Ten Things I Have Learned About How the World is Changed (and how I am changed)

David C. Leach, M.D.CEO, ACGMEAugust 1, 2007

God has no potential; we do.

Before we begin….

A moment of gratitude

Thanks to…

Paul Batalden

The ACGME Community

Don Berwick

Dee Hock

Parker Palmer

Brenda Zimmerman

Michael Quinn Patton

C. Otto Scharmer

Aristotle

Rosa Parks

Martin Luther King

Nelson Mandela

Vaclav Havel

The unremembered many

Recommended Reading

The Birth of the Chaordic Age – Dee Hock

Getting to Maybe: How the World is Changed – Westley, Zimmerman and Patton

Theory U – C. Otto Scharmer

The Way It Is

There’s a thread you follow. It goes amongthings that change. But it doesn’t change.People wonder about what you are pursuing.You have to explain about the thread.But it is hard for others to see.While you hold it you can’t get lost.Tragedies happen; people get hurtor die; and you suffer and get old.Nothing you do can stop time’s unfolding.You don’t ever let go of the thread.

--William Stafford

Lesson One: Be Clear about the Task…

Substance is enduring; form is ephemeral. Preserve substance; modify form; know the difference.

Dee Hock

The Tasks…

How can we be both faithful and effective trustees of the values our profession and traditions offer society?

…and how can we prepare the next generation of doctors to be faithful and effective?

The Task…

Be clear about the aim…

e.g. Improve patient care vs.

Save 100,000 lives by June 26, 2006

Lesson Two:

It is said that people resist change; in my experience people are attracted to change.

But…

They are not attracted to:

Transitions

Burden

Being told to change their way to my way

Lesson Three:

The future is bigger than we are; it is emerging as we speak; we cannot redesign it; we can only notice it.

Lesson Three:

The task is to pay attention ....

with others

Lesson Four:

The quality of conversation…

is predictable

is helpful in knowing the next step

is progressively more authentic

Predictable

I deny that we need to change.

I resist the change you are suggesting.

It was my idea all along.

Is A Helpful Marker…

…and progressively more authentic

●

●

● I-in-Me

I-in-It

I-in-You

I-in-Now

After Scharmer

●

●

● I-in-Me

I-in-It

I-in-You

I-in-Now

Downloading

Seeing

Sensing

Presencing

Voice of Judgment

Voice of Cynicism

Voice of Fear

Habitual

Rational

Relational

Authentic

“Self”

After Scharmer

●

●

● I-in-Me

I-in-It

I-in-You

I-in-Now

Downloading

Seeing

Sensing

Presencing

Voice of Judgment

Voice of Cynicism

Voice of Fear

Habitual

Rational

Relational

Authentic

“Self” “Time”

Disembodied

Chronos

Slowing Down

KairosStillnessPresencing

After Scharmer

●

●

● I-in-Me

I-in-It

I-in-You

I-in-Now

(Re-enactingpatterns from

past)

(Facing exterior data)

(Sensing through social mental fields)

(Connecting to source)

“Org. Action”

From within org. boundaries

From periphery of boundaries

From beyond org. boundaries

Across openboundaries

After Scharmer

●

●

● I-in-Me

I-in-It

I-in-You

I-in-Now

Downloading

Seeing

Sensing

Presencing

Voice of Judgment

Voice of Cynicism

Voice of Fear

Habitual

Rational

Relational

Authentic

“Self” “System”

Autistic

Adaptive

Reflective

Generative

After Scharmer

Lesson Five:

It helps to work with …

…rather than against nature

Working with Nature:Three Faculties and Their Objects

Intellect – seeks Truth

Will – seeks Goodness

Imagination – seeks Beauty

Human Faculties and the Work of Medicine

Intellect

Discerns the truth

Will

Makes good clinical/educational judgments

Imagination

Does so with harmony, creativity and beauty

Primary Values in Medicine with which to Arm Oneself

IntegrityDiscerning and telling the truth

Altruism Putting what is good for the patient/student before what is good for the doctor/teacher

Practical wisdom (Prudence)

Beauty in judgment

Arete: Integrating all the virtues to excellence

Lesson Six:

Change Makes these Values Manifest in Community and in Action

Arete: ExcellenceIntegrated Virtue in Action

The quality of patient care, the quality of health professional formation, and the quality of system performance are inextricably linked.

The Context of the Work of Healthcare

Relentless economic/time pressures

A focus on safety, quality, transparency….

More regulation, duty hours, etc.

New knowledge and technology

Fragmentation of care, alternative medicine, consumerism

Demographics – population, generational gaps…

The (Internal) Context of the Work of Healthcare

Truth telling (or lack thereof)• The 38/54% problem

Promises and forgiveness

Seeking goodness …for whom???

Imposed external controls

Discontent

A need for authenticity

The National Context of Health Professional Formation

Impending physician shortages

Outmoded educational models

Individual formation: role of context

The Institutional Context for Healthcare Work

Frenzy

There is a pervasive form of modern violence to which the idealist … most easily succumbs: activism and overwork. The rush and pressure of modern life are a form, perhaps the most common form of its innate violence.

To allow oneself to be carried away by a multitude of conflicting concerns, to surrender to too many demands, to commit oneself to too many projects, to want to help everyone in everything is to succumb to violence.

The frenzy of the activist neutralizes his (or her) work … It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitful.

Thomas Merton

From frenzy to wisdom…

…as individuals and as a profession

Lesson Seven:

We have to let go in order to let come.

After Scharmer

The problem is never getting new ideas into your head; it’s getting the old ones out.

Dee Hock

A Midrash

Lesson Eight

It helps to honor both arms of all paradoxes.

Six Paradoxes of Formation Space

Open -------------

Hospitable -------------

Voice of Individual -------

Personal stories ----------

Solitude ---------------

Speech ----------------

Bounded

Charged

Voice of Group

Archetypal stories

Community

Silence

Parker J Palmer

Lesson Nine

Crystallize intentions

After Scharmer

Lesson 9A

Keep Humility at the Ready

“ We exhaust ourselves supporting our illusions.”

Thomas Merton

Lesson Ten:

There are really only two questions

Two Questions

Who is my Self?

What is my Work?

Journey to Authenticity…

as individuals and as a profession

The Journey

One day you finally knewwhat you had to do, and began,though the voices around you kept shouting their bad advice-though the whole housebegan to tumbleand you felt the old tug at your ankles.“Mend my life!”each voice cried.but you didn’t stop.You knew what you had to do.

The Journey (cont.)

…little by little,As you left their voices behind,The stars began to burnThrough sheets of clouds,And there was a new voiceWhich you slowly Recognized as your own,That kept you companyAs you strode deeper and deeperInto the world,Determined to doThe only thing you could do-Determined to saveThe only life you could save.

Mary Oliver

Values are enduring; rules are ephemeral; preserve values; modify rules; know the difference

Dee Hock Modified

Community leads to clarity; clarity leads to courage

I Will Not Die an Unlived Life

I will not die an unlived life.I will not live in fearof falling or catching fire.I choose to inhabit my days,to allow my living to open me,to make me less afraid,more accessible;to loosen my heartuntil it becomes a wing,a torch, a promise.

I Will Not Die an Unlived Life

I choose to risk my significance,to live so that which came to me as

a seedgoes to the next as a blossom,and that which came to me as

blossom,goes on as fruit.

Dawn Markova