We Think We Can, We Think We Can….But What If We Can’t?

At one point early in my life as a physician-executive, I founded and ran an operating division of a global healthcare communications company. We were successful our first year; three years later we had more than tripled our revenue, grown to 10+ people and were contributing significant business to the parent agency

As I prepared for my annual planning meeting with the CEO, we were looking at 50% growth, adding 5 more staff and a serving as a channel for low 8-figures worth of agency revenue; the future looked bright.

On the morning of the meeting I flew in on the redeye from a client meeting in Los Angeles and went right to the office with my deck and spreadsheets; that evening I was scheduled to host an oncology-related panel of physician thought leaders at a NYC mid-town hotel.

As expected, the planning meeting included the agency CEO, divisional CEO and CFO. I started to tell a story about my trip to LA, but there was awkwardness in the room, so I paused.

….and was told the company no longer needed my services.

No harm or foul, they said, just business. They had already made arrangements for the panel that evening; everything else was taken care of as well. I was asked to leave right then; I left in a daze.

I could have found lots of things to blame: the CEO was new, he had not hired me nor been involved in the strategic thinking that created the division in the first place; my compensation package was structured in such a way so as to take significant cash off the bottom line if I hit my targets; shared clients looked to us for strategic counsel and the agency staff were relegated to subordinate roles on the team.

But I knew that day I had done something fundamentally wrong, and it took me a while to figure it out: I was unskilled and unaware of it. I may have had many successful projects and demonstrated a powerful capacity to understand, decipher and change the trajectory of complex situations, but I was not a successful leader, nor, in retrospect, did I truly understand the dynamics of the foreign ecosystems I had entered.

Having Answers is Not the Same as Having Knowledge

Smart people usually think they can figure things out, and people who are used to working on complex, multi-factorial problems even more so. But as I learned the hard way, skills mastered in one environment are not necessarily be transferable to another, and the capacity to formulate an answer is not the same as having real knowledge.

We all know the story of “The Little Engine That Could”, who, when other bigger and stronger engines reject the chance to help a train in need, digs deep down to overcome his own perceived limitations of power and skill to save the day. For decades, children (and adults) have been exposed to the “I think I can” mantra to represent the idea they can do anything if they just put their mind to it.

But what if they can’t? What do they do then?

According to a 1999 study entitled “Unskilled and Unaware of It: How Difficulties in Recognizing One's Own Incompetence Lead to Inflated Self-Assessments”, (J Pers Soc Psych. 1999 77:6) more often than not they do what I did: unconsciously miscalibrate themselves, overestimating their abilities.

This elegant paper describes four separate studies which confirm an important dynamic of personal and professional development: that individuals who are objectively incompetent (based on bottom quartile scores in tests on a range of common cognitive or subject matter specific skills) but who are unaware of their actual skill level, tend to hold overly optimistic views about themselves – and overestimate their abilities even more when they face more difficult tasks. For example, for one measure, individuals with test scores in the 12th percentile estimated their skills at the level of performance required to score at the 62nd percentile

In addition, the study found that even when faced with feedback as to their inabilities, the incompetents’ opinions of themselves largely remained unchanged. In contrast, “competent” individuals tended to underestimate their skills, were less secure in their capabilities but also optimistically – and generously -- assumed that peers shared their proficiency levels.

The bottom line: individuals may impede their own learning capacity by inflating their ‘sense of skill’; which, in turn, further inhibits their ability to recognize their own incompetence, further sustaining their potential for ‘mistaken conclusions and regrettable errors’.

There have been many reviews and critiques in the years since this has been published,, but the basic premises have held up remarkably well. Of course, no one wants to think of themselves as limited, so readers of this article tend to see the ‘incompetents’ as some form of ‘other’, (their boss, their colleagues, their competitors), but, in fact, the conclusions also hold up when considering individuals who demonstrate intelligence and skills in other areas. In fact the authors found that the tendency of people to overestimate themselves is linked to some internal threshold of ‘knowledge, theory, or experience that suggests to them that they can generate correct answers’. (Once again proving that a little knowledge is a dangerous thing).

The true take-away from this article is that we should worry more when we (think) we know what to do, and less about the competence of those around us. Fortunately for us all – and as I discovered in my own quest - when actively trained, people better understand the limits of their abilities and recalibrate their self-assessment to better align with their actual skills levels.

What happens to those who are ‘unskilled and unaware”? They persist, but they do not evolve, risking extinction. Kind of like our current health system.

This came to me recently during a meeting with a prospective hospital ACO client, who was struggling with “patient engagement.” (more specifically allocation of capital against engagement). Their efforts were grounded in two approaches: their EHR patient portal and a call center, staffed by nurses. But response rates were low, and actual ‘engagement’ – meaning interaction towards a goal -- was even lower.

With my background in communications, I asked some questions about message testing and customer segmentation. These concepts were unfamiliar to the clinical and administrative leadership (no one from marketing was in the room), however, received with great enthusiasm. Some very bright people were putting substantial time and attention against this problem and were simply unaware of methodologies that, until recently, would otherwise have been irrelevant to their careers. It started me thinking: in what other areas might healthcare as a whole be ‘unskilled and unaware”?

My sense is that in healthcare, when faced with tough problems, we think we can figure them out. Inflated self-assessment is as much a cultural phenomenon as an individual one; not only do we miscalibate our own skills, but we collectively inflate our capabilities as a community.

This is particularly relevant as the healthcare community at large attempts to embrace “population management”. As its foundation, population management requires implementing and mastering a separate and distinct operating model from traditional care delivery, including a specialized infrastructure with its own functional requirements and the capacity to orchestrate and optimize goal-directed collaboration and operating relationships among the people, programs, platforms and partners that make up that infrastructure.

Designing and executing on this requires knowledge, skills and competencies that are at best peripheral to healthcare and unlikely to be part of the knowledge base of health professionals or administrators. Systems design, analytics, customer segmentation, modeling and targeting, consumer engagement, behavior change, resource management and operations efficiency all have relevant and well proven solutions from outside of medicine yet at hospital after hospital, teams of people are investing hours of brain-power trying to ‘solve’ these problems (or relying on vendors who come to the table with categorical answers but expect the clients to manage the system-level context of their offerings). More often than not, the knowledge necessary is just outside the door.

While lifelong learning is a characteristic of healthcare professionals, this learning tends to be focused on matters external to the profession itself – science, patient care and other categorical subject matter. While it may seem extreme for me to say, in my 30 years experience, when healthcare does seek new knowledge, we tend to look within the four walls of the ‘house of medicine’ and sometimes assumes that if we cannot find the necessary answers there, they do not exist. I have also experienced situations where, when there was some indication of relevant knowledge, theory or experience in a problem area from outside of medicine, its value was diminished or dismissed as not having been studied with sufficient rigor to be trusted.

Evolutionary forces have presented us with some challenges; we have some new things to learn. Why try and figure it out ourselves? What can we learn from jazz musicians about how to collaborate for high-level performance? What can we learn from the oil industry about balancing resource allocation with care plan performance goals? What can the payers teach us about risk profiling? Can cable TV set top boxes be employed to collect health risk assessment data? What can credit cards teach us about customer loyalty and steerage? Could we design different CAD interventions if we had the “point of sale” data collected by supermarkets?

In his 1978 book, Behind the Mirror: the Search for the Natural History of Human Knowledge, Nobel Prize winning ethologist Konrad Lorenz, describes evolution as a process rooted in interaction with – and perception of -- the outer world. Drawing from his research with animals in the natural environment, Lorenz describes how organisms use information to advance their effectiveness. Lorenz considers “exploratory behavior” as a mark of the developing organisms and species (think fish who try and leave the pond, thousands may have tried and failed but the one who made it started something big) and highlights ‘learning after maturity’ in particular as an important evolutionary advantage (hence our brains developing consciousness to the disadvantage of our once massive musculoskeletal systems).

However, medicine is often unconsciously considered by its members to be a “mature species” – resulting in little exploratory behavior and associated ‘learning after maturity’ as a profession. When combined with a track record of miscalibrating our own skills when faced with new challenges, it is little wonder that healthcare is being buffeted by external forces and struggling to make progress in its evolutionary path. In fact, the forces of maturity are so strong, that, when stressed, healthcare (as a species) makes desperate attempts to achieve equilibrium -- when equilibrium is impossible and change is unavoidable – resulting in further marginalization from the evolutionary progress.

One of the greatest strengths and most vulnerable weaknesses of the American medical system is our commitment to subject matter expertise as the dominant criteria for authority and career advancement. The fact is that mastering a complex subject and achieving thought leadership status in a subject-specific field does not automatically make someone capable of solving equally complex problems in an unrelated field; they may understand the problem and generate answers, but do not necessarily have the knowledge necessary for optimal operational problem solving.

While there has been some demonstrable movement towards embracing ‘knowledge transfer” from other discipline (e.g, Lean and Six Sigma frameworks, quality practices from the aerospace industry and others), this approach is not normative (which historically will confer evolutionary advantage to some). As well, when some new ideas are considered, they are usually considered in the context of a specific problem (e.g., quality) or in support of a status quo objective.

The key to shifting our current evolutionary dynamic is for everyone to understand that future healthcare is going to require systems (and associated capabilities and competencies) with which the current healthcare community has very limited experience and even, in some cases, no real frame of reference. Evolution of our roles and responsibilities is inevitable and the more we explore the ‘outside world’ for models and solutions to integrate and adopt as our own, the more likely we are to make magical discoveries and support our own advancement and prosperity as a community and as professionals.

© Steven Merahn, MD 2015