Ten Things I Have Learned About How the
World is Changed (and how I am changed)
David C. Leach, M.D.
CEO, ACGME
August 1, 2007
God has no potential; we do.
Before we begin….
A moment of gratitude
Thanks to…
Paul Batalden
Aristotle
The ACGME Community
Rosa Parks
Don Berwick
Martin Luther King
Dee Hock
Nelson Mandela
Parker Palmer
Vaclav Havel
Brenda Zimmerman
The unremembered many
Michael Quinn Patton
C. Otto Scharmer
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 among
things 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 hurt
or 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
“Self”
I-in-Me
●
Downloading
Habitual
Voice of Judgment
I-in-It
●
Seeing
Rational
Voice of Cynicism
●
I-in-You
Sensing
Relational
Voice of
Fear
I-in-Now
Presencing
Authentic
After Scharmer
“Self”
I-in-Me
●
Downloading
“Time”
Habitual
Disembodied
Rational
Chronos
Relational
Slowing Down
Authentic
Kairos
Stillness
Presencing
Voice of Judgment
I-in-It
●
Seeing
Voice of Cynicism
●
I-in-You
Sensing
Voice of Fear
I-in-Now Presencing
After Scharmer
“Org. Action”
●
I-in-Me
I-in-It
●
●
I-in-You
I-in-Now
(Re-enacting
patterns from
past)
From within
org. boundaries
(Facing exterior
data)
From periphery
of boundaries
(Sensing through
social mental fields)
From beyond
org. boundaries
(Connecting to
source)
Across open
boundaries
After Scharmer
I-in-Me
●
Downloading
“Self”
“System”
Habitual
Autistic
Rational
Adaptive
Relational
Reflective
Authentic
Generative
Voice of Judgment
I-in-It
●
Seeing
Voice of Cynicism
●
I-in-You
Sensing
Voice of Fear
I-in-Now
Presencing
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
Integrity
Discerning 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: Excellence
Integrated 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
-------------
Bounded
Hospitable -------------
Charged
Voice of Individual -------
Voice of Group
Personal stories ---------- Archetypal stories
Solitude ---------------
Community
Speech ---------------- 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 knew
what you had to do, and began,
though the voices around you
kept shouting
their bad advicethough the whole house
began to tumble
and 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 burn
Through sheets of clouds,
And there was a new voice
Which you slowly
Recognized as your own,
That kept you company
As you strode deeper and deeper
Into the world,
Determined to do
The only thing you could doDetermined to save
The 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 fear
of 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 heart
until 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 seed
goes to the next as a blossom,
and that which came to me as
blossom,
goes on as fruit.
Dawn Markova