“A Powerful Thing”: The Obstacles Leaders Face in Driving Change

The history of medicine is filled with “expert” resistance to change. Marching in the brave parade of innovators who buck the system may sting, but the rewards usually outweigh the risks.

Fear’s a powerful thing

It can turn your heart black, you can trust

It’ll take your God-filled soul

And fill it with devils and dust

Bruce Springsteen is singing about the devastating effects that fear can have on the hearts and minds of soldiers on the front line. But his words can also apply to healthcare, and the fear many clinicians have about accepting new approaches to medicine. Of course, it’s reasonable to be cautious about new treatment options, especially when there is little empiric evidence to support their application. Still, the annals to medical history are filled with resistance to innovation that has done more harm than good. Two examples come to mind.

Andreas Vesalius’ 16th century textbook on anatomy revolutionized the way we view the human body. And while “On the Structure of the Human Body” was based on his firsthand experience during dissections, his contemporaries condemned him because he challenged the accepted wisdom, which was based on the sacred writings of Galen, a second century Greek physician. One such “expert” wrote: “I implore his Majesty the Emperor to punish severely as he deserves, this monster… the most pernicious exemplar of ignorance, ingratitude, arrogance, and impiety: and to suppress him completely lest he poison the rest of Europe with his pestilential breath.” Criticisms like this devastated Vesalius and caused him to resign his position at the University of Padua and burn all his notebooks.

Fast forward to the 20th Century: Beryl Benacerraf, MD, who died last month, saw the potential of ultrasound in diagnosing fetal abnormalities like Down Syndrome, but she too was widely criticized for her discovery. At the time, the standard was to perform an amniocentesis, which involved greater risk to the fetus. “I was almost booed off the stage at several national meetings… I was devastated but that much more determined to prevail because I knew I was right,” she said, recalling the time she presented her work to her colleagues. Subsequent studies vindicated her.

Why are so many of us unwilling to change our minds? Sometimes, it’s a fear of losing prestige and financial prosperity, or losing respect from peers. But all of us, whether at the pinnacle of academic medicine or working in the trenches, may fear change because it means a loss of control; change might require that we take on new responsibilities and learn new skills that are beyond our abilities.

A management consultant summed up the issue this way: “People fear change if they’re worried they won’t be able to do what you’re asking — will their skills be sidelined? Are they going to look stupid? But rather than telling you this is their concern they make it clear they disagree with the new approach, or challenge the very reason for the change.”

One key to addressing the fear of change, especially among clinicians in positions of authority, is to embrace structural humility. Helen Hansen, at UCLA, explains: “Structural humility has to do with pushing back against the idea that doctors are omniscient or omnipotent. Doctors in the U.S. still carry a lot of political and social authority, but we have to be much better at collaboration and seeking out the expertise that we don’t have as a product of our clinical training.”

On the other hand, innovators who face the harsh criticism of resistant thought leaders would do well to embrace the courage and insights of another songwriter:

“It’s OK, I’m not afraid

Of marching in this brave parade…

Who choose to love in an angry age

Refuse to bend to spite or rage

Who aren’t afraid of bad reviews.”

This piece, written by John Halamka, MD, president, and Paul Cerrato, senior research analyst and communications specialist at Mayo Clinical Platform, was originally posted to their blog page, Digital Health Frontier.