Freedom or chaos? Dealing with change - in medical management practices

For those of us in medical management, the past several years have proved hectic and quixotic, often marked by quicksilver instability and unnerving disorder. "Change," they say, "is changing faster than it has ever changed before." Our only certainty, it would seem, is that extraordinary uncertainty is certain to continue. This highly fluid state has led at least one highly regarded expert to label these times "chaotic" and to conclude that, because we are living in chaos, any rigid monolithic approach to governance is sure to prove unworkable.(*)

Admittedly, defining and describing "chaos" has become, at the highest theoretical levels, the equivalent of a cottage industry. I propose that we accept, as a working definition, terms suggested by Webster's "a state of utter confusion; completely wanting in order, sequence, organization, or predictable operation; an abyss." In this context, I submit that the current times, while highly unstable, are not (yet) truly chaotic. And it is fortunate that they are not. If these were times of true chaos, not only authoritarianism would be "workable," but it alone would be workable. Tyranny would ultimately be inevitable.

Rather than chaos, what we have been experiencing so far in America is a whirlwind escalation in degrees of freedom, harshly straining the bonds of our traditional limits and expectations. The continued expansion of these American freedoms will depend fundamentally on our ability, as leaders, to envision in this apparent disorder an endless array of proactive opportunities. Chaos, conversely, is disorder perceived as hopeless disarray - an interminable gauntlet of uncontrollable occasions to fail. The critical difference between freedom and chaos will lie in our flexibility and resilience as leaders.

Whether we succeed or fail will be of enormous consequence. Our responses will determine the difference between a future of freedom and one of chaos - between a boundless soaring and a bottomless tailspin. As agents of change-management and transformation, we need to skillfully devise and persuasively promote innovative adaptations.

Should we fail, the repercussions could be abrupt and brutal. The chaos that follows will likely prove short-lived. Goethe once observed that people fear a loss of order more greatly than they fear a loss of their freedom. History teaches repeatedly that power, like nature, abhors a vacuum. Hitler rose from demolished postwar Germany, Stalin and the Bolsheviks from Czarist Russian squalor, and Napoleon from the Reign of Terror.

The study of medical leadership, management, and administration, like that of economics, may seem at times to be drab, trivial, and tedious. However, a Jewish refugee from a German school of economics once warned his American students that the discipline of economics may seem dry, but, if these dry lessons are not heeded today in the classroom, he warned, they will surely be heard, loudly and clearly but too late, when tomorrow they are translated into the sound of soldiers' boots, marching over broken glass.

One might mistakenly surmise that leadership of such weighty import would be reserved to monumental decision making on the highest level. On the contrary, it is more likely to be in the small, seemingly mundane decisions made daily at the low and middle echelons of management that our leadership will effect (or fail to effect), drop by drop, the necessary sea-change of attitudes and expectations.

In no small way, the profound changes that occur in American medicine over the coming years are likely to foreshadow and significantly influence the course of our national economy and our entire social structure. Indeed, we may already be the first to experience, in response to a cleverly marketed perception of chaos - the "health care crisis in America" - a populist appeal to monolithic policies and absolute, oppressive, controls. If federalist statism succeeds in usurping overall control of medicine in America, only the extraordinarily naive would trust its promise to hold back at that point, meekly demurring at further intrusions into the private sector.

Thus, the commitment we pay, as leaders, to this new world vision of freedom and flexibility must be more than theoretical. This process demands of us far more than simply placing a cheerfully optimistic "spin" on our current predicament. It is essential that effective leadership establish, with concrete, but flexible and reachable objectives in mind, a new frame of reference, a new and constantly renewing vision of our world and its possibilities.

How we, as a profession and as a society, respond to this extraordinary challenge will determine whether our future holds the promise of unparalleled adaptability in a world of nearly limitless opportunities or, rather, threatens an abrupt and tragic end to all freedom as we know it. We ride the wild tiger of change unbound; will we be its firm master or its next meal?

All of America's leaders, and most certainly its physician executives, as agents of effective change and ongoing transformation, have a moral imperative to envision, effect, and evangelize a new world vision of unprecedented change, opportunity, and freedom.

(*) O'Connor, E. "Implementing Change." Presentation at Physician in Management Ill, Dana Point, Calif., Feb. 1993.

Richard A. Watson, MD (COL Ret.) is Associate Professor of Surgery, Urology Section, University of New Jersey School of Medicine, Newark. He may be reached at G536, 185 S. Orange Ave., Newark, N.J. 07103, 201/982-4488, FAX 201/982-3892.

COPYRIGHT 1996 American College of Physician Executives
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