ALLINA HOSPITALS & CLINICS
Adaptive Health Practice
N. Marcus Thygeson, MD
marcus.thygeson@allina.com
612-262-4945
CENTER FOR HEALTHCARE
INNOVATION
What is AHP?
• Application of Ron Heifetz’s Adaptive
Leadership model to clinical practice
• Three key “simple rules” changes:
– Patient must and can do their own adaptive
health work; we can’t do it for them
– But we can help them do it by upgrading
our skills and using Adaptive Leadership
principles.
– Technology (drugs, procedures, etc.) has
limited utility and significant potential for
harm—use sparingly and judiciously
CENTER FOR HEALTHCARE
INNOVATION
Fundamentals of Adaptive Leadership
• Complex systems face adaptive and
technical challenges.
• Adaptive challenges require learning
and behavior change—adaptive work.
• Technical challenges can be addressed
with technical solutions and expertise.
• Technical work will not solve adaptive
challenges, and often make the problem
worse.
• AL consists of knowing this, and how to
help people and organizations do
adaptive work.
CENTER FOR HEALTHCARE
INNOVATION
CENTER FOR HEALTHCARE
INNOVATION
Example: GERD and PPIs
• Heartburn mostly related to lifestyle: diet,
obesity, tobacco, alcohol.
• Treatment for GERD now: PPIs
• Feedback loops: hypergastrinemia and
failure to address lifestyle factors
• Long-term use of PPIs (> 2 months) causes
GERD sxs in normal people
• PPIs cause dependency and are addictive
• Prevalence of GERD has doubled in US
since PPIs introduced
CENTER FOR HEALTHCARE
INNOVATION
Adaptive Work Avoidance
• Failure to adopt healthy lifestyles
(patient)
• Failure to address unhealthy
lifestyles (MD)
• Terminal chemotherapy instead of
hospice
• Spinal fusion instead of active rehab
for disc DJD
• Drugs in lieu of exercise, light, talk
therapy, etc. for depression
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Implications
• We and our patients are both avoiding
the challenge of doing the adaptive
work required to be healthy and cope
with suffering.
• We collaborate in this by
inappropriately applying technical
solutions in lieu of adaptive
interventions, and by remaining
unskilled in adaptive leadership.
• This causes a lot of harm and
inefficiency (waste), and damages the
doctor-patient relationship.
CENTER FOR HEALTHCARE
INNOVATION
Why is this happening?
• Adaptive work is hard and often
avoided (by patients and providers).
• We aren’t incented to practice
adaptively.
• We don’t know how to do it.
CENTER FOR HEALTHCARE
INNOVATION
What should we do?
Support patient adaptive work by doing the adaptive
work to change our
• Philosophy of practice
– Explicitly identify adaptive challenges and
interventions, to ourselves and our patients
– Recognize the limitations of our technical expertise
– Use technology sparingly and judiciously
– Adopt a socio-ecological, whole-systems approach to
health
– Build our skills as adaptive leaders to help patients
do adaptive health work
• System
– Financial incentives
– Blind faith in technology
– Inputs (staffing, resources, culture)
CENTER FOR HEALTHCARE
INNOVATION
Facilitating adaptive work:
• Diagnose the system, and the
problem
• Establish a “holding environment”
• Identify the “ripe” issues
• Think about your framing
• Regulate the “heat”
• See yourself as part of the system
• Hold steady
• Keep the work at the center of
people’s attention
CENTER FOR HEALTHCARE
INNOVATION
The proper use of technology?
• Facilitate adaptive work (e.g., exer-gaming,
mobile health apps, analgesics to facilitate
PT, etc.)
• Relieve suffering that overwhelms patient
coping
• Manage risk factors until adaptive work is
effective
• Treat disease not amenable to adaptive
work
• Avoid technology with long-term negative
feedback loops on health
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INNOVATION
Implementation Issues
• What does AHP look like
behaviorally, for both patients and
doctors?
• For which patients will this work?
What to do for patients who respond
negatively?
• How do we do the adaptive work to
change our system and philosophy of
care?
CENTER FOR HEALTHCARE
INNOVATION
Basic AHP
• Staff trained on adaptive leadership
• New patients are introduced to the
practice’s philosophy of care
• SOAP approach modified to address
both adaptive and technical
components
• Measurement reflects both adaptive
and technical components
SOAP—New and Old
Traditional
Add health beliefs, social support and
network, family and work systems, patient
complexity, detailed lifestyle inventory, etc.
Standard physical and diagnostic testing,
(PHQ-9 in MN)
Measures of resilience, adaptive capacity,
learning orientation, etc. Social network
survey?
Diagnosis, prognosis
Distinguish adaptive and technical challenges
explicitly.
Treatment, referrals, testing, etc.
Distinguish adaptive and technical work.
Develop plan for supporting adaptive work,
including social and psychological
interventions. Avoid technical interventions
that reduce adaptive capacity/work.
A
P
AHP
Standard history
S
O
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INNOVATION
CENTER FOR HEALTHCARE
INNOVATION
Paths to AHP
• Incremental: train staff on
organizational Adaptive Leadership;
then support them in generalizing to
patient care.
• Transformational: train them directly
on applying AL to patient care, and
hope the culture accepts it.
• For full development, does this need
to be managed as a separate
company?
CENTER FOR HEALTHCARE
INNOVATION
Next Steps
• Design it
• Pilot and refine it
• Controlled trial? Or just spread it?
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INNOVATION
Suggested References
• The Practice of Adaptive Leadership,
by Heifetz, Grashow, and Linsky
• How Clients Make Therapy Work, by
Bohart and Tallman
• “Adaptive Leadership and the
Practice of Medicine” by Thygeson,
Morrissey and Ulstad, JECP 2010