One of the lessons of history is that small things in the present can have big impacts in the future. The big impact of little things is called "sensitivity to initial conditions." A tiny shift in an initial condition can create huge swings far removed in time and space.

Consider the stirrup. It changed the world by giving a mounted warrior the lateral support and leverage needed to transform the power of the horse into the power of the sword. So compelling was the advantage that every army soon wanted lots of warriors mounted on lots of horses. Lots of horses needed lots of fodder. Fodder required lots of land and lots of farmers. Land was appropriated by kings and given to lords. The lords owed their loyalty to the king. Peasants worked the land and gave their labor and loyalty to their lords. From the simple stirrup flowed the feudal system.

Not all big impacts flowing from small things are so gradual in their effects. Nassim Nicholas Taleb has a name for events that are a surprise, have extreme impacts and are explained only in hindsight. He calls them "black swans." Black swans live within a world characterized by very big wins and by very big losses and where prediction is illusory — a place Taleb calls Extremistan. Taleb argues that "almost all consequential events in history come from the unexpected." According to Taleb, we are slaves to experts and captives to the bell curve. We take comfort as distributions pile up predictably at the fat center of the curve, but it is the surprises that emerge at the narrow leading and trailing edges of the curve that are likely to have the greatest impact.

Except perhaps for the very near term, it's impossible to predict the future of health care. Things are just too complex, too connected and too tightly woven. The key to the future is not predicting; it's navigating. How can you steer your way through complexity and uncertainty?

Look for Velocity and Volume

Pay attention to momentum and volume. For example, when you're looking at demographic trends, say population growth, ask: How fast is the population growing? What is its velocity? Velocity generates momentum. Momentum carries things from their present position to a future one. This is as true for a demographic trend as it is for a thrown rock. If it is moving fast today, it will carry momentum into the future.

Big rocks, rocks with volume, create big splashes. Big splashes often ripple pervasively. If volume is high or building in the present, then it probably will make a big splash in the future. At the turn of this century, the volume of the elderly was still relatively small (around 12 percent), but it was already growing exponentially into a very big and accelerating rock. Think of trends in terms of a formula: MV = E (momentum multiplied by volume equals energy).

Skip Your Way Forward

A popular conceptual device for thinking about the future is the sigmoid curve (an S-curve resting on its side). You start at the lowest end of the S-curve and begin to climb the front edge of what looks like a bell-shaped curve. You reach an apex and then begin your decline.

This curve, according to Charles Handy in his book The Age of Paradox, sums up the story of life itself: "We start slowly, experimentally, and falteringly; we wax and then we wane. It is the story of the British Empire, and of the Soviet Empire, and of all empires always. It is the story of a product's life cycle and of many a corporation's rise and fall. It even describes the course of love and relationships. The secret to constant growth is to start a new sigmoid curve before the first one peters out … to get the new curve through its initial explorations and flounderings before the first curve begins to dip downward."

The S-curve represents another rock tossed from the present into the future. With skill you can skip the rock: Launch it on a path of multiple sigmoid curves by translating energy into a trajectory that glances off the surface of the water. Instead of sinking, the rock rises into the air and bounces off the water's surface again and again. The challenge is to leverage the past, present and future into sustained flight.

Get Out of the Chair

I once visited the Badlands in South Dakota. You can't see the Badlands when you're approaching them on the interstate because they lie below the adjacent terrain. And when you're down in the Badlands, it's impossible to see the surrounding flatlands or the Black Hills rising in the distance. Standing in that eerie moonscape, all I saw was randomness. There were no clues as to what had made the place. Water seemed too inadequate an explanation.

Flying home later, I could see very plainly the ancient vestiges of flowing water that carved the Badlands. But at that altitude it's hard to judge the elevation of things on the ground. You can see new things, important things, from every perspective, but you never see the whole picture. It takes an open mind to back off and see things whole, to not be dragged into the muck and mire by the gravity of details and siren song of conventional wisdom, and to look for "Yeah!" when you're being drowned out by "Yeah, buts." To get the whole picture, you have to look at it from several angles.

In dealing with uncertainty, try going "snake-eyed." Snakes have poor eyesight. But they do see two things: things they can eat and things that can eat them. Squint in order to blur out the nonessential and to see only the large pervasive patterns. This snake-eyed perspective is very useful when you're trying to navigate the fog-shrouded shorelines of the future. As psychologist William James once observed, "The art of becoming wise is the art of knowing what to overlook." Physician Hans Selge put it this way in his advice to young people at the beginning of their careers: "Try to look for the mere outlines of big things with your fresh, untrained and unprejudiced mind."

Squint from 30,000 feet and the one demographic trend in health care that overshadows all the rest is mortality. At ground level, we remain seemingly insensitive to the fact that we are, according to an article by John Tierney in The New York Times Magazine, "living through the greatest miracle in the history of our species — the doubling of life expectancy since the Industrial Revolution."

Constantly Bash Assumptions

Expert predictors are missionaries for assumptions. The predictions below are notable not only for their inaccuracy, but also for the stature of those who made them. All were experts seemingly well-positioned to see the future:

  • "The phonograph … is not of any commercial value." — Thomas Edison, remarking on his own invention to his assistant, Sam Insull, in 1880
  • "It is an idle dream to imagine that … automobiles will take the place of railways in the long distance movement of … passengers." — American Road Congress, 1913
  • "There is no likelihood man can ever tap the power of the atom." — Robert Millikan, Nobel Prize winner in physics, 1920
  • "Who the hell wants to hear actors talk?" — Harry Warner, Warner Brothers Pictures, 1927
  • "I think there is a world market for about five computers." — Thomas J. Watson, chairman of IBM, 1943

Predictions about the future are assumptions carried forward. To avoid being trapped by assumptions, deliberately and repeatedly attack them. Be reckless. Imagine a future that rips the guts out of your organization. Attack the expert predictors. Take the opposite view and see where you end up. The universal solvent for dissolving an assumption is the question "Why?" Children understand instinctively the power of "why," so they ask it repeatedly. Toyota used the five whys to blast past the obvious and reduce things to their roots. By routinely asking "Why?" five times, higher levels of understanding are created. Why is it important to own primary care practices? Why? Why? Why? Why?

Taleb identifies another problem that can have devastating consequences for organizations largely because it anesthetizes the critical thinking of leaders: "[W]e humans, facing limits of knowledge, and things we do not observe, the unseen and the unknown, resolve the tension by squeezing life and the world into crisp commoditized ideas." The opiate of too simple a simplicity can cause people to quit thinking; after all, they have the answer. Consultants have built an industry around simplifications and for that reason can be very dangerous. They become even more so when they start predicting, often at the request of executives who are comfortable delegating their thinking to others.

Engineer Collisions

Collisions release energy. Big rocks moving fast make for big collisions and lots of energy. When trends collide, energy is often released that exceeds the energy embedded in the trends independent of one another. The energy of such collisions can be both destabilizing and liberating.

By upsetting the status quo, such collisions inevitably create opportunity-rich environments. You can spot them by looking for convergence, which is often the precursor to a collision. A prime example of an opportunity-rich environment is the convergence and collision of telephone, television, computer and software technologies. Computers began to serve as telephones. Telephones became more computerlike and so did televisions. Computer monitors began to display images as fluid as those on televisions. Cell phones became cameras and video cams.
 
When the status quo is upset, you have ways to seize the opportunities: Simulate convergence and collision. Slam trends, assumptions and predictions together. Crash-test them. Collide even the seemingly unrelated.

Some technologies are disruptive. So are some organizations. According to Clayton Christensen, disrupters often emerge unnoticed, at a low price point, and then grow to a dominant market position. Bill Gates launched his startup with poverty-level income and capital costing a few thousand dollars. Imagining what Microsoft would become as it began to emerge would have been difficult, perhaps impossible. But like the pattern that presages a hurricane, a disruptive pattern may be discernable in advance. Big hurricanes emerge over warm water. Seeing a pattern early is the key to useful anticipation. The pattern may amount to nothing, or it may erupt into a storm that can erase the shoreline.

Swim in the Past

The past is poison to most futurists. They warn sternly of the dangers of being trapped by the past. But any honest student of history, biology, physics or systems thinking will quickly recognize the connections that link the future, the present and the past. They are not different things. They are all the same thing. Touch one and you touch all three.

While the present is in flux and the future is shrouded in fog, the past has had time to settle out. And the past is the only data we have. Invariably, the present and the future are mere speculation. Learning from what has come before remains one of the best ways to understand the present and anticipate the shape of the future.

Enslavement to the past has not really been a big problem for most organizations because few have a sense of history. They are captives of the present. Henry Adams captured this caged mentality perfectly: "Great as were the material obstacles in the path of the United States, the greatest obstacle of all was in the human mind. Experience forced on men's minds the conviction that what had ever been must ever be. In 1810, nothing moved faster than the speed of a horse. Nothing ever had moved any faster and, so far as the people of 1810 were aware, nothing ever would."

But then the telegraph changed things dramatically. According to historian Stephen Ambrose, "By the 1850s, information moved all but instantly. That changed everyone's lives. It unified the nation. It made the stock market possible. Its impact on commerce and trade was beyond description."

In colonial America, homeopathic physicians were the best trained and most respected. Allopaths were, for the most part, poorly educated apprentices. But they were also scrappy, entrepreneurial and insensitive to the niceties of the staid institutions of European training. They started their own medical schools and overwhelmed the homeopaths in the race for professional legitimacy and market share. Could such a disruptive pattern repeat itself in the future as nonphysician caregivers rush into the void left by shortages of physicians? Thinking of the future in terms of the past may be insufficient, but it is still better than simply speculating.

Stay Close to Your Customers

No perspective is more important than that of the customer. You can't make a living for your organization without customers. When Louis Gerstner Jr., took over as CEO at IBM in 1993, he determined that the company's biggest problem wasn't with its products or its competitors. IBM had fallen out of touch with its customers and squandered what was once a fundamental source of strength. He envisioned an organization once again in touch with its customers, and he dedicated himself to setting an example.

Shortly after arriving at IBM, Gerstner said, "I came here with a view that you should start the day with customers and organize around customers." In his early days at IBM, Gerstner spent 40 percent of his time with customers. He left them with the impression that IBM had figured out how the 21st-century, high-tech society and economy would unfold. And by being in touch with customers, he built a relationship of trust.

"The future is a lot about trust," noted renowned marketing professor Philip Kotler of Northwestern University. "More and more CEOs have become conscious that they are the CEO of marketing. You're selling trust." And customers generally won't trust a distant disinterested stranger.

Stand in the Future

Another way to look at the future is through the lens of the present. It's easy enough to see the various ways the present helps make the future. Many historians have suggested that the tough terms of the Armistice at the end of World War I set in motion the circumstances that gave rise to World War II. This connection is discernable in retrospect. The present always becomes clearer once you're able to look back at it from atop the high ground of the future.

Economist John Maynard Keynes was right when he observed that, "in the long term, we're all dead." But he was wrong if he meant to imply that the future has no influence on the present. The best way to ensure the present is to link it to a compelling future. A vision anchors the present to a desired future.

By definition, there's no way to navigate the future without putting your rudder in the water of the present and moving. A boat at rest has no steerage. But just as action in the present shapes the path into the future, intention set in the future reaches back to shape the present. That's the real pragmatic power of vision. A vision involves imagining a point in the future, then reverse engineering by asking, "What must we do in the present to become our future?" As you undertake actions designed to realize your vision, the future starts to dictate the present. And the organization transitions from reacting to the present by navigating toward a desired future.

Most health care organizations dedicate only a minuscule amount of time to considering their future. Managers and board members (sometimes with physicians) may get together once a year and spend a few hours earnestly considering the future. If executives have 2,080 hours of work time available in a year and spend a day of that time considering how to navigate the future, they will have dedicated much less than 1 percent of their time to one of their fundamental responsibilities: navigating the organization toward its aspirations.

Given the poor track record for predicting, leaders might be forgiven if they simply focus on the present and respond in the short term. Unfortunately, focusing on the short term may put them only at the front of a foot race that is heading off a cliff. If an organization can more effectively navigate the future, it obviously has an enormous advantage in realizing its aspirations.

Dan Beckham is the president of The Beckham Company, a strategic consulting firm based in Bluffton, S.C. He is also a regular contributor to H&HN Daily.