The transformation of our health care system requires new organizational infrastructures to support not only care delivery workflow redesign but also the personal transformation of the provider team members. The current emphasis on workflow redesign is evident given an examination of recent large grant opportunities. The Centers for Medicare and Medicaid Services funding opportunity for the Transforming Clinical Practice Initiative (TCPI) constitutes a multi-million-dollar federal investment toward catalyzing the sustainable creation of workflow delivery infrastructures called practice transformation networks (PTNs). The TCPI will invest up to $800 million in providing hands-on support to 150,000 practicing clinicians for participating in PTNs. Clinicians in these PTNs will focus on developing the skills and tools needed to improve care delivery and transition to alternative, value-based payment models.1 This funding opportunity is in addition to the Health Resources and Services Administration’s $230 million Teaching Health Center (THC) payment modality for primary care graduate medical education (GME) expansion aiming to increase access to health care for and reduce health disparities of geographically isolated and/or medically underserved populations by increasing the number of residents training in THC locations.2 These federal investments represent efforts to transform the health care industry to meet the quadruple aim: improving the care and health of patients and populations while containing cost and enhancing satisfaction of patients and providers.3
But will they work?
Framing Our Dilemma
The call for patient- and relationship-centered4 transformation in our care delivery system is worthy but requires focused resource investment for the mindful and intentional pursuit of more than technical change. Despite cultural tethers to the historically expert-centered reality in the industry, this paradigm change mandates convergent, intentional change in workforce development.
Medical education has taken action to ready future physicians to lead transformed care delivery. The Association of American Medical Colleges, the Liaison Committee on Medical Education, and the Accreditation Council for Graduate Medical Education have all called for curricular changes that focus on building physician skills in arenas of interprofessional teamwork, patient- and relationship-centeredness, shared decision making and self-management support, patient safety, reflective practice, quality improvement, and population management. If the good work being done in medical schools and residencies is to result in authentic transformation in the exam room, the clinical learning venues in which students and residents are training will also have to change. Much of this change will be technical, such as in the concepts guiding the patient-centered medical home (PCMH)- and TCPI-related investments in ambulatory and outcomes-based training. An often-overlooked aspect, however, is the change required in and of the individuals who make up the care delivery teams.4,5 In other words, everyone involved in the practice transformation process must, themselves, transform.
More Than Transforming Process
Leaders of clinical practice transformation find that transformation is disruptive and that, to be successful, organizations need to have the motivation to change.6 If this motivation is to bear the fruit of authentic transformation, it must be bolstered by leadership both formal (positional) and informal (charismatic).7–9 Only then can a culture of collective accountability and a pursuit of collective genius genuinely emerge.10
Transformation is a deep alteration of our frames of reference, which comprise habits of mind—the ways we think about things—and points of view guiding the actions we take.11 Researchers have clarified three kinds of transformation: content, or knowledge fund expansion; process, or ways of doing things; and premise, or changes in our definitions and interrelatedness of ourselves and the worlds we inhabit.11,12 Premise transformation is what is needed in health care. Premise transformation is whole-human, biopsychosocial spiritual13 system change.
To engage in premise transformation is to do more than change a process, adopt new behaviors involved with workflow redesign and tracking quality metrics, or report patient outcomes. Technical, process changes such as these are often challenging, but, as with any new technology in the clinical setting, they will become routine with accumulated learning.14,15 The transformation about which this essay is concerned is deeper; it is adaptive change at a fundamental core level.15,16 This transformation needs to occur by reinvention of professional identities, inspiring a development of the self.5,17 True, behavior leads attitude, and if behaviors pay off in increased effectiveness14 and/or psychological relief,16 attitudes change. But will this attitude change be more than an improved outlook regarding new technical processes without essential cultural transformation? Will a new attitude about the value added by increased reliance on point-of-care metrics translate into a new attitude about working in teams and engaging in authentic patient-centeredness? Will this attitude refocus the lens that reduces patients to categorical identities of noncompliant or disease afflicted toward a view that appreciates the true human life stories of patients and colleagues? Will the behaviors required for PCMH workflow lead to physicians letting go of having to, as emphasized by Dr. Robert Wachter in an address to the Institute for Healthcare Improvement,18 hold all the information in their heads, master all the skills, and take all of the pressure, blame, and victory as their own? Will this sort of process transformation—as so many define it—authentically change the culture of medicine?
Technical, process transformation will likely not, in itself, result in the sorts of transformation so many deem necessary.4,5,12,18,19 It is, however, considerably easier than convincing the members of the culture of medicine that the most needed change is a change in their very being. Those of us who have experience in teaching doctoring courses filled with preclinical students or who work to facilitate critical reflection with residents have felt firsthand the resentful pushback of a culture being told it is broken, expert centered, and not sustainable. This curriculum is considered fluff, nonsense, and a waste of time. Denial and aversion to change drive a belief that resistance to complex authentic transformation will prevail. Many of those who precept medical students and residents while maintaining a practice currently disagree about the degree of brokenness of the system, are frustrated with the challenges and complex work of process transformation, and are uncertain not only about their own futures but about whether potential future physicians should even bother entering the field. While it is true that transforming processes can be frustrating, we must keep in mind that transforming people can be fundamentally disorienting, emotionally painful, and thoroughly exhausting. Still, to transform a system, a culture, and the health care industry, we need to do both.
Transformation in people is a change in mental models and habits and all that entails: behavior modification, neurological pathway diversion, and the development of psychological and emotional grit, as well as social and spiritual strength. Every walk into a clinical learning venue where problematic habits were formed and validated can trigger these habits despite someone having learned new behaviors from continuing medical education (CME), conferences, and personal mentorship. Getting colleagues to change frames of reference can be as difficult as getting patients to quit smoking. Even when all the evidence in the world is widely known and readily available and points to the need for change, frames of reference often persist with tenacity.20
The deep challenge and pain often associated with transformation is something that many seem to miss or choose not to focus on when talking about transformation, even while they acknowledge its undeniable, multidimensional complexity. But to overlook this component of transformation is akin to teaching mindful reflection without ever mentioning that, when we are authentically mindful, we will inevitably become aware of our ugliest parts and restrictive comfort zones. Within the context of medical culture and the subculture of medical education, this means coming to terms with reactivity, individualistic competition, fear of vulnerability, and the prevalence of suicide and substance abuse. This ugliness is exacerbated by the pressures of increasing relative value units, accountability reporting, increasing social and educational pressures due to the proliferation of information, and the external and internal expectations that clinicians ought to never make a mistake. Transformation efforts such as Balint21 groups for reflection and Healer’s Art22 courses focus and do great work on healing the healers, but these workshops often only reach those who have already prioritized the need for personal change or those who have been mandated to engage because of disruptive behavior.
Our habits of premise, the frames of reference that explain how we understand ourselves and our worlds and our interrelatedness with those worlds and others in them, are likely to be the biggest hindrances to sustainable, large-scale practice transformation. Current policy definitions of and incentives for transformation lack appropriate acknowledgment of the importance of personal and professional premise transformation, and the adaptive change necessary for effective engagement with and leadership of mandated technical process changes. When we undergo these premise transformations, changing our frames of reference about who and where we are, we tend to feel a deep sense of confusion and disorientation, even fear. This may result in something akin to grief or, in some cases, actual grief. It can be painful to lose something held as dear as personal and/or professional identity, particularly when that identity is associated with prestige and power. We are vulnerable suddenly—no longer strong, coherent seeds but broken seed casings from which tender shoots attempt to emerge. In hurtful conditions, the shoots die and all that is left are remnants of brokenness and a deep sense of resentment for even having to have tried sprouting. But in benevolent and nurturing conditions, these shoots will become seedlings and then mature, bearing seeds of their own.
This may sound dramatic, but it is as much an essential outcome of practice transformation as are improved diabetic care measures and reduced readmissions. The transformation of clinicians in transforming environments is essential to authentic cultural transformation. As this type of change will be more than a little uncomfortable for many, there is a need for supportive conditions that create an environment of nurturance and benevolence. The challenging endeavor of premise transformation, of deep mental model and habit change, must be a part of the professional development of every clinician, not limited to those who tend toward reflection. This is going to require leaders both positional and charismatic who are willing and able to be the change and champion the movement.5,7,8,23–25
Organizations are conversations between members who bring with them their own frames of reference.4 Successful leaders enable the evolution of shared frames of reference and purpose. As the relationships within organizations grow and develop into systems and narratives and processes, culture emerges. Therefore, to change the culture and the systems that express that culture, we need to change the constituent members. To engage in practice transformation in the way we describe is to acknowledge that the frames of reference of the members of an organization profoundly influence and determine its culture. If a culture has challenges, the reasons for and resolutions of those challenges lie within the same resource: its members.
As we have said, whole-human transformation is no easy task. Often, despite our best intentions and education levels, we will fight change with all we have, sometimes explicitly, sometimes unconsciously. There is a reason why the literature on the subject talks about people having behavioral and psychological immune systems built to deny change16 and why people skilled in defensive martial arts become sought after as organizational change consultants.7
Suchman et al4 have recognized the difficulties of personal, professional, and cultural transformation and have called for nurturing leadership and transparent, safe communication. Leaders who model desired practices, inspire others to share in their visions of what can be, challenge the status quo, enable collaboration, and encourage whole-heartedness in those around them have been shown to increase the performance of systems in which they work and raise the cultures of which they are part.26,27 Leaders like this, leaders who have themselves begun to transform their premises, help to create environments of nurturance and benevolence, spaces for connection that are needed by people who are developing themselves through transformation.11,28 Physicians have long been considered leaders.29 Now, however, in the team-based care delivery model, physician leaders must be humble, appreciative, and learning oriented.30–32 Because of this, physicians must lead transformation by transforming themselves, as, without this leadership, authentic practice transformation will not and indeed cannot thrive.33
Transformation such as this requires considerable resources and faces multidimensional challenges as well as both visible and hidden resistance. Development of personal, team, and system transformation must be integral to the implicit and explicit curricula of the medical education continuum, undergraduate medical education through GME to CME. Engagement in the personal development of physicians will address the implicit curriculum. Methods such as immunity mapping23 and educational interventions based in appreciative inquiry and reflective work34–36 can be implemented at all levels of medical education, influencing the explicit curriculum. Methods such as the Coach Medical Home, a guide to broad-scale practice transformation in primary care, can be helpful in starting conversations about why and how things need to change.25 While there are many means to the end, the important thing is to choose a path and follow it with a mindful and intentional focus on premise change.
Implications of This Perspective
If we are to authentically transform health care and not merely layer technical complexity in pursuit of transformation, those who deliver care within organi zations and systems, defining the culture of health care, must transform at a core premise level. This will take time, energy, practice, failure, self-compassion, resilience, and benevolent coaching and mentoring from those in the medical community who have already begun the process.25 This is the high-touch, high-concept part of practice transformation, the part that requires not only rede signing workflow but fundamentally developing and transforming those who work within the industry.37 Mostly, it will take mindfulness and intentional, reflective practice. We must aim to transform our habitual ways of being as well as the environments in which we exist: being differently; redefining physicianhood as leadership not only of delivery teams and patient–provider team dynamics but also of the culture of medicine, of medical education, and of the self. Yes, technical progress in clinical performance is important, but authentic practice transformation is that and more—much more. It is the professional and personal development, the biopsychosocial spiritual growth of the practitioners themselves.
If physicians are truly to engage in and lead authentic practice transformation, physicians must actually practice and experience personal transformation.
Acknowledgments: The authors are humbled to have been invited to write this Commentary. They thank the editorial staff of Academic Medicine as well as David Sklar, MD, for this incredible opportunity. They are also deeply indebted to the residents and students they work with every day as well as their colleagues, friends, and patients, all of whom allow them to learn every day just how far they have come and how far they have yet to go.
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