Intuitively, we know changing times bring opportunities, but few
relish the idea of change. This article outlines why current conditions make
this a time of opportunity, how normal human neurophysiology makes it difficult
to realize that opportunity and what we can do about it. The solution is
probably not what you think — and that is good.
Anthony M. DiGioia III, MD
Technology & Innovation Editor
Now is the time of greatest opportunity in orthopedics since the
emergence of total joint replacement. It may not be what you think. Let us
explore why and how we, and our patients, have a new opportunity.
For starters, I am a vascular surgeon who believes that bones are
important. For me, one bone made a big difference — C2. In 1992, in the
midst of a busy, growing surgery practice, I fell out of a tree and broke my
neck. Fortunately, I sustained a non-displaced odontoid fracture. I did not
pith myself and, although disabled for 6 months, made a full recovery.
That experience changed my thinking. Surgical expertise and technology
were important — but, as a surgeon, I already knew that. I discovered my
recovery depended on something more: the efforts of hundreds of people, from
housekeepers to senior executives, who used their knowledge and creativity to
problem, solve “the system” to get me what I needed. “The
system” often did not help and even got in the way.
Great outcomes despite the system? That changed my thinking and started
me on a path to unexpected places, like 4 years as a visiting scholar at
Harvard Business School. Here is some of what I learned along the way.
Anthony M. DiGioia III
John W. Kenagy
Let us start with how “the system” works. In successful 20th
century health care systems, managers analyzed data in meetings, while the
frontline just got the work done.
The result: Successful 20th century health care systems increased
quality in silos and increased the cost of care. But now, we cannot afford
increased costs. That is the opportunity.
Just like total joint replacement in the 1970s, the factors that will
drive success in the future have changed.
- 20th century success = increase quality and increase cost.
- 21st century success = more and better care and decrease cost.
Those who deliver more care for less cost will be uncommonly successful.
It is a new basis of competition and that is why it is a time of opportunity
for all of us.
But, that is only part of the story. I am a surgeon. I needed to know
how to do it.
I focused my Harvard research on the few companies who gained
competitive advantage by innovating to provide more for less in ways others
could not duplicate. Apple is a good example.
Studying their success, I discovered that Albert Einstein was right:
“You cannot solve the problems of the present with the solutions that
In my research, the leaders who changed the basis of competition all
asked, “Will what got us here get us there?” and answered,
Therefore, following the path of Steve Jobs and Einstein (pretty good
company), we ask, “Will sending more data up to people in meetings while
the frontline just does the work get us more care at less cost?” The
rational answer is, “No!”
Now, it gets interesting. There are many alternatives to current
management and frontline methods; that is not the problem. More care/less cost
means both management and the frontline have to think differently. That is the
Thinking differently is the problem because, as John Kenneth Galbraith
said, “When faced with the choice between changing one’s mind and
proving that there is no need to do so, almost everyone gets busy on the
Recent advances in neurophysiology explain why. Human brains become
physiologically hard-wired to repeat what they have done successfully and are
non-consciously threatened by what they do not know how to do. The drive to
automatically repeat past success and view the unknown as a threat is a
non-conscious, neurophysiologic norm for every human.
When the world changes, the greater the past success, the harder it is
to think differently. In his book Collapse, Jared Diamond documents:
“The values that people cling to most stubbornly under inappropriate
conditions are those that were previously the source of their greatest
That is our successful management and physician brains, naturally,
“clingingly stubbornly.” Data is necessary, but insufficient to
change mindsets and behavior. You cannot think your way to a new way of acting;
you have to act your way to a new way of thinking. Management and physicians
experiencing success together — that is the only way to learn to think
differently. Our brains say it is so.
How to experience success together is not rocket science, just different
thinking. It starts when management and physicians decide together, “What
got us here will not get us there.” That opens the door. No one is at
fault. There is nothing to blame. The world has just changed. The slate is
Out of the silos
Secondly, the solutions are never big, complicated contracts designed in
meetings — that is 20th century thinking. Successfully coordinating care
across the silos in the new world of bundled payments means both management and
physicians first need to move out of our mental silos by experiencing success
together centered on the patient. You do that by starting small, proving it
works, and building trust and optimism with success.
Linking management to frontline success is the new opportunity. An
orthopedic service line is a perfect learning site for everyone to discover
that opportunity. It is the chance to get out of our silos.
Managers become leaders when they discover they can get
out of the meeting room, set direction, take down barriers and coordinate
rapid, real-time decision-making.
The frontline leads when they discover they can leverage their knowledge
and creativity to make improvement and innovation part of everyone’s daily
Then, it is a matter of working together to:
- align innovations with a simple, clear, meaningful purpose;
- link information to action to rapid results for patients, in
- use the mutual experience of success to realign, inspire and
replicate what works.
The results, documented in multiple environments, speak for
themselves. There is no ceiling to our potential. Our ceiling is our current
thinking, both for management and at the frontline.
The future is not what we currently think — and that is good for
all of us — staff, physicians, management and patients. When we align with
a meaningful purpose and experience success together in achieving it, we change
our thinking and commit — no ambiguity, no assumptions, no workarounds and
no tradeoffs. It is developing people to deliver ideal patient care at a
continually lower cost.
It is not the way we currently think — and that is a great
- Kahneman D. Thinking, fast and slow. Farrar, Straus and
- Kenagy JW. Designed to adapt: Leading healthcare in challenging
times. Second River Healthcare Press. 2009.
- Kenagy JW. Leadership versus the brain. White paper
available at http://johnkenagy.com/resources.writing.php.
For more information:
- John W. Kenagy, MD, is Director of Kenagy & Associates LLC. He
can be reached at 3434 Columbia Heights Road, Longview, WA 98632; 617 515-7209; email:
- Disclosure: Kenagy has no relevant financial disclosures.