Changing our culture

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Today, a great challenge of our profession is to envision how we will deliver exemplary neurosurgical care in the future. To accomplish this requires anticipating how economic, political, and societal influences will affect our ability to provide the highest quality of patient care in an arena that will look increasingly different from today's world of medicine. Already, our profession is battling a relentless assault as numerous sectors implement change that impacts us and our community every day. Surviving this requires an effective strategy that will involve significant cultural change. To accomplish this, neurosurgery must take an honest look inward and then commit to being the agents of positive cultural change.

Such a path will not be easy but should reap important benefits for all of neurosurgery and our patients. Several practical and proven strategies can help us to realize the rewards of changing our culture. Vital to this process is understanding that effecting behavioral change will increase the likelihood of achieving sustainable cultural change. Innovation and diversity are crucial to encourage and reward when trying to effect meaningful cultural change, while appreciating the power of a “Tipping Point” strategy will also reap significant benefits.

As a profession, if we adopt these strategies and tactics we can lead our profession to proceed in improvement, and as individuals we can use the spirit that drove us into neurosurgery to become the agents of an enduring and meaningful cultural change that will benefit our patients and us.

Abbreviation used in this paper:CSNS = Council of State Neurosurgical Societies.

Abstract

Today, a great challenge of our profession is to envision how we will deliver exemplary neurosurgical care in the future. To accomplish this requires anticipating how economic, political, and societal influences will affect our ability to provide the highest quality of patient care in an arena that will look increasingly different from today's world of medicine. Already, our profession is battling a relentless assault as numerous sectors implement change that impacts us and our community every day. Surviving this requires an effective strategy that will involve significant cultural change. To accomplish this, neurosurgery must take an honest look inward and then commit to being the agents of positive cultural change.

Such a path will not be easy but should reap important benefits for all of neurosurgery and our patients. Several practical and proven strategies can help us to realize the rewards of changing our culture. Vital to this process is understanding that effecting behavioral change will increase the likelihood of achieving sustainable cultural change. Innovation and diversity are crucial to encourage and reward when trying to effect meaningful cultural change, while appreciating the power of a “Tipping Point” strategy will also reap significant benefits.

As a profession, if we adopt these strategies and tactics we can lead our profession to proceed in improvement, and as individuals we can use the spirit that drove us into neurosurgery to become the agents of an enduring and meaningful cultural change that will benefit our patients and us.

Wayne Gretzky is the greatest hockey player of all time. You can watch him at the pinnacle of his career (http://www.youtube.com/watch?feature=player_detailpage&v&=vReIT6i66Pc). Gretzky was often asked about his accomplishments and he was never shy about his answers. He once said: “A good hockey player plays where the puck is. A great hockey player skates to where the puck is going to be.”3

Similarly, the challenge of our profession is to envision how to deliver exemplary neurosurgical care for the future, not just to fine tune and improve how we practice now. To accomplish this requires anticipating how economic, political, and societal influences will affect our ability to provide the highest quality of patient care in an arena that will look increasingly different from today's world of medicine. This brave new world must also allow appropriate levels of reimbursement to sustain us as professionals as well as the capacity to continue invaluable academic pursuits. To be great neurosurgeons, it is essential for us as a community and as individuals to embrace fundamental change of our culture. It is this concept that is explored in this Council of State Neurosurgical Societies (CSNS) Chair farewell.

The Perfect Storm: Neurosurgeons in 2013

Knowing the CSNS is a strong and vital organization, we can focus on Gretzky's message and the necessity for us to direct where our puck will be over the coming decade. To do this effectively, we need to first contemplate the dilemma of neurosurgeons in 2013. Right now, our profession is battling a relentless terror like that artfully depicted in The Perfect Storm.8 The weather assaulting us over the last years has lashed at us from many unanticipated angles including the legacy of Libby Zion, the impact of the Institute of Medicine (IOM) report, the fiscal crisis, International Monetary instability, Osama Bin Laden/Al Qaeda's influence on the United States budget, and the escalating cost of rapidly evolving and expensive technological advances within medicine. In response, numerous sectors have implemented change that impacts our community. The Accreditation Council for Graduate Medical Education (ACGME) is altering resident training through duty-hour restrictions, core competencies, portfolio projects, and the Milestone Project (https://www.acgme.org/acgmeweb/tabid/434/ProgramandInstitutionalAccreditation/Milestones/Milestones-SurgicalSpecialties.aspx#; http://www.acgme.org/acgmeweb/tabid/271GraduateMedicalEducation/DutyHours.aspx). Federal legislation is exerting control over how we deliver care through accountable care organizations (ACOs), quality reporting requirements, meaningful use incentives/penalties, and insurance exchanges among others efforts. Hospitals are influencing medical practice through physician employment and value-based incentive programs to name just a few (http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospitalvalue-based-purchasing/index.html?redirect=/hospitalvalue-based-purchasing). And in every state, additional local efforts are being initiated. What strikes me most about these changes is: 1) they have largely been imposed on us rather than been products of our own recognition for the need to change, and 2) they remain wildly unpopular among most neurosurgeons.

This prompts the question, why? It is not that neurosurgeons lack expertise about these issues. Let me cite just a few examples. In the arena of positive change in resident education, Tom Origitano initiated a Boot Camp project to provide rapid training to early-level residents to avoid unnecessary “rookie errors.” Now his concept has expanded significantly to the benefit of all!15 Similarly, Bob Harbaugh and Tony Asher have been early innovators in the realm of registries to promote quality outcomes research. Their brainchild, NeuroPoint Alliance (NPA), now serves as a model for specialty collaboration in assessing and promoting quality outcomes. For the most part, however, physicians have battened down the hatches and then taken positions difficult to defend. Despite this, or perhaps because of it, those who know considerably less about patient safety and care, medical education, and cost containment are forcing further change on us.

Neurosurgeons and Cultural Change

As with all terrifying storms, surviving the onslaught depends largely on preparation. If one is merely reacting to events, then calamity can prevail. Medicine seemed unprepared for these challenges and we have been reacting ever since. We must accept that part of the fault is ours—we have too often elevated the expectations of what medicine can accomplish and cared too little about quality and science. One consequence of this is the absolute presumption that in the United States, if you get sick, we (the world of medicine) will fix you. As a result, too many Americans feel that death is negotiable (http://www.ted.com/talks/nate_garvis_change_our_culture_change_our_world.html). Furthermore, our system has also evolved to reward outputs rather than outcomes. Taken together, this creates a dangerous spiraling system that will always be unsustainable and unsatisfactory to both providers and participants.

We also failed to appreciate that how the world of medicine “looks” to most Americans bears little resemblance to either how we or the politicians see it. Thomas Jefferson, on returning to Monticello after leaving elected office, remarked on how “different the world looked in rural Virginia than from the hallowed political halls of Philadelphia.”11 This view has been exacerbated by protectionism—our own brand of “Not in my backyard” (NIMBYism)—including doctors, hospitals, pharma, and politicians. A bill was recently introduced in New York proposing significant increases in the Certificate of Need (CON) process to control many aspects of larger medical practices. Digging into this effort reveals that hospitals and unions are working to hold their advantage over the growing influence of this sector. Despite all this activity, few participants are listening to or understanding what those “outside” (i.e., Americans receiving health care) are experiencing.

The Challenges of Cultural Change

The cultural foundation of this crisis, like all culture, is powerful and difficult to understand. We can't ignore it or conquer it, but we can adopt a proactive approach to changing it rather than continuing a futile defensive position. As individuals and neurosurgeons, we must take a serious, honest look inward, shed our comfort zone along with some bad habits, and then commit to being the agents of positive change for the culture of medical practice. This requires accepting that the status quo is not perfect and will certainly be suboptimal for the future. It will be hard, but taking a new road may uncover unexpected rewards. For many, fear of change is overwhelming. So listen to the sage words of Ben Franklin: “When you're finished changing, you're finished”!10

I don't think neurosurgery is finished and I bet you don't either!

In business, politics, or any professional sphere, there is little more dreaded than confronting the need for, and then implementing, cultural change. Cultures and organizations form for specific economic or political reasons that devolve from individuals coalescing around similar values, morals, and outlooks. Then managers, or those in positions of leadership, reinforce this culture by hiring more people like themselves.1,6 Too often this practice has been viewed as discriminatory when this reality exists passively based on issues of comfort and understanding. It is natural; all of us would prefer to gather with people we like and with whom we share common interests. This process is further magnified in training systems where inclusion decisions begin even earlier and behavioral molding occurs over a prolonged timeframe. The need for extensive teaching within a cultural system adds a deeper level to this.13 Many who teach or train others in close quarters may unknowingly question their own ability to effectively teach those who seem so different.12

Like many generational schisms, this has become one of the most daunting challenges within medical education. Clearly those under 30 have demonstrated that they learn very differently from us—with shorter attention spans, less reliance on individual learning, and a diminished need to memorize details so readily available (http://en.wikibooks.org/wiki/Web_2.0_and_Emerging_Learning_Technologies/Next_Generation). Fluidity in teaching approaches will become increasingly important as will the recognition that learners—just like backgrounds and personalities—come in a panoply of flavors. This will have important and far-reaching implications for all organizations and cultures with respect to interacting with the next generation and thus adapting our present structure and foundational concepts.

Neurosurgeons Must Drive Beneficial Change

Given the natural impediment to change, appreciating how all culture, not just medicine and medical education, is constantly evolving can be reassuring. Tony Hileman, an American humanist, writes, “Culture is created and recreated in a delightful and dizzy upward spiral—we have to work at it. There comes a point in this cycle…where we realize that what we held as rational has become rationalization…we once again uncover in our thinking a mythology masquerading as rationality.”5

Accepting that significant change has already been imposed on us and yet more is rapidly approaching, how can we regain significant control and then drive change in a more gratifying direction? The key to this daunting task is initiating a courageous path forward. While no one can elucidate a simple template for this process, there are vital, practical, and proven concepts that may be useful.

We should consider employing the elegant framework of the Blue Ocean Strategy (a consultant group focusing on helping institutions address cultural and organizational change in a positive and productive way).9 Their premise is that the best path to success (for an individual, business, or organization) necessitates swimming away from the strident competition in the bloody, red seas and thus into the blue ocean. They assert that finding calm waters will be more rewarding than fighting against a forceful tide. Moving yourself (organization or business) into the clear blue ocean will bring greater rewards and fewer scars than trying to win one devastating battle after another. Despite adopting this approach when undertaking organizational change, one will encounter hurdles in the following realms:

  1. Cognitive: including, Why is this change needed? Why abandon the status quo?

  2. Limits to resources: By definition, any change will involve give and take of this precious commodity

  3. Motivation: Inspiring meaning to all who must contribute to success of change

  4. Political: Opposition from powerful factions and individuals whose positions feel threatened

Let us consider just one specific example of how these identified barriers manifest themselves within our profession. As neurosurgeons and thus insiders, encounters with our own health care system can be skewed, precluding empathy with the challenges that many others face. If you doubt there are flaws in our medical system, I would encourage you to listen to the stories of many of our own colleagues who suffered recent personal nightmares when loved ones received questionable care for at least part of a serious illness despite their influence. Many privately acknowledge that had they not been informed and insistent on specifics of care outside their area of specialty, the outcomes may have been seriously compromised. Such colleagues unwittingly fulfill a key strategy frequently employed by the Blue Ocean Strategy group to help organizations overcome the cognitive roadblock—that is, getting influential people exposed to the harsh realities that are driving the need for change. In medicine it would be far better for us to cognitively accept that there is need for change rather than to personally experience tragedy; to acknowledge there are areas that need improvement without having to suffer unnecessary morbidity or mortality ourselves or for our loved ones.

Tactics for Successful Cultural Change

This strategy can be bolstered through the use of several tactics. The first is recognizing that change does not have to be cataclysmic; in fact, often the most effective adaptation is sequential. Willis Harman, a social scientist devoted to futures research, writes, “Fundamental changes have come about…through vast numbers of people changing their minds—sometimes only a little bit.”4 Vital to understanding this principle is appreciating that effecting behavioral change always increases the likelihood of achieving sustainable cultural change. Top business strategists list the number one principle of securing enduring cultural change as (http://danwaldschmidt.com/2012/09/business/keith-ferrazzi-says-forget-aboutculture-change):

  1. Cultures won't change without behavioral change

    Additional required elements are that:

  2. Personal motivation is essential to change

  3. Collaboration, candor, and accountability are key elements

  4. Peer-to-peer interaction is essential to sustain change

  5. Success will lead to change being accepted and sustained

These theoretical principles, while not difficult to comprehend, require considerable effort for successful implementation.

The 2013 CSNS luncheon program highlighted another component needed to ensure tactical success. Douglas Brinkley related “Historical Lessons on the Importance of Innovation and Diversity.” As leaders, our impact is incompletely realized if we ignore the potential of diversity. Mixing people with different strengths and backgrounds can help unleash a new font of talent and creativity. Reading this key leadership concept helps us understand some of the greatest successes within the CNS, AANS, and CSNS and unfortunately also some of the projects that fell short despite good ideas and strong leaders. There is this enduring but destructive myth that we must have unanimity to have unity, that being inclusive may impede success. Jefferson cautioned throughout the founding of the United States that a “difference of opinion is not necessarily a difference of principle” (Inaugural Address, March 4, 1801). Honoring this concept, meaningful change in our culture will require us to connect in new ways as well as embrace rather than fight diversity.

True innovation is equally important to welcome and reward. Steve Jobs is one of the great innovators of our time who used innovation to create a company and products with a lasting legacy. Walter Isaacson (2013 AANS Special Lecturer, Opening Ceremonies) told us a lot about this influential but controversial figure.7 Whatever one's opinion of Jobs, he had an unflinching dedication to innovation, and the resultant impact on our culture cannot be ignored. A remarkable celebration of the value of innovation is Apple's (Steve Jobs') clever advertising campaign: Think Different.14 You can watch and be amazed (https://www.youtube.com/watch?v=Rzu6zeLSWq8):

Here's to the crazy ones. The misfits. The rebels. The troublemakers. The round pegs in the square holes. The ones who see things differently. They're not fond of rules. And they have no respect for the status quo. You can quote them, disagree with them, glorify or vilify them. But the only thing you can't do is ignore them. Because they change things. They push the human race forward. While some may see them as the crazy ones, we see genius. Because the people who are crazy enough to think they can change the world, are the ones who do.

Many of us started out approaching life and learning like the innovative heroes in this ad campaign. Often we were viewed as crazy, rebellious, or just plain arrogant to consider a prestigious career in neurosurgery. We must continue to nurture that innovative part of us to push our profession forward.

One more tactic we should employ in effecting cultural change is a “Tipping Point” strategy made famous by Malcolm Gladwell in his widely acclaimed bestseller about change.2 Within any culture, there are select individuals with disproportionate influence on a broad range of individuals. There are at least two implications to our current conundrum. One is that every one of us is an individual within neurosurgery and medicine with extraordinary influence. Thus, we must be the standard bearers who welcome the potential that change offers for our profession. Equally important, however, is that neurosurgery—as a whole—has disproportionate tipping potential within the world of medicine, and we must recognize this crucial role and exercise such influence carefully. Starting today, we must try to reconnect to the daring youth inside us to propel neurosurgery forward and drive the culture of medicine to a new and better place.

Meaningful Cultural Change

Before closing, here are two very personal stories about cultural change. The first relates to a recent enthralling visit to Southeast Asia. After a few days in sacred and idyllic Luang Prabang, Laos, our small group headed to Vietnam. In our group was a 69-year-old lawyer who had been spared the draft at the 11th hour. The emotion he felt and expressed, as our plane landed in Hanoi, was overwhelming. Tears brimmed in his eyes when he quietly stated, “I never thought I would fly peacefully into Hanoi.” At that moment, thoughts of Dr. Patrick Kelly's 2002 Schneider Lecture (“Vietnam 1968–1969: A Place and Year Like No Other”) echoed. In this talk, he recounted one year that defined the rest of his life. As one travels the country today, there are still many scars from what they call “The American War,” and still remnants of Mao-style communism, but everywhere one also sees poignant evidence of spectacular cultural change. Dr. Kelly worked out of Da Nang, now a thriving city with beautiful museums and a brand-new airport. Nearby, the beaches still nicknamed China Beach are witnessing an explosion of luxury resorts while Hue's citadel, the epicenter of the Tet offensive and once an emotional symbol of the horror of this conflict, is now a World Heritage site and top tourist attraction that is slowly being restored. Aung San Sur Key says, “History is always changing” (Address to crowds, Bangkok, May 30, 2012). Close inspection of Southeast Asia today confirms that simple and poignant truth.

The second is about chairing the CSNS. Each of us comes to such an office on the shoulders of those who have built the CSNS, but my job challenges were compounded by being at a time of enormous instability in medicine. This presents both an opportunity and a challenge. Based on the sage advice of a friend, I formulated goals and objectives for my term. When I look back, I realize that I hoped my leadership years would be relevant and perhaps that I might leave the CSNS somehow different and better. In part, I thought I might help to change the culture of the CSNS and perhaps just a little of neurosurgery by implementation of my ideas. I set myself lofty goals about inclusion, diversity, and efficiency. Perhaps with the support of a remarkable Executive Committee and administrative staff, I have ticked off some of these boxes. In the end, however, what I would share with you is that the culture that has really changed has been inside of me. Working with so many dedicated and talented people within the CSNS, AANS, CNS, and the entire Washington office, has opened my eyes and my heart to many new ways of understanding. My years as Chair forced me to think about every aspect of neurosurgery, medicine, politics, patient care, and leadership in a new light. I have come to the difficult realization that I was a better leader when I abandoned imposing solutions and instead listened carefully and kept an open mind to the many divergent and creative ideas of others. As such, it has been an invaluable personal experience, which I will always carry forward with me.

Proceeding in Improvement

Regarding Science and the Perfectibility of Man, Jefferson said:

For as long as we may think as we will and speak as we think, the condition of (wo)man will proceed in improvement. (Letter to William Green Mumford, June 18, 1799)

Let us all heed Jefferson's words. Together let us embrace the strategies and tactics that can lead our profession to proceed in improvement. As individuals let us rekindle the spirit that drove us into neurosurgery to propel us forward so we will become the agents of an enduring and meaningful cultural change that will benefit our patients and us.

Acknowledgments

I would like to thank the entire Executive Committee of the CSNS, Sandy Meyer, and the officers of the CNS and AANS for contributing to the success of the CSNS during my time as Chair and thus contributing to this address.

Disclosure

The author reports no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

This paper was presented as the Chair's Address during the CSNS Spring Meeting, New Orleans, LA, April 27, 2013.

References

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Article Information

Address correspondence to: Deborah L. Benzil, M.D., 110 S. Bedford Rd., Mt. Kisco, NY 10549. email: dbenzil@mkmg.com.

Please include this information when citing this paper: published online February 21, 2014; DOI: 10.3171/2014.1.JNS131318.

© AANS, except where prohibited by US copyright law.

Headings

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