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The following is an excerpt from Barry Johnson's upcoming book AND. Advance Readership of the book as it is written is available here.

Chapter 14 – The Recalcitrant Oncologists

The CEO of a large hospital system wanted some help. He heard a presentation I made on polarity thinking and was wondering if it might be useful in his situation. “Barry, I want us to be the leader in Oncology for this metropolitan area. In order to do that, I need to make several $Million in changes to upgrade our facilities and system. I can’t make these changes, legally or politically, without the support of a group of ‘recalcitrant oncologists’ who have their own, independent group practice not far from our main facility. Some of the changes I want to make require an MD to sign off. This group is making a lot of money for themselves and for the hospital. I can’t afford to alienate them and they know it. Can you get them to support the changes I want? If you can, how would you do it?” Figure 1 summarizes his view. 

Polarity Map

He wants help in solving a couple of problems. The first is that his facilities and system need to be upgraded (­‐B) and the solution is to make several $million in changes (+C). He is invested in the “going after” energy to make some significant changes. His second problem is a group of “recalcitrant oncologists” who have significant power in this situation. He does not want to alienate them. They are very happy with the way things are and are “holding on” to the status quo. They are a road block to his vision. 

I understand his “going after” his vision (+C). And, from a Continuity and Transformation perspective, I assume there is wisdom in the resistance he is experiencing from the “recalcitrant oncologists.” I have our S.M.A.L.L. process in mind, which begins by engaging key stakeholders. I ask if it is possible to bring together some key players from his staff and some representatives from the independent oncology group. His response is, “That’s not very easy to do because it is not a billable hour.” I said, “We need to be figuring this out with them. What can you do to make that happen?” He replies, “I can get them to a 2 hour meeting if I feed them a meal.” Notice the power in his relationship with the oncology group. The CEO has trouble even getting them to show up for a meeting, let alone being able to dictate to them the terms of his desired hospital transformation. I ask, “Can you arrange for 2 of these 2-­‐hour meetings with meals?” His response, “I think I can do it if I make them at least a week apart.” So, the following process happened within 2 2‐hour meetings, which included breakfast at each. 

The S.M.A.L.L. Process (Seeing, Mapping, Assessing, Learning, Leveraging)

Seeing – I began with a brief introduction to Polarity Thinking including how polarities look and work. The message was clear that, with all polarities, it is essential to empower both poles. In this case, my intent was to make sure that BOTH the oncologist group AND the CEO’s executive team had their interests included and respected. A brief discussion of desires and concerns led to an underlying polarity they named: Traditional Care AND Innovative Care. For them, these two pole names were both neutral and positive. Notice how this parallels the names of the generic Continuity AND Transformation polarity. This was language that worked for them. Once we agreed on the names of the two poles, we could create a Polarity Map and include some of the information that had come up in the brief conversation about desires and concerns.  

Mapping – As you will recall, the building of a Polarity Map is always a values and language clarification process. We needed to make sure the content of the map worked for all those present. The first question was, “Where to start?” In one sense, it doesn’t matter what the sequence is for filling out the map as long as all the parts get filled out. At the same time, there are some general guidelines worth considering.

If it is seems relatively easy to identify a Greater Purpose Statement (GPS) that those present can agree to, having that GPS as a “True North” while filling out the rest of the map can be very useful. It becomes a constant reminder as to why we are investing in leveraging this polarity in the first place.

If it appears like it will be difficult to agree on a Greater Purpose Statement until those present have a chance to talk about their values and fears, you can start by filling in the 4 quadrants first. The agreed upon quadrants will then provide a richer context in which to create, together, a Greater Purpose Statement. In this case, there was agreement that they wanted to be a “Leader in Oncology” and that was the agenda the CEO had identified when inviting his executive team and the oncology group to the meeting. When you know your Greater Purpose, the Deeper Fear, at the bottom of the map, is the exact opposite. In this case, it was not being the Oncology care of choice.  

We had an editable Polarity Map in a laptop projected on a big screen easy for everyone to read. Figure 2 is a cleaned up outline of what we created together over breakfast at the first meeting. After agreeing on the two pole names, the Greater Purpose, and the Deeper Fear, we focused on the four quadrants.  

When filling out the 4 quadrants, as a general rule, it is useful to fill out the content of the two upsides first. That allows people supporting either pole to have their pole affirmed for what it brings. When the upside of one pole represents a change that one or more people are “going after” (+C), it is often a good idea to first fill out the upside of the pole that others will be “holding on” to (+A). In this case, I first asked everyone to identify, “What would be the positive results if we did a good job of going after the benefits of Traditional Care?” (+A)

The message to everyone in filling out the upsides of Traditional Care is that this upside exists, and that it contains essential benefits for the hospital system. This is the pole that the "Recalcitrant Oncologists” valued and were holding on to. My message to them, after the completion of this quadrant, is that we will fill out the rest of the map and then come back to this quadrant and look at how we can make sure we hold on to this content when pursuing the Greater Purpose of becoming Leaders in Oncology.

I then asked the same question for the positive results from a good job with Innovative Care.+C As we are filling out the map, I am making sure that both groups are contributing content to all four quadrants. This engages everyone in the process and it also asks everyone to identify, through their own words, that there is legitimate content in each quadrant.  

Once you have both upside quadrants filled in, you can fill out both downsides. It is less important where you start with these than where you start with the two upside quadrants. At the same time, I suggest that you move next to the downside of the Innovative Care pole. The reason is to first acknowledge the legitimacy of the concerns of the Oncologists around the possible loss (‐D) of what they value (+A) when going after Innovative Care (+C).  

The question that is asked to list the content for the downside of Innovative Care is not, “What is the downside of innovative care?” The reason is that those favoring Innovative Care will have trouble identifying any downside to what they value. In this case, the CEO would have trouble identifying this content. He and others “going after” Innovative Care, will be more likely to contribute content to this quadrant if asked something like this: “We have already agreed upon a number of positive results if we do a good job at Innovative Care (+C). Now what would happen if we over-focused on Innovative Care to the neglect of Traditional Care?” The answer is that we could lose the benefits of Traditional Care (+A). Everyone is asked to think of the opposite of +A in order to come up with content for –D. This step puts us all in touch with the legitimate fears of the oncologists.  

By filling out both the upside of Traditional Care (+A) and the downside of Innovative Care (‐D), we have recognized and affirmed the Oncologists point of view (+A/‐D). We have given them a place to stand which respects them and what is important to them. We have also given everyone the opportunity to see the wisdom within the oncologists’ possible resistance to “going after” Innovative Care (+C).

We then went to the final quadrant (-B) and asked the question, “What would be the negative results from over-focusing on Traditional Care to the neglect of Innovative Care?” This step completes the affirmation of the values (+C) and fear (‐B) of the CEO’s point of view (-B\+C). 

Polarity Map Healthcare Transformation

Assessing – Once we completed the map we did a quick “trend arrow” assessment in which I asked those present. “If you imaging the polarity infinity loop moving as an energy system through the 4 quadrants would you say, at this point in time, is it needing to move toward Innovative Care (+C) or toward Traditional Care (+A)?” We have already established that, over time, it will need to incorporate both upsides. There was a general agreement that, while holding on to Traditional Care, there was a need to move toward Innovative Care at this point in time.

Learning – Given the trend toward Innovative Care and our paradoxical orientation toward change, I concluded the first two hour breakfast letting them know that we would start the next breakfast by creating Action Steps to gain or maintain the upsides of Traditional Care.

Leveraging – When we gathered for breakfast a week later, we did a quick review of the process so far: Seeing, Mapping, Assessing and Learning. I then described the final step, Leveraging, which includes Action Steps and Early Warnings. We started with everyone thinking of Action Steps to gain or maintain the upsides of Traditional Care in Figure 4 below. 

The question for creating action steps is something like, “What are we doing or could be doing to gain or maintain the upside of this pole.” We can include things we are already doing and expand to new things. Like any project, it helps to have names of those accountable, dates for delivery and measurables for accomplishment. 

This is a very transparent process. As everyone was contributing to the Action Steps to support Traditional Care, I would ask the people from the oncology group, “If the CEO and his executive team agree to support these Action Steps (+A), are you convinced that we will do a good job of holding on to and improving the best of Traditional Care (+A)? They would say, “Not yet” and I would say, “What would it take?” I am clear with everyone that we will not move to looking at Action Steps in support of going after Innovative Care (+C) until everyone feels confident that we will do a good job of holding on to and improving Traditional Care (+A).

Once everyone felt confident about the Action Steps for Traditional Care (+A), we started creating Action Steps for Innovative Care (+C). To the surprise of the CEO and many on his executive team, the “recalcitrant oncologists” came up with more ideas for Innovative Care than the CEO and his team!! The CEO got more than he had hoped for in terms of Action Steps in support of Innovative Care. Several $Million worth of Innovation was agreed to, in principle, and we had not yet finished our second two hour breakfast! Why were the “recalcitrant oncologists” not so “recalcitrant?” I suggest that they saw this issue differently than them being the “problem” getting in the way of the CEO’s “solution.” The reframe was to see this as a polarity that could be leveraged and their values were essential in leveraging it.

Early Warnings – this final step would help them know, early, when they were getting into one downside or the other. We started with the Early Warnings for the downside of Innovative Care (‐D). The reason is to let the oncologists holding on to Traditional Care values know that we recognised that there is a potential downside to Innovative Care and that the system could easily find itself there. The question is, “How would we know early (what would we measure?) that we are getting into the downside of this pole (‐D) so we can self-correct and pay attention to what we might do as Action Steps to gain or maintain the upside of Traditional Care (+A). Finally, we identified Early Warnings for the downside of Traditional Care (‐B).


Clearly, not all processes are going to work this quickly, but a lot can be accomplished in 4 hours or 1 day when the shift occurs from misdiagnosing an issue as a problem to solve to recognizing it as a polarity to leverage. Once you know it is a polarity, all the polarity realities in this book are in play. And this powerful energy system, in which you sit, can be leveraged to serve you and the larger group of which you are a part. The wisdom within the map content and the Action Steps and Early Warnings was all within the participants and their two, equally valid points of view.

Think of what would have happened if I had joined the CEO in figuring out how to get around the resistance of the “recalcitrant oncologists” or how to get enough power to overwhelm their resistance and move to implement his vision of Innovative Care. 

Thirty years from now, this hospital system, if it exists, will be living within the Traditional Care AND Innovative Care polarity. The only question will be how well they are leveraging it. There will be the natural tension between the two poles. If there is a change in leadership or, for some other reason, the reality of this being a polarity gets lost and the tension gets treated as a problem to solve, the tension is likely to become a vicious cycle which serves neither the receivers of care or the givers of care or the community in which the hospital system sits.

Constant hope -­ Since polarities are indestructible, this polarity will be always be immediately available as a gift with the opportunity to create, from the tension, a virtuous cycle which serves the receivers and givers of care and the community.