Ten Things I Have Learned About How the World is Changed ( and how I am changed )

1. Ten Things I Have Learned About How the World is Changed (and how I am changed) David C. Leach, M.D. CEO, ACGME August 1, 2007

2. God has no potential; we do.

3. A moment of gratitude Before we begin….

4. Paul Batalden The ACGME Community Don Berwick Dee Hock Parker Palmer Brenda Zimmerman Michael Quinn Patton C. Otto Scharmer Aristotle Rosa Parks Martin Luther King Nelson Mandela Vaclav Havel The unremembered many Thanks to…

5. Recommended Reading • The Birth of the Chaordic Age – Dee Hock • Getting to Maybe: How the World is Changed – Westley, Zimmerman and Patton • Theory U – C. Otto Scharmer

6. The Way It Is There’s a thread you follow. It goes among things that change. But it doesn’t change. People wonder about what you are pursuing. You have to explain about the thread. But it is hard for others to see. While you hold it you can’t get lost. Tragedies happen; people get hurt or die; and you suffer and get old. Nothing you do can stop time’s unfolding. You don’t ever let go of the thread. --William Stafford

7. Lesson One: Be Clear about the Task… • Substance is enduring; form is ephemeral. Preserve substance; modify form; know the difference. • Dee Hock

8. The Tasks… • How can we be both faithful and effective trustees of the values our profession and traditions offer society? • …and how can we prepare the next generation of doctors to be faithful and effective?

9. The Task… • Be clear about the aim… • e.g. Improve patient care vs. • Save 100,000 lives by June 26, 2006

10. Lesson Two: • It is said that people resist change; in my experience people are attracted to change. • But…

11. They are not attracted to: • Transitions • Burden • Being told to change their way to my way

12. Lesson Three: • The future is bigger than we are; it is emerging as we speak; we cannot redesign it; we can only notice it.

13. Lesson Three: • The task is to pay attention .... • with others

14. Lesson Four: • The quality of conversation… • is predictable • is helpful in knowing the next step • is progressively more authentic

15. Predictable • I deny that we need to change. • I resist the change you are suggesting. • It was my idea all along.

16. Is A Helpful Marker… • …and progressively more authentic

17. ● ● ● I-in-Me I-in-It I-in-You I-in-Now After Scharmer

18. ● ● ● “Self” I-in-Me Downloading Habitual Voice of Judgment I-in-It Seeing Rational Voice of Cynicism I-in-You Sensing Relational Voice of Fear Authentic I-in-Now Presencing After Scharmer

19. ● ● ● “Time” “Self” Downloading I-in-Me Habitual Disembodied Voice of Judgment I-in-It Seeing Chronos Rational Voice of Cynicism Sensing Slowing Down I-in-You Relational Voice of Fear Kairos Stillness Presencing Authentic Presencing I-in-Now After Scharmer

20. I-in-Me ● I-in-It ● ● I-in-You I-in-Now “Org. Action” From within org. boundaries (Re-enacting patterns from past) From periphery of boundaries (Facing exterior data) From beyond org. boundaries (Sensing through social mental fields) Across open boundaries (Connecting to source) After Scharmer

21. ● ● ● “Self” “System” I-in-Me Downloading Habitual Autistic Voice of Judgment I-in-It Seeing Rational Adaptive Voice of Cynicism Relational Reflective I-in-You Sensing Voice of Fear Generative Presencing Authentic I-in-Now After Scharmer

22. Lesson Five: • It helps to work with … • …rather than against nature

23. Working with Nature:Three Faculties and Their Objects • Intellect – seeks Truth • Will – seeks Goodness • Imagination – seeks Beauty

24. Human Faculties and the Work of Medicine • Intellect • Discerns the truth • Will • Makes good clinical/educational judgments • Imagination • Does so with harmony, creativity and beauty

25. Primary Values in Medicine with which to Arm Oneself • Integrity Discerning and telling the truth • Altruism Putting what is good for the patient/student before what is good for the doctor/teacher • Practical wisdom (Prudence) Beauty in judgment • Arete: Integrating all the virtues to excellence

26. Lesson Six: • Change Makes these Values Manifest in Community and in Action

27. Arete: ExcellenceIntegrated Virtue in Action • The quality of patient care, the quality of health professional formation, and the quality of system performance are inextricably linked.

28. The Context of the Work of Healthcare • Relentless economic/time pressures • A focus on safety, quality, transparency…. • More regulation, duty hours, etc. • New knowledge and technology • Fragmentation of care, alternative medicine, consumerism • Demographics – population, generational gaps…

29. The (Internal) Context of the Work of Healthcare • Truth telling (or lack thereof) • The 38/54% problem • Promises and forgiveness • Seeking goodness …for whom??? • Imposed external controls • Discontent • A need for authenticity

30. The National Context of Health Professional Formation • Impending physician shortages • Outmoded educational models • Individual formation: role of context

31. The Institutional Context for Healthcare Work • Frenzy

32. There is a pervasive form of modern violence to which the idealist … most easily succumbs: activism and overwork. The rush and pressure of modern life are a form, perhaps the most common form of its innate violence.

33. To allow oneself to be carried away by a multitude of conflicting concerns, to surrender to too many demands, to commit oneself to too many projects, to want to help everyone in everything is to succumb to violence.

34. The frenzy of the activist neutralizes his (or her) work … It destroys the fruitfulness of his (or her) work, because it kills the root of inner wisdom which makes the work fruitful.Thomas Merton

35. From frenzy to wisdom… • …as individuals and as a profession

36. Lesson Seven: • We have to let go in order to let come.

37. AfterScharmer

38. The problem is never getting new ideas into your head; it’s getting the old ones out. • Dee Hock

39. A Midrash

40. Lesson Eight • It helps to honor both arms of all paradoxes.

41. Open ------------- Hospitable ------------- Voice of Individual ------- Personal stories ---------- Solitude --------------- Speech ---------------- Bounded Charged Voice of Group Archetypal stories Community Silence Parker J Palmer Six Paradoxes of Formation Space

42. Lesson Nine • Crystallize intentions

43. AfterScharmer

44. Lesson 9A • Keep Humility at the Ready

45. Thomas Merton “ We exhaust ourselves supporting our illusions.”

46. Lesson Ten: • There are really only two questions

47. Two Questions • Who is my Self? • What is my Work?

48. Journey to Authenticity… • as individuals and as a profession

49. The Journey One day you finally knew what you had to do, and began, though the voices around you kept shouting their bad advice- though the whole house began to tumble and you felt the old tug at your ankles. “Mend my life!” each voice cried. but you didn’t stop. You knew what you had to do.

50. The Journey (cont.) …little by little, As you left their voices behind, The stars began to burn Through sheets of clouds, And there was a new voice Which you slowly Recognized as your own, That kept you company As you strode deeper and deeper Into the world, Determined to do The only thing you could do- Determined to save The only life you could save. Mary Oliver