3/17/2011 by Patrick Marx

PHOTO: Carl Heltne, M.D.

The public political furor over health care has been so rancorous, divisive and hotly contested that here in the Northland it was a major reason 18-term Congressman Jim Oberstar lost his job in the November election. The controversy continues in Congress, in state legislatures, the courts and is never far from flaming new headlines.

With all the public heat surrounding the healthcare industry, what does it look like these days on the ground – in the clinic or the hospital – and from the perspective of the physician?

“Chaotic,” is Dr. Thomas Lee’s assessment, which surfaced last April in a provocative article he wrote for the Harvard Business Review (HBR). With laser-like acuity, he says that while greed, incompetence and corruption exist, “the biggest driver of healthcare costs is medical progress: new drugs, new tests, new devices and new ways of using them.

“This explosion of knowledge is going off within a system too fragmented and disorganized to absorb it. The result is chaos,” he said. And, his principal prescription for change may seem unexpected, unusual, and perhaps odd: turn doctors into great leaders.

“Taming this chaos requires a new breed of leaders at every level,” Lee declares without a bit of hesitation. Though not the stuff of headlines or loud public debate, it’s an idea that quietly has been gaining force all over the nation. And, several Minnesota systems are in the forefront, including, for instance, Duluth-based Essentia Health, which operates a network of 17 hospitals and 64 clinics in Minnesota, Wisconsin, North Dakota, South Dakota and Idaho.

“Leadership is in our DNA,” says Dr. Carl Heltne, Essentia’s chief medical officer, who also serves on the faculty for the Physician Leadership College at the University of Saint Thomas. That program, created in 1999, was among the forerunners of physician leadership education programs; at the end of 2011, it will have matriculated 179 doctors from its intense 18-month curriculum.

When Lee and Heltne talk about “leadership,” it’s not about pious platitudes, high-sounding inspirational speeches by Roosevelt, Churchill or Lincoln, or falling in line behind charismatic figures like Mother Teresa, John F. Kennedy, Gandhi, or Einstein. It’s leadership as an emergent discipline of education and practice that’s been taking shape since the 1970s.

In principle, what drives the leadership discipline is a philosophy that leadership is an activity that can be learned and developed, rather than the age-old trait-based notion that “leaders are born and bred.”

The Saint Thomas program, according to faculty lead Dr. Steven Akre applies approaches to leadership that “puts the patient in the middle of the equation.” One such approach is called “adaptive leadership.”

The art and practice of “adaptive leadership” was developed by Dr. Ronald Heifetz and his colleague Marty Linsky at the Harvard Kennedy School and popularized in their best-selling book “Leadership on the Line: Staying Alive through the Dangers of Leading.”

Early in February 2011, Dr. Val Ulstad, who has studied leadership at the Kennedy School with Heifetz and Linsky, began facilitating an intensive year-long adaptive leadership program at Grand Itasca Clinic and Hospital based in Grand Rapids.

In all of her work, Ulstad says that it is vital to “look reality in the eye and maintain the ability to be hopeful. That often means to fearlessly ask questions. Discovering the gift of a really good question – one where you can’t possibly know the answer – is a hurdle for docs to get past because we want to be experts.”

Ulstad, a cardiologist by training, turned her attention to leadership education and professional development in 1999 upon earning her MPA at HKS. Since then, she has worked with major systems, including Allina Health, Avera Hospitals and Clinics, Fairview Health Services and Sanford Health. She was on the Saint Thomas faculty for several years and in 2005, she earned the Lifetime Distinguished Teacher Award from the Minnesota Medical Foundation.

Ulstad says that “modern medicine has made remarkable progress on treating illness, largely as the result of technological advances, yet, we are challenged by an epidemic of lifestyle related chronic illnesses and out-of-control healthcare costs.”

In short, Ulstad says, medical practitioners and patients fall short when it comes to addressing the so-called “upstream” behavioral, social and environmental influences that determine health.

“People must adapt,” said Ulstad in a recent journal article. “This requires that they recognize the need to change, learn new behaviors and abandon those behaviors, beliefs and attitudes that no longer serve them.

“Over time, people have become disabled and disengaged. and we need to activate patients to be part of the solution,” Ulstad said. “American culture is up for the ‘quick fix,’ take the pill and treatments that reset things to zero. They have to learn how to share responsibility for their health.

“Perhaps, most importantly,” she says, “the adaptive leadership framework makes explicit our need to actively address provider and patient interdependence.”

Sharon Quinlan, a nurse and clinic director at Essentia East in Duluth, is thoroughly conversant with the adaptive leadership framework in her responsibilities for building and enhancing “partnerships” with patients, coordinating patient-family councils that meet regularly with medical staff and directing other relational programs.

“We work with patients to engage doctors, to learn to tell their stories,” said Quinlan, who has been a nurse for 30 years, 20 of which have been in administration and the past five have involved practicing adaptive leadership approaches.

Quinlan is teaming up with others to address the “adaptive challenge where there are fewer primary care doctors to deal with aging patients and chronic obesity,” which means developing new processes involving different teams and, perhaps, ‘electronic’ visits with patients.

She says that one of the more important adaptive leadership skills she has learned is the “ability to get on the balcony.” Getting on the balcony is an expression Heifetz coined as an image “that captures the mental activity of stepping back in the middle of action and asking, ‘What’s really going on here?’ ”

Ulstad points to an especially poignant balcony moment doctors frequently face, like when a doctor brings a diagnosis of cancer to a patient.

“Going to the balcony is to ask ‘how should I be in this moment?’ It’s a time to slow down to be mindfully present.”

Going to the balcony isn’t easy. but it is a leadership skill that is vital in the “heat” of the hospital, the clinic, and enormously complex external pressures.

Patrick Marx is a leadership development facilitator who applies the adaptive approach in his work, including the Minnesota Editors & Publishers Community Leadership Program, which he created. He too studied with Heifetz and Linsky at the Harvard Kennedy School, were he earned a Masters in Public Administration degree. A long-time journalist, Marx lives in Missoula Mont., and Grand Rapids, Minn.

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