LAUSR

Hospital medicine leaders often face what seem like unsolvable problems involving two opposing sides or viewpoints. Examples include individual versus team, margin versus mission, learner autonomy versus supervision, and customization versus standardization. Dr. Barry Johnson describes these dyads as polarities, which are two different values or points of view that are interdependent.1,2 Leaders who fail to realize this concept create a problem by artificially inserting the word ‘versus’ between the poles. Polarities are not problems to be solved. How does one solve individual? Or team? How can a hospital have one without the other? When leaders treat polarities like problems to be solved, they typically crusade for one side over the other, until the losing side rises up for its own cause, causing a perpetual back and forth cycle described as an infinity loop where nobody is happy for long.1 How then can leaders avoid getting caught in this fruitless cycle? Instead of trying to solve the unsolvable, learn to manage polarities. Polarity management seeks to maximize the best of both poles while minimizing the worst. Both sides of a polarity carry upsides and downsides. When leaders want change, or want to resist change, it is the fear of being caught in the downsides of the opposite pole that motivates behavior, and dominates conversation. The first step to changing this conversation is to introduce the concept to your team so they recognize polarities when they arise and model approaching issues in this manner. Some issues truly are problems to be solved (for example, the ultrasound machine is broken and needs to be repaired), but many conflicts are polarities masquerading as problems. To identify polarities, ask two questions. (1) Is the situation ongoing? (2) Are there two interdependent poles? If yes, then the issue is a polarity. Ideal polarity management involves maximizing the upside values of both poles before potential conflict even begins. People often force themselves into unnecessary “either/or” mindsets rather than striving for “both/and”. Here is a classic example in Hospital Medicine: Pole 1: customization Pole 2: standardization -The Chief Medical Information Officer (CMIO) wants everyone to use the same electronic health record (EHR) template, while the hospitalist group wants to innovate templates using rapid cycles of change. Typical patterns of conflict: the CMIO releases a template and the hospitalists resent it, or the hospitalists each create their own notes but the CMIO bemoans the variability. Once polarities are recognized, teams can draw a ‘polarity map’ to see the whole picture, identifying the upside values and downside fears of each pole.1,2 For example, standardization reduces unnecessary variation, but stifles innovation, while customization does the opposite. In fact, the upside values of one pole are usually the opposite of the downside fears of the other. Leaders can actively engage people in both poles to make opposing views productive rather than destructive. The CMIO in our standardization/customization example could insist that everyone begins with the same template, but allow hospitalists to innovate to find a better way. Now the most resistant hospitalists become improvement agents. If a better way is found, then this becomes the new template that all hospitalists use, until the next better way is found. If an innovation is not an improvement, then hospitalists agree to return to the most recent successful template until a better way is found. This method of action and compromise produces both standardization and customization. Using polarity management strategies does not guarantee success, but it can help engage all stakeholders, and break the frustrating cycle of repeatedly trying to solve the unsolvable.