At the 2019 International Forum on Quality and Safety in Healthcare in Glasgow, IHI President Emeriti Don Berwick and Maureen Bisognano shared times they’ve changed their minds throughout their careers as leaders in health care. In a new interview, Berwick reflects on what he said in Glasgow, why he and Bisognano felt it was so important to share personal examples of vulnerability and growth, and how leaders should learn by listening to others.
You and Maureen Bisognano decided to focus your International Forum plenary in Glasgow earlier this year on what you’ve changed your mind about over the years. Why?
I regularly have the flattering opportunity to give speeches and to teach at IHI conferences. That does not often give me the chance to reflect on the immense list of things that I don’t know. Maureen Bisognano and I thought that if we took one of our plenaries and, instead of talking about what we did know, we talked about what we didn’t know ― or about what we are learning ― that would be fun. And it was fun.
The theme of “changing my mind” contains the underlying message that, as learners, we all need to be open-minded and willing to consider new ideas. Some of the most dearly held beliefs we have ― whether they’re about improvement, health care, or the way society works ― they’re just our theories. Somebody likely has a better one. We wanted to talk about that.
Curiosity and open-mindedness are key to improvement. When Maureen and I began inspecting things that we really had changed our minds about, it was easy to come up with some examples where we once knew far less than we do now. We made a list of these things. We overlapped some and had some differences. It was a fun enterprise.
What was one of the most interesting things that you talked about changing your mind about or something that you got feedback about that seemed to resonate with people?
I’ll give you several examples. One is digital health. In the past, I was a little bit casual about it. I thought, “Isn’t it cute that these people have apps and there are so many new vendors out there? Yes, artificial intelligence does sound intelligent!” But about two years ago I began really digging into this and visiting places that are innovating around digital health.
One important encounter I had was with Dr. Sanjeev Arora, the founder of Project ECHO, in New Mexico. I’ve now visited ECHO several times, and it’s left me astounded by what’s possible with relatively simple telemedicine, especially through what Dr. Arora calls “force multiplication.”
I’ve also become involved a bit now with digital health through artificial intelligence and machine learning as an occasional advisor to the Google Health team. For example, they are using artificial intelligence and machine learning to read chest x-rays, optical tomograms, and mammograms ― and that’s just the beginning. I am impressed by what’s possible when you harness the processing capabilities of computers and machine-learning algorithms in partnership with clinicians. You get results that likely aren’t achievable any other way.
I’m also intrigued by burgeoning movement toward self-care. I think that people really can do for themselves a lot more than I was ever taught as a doctor they can do. Now we have apps and developing technologies that will coach people and help them, if they wish, to become their own doctor. It’s an edgy way to say it, but maybe everybody could be a doctor in some way. They have the brains, and now they can have the support. It changes our role as health care professionals, but I think that’s exciting.
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Besides digital health, a second area on which I’ve changed my mind is about social determinants of health. I’m a pediatrician; I know what makes kids feel ill or not thrive. But when I, again in the past two years or three years, began looking at the data and reading the writings of scholars ― for example of Sir Michael Marmot, whose work I’ve been talking about quite a bit ― I was astonished. Social determinants hardly capture what’s going on here. These are monstrous, massive influences on longevity, on wellbeing, and on energy that dwarf anything that health care does. I’ve learned to say, “Look, if we’re healers, we’ve got to deal with causes, and the causes lie in these community structures.” That’s been a big wake up call for me.
Why do you think it can be so difficult for leaders, including in health care, to openly admit that they could change their minds about something?
There’s a heroic view of what a leader is — the person with the answers. The leader is supposed to be very smart and knows the answers, and his or her job is to deploy the answers to the workforce. We even call the workforce in some places the “hands” ― not the “brains,” the “hands.” Maybe it goes back to Taylorism. It was Frederick Winslow Taylor’s great breakthrough in the era of mass production that the workforce was just supposed to carry out instructions in the manual, but they don’t write the manual. In Taylorism, the manual is written by people who are trained to think about what the work ought to be. In that view, the leaders’ job is to get workers to do what you know they need to do, to follow the instructions.
This thinking is everywhere. It’s a two-way conspiracy, or a folie à deux. It’s not that control-freak leaders are keeping people from doing what they want; the workforce is trained the same way ― to turn to the boss and say, “Okay, what’s my instruction? What do I do?” People often lack confidence that they actually have the answers themselves. We have all have been trained to believe in a hierarchy of ideas, which isn’t helpful.
It takes good mentoring and a lot of self-scrutiny to begin to realize that leadership of the best type shows humility and curiosity. Instead of “I know the answer,” the best leaders say “You know the answer. How can I help you use what you know?” Approaching the work this way is transformative. It’s a rocky ride because you don’t know what the workforce is going to think or bring to you. If you did, we’d be back in the first mode. This ability to ask authentic questions is key.
What advice do you have for leaders about the value of being open to having one’s mind changed?
All I can say to leaders who think that maybe helping people thrive instead of controlling what people do is the most important part of their work is to be vulnerable and share your confusion when you have it with others so that they may offer solutions. Ask real questions, and don’t assume you have the answers. You don’t have to have the answers. If you’re not prepared to model that kind of openness in your own behavior, don’t expect that to emerge in the organization. Curiosity really does start in the C-suite and the board. Be curious.
Editor’s note: This interview has been edited for length and clarity.
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