Blog

The Haphazardly Informed We

18 May 2017

This blog is adapted from two passages of my new book Managing the Myths of Health Care.

The patient is the “single most underused person in health care”. This means you and me. We are not casual players when it comes to our health, no matter how passive we may be in front of our doctors.

Much of the time, we are not even in front of them, or even patients. We have to take primary responsibility for the care of much of our own health, including the prevention of diseases. Moreover, we are often the “first responders.” We feel something coming on and get ourselves to a professional, or else just deal with some problem ourselves. (Have you put on a bandage lately?)  And not just for ourselves. We can be the first responders for our children, sometimes even for our elderly parents. So we better be well informed.

This blog is adapted from two passages of my new book Managing the Myths of Health Care.

The patient is the “single most underused person in health care”. This means you and me. We are not casual players when it comes to our health, no matter how passive we may be in front of our doctors.

Much of the time, we are not even in front of them, or even patients. We have to take primary responsibility for the care of much of our own health, including the prevention of diseases. Moreover, we are often the “first responders.” We feel something coming on and get ourselves to a professional, or else just deal with some problem ourselves. (Have you put on a bandage lately?)  And not just for ourselves. We can be the first responders for our children, sometimes even for our elderly parents. So we better be well informed.

How well are we informed? There is a vast array of health care information out there: how much of what we need to know actually gets to us? Is 10% a gross exaggeration?

I go into the supermarket and see eggs, Omega 3 and Organic. Which is better? I always mean to check on the Internet when I get home, but I always forget. What’s the use? The answer will probably change soon anyway. But it’s not the reliability of the information that bothers me so much as the rendering of it for my personal use.

So how do I get informed for my very survival?  Haphazardly. Had I not had the radio on a particular day last year, I would not have heard that I no longer need to force eight glasses of water down my throat every day. But this year, had I listened to my medical friends and not gone to see a naturopath, I would not have found out that, for a particular condition I have, I had better drink all that water after all. Is this any way to get informed about my health—a radio program here, TV news there, a consultation, an article sent by a friend, and most systematically of all, ads telling me what pain killer to swallow?

And I’m advantaged: well educated, with time to read. Plus I have physician friends I can call about these things. And now, thanks to the Internet, I can find all kinds of information to misinterpret. Mostly, however, I am overwhelmed by the information available, and underwhelmed by what of it I get. I need HELP!!!

Health Navigator to the rescue

General practitioners, even the most responsive ones, are busy people. They have to diagnose, treat or refer, and advise—usually with a waiting room full of anxious people. We, the people out there, need something more.

So let me suggest the role of health navigator. Don't confuse this with nurse practitioner, who comes from the perspective of medicine, as a supplement to physicians. It should be noted that there's a lot more to health care than what physicians mostly do, including the promotion of health (especially diet), the prevention of many illnesses, and the treatment of those that medicine has yet to address (such as IBS and many auto-immune conditions).  Other services, such as acupuncture, naturopathy, and homeopathy, do treat some of these conditions—in my experience, at times remarkably well—yet get marginalized by a medical establishment that can be doubly blind.

A health navigator, professionally trained, would provide information and advice to you and I, the persons beneath the patients—in our communities, beneath the epidemiologists’ populations. The health navigator would:

  • Get to know us, as individuals and in our community, beginning with an extensive first interview about all aspects of our health (as homeopaths do), and continuing to maintain that understanding.
  • Remain abreast of health care information in general, as well as of the reliable sites that provide it, and of the services that are available in our community.
  • Provide us with whatever of that information each of us needs, alongside advice to help maintain our health.
  • In the event of illness, guide us through the intricacies of diagnosis, treatment, and especially recovery.

The diagram below shows the five key aspects of health care—maintaining health, detecting illness, diagnosing disease, treating disease, and recovering health—around two concentric circles. The outer one is labelled the Professional Ring while the inner one, closer to ourselves, is labelled the Personal Sphere. The health navigator would work all around he circle—as shown in the diagram, in the Professional Ring but close to the Personal Sphere.

Seeing the Parts around the Whole

 

Must we leave the fate of our health to the haphazardness of the information marketplace as well as to the limitations of medical practice? Or shall we find our proper place in the care of our own health?

© Henry Mintzberg 2017 with passages from Managing the Myths of Health Care.

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Don’t just sit there…

4 May 2017

Co-authored with Jonathan Gosling

Imagine a conference with a keynote listener instead of a keynote speaker. How about a meeting of the executive committee with the CEO facing backward, eavesdropping on the discussion but speechless until the end? Or picture a gathering of managers sitting in a circle to “show and tell” about their interests, just like they did in kindergarten.

Does all this sound like some other world? It could be yours. For years, we have had great success doing such things with managers in our programs. This began with our International Masters Program for Managers (impm.org), created to get past training about the business functions (the MBA), toward true education for managers. While a manager cannot be created in a classroom—this is the misconception of so many MBA programs—people who practice management can enhance their capabilities in a classroom that respects their experience.

Co-authored with Jonathan Gosling

Imagine a conference with a keynote listener instead of a keynote speaker. How about a meeting of the executive committee with the CEO facing backward, eavesdropping on the discussion but speechless until the end? Or picture a gathering of managers sitting in a circle to “show and tell” about their interests, just like they did in kindergarten.

Does all this sound like some other world? It could be yours. For years, we have had great success doing such things with managers in our programs. This began with our International Masters Program for Managers (impm.org), created to get past training about the business functions (the MBA), toward true education for managers. While a manager cannot be created in a classroom—this is the misconception of so many MBA programs—people who practice management can enhance their capabilities in a classroom that respects their experience.

The IMPM does things differently, starting with our 50:50 rule: faculty get half the class time to introduce ideas, but the other half is reserved for the managers to reflect on their own experience and share their insights with each other. In this program, which runs over 16 months, the managers come into our classrooms for five modules of 10 days, each one devoted to a managerial mindset, delivered by leading business schools around the world. (The reflective mindset takes place in Lancaster, England; the analytic mindset in Montreal, Canada; the worldly mindset in Bangalore, India; the collaborative mindset in Beijing, China; and the action mindset in Rio de Janeiro, Brazil.) Call this an emba if you like, so long as you realize that here it means engaging managers beyond administration.

“How are you going to seat them?” asked Nancy Badore, who had created a novel program for Ford executives and was helping us think through ours. “I suppose in one of those U-shaped classrooms?” one of us answered. “Not those obstetrics stirrups!” Nancy shot back. We got the point! With that, we were off—never looking back (except when the class asked us to face backward, to receive some feedback).

Nothing explains these differences better than the seating arrangements that we have established in the IMPM. These enable the managers to listen more attentively, speak more thoughtfully, and address their problems together more effectively.

Table Talk 

Thanks to Nancy’s comment, we decided that the managers in our classrooms would sit at small round tables to facilitate learning from each other. No need to “break out” in some other place.

Round tables turn a collection of individual students into a community of engaged learners. (See Figures 1 and 2 at the end.) Managers bring wonderful experience to the classroom, so why not let them build on that with each other? So much better than pronouncing on cases that no-one in the room has experienced, or listening to theory without connecting it to their reality. We have a ritual starting every day in the IMPM, called morning reflections.  It begins with everyone scribbling personal thoughts in his or her Insight Book (empty except for their own thoughts), followed by sharing their insights around the table, and then on to the plenary…

Show and Tell in a Big Circle  

For these plenaries, we used to do what most programs do after workshops: ask for comments from each table—that dreadful go-around. Tell the teacher what was learned. Then one day, a new colleague put everyone in a big circle and sat down too. A great “show and tell” discussion followed. The next day, another colleague put them in the circle again but stood there, as if to say: I will give you permission to speak, and you will direct your comments to me, which I will follow with a smart reply. (Professors hate to stop professing.)

We had a photo of this, and so we whited him out. The next day, one of us repeated the circle, stood there too, and announced: “I’m in charge”—and promptly walked out. When he returned after the plenary, the class informed him that next time he was to take his place in the circle, like everyone else.

Eavesdropping  

How about this? Instead of just discussion around each tables, followed by a big circle, turn around one person at each table, to eavesdrop without speaking, and then have these people report in the plenary on what they heard. Focused on listening, instead of waiting to speak, they hear a lot more of the nuance.

Here’s an example of using this eavesdropping. A colleague who was doing a session on managing retrenchment polled the class in advance as to who had positive, negative, and no experience with retrenchment. The positives sat at some tables and the negatives at others, to share their what they had learned about retrenchment. But what were we to do with the few who had no experience? Of course. have them eavesdrop at those tables! They all took profuse notes, and then…

The Inner Circle  

…we brought these eavesdroppers together in the middle, facing each other in a little circle, to chat about what they heard, with the everyone else listening all around. (They became the eavesdroppers, about what they had just said!) Everyone loved this. One manager in the middle said that her group probably learned more about retrenchment than anyone else. Another, on the outside, said this was the best reporting out of a workshop that she had ever seen. The class dubbed the circle in the center “The Neutral Zone.”

Tapping In  

Why stop here? After those in an inner circle have had their say, and some others are itching to add something, why not let them tap someone on the inside and replace him or her. The discussion carries on, in fact gets enlivened, still with the same number of people. Here we have something quite fascinating: a running conversation, with a few people at a time, yet everyone participating—listening intently and able to join, with no-one in charge. Once, when a journalist from the New York Times was in the class to write an article about the IMPM, we put him in the inner circle. Trouble was, everyone hesitated to tap him out!  (See his article, “The Anti-MBA.”)

Keynote Listener  

If we can have eavesdroppers at the tables, then why not in the whole class? One time, in another of our programs, we invited Marshal Ganz from the Harvard Kennedy School to do a session. He came early, to see what we were doing beforehand—presentations on some earlier work. So we designated Marshall to be the keynote listener, and comment on the presentations. Everyone, Marshall included, sat in a big circle as he discussed what he had heard. No canned speech, just honest reactions from a thoughtful listener.

Beyond the Classroom  

OK, so all of this is well and good for a bunch of managers and professors having a good time while learning a lot in a classroom. But it hardly needs to stop there. We have used keynote listeners to replace keynote speakers in large conferences. We have used inner circles in rooms of 200 people, all sitting at round tables. After a presentation and workshop discussions around these tables, we said: “Quick, point to someone at your table who had a really good idea.” We invited the first few targets to come forward and share their ideas. One participant described this kind of exercise as a “great way to turn a large meeting into a series of meaningful conversations”—as well as one big conversation.

And into the Managerial Workplace  

We have yet to turn the CEO of some major corporation around. (Maybe because they are too busy turning their companies around.) But imagine bringing all of this into the workplace: round tables, morning reflections, eavesdropping, taping, keynote listening, big circles and inner circles. Carlos Ramos was exposed to the seating in another of our programs (EMBA Roundtables), and when he got back home, installed a round table on the floor of his factory in Mexico City. Here is the picture he sent us, with the comment that “We use it very often” when there is the need to reflect on a difficult issue.

Coaching Ourselves

The two of us are part of another program, called CoachingOurselves.com, that dispenses with the professors and the classroom, but not the ideas. Managers gather together in their own workplace with a few of their peers or reports, and download slides on a particular topic (for example “Strategic Blindspots” or “Developing our Organization as a Community”). These they discuss with each other while relating the ideas to their common experience, to carry their insights forward to improve their organizations. In other words, change how and where managers sit, and suddenly management development can become organizational development!

As we mentioned earlier, you can experience all this for yourself. The next IMPM cohort begins in September (impm.org; for other innovations in the program, see “How about an emba that engages managers beyond administration”). Another version, in health care (imhl.org), begins its next class in April of 2018. The embaRoundtables.org, a one-week IMPM-type program for managers, runs every May (this year from May 1 in Dublin), and the McGill-HEC EMBA, modeled after the IMPM but with shorter modules in Montreal, runs from September every year.

Morning reflections in our IMPM module in Rio de Janeiro.

© Jonathan Gosling and Henry Mintzberg 2017; edited from an initial posting on this site on 1 July 2015. 

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ANNOUNCING my new book

19 April 2017

Managing the Myths of Health Care

BERRETT-KOHLER  AMAZON UK  AMAZON

From the back cover:

“Health care is not failing but succeeding, expensively, and we don’t want to pay for it. So the administrations, public and private alike, intervene to cut costs, and herein lies the failure.”

Managing the Myths of Health Care

BERRETT-KOHLER  AMAZON UK  AMAZON

From the back cover:

“Health care is not failing but succeeding, expensively, and we don’t want to pay for it. So the administrations, public and private alike, intervene to cut costs, and herein lies the failure.”

In this sure-to-be-controversial book, leading management thinker Henry Mintzberg turns his attention to reframing the management and organization of health care.

The problem is not management per se but a form of remote-control management detached from the operations yet determined to control them. It reorganizes relentlessly, measures like mad, promotes a heroic form of leadership, favors competition where the need is for cooperation, and pretends that the calling of health care should be managed like a business.

“Management in health care should be about dedicated and continuous care more than interventionist and episodic cures.”

The professional form of organizing is the source of health care’s great strength as well as its debilitating weakness. In its administration, as in its operations, it categorizes whatever it can to apply standardized practices whose results can be measured. When the categories fit, this works wonderfully well. The physician diagnoses appendicitis and operates; some administrator ticks the appropriate box and pays. But what happens when the fit fails—when patients fall outside the categories or across several categories or need to be treated as people beneath the categories, or when the managers and professionals pass each other like ships in the night?

To cope with all this, Mintzberg says that we need to reorganize our heads instead of our institutions. He discusses how we can think differently about systems and strategies, sectors and scale, measurement and management, leadership and organization, competition and collaboration.

“Market control of health care is crass, state control is crude, professional control is closed. We need all three—in their place.”

The overall message of Mintzberg’s masterful analysis is that care, cure, control, and community have to work together, within health-care institutions and across them, to deliver quantity, quality, and equality simultaneously.

Some other excerpts:

In management no less than medicine, scalpels usually work better than axes.

Narrowness pervades health care, from professionals on the ground who can’t see past their specialities, to managers in the offices who can’t see past their institutions, analysts in governments and insurance companies who can’t see past their numbers, and economists in the air who can’t see past their dogma.

Reorganizing is the expected disjointed intervention for a health care “system” built on disjointed interventions.

While the ill act as a concerted force for spending more locally, the healthy act as a general lobby for spending less nationally. This makes the field of health care sick.

There are no management problems in health care, separate from medical problems, nursing problems, or prevention problems. There are only health care problems.

Because economics begins before medicine ends, the technocrats of health care have too often trumped the professionals.

In the name of competition, health care suffers from individualism: every patient, provider, and institution for themselves.

The field of health care may be appropriately supplied by businesses, but in the delivery of its most basic services, it is not a business at all, nor should it be run like one. At its best, it is a calling.

I can think of no field that is more global in its professional practices yet more parochial in its administrative ones than health care.

Certainly we have to measure what we can; we just cannot allow ourselves to be mesmerized by measurement—as we so often are.

Physicians who like to belittle hierarchies of authority are often slaves to their own hierarchies of status.

Who can possibly be against evidence in medicine? Me, for one, when it is used as a club to beat up on experience.

The essential problem in health care may lie in forcing detached administrative solutions on to practices that require informed and nuanced judgments.

It can be taken as almost an axiom of professional work that dysfunctional practices cannot be fixed by tighter administration. The problems have to be addressed within the work itself.

Strategy making in the field of health care tends to be about venturing more than visioning, and personal and collective learning more than institutional planning.

When we promote leadership, we demote everyone else. How about plain old management?

Instead of people pointing the finger at each other, they should be pointing their fingers together at the procedures and structures that set them apart.

Health care doesn’t need more measuring and reorganizing so much as better cultures of collaboration that open up the pathways of communication.

A systems perspective requires a focus on the person in the community, beyond a patient in a population.

There’s a massive amount of health care information out there, some of which I need to know. How much of that part am I actually getting? Is 10 percent a gross exaggeration? And how do I get even that? Haphazardly!

To find the systems perspective in health care, look first in the mirror: we are as close as we are going to get. That is because you and I are significantly responsible for promoting our own health, preventing our potential illnesses, and even treating many of our own diseases.

The invisible hand that is supposed to serve everyone by serving ourselves turns out to be a visible underhand in much of health care when it serves some users at the expense of others.

See full Table of Contents

© Henry Mintzberg 2017

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