiene in Health Careas well as a set of complementary implementation tools for changing the behavior ofhealthcare workers. The core concept of“My Five Moments for Hand Hygiene” isbased on breakthrough research conductedduring the 1990s at the University of Geneva
hospitals and later fully developed based onhuman factors principles during the Swiss
National Hand Hygiene Campaign in 2005.*“Five fingers, five life-saving moments, five
strategies of action” is a simple, user-centeredconcept for understanding, training, monitoring, and reporting on hand hygiene in a wide
range of healthcare settings in the fight for
infection-free hospitals.
The number “five” is also reflected in thedesignation of Global Hand Hygiene Day on
May 5 each year. In 2012, more than 15,000
healthcare facilities in 156 countries worldwide, with approximately 10 million healthcare workers and 3.7 million patient beds,
participated in this event. Since 2005, 48
countries have taken the additional actionof initiating their own national handhygiene campaigns.
Despite this progress, hand hygiene performance is still suboptimal, and too many otherwise avoidable infections still occur. Much
remains to be understood and implemented
regarding infectious risks and human behavior.

* Sax, H., Allegranzi, B., Uckay, I., Larson, E., Boyce, J., & Pittet, D. (2007). “‘My Five Moments for Hand
Hygiene’: A User-Centred Design Approach to Understand, Train, Monitor and Report Hand Hygiene,”
Journal of Hospital Infection 67(1): 9–21.

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with two younger physicians and asked how I was.
They told me about some difficulties caused by
my inclination to turn on my right side where thewound was, and about the need to treat a rashcaused by the opioids with an antihistamine. But
they didn’t use the hand sanitizer before shaking
hands either. They walked on to the next patient
without cleaning their hands. Why should I pose arisk to the next patient? How would she know that
I didn’t?
Time went by, with me diving in and out of sleep.
The cough came back as the opioids wore off, andI ran a high fever. Someone wanted my opinion onwhether I thought I should have antibiotics. The
anesthesiologist with the beard came for a visit,and he thought blood cultures were not necessary.
Then a nurse came and did take blood cultures.
She had to draw blood for lab tests as well andwanted to access the vein on my left arm where
the IV was running. I mentioned the possibility ofthe tests being corrupted and suggested she use
the arm without the IV. She obviously did not like

The nurse had perceived my remark as confrontational. Not good. And maybe she was right. Maybeit was a rule without much real value. What is thesafety margin around this kind of procedure?
Would an incorrect value in a blood test lead to awrong decision that would end up harming me?
I was much less enthusiastic without opioids andback in my room. Many nurses came to see me.
On the third morning, I realized that I had been
served hot chocolate instead of coffee. I neverdrink hot chocolate for breakfast. I told the nurse,
and he said no problem at all – he would see to itthat I got coffee. The coffee never made it to me.
My surgeon came daily and made certain decisions that he said he would communicate to thenurses on his way out. The prescription he men-

Illustration: Hugo Sax

My not-my-ear
ear feels like myother ear fromthe inside but
like someone
else’s ear fromthe outside. I still
wonder how itgets along being
disconnected likethis.

my interference, argued that the IV liquid was running down a different vein than the one she would
be using, but nevertheless went around the bed
to draw blood from my right arm.

!

F E AT U R E | S A X

tioned didn’t materialize. On the third day, I wastransformed back to a civilian in private clothes,sitting on the balcony to test my overall condition
for half an hour. Then I left, dragging my wheeled
carry-on bag over many curbs to the local suburban train station. My ear was covered and hurt
only faintly. It still belonged to the hospital until
I got home.

Reflections
This experience made me reflect on systems. I had
the rare chance to see a system from the otherside. It recently occurred to me that observing myself was probably the most valid research method
I had ever used, breaking through a solid mental
model on the value of more prescribed researchmethods. But there is a clear limit to that N=1 sample size. As a physician, I have certainly had a huge
blind spot in terms of considering patients’ experiences. Here was an opportunity to see what happens to a patient by being the patient, which isradically different, a 180-degree role change.
What impressed me most was the normality ofwhat was going on in the hospital, the ease withwhich everyone navigated the system and theirroles in it, and the empathy and good intention
with which everyone approached me as a patient.
The nurse certainly took it to heart that I would
not agree with her first choice of arm from whichto draw blood, probably not because she felt
“caught” but because she had been doing it thatway for a long time to the best of her knowledge
and with professional pride.
In my professional life, I work to help hospitals
identify and avoid medical errors. Where are thesekinds of errors hidden? When people are ferociously
focused on the task at hand, errors may be latentand difficult for those involved to see.2 While writing about my hospital experience, I serendipitously
read the work of Carol Moulton and colleagues.
They suggest that true expertise is the ability toswitch from routine task-execution mode to amore conscious reflection-in-action mode whenever the situation becomes non-routine. It is, they
explain, the ability to “slow down when you

should.”3 When freed from their reliance onlearned routines, experts should then be able
to invest their mental resources in approaching
more complex aspects of their work withgreater mindfulness.
During my three days in the hospital, I saw many,
many small bits of information get lost, muchguesswork around decisions, missing data thatmight inform those decisions, breaks in information chains, and information stored only in thememories of people who then left, with others
coming in and starting off at zero. It seemed as
though the stream of information was broken inpieces. These details mostly concerned trivial
things, but aren’t big incidents the result of theunlucky lineup of small glitches? I noticed how
important an increased flow of systems-level
information could be.

True expertise is the ability to switchfrom routine task-execution mode toa more conscious reflection-in-action
mode whenever the situation becomes
non-routine.
I was equally impressed with how easily I gave up
my usual role and became a patient to fit the system.
It was as if the system had invaded me and theonly chance I had to survive in this other reality
was to blend into the general flow, to borrowfrom that normality. Maybe I felt that if I objected,
I would make myself more vulnerable to fate.
My failure to react more strongly to each missed
hand hygiene opportunity may have been rooted
in my same reluctance to disturb a system runningsmoothly. But then, it may have been a bias toward
optimism in the face of more severe and immediate
threats such as the possibility of not waking up
from anesthesia, my cough becoming bacterial
pneumonia, or my tumor being cancer after all.
The risk of being infected by an individual touchof unclean hands is indeed very, very small, with

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the overall risk definitively lying in the many, many
hands touching many, many patients every day ina hospital. This risk paradox is a huge motivational
challenge. When I think back to my excellent surgeon and all the other kind, competent staff, ahalo effect might be at work here: how can someone competent do something that would harm me?

Was I just lucky or is the systemsufficiently redundant, equippedwith the necessary safety margins?
Healthcare workers who participated in our focus
groups on hand hygiene have told us that theyswitched roles in a snap when they became patients. I have now confirmed this trend. My experience reminded me of innovative research into thepatient’s view of the system by Dr. Gretchen Berland. She gave patients video cameras to capture
their lives in wheelchairs.4 An exceptionally rich
picture resulted from their interactions with thehealthcare system, something Dr. Berland felt
would be healing for those on the other side
to see.

To me, the question of how and where healthcare
workers and patients can come to a meeting ofminds remains open. I’m not just talking about
physicians allowing patients to participate in thedecision-making process, but also both parties
sharing the experience of uncertainty. Today,
patients are involved in therapeutic decisions.
Doctors try to explain the data behind eachchoice. But since the outcome of each choice ismostly unpredictable, much determining data is
missing, and the boundaries of intuition remain
fuzzy even to the experts, making a choice asa patient really comes down to tempting fate,
which is very scary.
The most constant element during my hospital
stay was my surgeon’s daily visit. He looked at mewith his straight gaze and focused on the healingof the surgical site. Was this approach his mind’s
way of avoiding being trapped by complexity?
He had told me there would be no infection andthere wasn’t. And other bad things did not happen either. Was I just lucky or is the system sufficiently redundant, equipped with the necessary
safety margins? Or did the “What is frequentis frequent” rule apply here as well? !

ENDNOTES
1 World Health Organization. (2012). Hand Hygiene in Outpatient and Home-Based Care and Long-Term Care Facilities:
A Guide to the Application of the WHO Multimodal Hand Hygiene Improvement Strategy and the “My Five Moments
For Hand Hygiene” Approach. WHO Press.
2 National Research Council. (2000). To Err Is Human: Building a Safer Health System. The National Academies Press.
3 Moulton, C.-A.E., Regehr, G., Mylopoulos, M., & MacRae, H.M. (2007). “Slowing down when you should: A newmodel of expert judgment,” Academic Medicine 82: S109–16.
4 Berland G. (2007). “The View from the Other Side: Patients, Doctors, and the Power of a Camera,” New England
Journal of Medicine 357(25): 2533.
ABOUT THE AUTHOR
Hugo Sax heads the Infection Control Program at the University Hospital of Zurich and is private
docent at the University of Zurich. He also serves on World Health Organization’s First Global Patient
Safety Challenge. hugo.sax@mac.com

C O M M E N TA R Y | PAWA R

19

CO M M E N TA R Y 12.3

Commentary
M A N O J PAWA R
In “Seeing the System Inside-Out,” a medical procedure provides Dr. Sax with a newperspective on a healthcare system that he has been working to improve. His reflections
on his experiences as a patient bring the human element to the surface in what is often
an abstract analysis. As a physician who has also been a patient within an organization
I was trying to improve, I recognize in Hugo’s story the familiar struggle in any kind ofchange work to see past our entrenched mental models in order to have a significant
impact, in this case, to ensure the delivery of safe, high-quality healthcare.
Manoj Pawar

Being able to touch, feel, and experience the system as a participant, and then to beable to reflect upon it as one of its designers, is an insightful gift that Dr. Sax offers through his story. A numberof insights – lessons related to how we see systems and how we might more effectively work to change them –are worth mentioning here.

1. Fragmented Perceptions Present a Significant
Barrier to Whole-System Improvement
It is no surprise that, in healthcare, disconnection among
different functions and specialties often leads to negative outcomes, including harm to patients, inefficiencies,
and high costs. Many of the lapses that Dr. Sax experienced during his treatment are fundamentally related
to the fragmentation of a system intended to serve andheal individuals in their most vulnerable moments.

© Thinkstock

As a physician, I can’t help but wonder if some of thisfragmented world view is tightly intertwined with ourdiagnostic approach. We have been trained to think in
a manner that is deductive and reductionist in order tosift our way through a long list of potential diagnoses(this list is the so-called “differential diagnosis”). Whensomething is “ruled out,” it’s removed from the list of
possibilities and never considered again. Essential inproviding clarity in our journey toward a diagnosis, thisapproach doesn’t always serve us well in understanding
complex and highly interrelated systems, where effects can be separated significantly in time and space froman intervention. In my experience, this reductionist way of seeing the world isn’t unique to physicians, but has atendency to migrate to other disciplines in the industry such as nursing and management.

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It is this fragmentation that leads to unsatisfactory experiences for a patient, such as multiple referrals and handoffs, information gaps, and unintended consequences. We see that from the time of Hugo’s diagnosis, many different providers are involved. The nurse, the chief of internal medicine, the personal physician, the anesthesiologist,
and the ear-nose-throat specialist are all highly trained and do exceptional work in their respective areas. But
who is responsible for the systems perspective? If the ear-nose-throat specialist makes a recommendation withan unintended consequence that occurs in an area outside of his specialty, how is he to know and how areothers involved in the patient’s care to know?
We frequently find out about decisions by other medical professionals that affect our patients after the fact, when
we may have missed the opportunity to foresee, prevent, or mitigate an unintended consequence. We assume that
communication takes place to avoid these sorts of dilemmas, and indeed it often does through a letter or a quick
phone call from one physician to another, but the quality of these communications (often asynchronous, linear, andunidirectional) is suboptimal for seeing the patient as an integrated person. The system is unable to view itself asa whole, something that often creates unsettling experiences for the individuals it is intended to heal.
This fragmentation also leads to challenges with the implementation and spread of best practices based onevidence (such as hand hygiene procedures). We hope educating and reminding health providers about thesepractices will be sufficient to change their behavior, but our experience does not bear this out. Even well-meaning,well-educated individuals may have difficulty adhering to a standardpractice consistently because of unseen systemic barriers. Declarations
The good news is thatalone simply don’t work. I have seen organizations in which purchasing policies have resulted in situations that actually discourage
many health systems
hand hygiene – dispensers that jam so that product can no longer
are moving away frombe dispensed, products that lead to excessive drying and cracking offragmentation and silos
the skin, or dispensers installed in locations too distant from where
the patient workflow takes place to be convenient. In these cases,
and toward greater
the costs of an unnecessary infection far outweigh the costs oflevels of integration
improving the flawed policy or faulty practice.

through team-based
approaches to care.

For a practice to be fully adopted, we must clearly understand how
the system’s dynamics can either help or hinder its implementation.
Common systems archetypes are everywhere in healthcare; the examples above are related to the “Fixes That Fail” archetype, but others are frequently at play in healthcare scenarios
as well. By learning to identify these common patterns of behavior, we can design interventions that avoid theirmost damaging effects.

2. Systems Thinking Is Essential for Success in Health System Redesign
The good news is that many health systems are moving away from fragmentation and silos and toward greaterlevels of integration through team-based approaches to care and through fostering collaboration among the functions within a particular system. In the United States, massive efforts are underway to implement practices such as
capitation (an annual fee paid to a physician or group of physicians by each participant in a health plan), bundledC O M M E N TA R Y | PAWA R

payments, accountable care organizations, and clinically integrated networks. In essence, all of these arrangements
involve the creation of a shared economic interest around a common resource pool that must manage all parts ofthe system for its mutual benefit. As these models are created, it is increasingly common to see systems archetypes
such as “Tragedy of the Commons,” “Accidental Adversaries,” and “Shifting the Burden” (or some variation of thesebasic archetypes) emerge as competitors find themselves having to collaborate in new ways. Among health system
leaders, a better understanding of system dynamics and an awareness of common systems archetypes will improvethe chances for success.

3. Emotions Have an Effect on Seeing Systems Whole
Why is it so difficult for leaders to see and understand systems? Too often, we have the best intentions as we
attempt to understand the big picture, but we underestimate the effects that our emotions have on how we see(or do not see) what is actually happening. Strong emotions such as fear and anxiety can activate our fight-orflight response and introduce a significant bias that colors our perceptions of the dynamics at play. This response,
designed for survival and self-protection, causes us to focus ona subset of available data, from which we make rapid interpretaToo often, we underestimate
tions, akin to “climbing the Ladder of Inference.” At a time when
we’re trying to understand the nuances of a complex challenge,
the effects that our emotions
our emotions can limit our perceptive capacity.

have on how we see (or do
not see) what is actually
happening.

As a patient, Dr. Sax notices failures of individuals within the system to follow a well-proven hand-washing protocol designed toreduce avoidable infections for hospital patients. When patientsor coworkers observe failures to follow the protocol, what hinders them from reminding the individual about the appropriate behavior? Physicians tend to have a worse trackrecord in adhering to hand hygiene recommendations than other groups, yet patients and nurses seldom point out
their lapses to them. Power dynamics and culture, anchored in long-standing mental models, may hinder people’s
willingness to question those with more perceived authority.
Without the ability to question itself, though, the system is deprived of the feedback necessary to improve performance. And when we fail to see safety lapses as stemming from properties of the system, we tend to place theblame for less-than-ideal outcomes on individuals, further contributing to a reinforcing loop that diminishes curiosity and impedes learning. For this reason, if leaders in health system redesign are to increase their capacity tosee, understand, and transform systems, they must manage fear and anxiety, while creating a place for mindfulness and curiosity. !

ABOUT THE AUTHOR
Manoj Pawar, MD, MMM, is vice president, Clinical Operations & Physician Leadership Development, at Catholic
Health Initiatives. manojpawar@catholichealth.net

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F E AT U R E 12.3

I Have Never Been Here Before:
The Nonlinear World of Cancer
M A R I LY N H E R A S Y M O W YC H A N D H E N R Y S E N K O
When consultant Marilyn Herasymowych was diagnosed with non-Hodgkin’s lymphoma, her world wasturned upside down. But rather than become paralyzed by fear, she and her husband Henry Senko did what
they had always done when facing uncertainty – they applied the learning system they previously designed
to help people in organizations think and act more effectively in highly complex situations. Marilyn andHenry share their reflections on how Marilyn’s cancer diagnosis and treatment forced them to surrendertheir fixed ideas of truth and accept that complexity requires us to rethink everything we thought weknew, including our definitions of success. They find that by giving us a way to simultaneously observeand participate in a system, systems thinking can provide us with a sense of calmness and control inthe most challenging circumstances.

Planning for Limits
M A R I LY N
At 1:00 pm, March 17, 2009, I was diagnosed with non-Hodgkin’s lymphoma.
At 4:00 pm that afternoon, I was admitted into the hospital because I had a lotof trouble breathing. There I was, sitting on a bed in Emergency, Henry holding
my hand, waiting to meet the oncologist. I remember feeling like a little girlgoing to her first day of school. It was surreal. I had a paradoxical feeling of bothanxiety about the cancer diagnosis and curiosity about being admitted into a
Marilyn Herasymowych hospital. Henry was very calm, and I was a chatterbox, talking about what we
had just heard and what this might mean. We had just sold our house and we
needed to move, and here I was being admitted into the hospital in a city thatwas two and half hours away from where we lived. Henry smiled and said,“I guess we better start planning for limits.” We both laughed.

Henry Senko

Henry and I had no idea how important “planning for limits” would become tohelping us to deal with the most profound uncertainty of our lives – my cancer
diagnosis. This would become even more critical as we went through cancer
treatments, and dealt with the aftermath of vicious side effects and theagonizing change in our life that would become our new normal.

We had spent the last 20 years in MHA Institute creating a learning system to help people in organizations
to think and act more effectively in highly uncertain situations. Part of this learning system, which isbased on the classic systems archetypes, uses a language and patterns of behavior to describe what
people are experiencing. Another part of the learning system provides pathways through the difficulties,
in order to create new patterns of behavior that are beneficial to both people within organizations andF E AT U R E | H E R A S Y M O W Y C H A N D S E N K O

the organizational goals. This learning system
works because it gives people a way of thinking
about uncertainty that makes it easier to act,
rather than to react to the difficulties that
uncertainty unleashes.

23

introduce the idea of systems thinking to a client.
From that point forward, we continued to workwith the ideas associated with the learningorganization.

When Henry said, “I guess we better start planning for limits,” he was using the language of thislearning system we had created. We were dealing
with a pattern of behavior called “Limits to Success,”
and the pathway through “Limits to Success” iscalled “Plan for Limits.” When Henry referred to“planning for limits,” he refocused our thinking sothat we could quickly identify our limits and startdealing with them effectively, thus reducing theanxiety that we felt about the uncertainty. Doing
this helped us to feel more in control, and moreable to take in information about what was happening and what choices we might have to make.
“Plan for Limits” provides a number of strategies
to consider when dealing with “Limits to Success.”
The one that was most relevant to us at this time
was to identify current limits. While we waited in
Emergency for the doctor to arrive, we started
talking about our current limits and what we
had to do to deal with them. The first limit that
we faced was that I was in a hospital in Lethbridge,
Canada, and we lived in Calgary, two and a half
hours away. The second was to reschedule ourwork with clients, so that Henry could deal withemerging issues from this diagnosis and my stayin the hospital. The third was that we had just soldour house and we had less than 60 days to find a
new place to live, then pack and move. We had
to deal with the first two limits right away. The
third limit would have to wait until tomorrow.
HENRY
We were introduced to the field of systems thinking many years ago when Marilyn read Peter
Senge’s first book, The Fifth Discipline.1 At the time,
she was working in curriculum development fora government agency. A few years later, we went
into business for ourselves. We took courses from
Innovation Associates in Canada to learn aboutsystems thinking. We then had an opportunity to© Thinkstock

Henry and I had no idea how
important “planning for limits”
would become to helping us todeal with the most profounduncertainty of our lives –my cancer diagnosis.
In February 1995, we met Peter Senge andCharlotte Roberts at a presentation in Edmonton.
Marilyn asked for their signatures in her copy of
The Fifth Discipline Fieldbook.2 She had used it somuch in testing the activities with others that it
was falling apart. I remember both Peter and Charlotte being surprised at the condition of the book.
The book was ragged because we used it in learning circles once a month. These learning circles
were open to anyone. We started in our home andthen moved to hotel meeting rooms owing to thenumber of people wanting to attend. We decided

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R E F L E C T I O N S | V O LU M E 12, N U M B E R 3

to focus on the systems archetypes, or universal
patterns that describe patterns of behavior incomplex situations. At the time, researchers andpractitioners at MIT’s Center for Organizational
Learning had developed 10 archetypes that described negative or undesired patterns of behavior.
For example, “Fixes that Fail” summarizes a patternof behavior in which people react to a problem
in real time without considering possible
negative side effects. (See Table 1 on page 26.)

When we found ourselves in theemergency room faced with anuncertain, ambiguous situation,
we turned to our learning system
for guidance.
People in our learning circles found these archetypes very useful in understanding the complexityof their situations and were able to take more
effective actions as a result. They noticed that thearchetypes made it easy to have a respectful andhonest dialogue about what was really goingon in their situations. At the same time, the test
groups also wanted a way to understand what wasworking in their situations. As a result, Marilyn andI developed 10 complementary positive archetypes that describe positive or desired patternsof behavior. (See Table 2 on page 27.)
When we found ourselves in the emergency room
faced with an uncertain, ambiguous situation, we
turned to our learning system for guidance. Thisapproach gave us a language for sorting throughthe information we had and planning for the near
future. Even though our emotions were runninghigh, framing the information using the positiveand classic systems archetypes helped to put us
in a logical mindset rather than running purely on
emotions. It helped us to identify the key variables
and maintain a level of control of what initially felt
like an uncontrollable situation.

The definition of “Planning for Limits” is that you
continuously identify, monitor, and plan for limits
that may occur and/or are occurring in the system.
These limits are constraints or pressure. For us, theimmediate pressure was related to client work.
Over the longer run, the 20 classic and positive
archetypes gave us a way to come up with what
we thought of as a strategic plan and to evaluate
and test different courses of action. Other people
in a similar situation may find a different approach
useful. The key is to find a way to sort through thereams of information and make meaning from it,
to turn chaos into complexity. For us, the archetypes provided a shorthand language and setof storylines to guide our thought process andcommunication.

Living in Ambiguity
M A R I LY N
From a linear perspective, there is only one truth.
We can know it, and thus we act as if it is true. If
something tells us that our truth is not true, weeasily deflect this by saying that whatever is happening is the problem, not our truth. We easily
believe that the stories we tell about the patterns
we live are accurate reflections of reality. We
believe we know what we need to know about
the system, so we operate as if we know enough.
We believe that the rules are fixed and that there
is only one way to work within the system, andwe must follow that one way.
I knew I had strong linear thinking tendencies,
but never realized just how strong they were. My
experience with cancer taught me just how deeply
linear thinking was ingrained in my ways of operating. I was shell-shocked and deeply woundedby five months of chemotherapy treatment; now I
was in “recovery,” a hopeful place, a place of return.
I was convinced that I would now regain my ability
to think clearly once again, to walk and run andride my bike, to visit with friends and family, andto go out for evening events like the ballet. I
would be myself again. That’s what recovery
meant to me. All I needed to do was to figure out

F E AT U R E | H E R A S Y M O W Y C H A N D S E N K O

when recovery officially started. Then I would
be on my way back to health and to work.
My last chemo was on July 14, 2009. Add three
weeks for the chemo to do its thing. According
to my calculations, my recovery would start on
August 4, 2009. Instead of feeling sicker and sicker,
I would now be feeling better and better. That’s
what my oncologist told me would happen, so
that’s what I expected.
You can hear the linear thinking in my plans toreturn to normal. There is a normal life that I have,and I will return to it. I recall talking with my oncologist and saying, “I’ll be back at work by October
2009.” This was my truth, and to me it was the only
truth. But, like everything else in my cancer experience, my recovery would prove to be the exception to the rule.

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chemo, I would complain bitterly about how ill
I felt. It felt as if the chemo was still acting on me
well after the infusions, even though I was toldthat the chemo was flushed out of my system intwo days, so I was simply feeling the effects fromthe damage left in the wake of the drugs.

What I had failed to understandwas that in my body, in my mind,
and in my spirit, something had
irrecoverably changed.
© Thinkstock

From a nonlinear perspective, truth is an emergent
and dynamic property of a system. We cannot
know truth, because stories and narratives on
which truth rests are socially constructed. The
stories we tell about the patterns we live create
relational expectations, possibilities, and constraints. We appreciate that we can only understand the partial system, and that stories told cannot be accurate representations of patterns lived.
We know little about the system, so we operate asif we do not know everything. We believe that therules are emergent. The system is dynamic, so we
can learn as the system changes. Our learning inturn changes the system, thus creating new rules.

Even though my treatment
was over and the drugs had
supposedly cleared from my system,
the damage from the drugs was still expressing
itself. Nobody could tell me why I was feelingworse and not better. After all, most people on
this form of chemo went back to work withina month of ending the treatment.

What I had failed to understand was that in mybody, in my mind, and in my spirit, something had
irrecoverably changed. It would take me morethan two years to realize this. I would hold on to
my belief that I would get better until the day mybelief would be shattered and swept away. I didn’t
read the signs very well. How could I? I had neverbeen here before. On the day my recovery was
supposed to start, I actually felt worse, not better.
It was almost as if I had had a chemo treatment.
What was happening to me was much more complex than I understood at the time. After each

Being a person who needs a reason for everything,
I went in search of an explanation. When I couldn’t
find any, I made up my own. What I think happened to me was something called the cumulative
effect. The oncologists talk about the cumulative
effect during chemo, in terms of producing cumulative side effects. In other words, the side effects
get worse with each treatment. Oncologists arequick to point out that the side effects start diminishing once treatment is over. But what if the treatment did more damage to my body than to mostpeople’s because it is so sensitive? What if my26

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T A B L E 1 Classic Systems Archetypes

Description

Mental Model

Key Strategy

Limits to Success

Success or growth is leveling off
or declining.

“We’ll get bigger and better bycontinuing to do more of what weare doing now.”

Identify the limit that is causing
the decline, then plan for that
limit.

Success to theSuccessful

Decisions are being made in allocating resources, so that one party
is getting attention and resourcesat the expense of another party.

“Because that person (department,
project) is successful, they must be
good and others are not.”Avoid win-lose situations inallocating resources. Find ways tomake teams collaborators rather
than competitors.

Tragedy of theCommons

Everyone is using a common resource that nobody owns. Overall usage goes up, but returns to
individuals go down. Eventually,
the resource may be destroyed.

“This resource belongs to me.”Or “This resource is so vast that it’ll
never run out/collapse.”

Identify the common resource andhow people are drawing on it. Then
work with users to plan how toallocate and/or limit access to theresource.

Growth andUnderinvestment

We neglect or are unable to invest
in the capacity to succeed.

“We don’t need to invest in
capacity; we can get through thepresent crunch by applying greater
effort. We can invest down theline.”

Identify the limited capacity that is
causing the heroic efforts. Recognize the unintended consequencesof the current course of action,then plan to invest in capacity or
to deal with the consequencesof choosing not to do so.

Fixes That FailAll the quick fixes we have tried
have worked at first but the problem
keeps getting worse.

“Time is money, and neither time
nor money should be wasted.
Therefore, the first answer must
be the right one.”

Identify the quick fix and understand how it has undermined along-term solution. Take robust
actions that solve the problem
once and for all.

Shifting the
BurdenWe know the fundamental solution,
but are unwilling, or unable, to takeit, so we implement a symptomatic
solution and deal with the side
effects.

“We know what we need to do,but it’s too difficult to deal with, so
let’s put on a bandage instead.”

Identify the addictive behavior
to the symptomatic solution. Thencommit to implementing the fundamental solution, no matter
how difficult it may be.

Drifting Goals

We have lowered our standards toclose the gap between the actualand desired performance.

“Our current level of activity is
acceptable, even though it is below
standard.”

Identify the goal and how it has
shifted. Recommit to or possibly
redefine the goal. Then stay
focused on the goal.

Escalation

Each party sees the other’s actions
as a threat and responds in a waythat threatens the other.

“We’re under attack or being
threatened, and we need to takeaction to defend ourselves.”

Identify the threat, how it is perceived, and how it is escalating.
Then stop reacting to the situation.

Accidental
Adversaries

Each party is doing something thatis undermining the other party’s
success.

“What that person is doing ispreventing me from accomplishing
my goal.”Identify each other’s goals and see
how they have put the two sides inan adversarial position. Then seek
ways for both parties to accomplish
their goals.

AttractivenessPrinciple

We are trying to be all things to
all people.

“We must please everybody allof the time.”

Identify actions you are taking
to appease others. List your own
goals, then make choices about
what you will do and what you
will not do. Stick to your decisions.

Reprinted from Herasymowych, M., & Senko, H. (2004). “’Positive’ Systems Archetypes,” The Systems Thinker, Vol. 14 No. 5.

F E AT U R E | H E R A S Y M O W Y C H A N D S E N K O

T A B L E 2 “Positive” Archetypes

Description

Mental ModelClassic Archetype

Plan for Limits

We identify, evaluate, and plan
for limits.

“We can overcome limits byplanning for them.”

Limits to Success

Strut Your Stuff

Decisions are being made inallocating resources to give appropriate attention to all parties.

“We can create win-win situations
for everyone, including the organization as a whole.”

Success to the Successful

Collective
Agreement

Everyone collectively agrees on
overall use of a common resource.

“This common resource belongs
to everyone.”

Tragedy of the Commons

Invest for Success

We take actions to invest in future
capacity.

“Investing in the future is the key
to success.”

Growth and Underinvestment

Fixes That Work

We identify possible side effectsof short-term fixes.

“We consider possible alternatives
and their side effects before acting.”

Fixes That Fail

Bite the Bullet

We are willing and able to invest
the time and effort required to
implement the fundamental
solution.

“We take responsibility and spend
the time and effort required to beeffective, even if it’s difficult.”

Shifting the Burden

Stay on Track

We monitor, evaluate, and adjust
performance standards in orderto achieve our goals.

“We know where we are going andwhat it will take to get there.”

Drifting Goals

Cooperative
Partners

We work together and communicate openly for our collective
success.

“There is always a way for us towork this out together.”Accidental Adversaries

Win/WinAll parties pay attention to theirown behaviors.

“We can work this out, so thateverybody wins.”

Escalation

Be Your BestWe have boundaries of what we
can and cannot do.

“We cannot please everybody.”

Attractiveness Principle

Reprinted from Herasymowych, M., & Senko, H. (2004). “’Positive’ Systems Archetypes,” The Systems Thinker, Vol. 14 No. 5.

body just couldn’t take the cumulative effect that
occurred from successive rounds of chemo? What
if my body was in breakdown and the side effects
in runaway, like a semi-tractor trailer that loses
its brakes as it is going down a hill and can’t stop?
My side effects were gaining speed and effect,with no exit runaway lane to slow them down.
Even though I was no longer receiving chemo,
the cumulative effect of six rounds of chemo
was still affecting me.
You interpret reality from the stories that you tell,
the stories that you live, and the stories yet to be
told. These stories are called patterns of meaning

and action. When we tell stories about our experience, they help us to make sense of that experience.
Often, our stories are not that useful in helping
us to understand the system in its more complex
sense. But they can help us to cope with situations
for which no explanations exist.
By October 2009, I was so sick that my oncologist
was unsure as to whether or not to start me on the
two-year maintenance treatment. I was nauseated
all of the time. I couldn’t walk without the aid of
a walker or canes. I was muddled, unable to think
clearly, and having difficulty remembering andcarrying on conversations. I had debilitating deep-

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muscle hip pain. I had severe neuropathy (anumbness in a glove-and-stocking pattern, frommy waist down and from my elbows down). I was
always exhausted, without enough energy evento get through a day without an afternoon nap.
I remember asking whether doing the two-year
maintenance treatment would really delay thecancer coming back. My oncologist said yes, butthat my subtype of cancer was so rare that nostudies had been done on it.

Whether I liked it or not, I was now
fully entrenched in the nonlinear
world of cancer – cancer
treatments, recovery, andsomething called a new normal.
Henry and I didn’t know what to do. Before our
appointment, we had discussed the options. The
oncologist said that he wasn’t sure what kind ofside effects I would get but that most people don’t
get any. It was logical to assume that the side effects would be much less than before, because I
was now only taking one drug, not four, and of thefour, Rituxin had the fewest side effects. It was anightmare: there was no certainty, no stability,
and certainly no one truth.
I couldn’t find my way back to the comfort of mylinear thinking. All I knew was that I was terrified,terrified of the cancer coming back, terrified ofgoing through chemo again, terrified of yet moretreatments with Rituxin for the next two years.
We had no data on what would happen to me
if I received just Rituxin. So, I closed my eyes andjumped. I took the Rituxin treatment. I was soscared during the infusion that I started reacting
to it before it even started going into my body.
I didn’t realize it at the time, but my body wasrebelling. My body was saying no, but I couldn’t
hear it. I never recovered, and even though I got
a bit better, I never returned to any semblanceof normal.

Whether I liked it or not, I was now fully entrenchedin the nonlinear world of cancer – cancer treatments, recovery, and something called a newnormal. My world had changed forever. Even if
I got better, I now lived with an incurable cancer
that would return again and again about every
four to five years. When it came back, I would be
subjected to such withering options as morechemo, radiation, and even a stem-cell transplant,
all of which would probably destroy what little life
I now had. I had been too sick to be scared during
the chemo. But I was scared now. What if I didn’t
get better? What if this was now my life? Henryand I still believed that maybe I just recover more
slowly than other people. It wouldn’t be until
Christmas 2009 that it started to sink in that I
was not going to get much better.
In January 2010, I was diagnosed with a second
cancer, breast cancer. There’s no question that myworld fell apart after the second diagnosis. In January 2011, I entered yet another nonlinear hell. I
had been experiencing drenching night sweats
throughout August-October of 2010, and night
sweats were a possible sign that the cancer wascoming back. The CT scan showed that I was stillclear of any sign of lymphoma, which was really
good news. The bad news was that my neuropathy and lack of ability to walk without aids was
now considered chronic. I now had chronicside effects that would not go away.
Nonlinear systems are paradoxical. Ralph D. Stacey, author of Strategic Management and Organisational Dynamics, states that cause and effect andinterconnections between agents in the system
become unclear because nonlinear systems arevery complex.3 Even though people are dealing
with the system as if it were operating undersimple cause-and-effect rules (linear), the system
is more complex than that and produces contradictory effects. Therefore, complex systems
require counterintuitive or nonlinear thinking.
My life has not returned to the old normal, nor has
it arrived at a new normal. With no linear thinking
left for me to hold on to, I finally surrendered toF E AT U R E | H E R A S Y M O W Y C H A N D S E N K O

the forces of nonlinear thinking. Nothing is as it
seems. What worked before no longer works now.
The lesson that I have learned is that the longer
and harder I hold to my fixed ideas of truth, thelonger and harder it is to move forward.
This is true for all of us, whether we are talking
about our families or world affairs. Holding on no
matter what it costs is a form of linear thinking.
Linear thinking works really well when there isstability, but fails catastrophically when there is
too much instability. Every day, I watch the world
suffocating in its rigid linear thinking as it grapples
with an economic system that no longer works.
For most people, the answer lies in more of thesame and not in something different. Perhaps theworld is simply going through its own form ofchemo, side effects, and failed recovery to realizethat the answers lie somewhere else – in theland of nonlinear thinking.
HENRY
Health issues are generally treated as a problem
to be fixed or solved. During treatment, your problem is identified and solved with a protocol. Most
times this works, but in situations where these
protocols don’t work, you need to consider a nonlinear approach. The nonlinear approach takes
into account the whole human, all systems
interacting internally and externally.
Right off the bat, Marilyn’s situation didn’t fit themold. Even when it was clear that certain protocols weren’t having the desired effect, the doctors
found it difficult to change the treatment plan.
They are trained in a linear mindset, which canbe effective with straightforward diagnoses but
not as effective when they face unanticipated
responses.
We try to approach our lives as learners. In any
new situation, someone begins as a dependent
learner, moves to being an independent learner,and optimally becomes an interdependent learner,
learning in conjunction with others. This applies
to children in kindergarten as well as people
dealing with health crises.

In a healthcare setting, when you are first diagnosed, you are a dependent learner; the medical
professionals walk you through the process of“being fixed,” according to established protocols.
If your case is complex, after a while, you find thatyou need to assume responsibility for learning
about and managing your own condition. You
become an independent learner. Finally, we’ve
observed that when it’s clear that someone can’t
be “fixed” and moves to palliative care, the patientand medical professionals become more of alearning team. The patient and the rest of theteam become interdependent learners. Both parties
are more open to taking a nonlinear approach, totrying small experiments to see what the ripple
effects may be. In palliative care, there’s no one
formula; it’s a process of action learning. The
definition of success – the patient’s quality oflife – changes day to day.

Doctors are trained in a linear
mindset, which can be effectivewith straightforward diagnoses
but not as effective when they
face unanticipated responses.
If you’re open to learning, to trying things, toquestioning your assumptions and rationalizations,
it makes the journey a lot easier. The truth is, you’rebeing put in a situation where you don’t have a
choice whether to try something new. You caneither freeze and not talk about what you’re experiencing, or you can let those emotions come andtalk about them – why this is feeling awkward, why
it isn’t easy, etc. Letting go and embracing the newtakes you to a place you’ve never been before.

The Conscious Unconscious
M A R I LY N
A new science called “cognitive science” is exploding with information on how humans think andhow our thinking gives rise to our behaviors.
Cognitive science covers a broad spectrum including brain research, thinking, neurobiology,

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biochemistry, and psychology. The discoveries
emerging from cognitive science are challenging
the foundation of what we believe as a Westernculture and what it means to be human. For example, we now know that our minds are embodied,that most of our thinking is unconscious, and that
nothing we think about or experience is emotionfree. This changes the way we consider our ability
to exercise free will, and whether or not we canbe rational without engaging our emotions.
I have no question that these recent findings aretrue, especially now, with the experience of twocancer diagnoses, treatment, surgeries, and a protracted recovery. As a result of my first cancer,
non-Hodgkin’s lymphoma, I was given the gift ofobserving what it might be like to die. I was in thehospital, watching myself desperately trying to
get enough breath to sustain myself. My lungs
were screaming in terror, my chest in shock aswater drained uncontrollably off my right lung. It
was Wednesday, March 25, 2009, only two days
after my first chemo treatment.

The discoveries emerging from
cognitive science are challenging
the foundation of what we believe
as a Western culture and what itmeans to be human.
I vividly recall having a chest tube inserted into myright pleural cavity to drain the water off my lung.
At first, it was all so new to me, something I had
never experienced. I had allowed student nurses
to be present during the procedure, so a lot of
people were surrounding my bed. I was listening
to what the doctor was saying and imagining
what it all looked like. It didn’t take long before
I could breathe easily again, as 2.5 L of waterdrained quickly off my right lung. All seemed to
be going well, and everyone left while I rested.
Then suddenly, I was watching myself struggling
to breathe. I was no longer in my body. Somehow,
I was outside of my body, standing slightly besidethe bed, calmly trying to figure out what I should
do. I saw myself frantically pressing the call button. I saw the nurse rush into the room and clamp
off my chest tube to stop the fluid from draining.
I watched everything going on with no fear, noemotion, no curiosity – simply watching andthinking what I could do to help. There was mybody flailing, desperate to breathe. And there
was me watching as if there was no problem.
In his book, The User Illusion, Tor Nørretranders
describes how John Wheeler, a famous physicist,summarized what he believed humans knew
about the world.4 His model is called Wheeler’s U(shown below).
F I G U R E 1 Wheeler’s U

Wheeler believed that the way in which weobserve the universe also helps to create it. For
example, if we think in linear ways, we will see alinear universe; therefore, we will create a linear
universe. When faced with complex nonlinear
problems, we will try to solve these problems inlinear ways, without understanding why our solutions do not work. If we consider that we are also
running in an unconscious mode most of the time,
it is small wonder that we cannot seem to solve
complex problems or take advantage of complex
opportunities. In the situation with the chest
tube, I was the observer watching my body (theparticipant) flailing, desperate to breathe.
But I have also been on the other side, a participant,unable to find the observer in me. When diagnosed
with breast cancer less than a year after being
diagnosed and treated for lymphoma, the world
as I knew it imploded. When the day of surgery

F E AT U R E | H E R A S Y M O W Y C H A N D S E N K O

arrived, I lost it. I couldn’t hold onto myself, and I
became a crazy person, totally irrational and outof control. I went to bed the night before in tears,
crying so hard that I couldn’t breathe. I woke up
in tears, needing Henry to help me to get dressed.
I cried in the waiting room at the diagnostic center.
I cried when I was given a needle with the radioactive tracer. I screamed when the technicians
inserted the surgical wire that would guide thesurgeon to the tumor. I cried when I got into the
car and Henry drove me to the hospital. I cried
while I waited to be admitted into the hospital.
I cried while getting changed for the surgery. I
cried while being wheeled into the surgical waiting area. I cried when the surgeon came to talkwith me, and again when the anesthesiologist
came to discuss the situation with my leg weakness. I cried and cried and cried, and cried somemore. Then the procedure was over, and I
couldn’t cry anymore.
Wheeler’s U demonstrates the degree to which weare thinking and acting from our unconscious. In
their book, Philosophy in the Flesh, George Lakoffand Mark Johnson state that most cognitive operations in the human brain are largely unconscious.5
In fact, it is thought that the estimate now usedthat 95% of our cognition is unconscious is aserious underestimate. They call these cognitive
operations the cognitive unconscious and describe
it as all of the unconscious mental operations andstructures involved in language, meaning, perception, conceptual systems, and reason. This 95%
below the surface of our consciousness shapes
all of our conscious thought. Lakoff and Johnson
call this cognitive unconscious a hidden hand thatshapes the stories we tell about the experiences
we have. Superimposing this 95% unconscious on
Wheeler’s U, you can see that most of our waking
moments are actually unconscious. If we are notaware of how much we do that is unconscious,
we can find it very difficult to think and act ina conscious state.
That day in the hospital with the chest tube, I think
I touched death, or at least the impression of it. As
I observed myself, I was “holding death lightly,” asF I G U R E 2 Wheeler’s U and the Unconscious< 5% conscious> 95%
unconscious

if it were a newborn child lying patiently and contently in my arms. This is an example of melding
the observer with the participant in Wheeler’s U,
from an unconscious state to a more conscious one.

To find the eye in the storm thathas become my life, and to regainsome sense of control, I use all of
the forms of systems thinking I
have available to me.
With the breast cancer surgery, I couldn’t lift myself from an unconscious state to a more conscious one. The trauma was too great, and I succumbed to what was happening, living the nightmare as a pure participant, totally operating frommy unconscious. I was numb, unable to breathe,unable to smile, unable to talk. I got better after a
few days, but I still couldn’t lift myself into a more
conscious state. All I could do was lift the experience into a more conscious state. I could dissect
the experience, but I was still completely grippedby the trauma. I kept thinking about how breast
cancer is a killer. I couldn’t get it out of my mind. I
kept seeing my mother’s face just before she died,writhing in agony as cancer ripped out her humanity and her soul. I was losing my grip on reality, drowning in fear.
To find the eye in the storm that has become mylife, and to regain some sense of control, I use allof the forms of systems thinking I have available tome. Any form of nonlinear systems thinking brings

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the cognitive unconscious to a conscious level,
and with it a sense of control and calm. Systems
thinking brings us out of an observer role in a system and into to the role of a participant-observer
within the system dynamic.

conscious level, to bring us into the role of a participant-observer within the situation in which wefind ourselves. Once we are conscious of the factthat we are operating from our cognitive unconscious, we can make choices about what we want
to do with this knowledge – how we think and act.

F I G U R E 3 Wheeler’s U and Systems Thinking< 5% conscious

Systems thinking
brings theunconscious to a
conscious level> 95%
unconscious

According to Lakoff and Johnson, unless we gain
an understanding of the cognitive unconscious,and its effect on our thinking and actions, we cannot easily create new ways of thinking and acting.
The key is to bring the cognitive unconscious to a

I have few choices now in terms of what I can dowith my life. None of these choices, in my opinion,
are good choices, and all of them are hard. The
trick for me is to be able to live a life worth living,while in the grip of two incurable and advanced
cancers, and the side effects of treatment. To me,
this means living both the participant and theobserver experience simultaneously. I don’t know
if I can ever shut off the fear and anxiety that is
now so much a part of my life, and deeply embedded in my unconscious. But this cancer experiencehas shown me that it is possible to hold both places
together, as I did when I had the chest tube inserted
in my pleural cavity. The participant and observer
don’t necessarily cancel each other out. Rather,
they find a way to co-exist. !

ENDNOTES
1 Senge, P.M. (2006). The Fifth Discipline: The Art and Practice of the Learning Organization, Revised Edition. Crown
Business.
2 Senge, P.M., Kleiner, A., Roberts, C., & Ross, R. (1994). The Fifth Discipline Fieldbook: Strategies and Tools for Building a
Learning Organization. Crown Business.
3 Stacey, R. D. (2011). Strategic Management and Organisational Dynamics: The Challenge of Complexity to Ways ofThinking About Organisations, Sixth Edition. Prentice Hall.
4 Nørretranders, T. (1999). The User Illusion: Cutting Consciousness Down to Size. Penguin Books.
5 Lakoff, G., & Johnson, M. (1999). Philosophy in the Flesh: The Embodied Mind and Its Challenge to Western Thought.
Basic Books.
ABOUT THE AUTHORS
Marilyn Herasymowych is a founder and a managing partner of MHA Institute Inc. If you’d liketo know more about Marilyn’s cancer journey, check out her Cancer Broke All My Pencils blog.
marilynh@mhainstitute.ca
Henry Senko is a founder and a managing partner of MHA Institute Inc. henrys@mhainstitute.ca
In 2011, Henry and Marilyn won the University of Alberta Faculty of Extension 2011 Award for
Excellence in Program Innovation and Design for Lifelong Learning for their “Leadership ThroughLearning” program.

C O M M E N TA R Y | T I P T O N

CO M M E N TA R Y 12.3

Commentary
E M I LY T I P TO N

I
Emily Tipton’ve known and worked with Marilyn Herasymowych and Henry Senko as an associate of
the MHA Institute for more than 10 years. When I first met them and was introduced totheir work in action learning and systems thinking, I was struck by what a difference thistype of learning system made to clients’ abilities to think and act more effectively. Applying
this work first in the oil industry and subsequently with software companies and government, I was fascinated by its seemingly paradoxical nature: the simplicity of archetypes incontrast to the organizational complexities in which they can be effectively applied.

A New Application
For Marilyn and Henry, Marilyn’s illness presented a whole new arena for application of these concepts. They reallydo live their work, so it was no surprise to see them turn to the language of systems thinking to try to make senseof their situation. Systems thinking can help people move quickly to a shared understanding of the most complex
problems. When Henry said to Marilyn that first day in the hospital, “I guess we better start planning for limits,” theyboth instantly and intuitively understood what they would need to do to meet the challenges ahead of them. I’ve
seen the use of systems archetypes create this same kind of shared understanding in teams, allowing people tocommunicate recognizable patterns in the system and quickly
move to shared understanding and action. Equally important,Archetypes can be very helpful
in situations like Marilyn and Henry’s, archetypes can be very
helpful in diffusing emotion, which can be a significant barrier
in diffusing emotion, whichto accessing our unconscious ways of knowing.

can be a significant barrier toaccessing our unconscious
ways of knowing.

One of the more profound aspects of Marilyn and Henry’s
learning system is that it focuses on moving forward in a nonlinear way through a cycle of reflection and action. Throughout
this health crisis, they have remained open to learning and toquestioning their assumptions and rationalizations. Continually focusing on both participating and observing
has allowed them to freely express their emotions and convey information about what they are going throughto family, friends, and colleagues.

I was shocked when Marilyn started sending emails to hundreds of people about her health. She told them what
the doctors said, what would happen next, and how it made her feel. I remember the initial email in which Marilyn
talked about her first experience with chemotherapy. She described how the treatment cycles worked, how manydifferent drugs she had to take, and how the drugs were designed to both attack the cancer cells and destroy
her immune system. She explained that it would be difficult for her to have visitors during the next 6–8 months
because her immune system would be so weak. She was on four different chemotherapy drugs plus a host ofother medications to control the side effects. Marilyn joked about feeling like a pharmacy and about losing
her hair. She talked in some detail about how the drugs made her feel and the side effects.

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At first, I couldn’t fathom Henry and Marilyn’s commitment to keeping us all so well informed with these emails.
But I soon came to realize that it was part of the learning process for them. It was such a relief not to have to wonder and worry about what Marilyn was going through. I felt as though I was part of the experience, as if I was on
the roller coaster with her. Perhaps that’s why the process has affected me – and others – so profoundly.

Adaptation Planning
Throughout her journey, I watched Marilyn vacillate between linear and nonlinear approaches to making senseof her situation. News of a life-threatening illness offers some sense of when or how we will die. It is natural towant more detail, more specifics about how long our life will be and how things will unfold for us. Our usual linear
thinking draws us into a certain set of expectations of what “should” happen and how things “should” be insteadof giving us the opportunity to become fully conscious of our new reality.

Our usual linear thinking
draws us into a certain set of
expectations of what “should”
happen and how things“should” be instead of giving
us the opportunity to become
fully conscious of our new
reality.

The same archetypal patterns are apparent in the world’s
response to the complex problems we face. With climate change,
the actions of the past and present will have a significant but
highly uncertain impact on the distant future. By relying onlinear scientific models, we have become fixated on andcomfortable with predicting what will happen. We spend an
extraordinary amount of time and money understanding thepotential impact of global warming. We want to know how highthe sea level will rise, how much hotter and drier the summers
will be, and how much more rain we’ll get in the winter. We
seek to determine the “one” truth and to “know” precisely
what will happen before we take any actions.

But adaptation planning is different. Instead of planning for a particular outcome or planning for the purposes ofcontrolling future outcomes, adaptation planning is about building our capacity to adapt to uncertain outcomes.
It is about developing community resilience, support structures, emergency response, and resources. It is about
accepting that outcomes are uncertain, about letting go of our need to find “the” truth or to fix the problem. And it
is about understanding that we ourselves are part of the system, continuously changing and adapting in concert
with it.

A New Perspective
Marilyn’s experience with two cancers and her commitment to learning from the experience both as participant
and observer has inspired me to examine many of my own personal experiences from a new perspective. I’ve
started to be more conscious of systems versus linear thinking, not just at work but also in my personal life. For example, a systems perspective has helped me reflect on my relationship with my eldest son when he was an infant.
I was educated as an engineer and spent much of my career in various project management roles. I approachedmotherhood as a project and was quite confident that I would be able to strategize, organize, and manage all
aspects of this new role in my life. But I was unprepared for the emotional side of motherhood. At nearly one year
old, my son was still waking me several times a night and adamantly wanting to nurse, because that’s how hesoothed himself.

C O M M E N TA R Y | T I P T O N

At the time, I felt as though I was trying everything, but I found it challenging to be consistent. When my son wasteething, when we were traveling, or when I was just too tired to do anything else, I would succumb and nurse him,even though I knew I was reinforcing the very behavior I wanted to stop. I found the situation difficult on so many
levels – my rational and emotional selves were not aligned, it was hard to communicate the decisions I made in thewee hours of the morning to my (very supportive, but frustrated and sleep-deprived) husband, and I was desperate
for sleep. I believed that I was somehow failing to solve this problem, when every other mother in the world
seemed to have it beat.
What I didn’t understand at the time was that my son was not a problem to be solved. Instead, I needed to start
thinking about him and his sleeping patterns as a mystery to be explored. When I began treating my children as
opportunities to learn instead of problems to be solved, my feelings about the situation shifted. It is not wrong todesign rules or try different things I read in books, but it is wrong for me to expect my kids to respond in certain
ways and for me to feel like a failure when they don’t live up to those expectations. I have learned that when I tella story about how my children and I have failed, I am focusing on a linear truth, a single solution. Instead, when
I am able to openly observe and learn from how we are behaving,
I can parent mindfully and consciously.
Through their example, Marilyn and Henry have shown me thatwhen we truly take this work home, inside ourselves, we are able
to use our most difficult experiences as human beings to learn
from the system in which we are operating, rather than remain a
victim of circumstance. When we let go and bring our observer
into our consciousness, we empower ourselves by accepting theuncertainty and learn to better appreciate each small momentof our lives. !

When we let go and bringour observer into ourconsciousness, we empower
ourselves by accepting theuncertainty and learn tobetter appreciate eachsmall moment of our lives.

ABOUT THE AUTHOR
Emily Tipton, a professional engineer and sustainable development consultant, has been an associate of MHA
Institute for over 10 years. emily.tipton@gmail.com

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F E AT U R E 12.3

Change on the Scale of the Whole:
Health, Peace, and Prosperity for All
V I C TO R G A R C I A
As a pediatric surgeon at one of the world’s most prestigious children’s hospitals, Dr. Victor Garcia was deeply
disturbed by the growing number of children being admitted with intentional gunshot wounds. Determined
to find a fundamental solution to the cycle of poverty and violence that plagued the city’s “inner core,” Garcia
turned to Peter Senge’s work on systems thinking and David Cooperrider’s Appreciative Inquiry methodology
for guidance in creating sustained “change on the scale of the whole.” Victor gives an overview of theworsening trends buffeting many of our inner cities and the steps a group in Cincinnati has taken to begin
to turn the tide in a more positive direction. By building on the community’s inner strengths, this groupseeks to promote true health and prosperity for all of the city’s residents and stakeholders.

M
Victor Garcia

y purpose in this article is twofold; my messages are three. It’s
my strong desire both to inform you and to persuade you. The
messages are as follows: Cincinnati, Ohio, like many urban communities, has a violence problem. But it goes beyond violence, eventhough that’s the one social issue that dominates the headlines. We have, in asense, a perfect storm, a constellation of health and social disparities (including
violence) whose trends are worsening, threatening generations and impacting
the lives of all of us who live in Cincinnati.

Second, our current ways of thinking and responding to these worsening trends not only leave much to
be desired, but in many instances have opposite the intended consequence. Third, there is a better way
that takes into account the diversity, interdependence, connectedness, and adaptability of the entities
involved. Although we have a number of imperatives that threaten the livelihood of a segment of ourpopulation and thereby our city, the power and potential of systems thinking and Appreciative Inquiry
can transform the city and bring about the sustained, large-scale change of the whole that we’ve been
pursuing for decades, if not generations. If you come away with only these three points, then I will haveachieved my goal.

Images of a Better Future
I’d like you to take a moment and imagine something. Imagine a world in which we have buildingsthat actually create energy as opposed to consume it, and that the excess energy that these buildings
generate is shared with other buildings. Imagine, if you will, that many commercial buildings areregenerative and produce energy that can then be fuel for other industries.
Imagine corporations like BMW, Nike, and Costco collaborating openly with the World Wildlife Foundation,social institutions, and nongovernmental organizations to bring about a more sustainable world. And

F E AT U R E | G A R C I A

imagine that these organizations are guided byindividuals who willingly share their insights andknow-how with other organizations and communities that also truly aspire to create a different
kind of future.
Finally, imagine that local communities such as
Cincinnati offer a multitude of opportunities forevery citizen, regardless of his or her station in life,
to create value – meaningful, purposeful value.
I have come to realize that the poor are some ofthe hardest working and most creative individuals
around. Young people who survive beyond their
20s in the urban core are creative by necessity. In
this scenario of a better future, organizations andbusinesses find a way to harness that ingenuity
and aim it in a direction that makes the community as a whole better.

for all. But let me bring into sharp relief the challenges that we currently face. As recently as 2006,
Cincinnati had the dubious distinction of having
the highest homicide rate of any city in the state.
In fact, the homicide rate surpassed that of Chicago,
Illinois, and Atlanta, Georgia. Our homicide rate isstill four times the national average. What should

We have a perfect storm, aconstellation of health andsocial disparities whose trends
are worsening, threatening
generations and impacting the
lives of all of us who live inCincinnati.

Disturbing Trends
I want you to know that individuals and organizations with this kind of vision do exist and are working in Cincinnati to bring about a safe, sustainablecommunity that will provide health and prosperity

be clear by now is that as a society we cannot andwill not “arrest ourselves” out of this predicament;
the violence persists, despite the number ofpolice officers we put on the streets.

37© Thinkstock

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injuries; they were intentional gunshot wounds. If
this epidemic stemmed from an infectious disease,the public would demand immediate action toaddress it.
What further disturbed me was that we wereseeing younger and younger children coming in,in some cases with repeated gunshot wounds.
This to me was intolerable, unconscionable, andchallenged me to ask what more I could do. It also
drew me to the research that contends that urban
violence and related health inequities are “social
diseases,” arguably more a consequence of thesocial context where people live rather than ofindividual deficiencies. When we look at othersocial trends in our city, we find that we have thehighest infant mortality rate in Ohio. There aredeveloping countries with better survival rates
for their infants, Cuba being one. An explanation
for this state of affairs is related to the homicides
and other societal factors in our inner city.

A Perfect Storm© Thinkstock

The United States has thehighest incarceration rates in
the industrialized world.
But what was most disturbing and compellingfor me as a pediatric surgeon at one of the world’s
most prestigious children’s hospitals – where we
pride ourselves on the excellent care that we
provide for children who come within our walls– was the nearly 300-percent increase in the number of children coming to the medical center withgunshot wounds. And these were not accidental

In 1997, Margo Wilson and Martin Daly publishedin the British Medical Journal an analysis of 10
neighborhoods in Chicago suggesting that theneighborhoods with the lowest life expectancy
had the earliest fertility.1 Basically, what that figure
shows is that men and women with limited resources, recognizing that their life expectancy was
20 or 30 years shorter than for their peers in mostother neighborhoods, were engaging in multiplepartner fertility because they didn’t know how
long they would live. Life expectancy, economic
inequality, homicide, multi-partner fertility, andreproductive timing were interrelated. This multipartner fertility led to an extraordinarily high infant mortality rate, with some babies being bornthat were not even the size of a pen. What are
the chances of that child living a fruitful andproductive life?
To further complicate the picture, the UnitedStates has the highest incarceration rate in theindustrialized world. We exceed even Russia asa developed country in the proportion of our
citizens we imprison. Indeed, we have surpassed

F E AT U R E | G A R C I ASouth Africa at the height of apartheid, in termsof the percentage of the population that isincarcerated.
The prison-industrial complex contributes to thisperfect storm. An individual who does not graduate from high school has a 50 percent chance ofgoing to prison. Ninety-three percent of those incarcerated are later released, but they’re released
with a felony record that permanently changes
their lives. In fact, two-thirds of the young men
who are released from prison are re-incarcerated
within three years, principally because theycannot find work.
This phenomenon of mass incarceration that
we find in areas of concentrated disadvantage has
now been recognized as one of the major factorsthat fuel the epidemic of violence in communities
around our country. Noted civil rights attorney
Michelle Alexander appropriately characterizes
it as “The New Jim Crow.” In longitudinal studies,
urban sociologist Devah Pager from Princeton
demonstrates that when people’s life chances
are so permanently altered, it contributes tothe perpetuation of poverty, recidivism, and reimprisonment. Other research suggests that thispolicy of mass incarceration, which we haveembraced with almost fanatical delight, directly
harms the disadvantaged communities thepolicy intends to benefit.

Breaking the Cycle
So a perfect storm of high infant prematurity
and infant mortality, poor educational achievement, low skills, no skills, joblessness, youth gang
violence, and mass imprisonment – along withthe related epidemic of obesity and diabetes,
especially among children – is not only is destroying our communities and our cities but in somerespects is also irrevocably compromising thehealth of our children. Many of us would ask, “Whyis this happening despite our best efforts?” I would
suggest that the reason is that we’re focusing on
the events, and much of our public policy is not
informed by the best available evidence of root
causes. When we focus solely on the events, wehave only about a 10-20 percent chance of successin bringing about permanent change.2
Systems thinking gives us a way to look below thesurface and beyond the events and patterns of
behavior into the system structure to determine
the fundamental solutions. A group of us in Cincinnati has embarked on this discipline with thehelp of Peter Senge, perhaps the foremost
thought leader in the practical application of systems thinking and the creation of “learning communities.”

A perfect storm of high infantprematurity and infant mortality,
poor educational achievement,
low skills, no skills, joblessness,youth gang violence, and mass
imprisonment – along with therelated epidemic of obesity anddiabetes – is destroying our cities.
Through our work with Peter, we’ve learned thatthe symptomatic solutions we’ve tried to date tocombat this negative dynamic in our community
merely feed the cycle so that it continues and continues and continues – the quintessential reinforcing loop. Only when we have the courage to “reflect” and “inquire” and have the conscious will tolook at fundamental solutions will we be able tobreak the cycle.
It is our addiction to the quick fixes that has left us
in the situation we are in today. You might ask,
“Why is it so difficult to bring about sustainedchange?” I would suggest part of the problem isthat we think we’re not part of the system, that thesystem is out there (especially as it relates to the“ghetto”) and we, as noble change agents, are here
to fix the problem. When we excel at seeing thesystem, we come to recognize that we are part ofthe problem. And only when we’re able to look at
our role as contributors will we be able to bring

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R E F L E C T I O N S | V O LU M E 12, N U M B E R 3

about an open awareness of what’s possible andwill positive changes begin to take place.

What Is Good Health?
So the question arises, then, “What is needed toachieve good health?” Sociologists suggest that
good health is not really about healthcare. Researchshows that a population’s health is largely embedded in the social and economic environment. Thisfinding means that health is not just about medical care or the quality of health within a hospital.
Good health means housing policy. Good healthmeans educational policy. Good health means
economic justice and economic self-sufficiency.
Good health means an antiviolence policy that isbased in systems thinking. Sociologists have longrecognized that health campaigns focused solely
on changing individual behavior are naïve because individuals’ choices are most often limitedby their social context.

Through a series of brilliant
accidents, necessary failures,
attempts to bring about sustainedchange, and improbablebreakthroughs, I've come to theconclusion that change on thescale of the whole is possible
in our lifetime.
With humility and some vulnerability, we havecome to acknowledge that too many of our fellow
citizens in Cincinnati are not benefiting from orcontributing to a healthy, prosperous quality oflife. As a consequence, we all suffer.
And so the question further arises, “How do we
make an unhealthy neighborhood healthy?” Basedon our new understanding of systems thinking,
I would submit that it’s not with quick fixes or
symptomatic solutions, but with what we refer toas “change on the scale of the whole,” which thenfurther begs the question, “Can it occur? And canit be sustained?” Through a series of brilliant accidents, necessary failures, attempts to bring aboutsustained change, and improbable breakthroughs,
I’ve come to the conclusion that change on thescale of the whole is not only possible, but it ispossible in our lifetime.

A “Brilliant Accident”
One of the brilliant accidents I experienced wasmeeting Peter Block, who introduced me to John
McKnight and his theories on asset-based community development, to Byron White, who at thetime was vice president for University Engagement
at Cleveland State University, and to Peter Senge,
who in turn introduced me to David Cooperrider.
David Cooperrider is the founder of a field of practice called Appreciative Inquiry. The consequenceof this series of events was an immersion in systems
thinking and related disciplines, and an understanding that, in order to bring about sustainedchange, we need to develop three core learning
capacities:t TFFJOHTZTUFNTBOEPVSSPMFBTQBSUPGUIPTF
systems,t DPMMBCPSBUJOHBDSPTTCPVOEBSJFTJOBXBZUIBU
has not been done before and typically cannot
be done without some particular skills, andt DSFBUJOHUIFEFTJSFEGVUVSF OPUQSPCMFN
solving or reacting to the crisis, but envisioning
the future that we desire for this city.
We designed – and continue to design – initiatives based on systems thinking and Appreciative
Inquiry to engage all the stakeholders in Cincinnati.
All corners are represented. Everyone is convened.
Everyone is at the table. And everyone is involvedin a generative, empathic conversation about
the future.
Appreciative Inquiry is different from most other,
if not every other, change initiative, 90 percentof which ultimately fail. The reason Appreciative
Inquiry has resonated with people, not only globally but with those of us in Cincinnati who are
working on this initiative, is that it is asset based.
This means that we look at the positives in the individual, in the community, in the neighborhoods,

F E AT U R E | G A R C I A

and in our city. And we leverage those so that ourstrengths then surpass our weaknesses or, as Peter
Drucker says, our weaknesses become irrelevant.
Together, Appreciative Inquiry and systems thinking frame the focus that inspires the entire community and motivates all stakeholders to work
toward creating this vision of a safe, sustainable
Cincinnati. As Peter Block has taught us and longespoused, through conversations that matter,
we can transform this vision into a reality.
We acknowledge that it will take a sustainable systems approach to bring about the kind of changes
that we desire. We can accomplish this outcome
in our lifetime by collaborating in a way that has
not been previously achieved. As a first step in thisjourney, in 2010, we organized a workshop basedon the Appreciative Inquiry methodology.

41

Appreciative Inquiry is distinctly different from
more traditional approaches to change. Rather
than focusing on solving problems, AI looks at
the community as a living system and in sodoing focuses on:t BQQSFDJBUJOHXIBUHJWFTMJGF XIBUTXPSLJOH 
and what’s best;t JNBHJOJOHXIBUDBOIBQQFOt EFTJHOJOHXIBUmight be; and thent DSFBUJOHXIBUwill be.

We are so focused on thenegatives within a communitythat we don’t realize that, withinthat same community, enormous
strengths exist.

Initial Steps with Appreciative Inquiry
David Cooperrider pioneered Appreciative Inquiry(AI) at Case Western Reserve University in Cleveland, Ohio. It has been applied not only in individual communities throughout the country, but innations throughout the world. In addition to its
application in business settings, it has been used
to address issues ranging from large-scale ecological challenges to social issues such as poverty.

On September 11, 2010, David Cooperrider andPeter Senge hosted a workshop at the Cintas Center at Xavier University in Cincinnati. Initially theevent was supposed to involve 70 people, but it
grew to 120. We had to turn individuals away justbecause of the limited room capacity. Participantslearned how to harness the power of systems
thinking and Appreciative Inquiry to create the© Thinkstock

42

R E F L E C T I O N S | V O LU M E 12, N U M B E R 3

future that we all want. They learned about what
we currently know about change in human systems,
especially change on the scale of the whole, which
so many people think is improbable. And they
took away lessons and insights about what itreally takes to collaborate at a systems level.

was that these individuals were talking with eachother, not at each other. They did so in a generative, empathic way, understanding the limitationsof the human condition and with the knowledge
that what we say and what you hear are notnecessarily always the same.

At this workshop, we had CEOs listening intently.
But we also had gang members, former gangmembers, community residents, and community
activists listening equally intently. More important,
and what I found most touching and poignant,Once we got everybody to appreciate – or atleast exposed them to – the concept of systems
thinking, we transitioned into the power of tapping our inner strengths. We are so focused on thenegatives within a community that we don’t realize that, within that same community, enormous
strengths exist. How can we tap those? How can
we help these inner strengths erupt like a volcano,in a positive sense, to create our vision of abetter future?

Quotes from Summit ParticipantsPeter Strange"It will be impossible to be a high-end builder in communities where people don’t want to invest. In order for us to havea future, we’ve got to be part of creating vibrant economic
environments where every citizen has the opportunity andthe motivation to be part of value creation."

Carl Satterwhite“We have to think differently. Because the reality is that we
do have to give these young people some opportunity. It
don’t matter how big the wall, how big the gate, no matter
how we are in our own communities. It’s folks who don’t
have coming to get. And eventually, they’re going to stoptrying to get it from each other, and come and get it fromus who have. So we’ve got to try to work with them.”

Doug Hall“We’ve got to get jobs, straight up. People need jobs.
But we’ve got to give them jobs that have a future.”

Joe Prather“We’re used to people always coming to the neighborhood
house and telling us what we should do and how we should
do it. So we’re like, we ain’t about to go here and listen towhat they’re telling us what we should do. They don’t evenknow us. We’re from two different sides of life. To change thecity, you have to change the youth. Because a lot of the older
people are already set in their lives. And how you change theyouth, you don’t tell them what to do. But you help them atwhat they want to do.”It was just extraordinary to see the energy,
engagement, and commitment on everyone’s
part. As Byron White says, “Every single personbrings gifts, talents, experiences, and insightsthat are necessary for us to be successful.” This
event underscored how promising the future is
despite the daunting challenges we face.

Appreciative Inquiry Summit
In February 2012, Peter and David, along withMark Chupp of the Mandel School of Applied Social
Sciences at Case Western, facilitated the Core
Change Summit. The Core Change Summit drew
more than 500 residents and leaders who normally don’t work together to address the greatest
challenges in the urban core. The ultimate goal is
to increase employment, educational achievement, and safety in Cincinnati’s core neighborhoods while improving residents’ overall health.
Support for the program came from organizations such as Cincinnati Children’s Hospital Medical Center, United Way, Xavier University, the Cityof Cincinnati, Urban League of Greater Cincinnati,
Cincinnati NAACP, Cincinnati Public Schools,
STRIVE, Elementz (a center that works with neighborhood youth), and local chambers of commerce.
With the Summit serving as the “crucible,” some
15 action teams continue the work of enablingF E AT U R E | G A R C I A

43ArtsWave Paint the Street Public Art Project in 2010 for UrbanCincy – © Jenny Kessler

communities and their citizens to see their individual strengths. The goal is to collectively leverage these assets to create the change the community truly wants. With the added tool of “design
thinking,” a methodology for coming up with positive, practical solutions to challenges, the average
citizen – even those with little formal education –can reclaim hope for and envision a better future
and take steps toward that reality. Three communities are actively working to do for themselves
what the government cannot or will not do. They
are in the process of developing a sustainable business model “in the core, for the core, by the core.”
One project involves building aquaponic systems
that combine aquaculture with hydroponics.
A nascent partnership with Toyota represents
another initiative. These initiatives, which will belocated in and co-owed by the community, areintended to address the disappearance of meaningful, purposeful work in the urban core. As such,they stand to provide a source of community
pride and sense of accomplishment.

The ultimate goal is to increase
employment, educational
achievement, and safety inCincinnati’s core neighborhoods
while improving residents’
overall health.
Gathering “Our Best Minds”
We find ourselves today grappling with the same
conditions that were brought to the surface as far
back as 1899. W.E.B. DuBois, one of the first civilrights activists and sociologists, refuted Frederick
Hoffman’s claims that Negroes in Philadelphia hadmortality rates higher than the white population
because of their immorality, intemperance, andracial inferiority.
Combining scholarship and fervent advocacy,
DuBois demonstrated that if the economic and44

R E F L E C T I O N S | V O LU M E 12, N U M B E R 3© Thinkstocksocial disparities and inequalities were addressed,
the lifespan of the Negro infant would be extended
and approach that of the majority population.
Where we live, where we work, and the neighborhoods where our families reside are more potent
determinants of our life and longevity than germs
and viruses. In his 2007 commencement address
at Harvard, Bill Gates, Jr., asked, “Should our bestminds be dedicated to solving our biggest problems?” He did not pose this question in a rhetoricalfashion, but rather meant it as a sort of challenge.
My wish is for the best minds in our city to join
me and others to deal with some of Cincinnati’s– and our country’s – most vexing and seemingly
immutable problems. !

ADDITIONAL RESOURCES
Video of Victor Garcia at TEDxCincy

ENDNOTES
1 Wilson, M., & Daly, M. (1997). “Life expectancy, economic inequality, homicide, and reproductive timing in Chicago
neighbourhoods.” British Medical Journal 314: 1271-1274.
2

Iton, A. (2006). “Tackling the Root Causes of Health Disparities through Community Capacity Building,” in Tackling
Health Inequities through Public Health Practice: A Handbook for Action, ed. Richard Hofrichter. National Associationof County and City Health Officials.

ABOUT THE AUTHOR
Victor Garcia, MD, is the founding director of Trauma Services at Cincinnati Children’s Hospital
Medical Center, a professor for the Division of Pediatric Surgery, a pediatric surgeon, and co-chairof the CoreChange Initiative. Victor.Garcia@cchmc.org

Reflections
The SoL Journal

on Knowledge, Learning, and Change
Volume 12, Number 3

EDITORIAL TEAMManaging Editor
Janice Molloy
Contributing Editor
Deborah Wallace
PublisherFrank Schneider

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