Adaptive Health Practice

1. Adaptive Health Practice N. Marcus Thygeson, MD marcus.thygeson@allina.com 612-262-4945

2. What is AHP? • Application of Ron Heifetz’s Adaptive Leadership model to clinical practice • Three key “simple rules” changes: • Patient must and can do their own adaptive health work; we can’t do it for them • But we can help them do it by upgrading our skills and using Adaptive Leadership principles. • Technology (drugs, procedures, etc.) has limited utility and significant potential for harm—use sparingly and judiciously

3. Fundamentals of Adaptive Leadership • Complex systems face adaptive and technical challenges. • Adaptive challenges require learning and behavior change—adaptive work. • Technical challenges can be addressed with technical solutions and expertise. • Technical work will not solve adaptive challenges, and often make the problem worse. • AL consists of knowing this, and how to help people and organizations do adaptive work.

5. Example: GERD and PPIs • Heartburn mostly related to lifestyle: diet, obesity, tobacco, alcohol. • Treatment for GERD now: PPIs • Feedback loops: hypergastrinemia and failure to address lifestyle factors • Long-term use of PPIs (> 2 months) causes GERD sxs in normal people • PPIs cause dependency and are addictive • Prevalence of GERD has doubled in US since PPIs introduced

6. Adaptive Work Avoidance • Failure to adopt healthy lifestyles (patient) • Failure to address unhealthy lifestyles (MD) • Terminal chemotherapy instead of hospice • Spinal fusion instead of active rehab for disc DJD • Drugs in lieu of exercise, light, talk therapy, etc. for depression

8. Implications • We and our patients are both avoiding the challenge of doing the adaptive work required to be healthy and cope with suffering. • We collaborate in this by inappropriately applying technical solutions in lieu of adaptive interventions, and by remaining unskilled in adaptive leadership. • This causes a lot of harm and inefficiency (waste), and damages the doctor-patient relationship.

9. Why is this happening? • Adaptive work is hard and often avoided (by patients and providers). • We aren’t incented to practice adaptively. • We don’t know how to do it.

10. What should we do? Support patient adaptive work by doing the adaptive work to change our • Philosophy of practice • Explicitly identify adaptive challenges and interventions, to ourselves and our patients • Recognize the limitations of our technical expertise • Use technology sparingly and judiciously • Adopt a socio-ecological, whole-systems approach to health • Build our skills as adaptive leaders to help patients do adaptive health work • System • Financial incentives • Blind faith in technology • Inputs (staffing, resources, culture)

11. Facilitating adaptive work: • Diagnose the system, and the problem • Establish a “holding environment” • Identify the “ripe” issues • Think about your framing • Regulate the “heat” • See yourself as part of the system • Hold steady • Keep the work at the center of people’s attention

12. The proper use of technology? • Facilitate adaptive work (e.g., exer-gaming, mobile health apps, analgesics to facilitate PT, etc.) • Relieve suffering that overwhelms patient coping • Manage risk factors until adaptive work is effective • Treat disease not amenable to adaptive work • Avoid technology with long-term negative feedback loops on health

13. Implementation Issues • What does AHP look like behaviorally, for both patients and doctors? • For which patients will this work? What to do for patients who respond negatively? • How do we do the adaptive work to change our system and philosophy of care?

14. Basic AHP • Staff trained on adaptive leadership • New patients are introduced to the practice’s philosophy of care • SOAP approach modified to address both adaptive and technical components • Measurement reflects both adaptive and technical components

15. SOAP—New and Old

16. Paths to AHP • Incremental: train staff on organizational Adaptive Leadership; then support them in generalizing to patient care. • Transformational: train them directly on applying AL to patient care, and hope the culture accepts it. • For full development, does this need to be managed as a separate company?

17. Next Steps • Design it • Pilot and refine it • Controlled trial? Or just spread it?

18. Suggested References • The Practice of Adaptive Leadership, by Heifetz, Grashow, and Linsky • How Clients Make Therapy Work, by Bohart and Tallman • “Adaptive Leadership and the Practice of Medicine” by Thygeson, Morrissey and Ulstad, JECP 2010