This is a tumultuous time in healthcare: regulatory burdens, payment reductions, public scrutiny. And the rapidity of change is mind-boggling. All of this would probably be fine, except that people generally resist change, especially rapid change. Here today, gone tomorrow. That usually does not go over very well.
But given that this is the state of affairs for the foreseeable future, the question is, why is change so hard, and what can we do make it easier?
I thought about this at church the other day. My family and I attend church weekly (except when we don’t) at a small, old, quaint Catholic church built in 1789. My husband and I were raised Catholic, but as you may know, not every Catholic is really a Catholic. Based on my childhood churchgoing routine, my family would best be described as “Creasters,” which are “Catholics” (in quotations on purpose) who dedicate most of their religious energy to showing up only on Christmas and Easter. We are also known as “diet Catholics” or “lite Catholics.” Although I can plow through the “Our Father” with ease and grace, the Lord’s Prayer usually results in some mumbling, hushed tones and ceiling-staring.
My husband, on the other hand, was raised a real Catholic. He went to Catholic grade school, received communion six days a week, routinely served as an altar boy, and only missed Sunday Mass for a fever of more than 101 degrees (and even that was a stretch). For years, I have looked to him for cues on when to sit, stand, kneel, talk, sing, and be silent. When Sunday school questions come to the dinner table by way of our 8-year-old, I generally feign a choking episode and defer to my husband.
So this has been our routine for more than a decade: he the leader and I the limper. But then something shocking happened several months ago. In the middle of Mass, I realized my husband had no idea what was going on. He fumbled awkwardly through the service, lowered his speech volume with each passing misstep, and was almost completely silent by the end of the service.
As it ends up, every couple of hundred years, the Catholic Church decides to shake things up and change the Mass around. During key repeatings, the words are now different. What used to be “and also with you” is now “and with your spirit.” These changes were not monumental and went relatively unnoticed by current or former Creasters, but they were mind-boggling for the real Catholics.
The Church must have anticipated that these changes would be difficult to assimilate, as they placed countless numbers of laminated cue cards all over the church, in every pew, the confessional stand, and at all entry and exit points. Undoubtedly, they were hoping (assuming) we would take them home and learn the changes on our own, outside of Mass. So some months passed by, and after a few weeks with a cue card, I was in pretty good shape. My brain rewired the sayings, and I was able to shed my cue-card crutch.
My husband, on the other hand, is still reaching for the cue cards, with a long-standing dependence that now resembles that of an addict. Occasionally feeling confident, he will lay the card down, and will start spewing out the old sayings from a short circuit in the amygdala, programmed in fifth grade and hard-wired for accuracy. Then he will regain consciousness and realize everyone is staring at him.
As hospitalists, we know how hard it is to change, but we also know we have to routinely change to keep pace with the industry. So how do we reconcile the differences?
I recently read the book “Switch,” which describes some techniques on how to change when change is hard.1 The authors write about a rider, an elephant, and a path. If all three are aligned toward a change, it will most likely succeed; without all three, change will be very difficult or unsuccessful altogether.
The rider is the intellectual portion, which will find the rational, statistical, logical solution to get from point A to point B. But the rider is steering an elephant, which is bulky, unruly, and emotional. The rider has to figure out how to motivate and direct the elephant; the two of them then have to get down a common path, which could be winding, confusing, and full of roadblocks. So to overcome all of these, the book gives innumerable, tangible examples of how to maneuver all three of these to facilitate change. In the case of my husband’s Mass issue, a few things could have facilitated the change for many:
Direct the rider:
- Find the bright spots. Find a success story of how others quickly relearned Mass within weeks and see how they accomplished it.
- Script the critical moves. Be very precise about what needs to be done differently; don’t just tell people to “learn the Mass,” but instead tell them to “repeat three new lines every day in the shower” until they have an error-free Mass.
- Point to the destination. Be very specific about the future goal, such as “You will be cue-card-free by October.”
Motivate the elephant:
- Find the feeling. Find a “heavy” emotion that will motivate the change. Shame, embarrassment, or anger from being stared at by a 10-year-old after missing so many lines should be pretty effective.
- Shrink the change. Make it seem like all the lines are easy to learn, if learned only one at a time.
- Grow the person. Motivate the Catholic to learn it as quickly and seamlessly as they did in fifth grade; if you already did it once, you just have do it again!
Shape the path:
- Tweak the environment. Have cue cards all over the place, laminate them, make them easy to fit in a pocket or purse.
- Build habits. Have the Catholic go to church every week until they have an “error-free” Mass.
- Rally the herd. Have them watch others for cues on behavior; this has worked for me for decades!
You can see that many of these techniques should be easier in healthcare than in other industries, especially motivating the elephant and shaping the path. To facilitate change, hospitalists should find ways to direct the rider, motivate the elephant, and shape the path, and we may find that change is not as daunting and overwhelming as it might at first seem.
And when you finally do make a positive change happen, give yourself a high-five—and send a “Hail Mary” to the Creasters.
Dr. Scheurer is physician editor of The Hospitalist.