In 480 B.C., Themistocles was compelled to engage in an argument with consequences. A vast Persian force was pushing its way relentlessly across Greece and had Athens in its crosshairs. The oracle at Delphi had advised the Athenians to move themselves behind the protection of a wooden wall. For nearly all, the intent of this warning was clear: The best recourse was to stay behind the wooden fortification that surrounded the city.
Themistocles had a different interpretation. He saw the wooden ships of the Athenian navy as the sheltering wall that the oracle had prophesized. After much debate, he convinced the Athenians to evacuate their city and place their faith in a naval victory. The Athenian navy then lured the much larger Persian fleet into the narrows of Salamis where its size advantage was negated. The Persian emperor, Xerxes, who had placed his throne near the water to watch an expected triumph, was forced to retreat. Many historians feel the fate of Western civilization hung in the balance on that day.
The Fate of Patients
Back in 1999, in an article in Fast Company, Paul Roberts observed that: "Each afternoon, in a tiny workroom on the 12th floor of the Mayo Clinic, the battle against cancer begins with an argument. … The space fills with a small crowd of cancer specialists, surgeons, residents and nurses. For the next three hours, this talented team will debate the condition and treatment of the day's patients."
These, too, are arguments with consequences, the fate of patients and their families hanging in the balance. There are other arguments in health care that have broader consequences, some of which impact populations of patients and others that roll through the health of the entire nation.
Arguments matter. And some arguments matter much more than others. Leaders in health care, be they physicians, nurses, executives or board members, are all entrusted with the responsibility to argue with particular vigor and intensity because, to put it directly, their arguments matter much more than the arguments that may arise within most of the organizations in America. Indeed, an active, engaged health care leader can have more impact on the health and welfare of a community than the president of the local bank or an elected official.
The consequences of good arguments can be seen in the description of Mayo set forth by Roberts here:
"Patients who walk into the Mayo Clinic in Rochester enter an environment of comfort and tradition that is worlds apart … . Professional greeters ease new patients through the admission process, reassuring them in homey upperMidwestern accents. They greet returning patients by name. Doctors see patients in private offices — cozy spaces decorated with personal items — rather than in sterile white-and-chrome exam rooms."
That "environment of comfort and tradition" could have turned out differently at Mayo absent the willingness to have and act on many an argument over more than a century.
Willing to Offend
What is a good argument? It is consequential. After all, things that aren't consequential aren't worth arguing about. It requires that parties to a decision or policy think and speak with intensity. That a point of view be pursued with tenacity. That those engaged in the conversation be intentional in listening and put aside tendencies to make the argument personal. It is the question at the heart of the argument that needs to be attacked from as many angles as possible. The more consequential the question, the greater the intensity of the attack should be.
One enemy of a good argument is politeness, by which I mean the tendency to avoid, almost at any cost, the potential to offend. Possible alternatives get smothered by the warm and fuzzy desire to just get along. Conflict, after all, is often awkward and uncomfortable. But arguments of consequence deserve awkwardness and discomfort even at the cost of embarrassing your friends. A good argument concludes with a decision by someone empowered to decide. Too often, the best decision loses out to consensus: a desire to get along and keep people happy on average.
Margaret Thatcher once spoke pointedly of the perils of consensus: "To me, consensus seems to be the process of abandoning all beliefs, principles, values and policies in search of something in which no one believes, but to which no one objects — the process of avoiding the very issues that have to be solved, merely because you cannot get agreement on the way ahead. What great cause would have been fought and won under the banner, 'I stand for consensus'?"
Constructive discussion is not characterized by polite pointless banter. At the root of the word "discussion" is "cussion." It's the same root found in "concussion" and "percussion." It suggests impact. Absent a good argument, good results can wither and go unrealized. This applies to the decisions related to the treatment of a single cancer patient and the decision to change one step in the process that impacts central-line infections as well as the decisions necessary to drive down diabetes across an entire population or to consolidate inpatient capacity.
There are other enemies of a good argument including selfinterest and political calculation. The seismic transition of American physicians from predominantly independent agents to employees of hospitals has implications for the future of good arguments in health care. I've already seen instances of physicians who, when they were in independent practice, would have fearlessly pursued a good argument but who now, as hospital employees, seem compelled to hold fire. They have become part of an organizational hierarchy where power has implications. Now in the boat, they are understandably hesitant to rock it.
What might have been said before now goes unsaid. The benefit of spirited tension between the medical staff and hospital administrators is constrained. Admittedly, this tension has had negative effects when it has crossed over into destructive conflict but, in the end, tension is what animates the world. Without it, things settle into nonproductive stasis.
Good arguments don't happen for other reasons. In science, there has been a long search for a "theory of everything" that links the laws of physics into a coherent integrated whole. In management, theories of everything abound in the form of silver bullets promoted as comprehensive pathways to certain success. Unfortunately, unlike the laws of physics, such management solutions lack anything resembling scientific rigor or proof. This does little to dampen their allure, and they can have an anesthetizing effect on organizational debate.
Why argue a point when all the answers lie within the framework of a theory of everything? There is sage advice that warns, "Beware the man of one book." The same advice can be applied to organizations. The underlying message is straightforward: Big questions require multiple perspectives, and a good argument brings energy to the application of those perspectives.
Many people are understandably reluctant to enter into an argument when they feel unarmed — when they feel they don't have a sufficient grasp of terminology and technologies. In health care, we make it very difficult for laypeople to engage in productive discussion and decision-making because of a proclivity for abbreviating every term that can be abbreviated. We leave things that beg explanation unexplained. So, board members don't ask the tough questions or spark consequential debate.
The same effect occurs when physicians are confronted with management terminology and managers are confronted with clinical language. What's needed is an explicit expectation that parties to consequential decisions have a responsibility to ask a question when confronted with unfamiliar language and those communicating have a corresponding responsibility to dispense with deadening abbreviations and to provide an explanation when it's apparent that their message is shrouded in technobabble.
Good arguments don't necessarily result in a definitive conclusion. There was a high level of strategic argument at Mayo over the merits of opening Mayo campuses in Florida and Arizona and the impact such investment would have on the clinic's ability to invest in its main campus in Rochester. Today, that question remains alive.
There are many questions that deserve a good argument, such as:
- whether physicians are predominantly shaped by economic incentives;
- whether only big health systems will survive;
- whether tomorrow's health care leaders must combine business knowledge with clinical experience;
- whether to invest in facilities in an era of population health.
Absent the capacity for good arguments, an organization loses its assertiveness. And when assertiveness is gone, an organization is compelled to react. Good arguments are at the heart of strategy, innovation and entrepreneurialism. In each case, leaders must cultivate an environment in which good arguments can be made against the status quo. Anyone who champions transformation, by definition, must engage in an argument against what is.
It is in periods of great change, when the stakes are high and the road ahead is uncertain, that good arguments become most vital. They can capture the energy of change and focus attention on questions of consequence in a way that heightens organization sensitivity when it matters most. There is an alternative, of course, and that's the kind of polite avoidance that leaves tough questions unexamined and the organization pleasant but impotent.
Dan Beckham is the president of The Beckham Co., a strategic consulting firm based in Bluffton, S.C. He is also a regular contributor to H&HN Daily.