F. Marian Bishop, Ph.D., MPH
Chair Emeritus, Dept of Family and Preventive Medicine
University of Utah
Presenting The Sixth G. Gayle Stephens Lecture at the Seventh National Conference on Primary Health Care Access, Colonial Williamsburg, Virginia, March, 1996.
Introduction of the Stephens Lecturer:
David Sundwall, MD (President, American Clinical Laboratories Association): I feel especially honored to be asked to introduce Marian Bishop. I’m not going to give a literal review of her education and career. I’m going to give a personal introduction.
I can’t resist telling you how I first met her. I was a grant reviewer, like many of you for the Bureau of Health Professions in the Health Resources and Services Administration, reviewing residency grants. I couldn’t believe this person who was so elegant, so dignified, and so sophisticated. She looked more like a Park Avenue woman. She presented herself well, she spoke well, and she obviously knew what she was doing. And I didn’t. Let me explain to you why. I’d been asked to review a proposal and then present it to the whole group before we divided up. I did my presentation. I took my work very seriously. I had typewritten notes. I had a column of strengths and weaknesses. I gave my presentation on a program in South Chicago. I listed about 22 weaknesses and about two strengths. Then I came to my recommendation and I said, “Recommend full funding.” Dr. Bishop spoke up across the table and said, “David, you can’t do that.” I said, “Why not? They are very deserving people doing honorable work.” She said, “You are reviewing the grant. You are not to assume how worthy the people doing the work are.” Anyway, she dressed me down in a very nice way in public. She pointed out that if I were going to review grants fairly, I review the grant not how good I thought the people were who would do it. So, she has been my mentor, my friend and an advisor on more than one occasion.
The other point I want to make is, I am from Utah and very proud of that. We’re very proud of our pioneer heritage. When I think of pioneers, I think of people who dare go where others haven’t gone before — people who will face adversity and will survive. Marian has been a pioneer. Although not originally from Utah, she has been there for some time. She has pioneered for family medicine. She’s pioneered for academics. She’s the first woman, non-physician chair of a department at University of Utah. Marian has blazed a trail for women in academics and family medicine that we all can be proud of.
Dr. Marian Bishop has had numerous awards, but I’m not going to list the awards. I’m just going to tell you I did attend a dinner to honor Dr. Bishop on the occasion of her stepping down as Chair of the Department of Family and Preventive Medicine in Salt Lake City last September. It was a speculator event. I don’t know how many people came from outside of Utah but there were at least a dozen or more. It was really an amazing tribute. It was a wonderful honor for her and something I was proud to participate in.
I talked to Marian’s son, Wynn, to see if he could give me some insights into his mother. He pointed out that it is appropriate that she is giving the Gayle Stephens Lecture because she was a colleague of Gayle’s for some time in Alabama. She and Gayle shared responsibility and opportunities for a lot of things that he accomplished. We really could call this the Miriam Bishop Lectureship as well as the Gayle Stephens Lectureship although we are all pleased to honor him as well. So, Marian, my friend, mentor, advisor, we welcome you for this Gayle Stephens lecture.
Bishop: David, thank you. You make me so interesting that I think I might even get to know myself a little better. I appreciate that you emphasized some of the achievements and disregard some of the failures you know about. It’s always good to have special friends who look at the good and leave the bad alone. It’s always good to be among friends and that’s what this group is, too.
About five years ago, I decided to give up the stress of preparing and publicly presenting major talks. I thought it would be much more fun and less stressful to concentrate on the fluff, introducing people and moderating panels. The other reason was that there was just so many younger people coming along who had so much to say and needed their place in the sun. It seemed to me I was saying the same thing over and over again, and hearing the same thing over and over again and maybe it was time for a change.
But there are two reasons that I could not resist to do the Stephens lecture. The first is, as David alluded to, Gayle and I have been friends and personal colleagues for about thirty years. In fact we first knew each other when he was in Wichita, Kansas, and I was in Missouri. As Gayle says, Marian knows all my warts and they’re still warts. I refuse to use the word warts and say that Gayle knows all my frailties and we’re still friends. So, anything I can do for Gayle and his wife, E.J., I would do it. Now, the second reason that I did this lecture is that I have found no way to say no to Bill Burnett and make it stick. Most of you know that when Bill makes up his mind you might as well just give in and save your energy. Besides, I want to remain an FOB and if you remember from last year’s conference that’s “a Friend of Bill’s”. So, those were the two reasons that I had to say yes.
As I reflected on an appropriate topic for the Stephens Lecture, two things came to mind. The first, we have talked about from the day one, is the inordinate amount of turmoil and changes which we are experiencing in health care, in medical education, and the very critical need to manage it rather than react to it. Jerry Rodos made the comment that most of the things that are happening today are happening because other people have done them to us rather than things that we have done to ourselves. So we do need to get into the management mode rather than the reaction mode.
The title for this conference, The Implications of Health Care Restructuring for Primary Health Care Access, is a reflection of the changes we are experiencing. We’ve been discussing the implications for restructuring medical schools, medical school reforms, and community oriented institutions. So these discussions have certainly implied that changes are upon us. There is a need to restructure.
The second thing is that in thinking of the leadership contributions that Gayle Stephens has made to family medicine, I believe that almost everybody recognizes Gayle as the premier family medicine philosopher. As such, his writings and his talks have often broken new ground, lead a new way toward a new understanding of the discipline of family medicine. Often the topics of change (and the new buzz word doesn’t seem to be change, it seems to be restructuring, downsizing or rightsizing) to leadership seem to fit this conference and Gayle Stephens, and the title “He will Lead the Way” fell into place. Now I’m doing it the Gayle Stephens way, no slides and a yellow pad. At the dinner that David mentioned, I did receive many letters from many of you in this room, but it amused me to get Gayle’s on a yellow pad. About five pages of handwritten yellow pages, that’s the Gayle Stephen’s way.
I tried to follow the elements of good talk, have a good beginning, have a good ending, and have them close together (Laughter). But after a five year retirement from the podium, the temptation to fill in the middle was just too great, so you are in for it. Now the first thing that I want to talk about is three things that really have been alluded to in the meeting. The first is that changes are going to occur whether or not we want them to. It’s going to happen. The second thing is that there a sense of dis-ease, D i s e a s e, that comes with all change. And the third is that in making change work, attitudes are more important than structures.
On the first point, from the presentations and discussions that we’ve had at this meeting, it’s very clear that changes are occurring everywhere. Peter Drucker whom I like very much as an author, wrote, “Every organization has to build the management of change into it’s very structure. Every organization has to prepare for the abandonment of everything it does.” Another statement, to whom I don’t know who to attribute, but it goes something like this, if we keep on doing the same things that we’ve been doing, we’ll keep on getting the same results we’ve been getting, or perhaps even worse results, but certainly the results will not be any better. Another author said it a little more scholarly, yesterday’s successful response used in the face of new challenges, lead to a decline.
Organization management experts note that there is a dynamic tension in organizations and groups and that this is the normal state, not the exception. They also note that long term agreement is quite the rarity, not the standard thing. So there is always continuous adjustment going on in groups, for that matter, always going on in our personal lives. There’s always some, quote, fine tuning, unquote, taking place although at the present time changes in the health care, primary care, and medical education certainly seem like a little more than fine tuning.
In some respects I feel like family medicine,(I’m using the word feel deliberately rather than believe) survived the cold war of the earlier development years only to find our discipline being eaten away by termites. The adversity and feeling of being the newcomer provided us with a very clear purpose and a unifying theme during these earlier cold war years. In medical education we wanted to become an equal partner, an equal player, one of the big boys.
Now that we are desirable partners in the health care arena, there’s much less agreement in our purpose and the direction of change and we sometimes seem to be moving in multiple directions that are conflicting, thus the termites. In fact, now that we have become so popular and on the verge of making it big time, it might not hurt to remember the quote attributed to Peter Drucker that I saw in the Wall Street Journal, “Who the gods want to destroy, they send forty years of success.” Now while this may apply currently to anesthesiology and cardiology, or pathology or radiology, or whatever ?ology? you want to put on it, forty years from now it may well apply to family medicine and primary care.
The second point about change and people is this sense of dis-ease that comes with all change. How many of you in the room has been through at least one reorganization in your work place in the last ten years? Hands are almost unanimous. Now, how many of you would admit and say that there was some personal disruption and dis-ease that associated with it? Again, the hands go up. The point that I think we need to recognize is that change is inevitable, it is always disconcerting and at times upsetting. Why? Well, because we are faced with developing new ways of behaving. Put more psychologically, if we are to successfully manage change, or restructure, as the term is used in this conference, we have to adapt. In order to adapt, we have to develop new partnerships, bond with new alliances and find new points of self identify. Let me emphasize this again. Successful management of change requires adaptation. Adaptation requires developing new partnerships, bonding with new alliances and finding new points of our own identity. This last requirement, finding new points of self identity can at times be devastating and a disruptive experience. We’ve all had our own experience in trying to adapt to change, and it’s not always easy, even when we recognize that change needs to occur.
Now, some people believe that if we could just discover or create the right organization and the right way to do something, all of our problems would be solved. Unfortunately, this does not seem to be true. If individuals are of a mind to make something work, almost any organizational barrier can be overcome. If people are opposed with the ideal or the development of a new plan of action, no organization appears to be capable of achieving on its own, all the interpersonal and intrapersonal relationships that are required for successful.
So the third point is that when the rubber hits the road, attitude change is more significant than organizational change in making something work. I believe that Joseph Hopkins made this point in his talk the other day, that the attitudinal change was really more important than the organizational change.
Then the question becomes, how do we affect attitudinal change? How do we lead the way? Well, I think that the only way that we can do it is by communicating with others. A major requirement is to communicate with others, involve others in the plans and procedures. Mark Clasen made the point of culturally sensitive communication. Cultural sensitive communication is a requirement in leading the way. We have to involve others in the procedures, the processes and the directives, because if they are not understood, they seem to be arbitrary, and individuals affected may feel that they haven’t been involved in determining the change. Thus the organizational chart may be there, but it won’t work.
I think it is very important for each of us to remember that each of us brings our own personal story with us, to this meeting, to our workplace, to our family, and that that story speaks profoundly to what we are about. Few of us have ever been moved to change our views by a complex system of intellectual reasoning or revised organizational chart. Few of us have changed our mind about a very emotional issue because of a well documented paper that persuaded us to do so. Few of us are as systemic convictions as we might like to think we are. If you don’t believe it, try to pin those convictions in an orderly way on one sheet of paper. Instead, we are driven by the experiences in our lives and these experiences become our story. Our unique experiences influence us to look at things from our own special point of view. No wonder leaders have problems in restructuring and moving people to affect change. I don’t know your story and you don’t know mine, but hopefully, somewhere through communication, our experiences will intersect and form that base where we can move together.
So the bottom line is that change is about people, leadership is about people, it is people who make change productive and functional. Or conversely, it is people who make change stressful and dysfunctional. It’s people who make the difference between success or failure. It’s people who both think and feel, but more often override their thoughts with feeling, and the question becomes then, who will lead the way? What does it take to lead the way?
I’ve talked about three points that I wanted to clarify about change, now let us talk about leadership. There are two myths that I would like to dispel about leadership. The first is that those who lead the way must be nationally known or widely recognized leaders with name recognition and who control natural resources. The second myth is that the only leadership which really counts is that which has a catalytic impact. Now, obviously there are national leaders, well know leaders who have access to a lot of resources and do make catalytic changes, however there is no way those individuals in the national or international arena can affect all of the changes that will inevitably occur in our individual environments. We are the ones who must meet the challenge.
Author, biographer Gerald White Johnson wrote, “Heroes are created by popular demand, sometimes out of the scantiest of materials.” Now real heroes and real leaders don’t change clothes in phone booths. They don’t wear tights, masks, or capes. They are ordinary people who take extraordinary risks to make a difference. While we all have a genetic makeup which may give us a floor, you have to remember that God in her infinite wisdom, gave us the capability of using our daily experiences to enhance these abilities. To my knowledge, none has yet discovered the gene for leadership and you have to remember that Utah is on the forefront of gene mapping (laughter). None has come forth to day. Now, we have all heard the cliche that there are three kinds of people. Those who make things happen. Those who watch things happen. Those who wonder what happened (laughter).
I recently heard another version of the three kinds of people. The wills who accomplish everything. The won’ts who oppose everything. The can’ts who fail in everything. At some point in our lives each of us will be instrumental in making something happen and at another time we will be a person who sits on the sidelines and watches, and likewise, we will exhibit the attributes of an achiever, who will, and at other times a non-achiever who won’t or who can’t.
The question is on balance what kind of person are we, who will lead the way. Indirectly I have suggested several qualities that are helpful if not critical for those who lead the way. As I go through these in review, I would like for you to think about, you, yourself and I, and how these apply.
The first is adaptability. Adaptability is the ability to do things differently and the willingness to constantly test and improve. The second is the ability to make decisions. At any moment of decision the worst thing one can do is nothing. Doing nothing is a decision and sometimes we forget that. The third is a willingness to risk. Nothing ventured is in fact nothing gained. You know, it is almost impossible to find a joke or story anymore, but I think I have found one that I can use that illustrates the willingness to risk. It’s the story about a person who after a long but somewhat questionable life was asked on his deathbed to praise the Lord and renounce the Devil. After a moment of hesitation the dying man said, “Well I don’t mind praising the Lord, but I don’t know if I’m in any position to antagonize anybody.” (Laughter) Risk taking is a part of leading that way. The fourth quality is to have a plan or vision which is clearly communicated and articulated to others. Leaders are comfortable in dreaming the impossible dreams. I like the Robert Kennedy quote or statement of seeing things as they can be and saying why not, rather than seeing things as they are and asking why. The fifth attribute of leadership is the ability to share the vision and share the credit. Those who lead the way bring other people into the process as partners and team members (communication). The vision is shared and at times modified to meet the needs of individuals and groups based on what leaders learn about those unique and individual experiences.
We all know the importance of giving praise to others whenever possible. Remember there is always enough credit to go around. Ann Landers in her column, she gave the following gem of the day, “There are two kinds of people in the world, those who do the work and those who take the credit.” Try to be in the first group, there is less competition there. (laughter) Those who are all show, and no go, may have a brief place in the sun. But those who go, with or without show are the long term leaders. The all show or no go can be illustrated with this story. I think there is no one in the room that this can hurt their feelings. It’s a story about cardiologist and a state health officer who were spending a quite afternoon on the bank of a river. As they were contemplating, all of a sudden, a body floated down the river. The cardiologist jumped into the river, pulled out the body and did CPR. Then another body floated down the river. The cardiologist repeated this heroic act, but he decided that if there were two, there were going to have to be three, and he turned to the health officer to tell her that she had better get ready to take the next body. But he only found that she was long since gone. She had run upstream to try to prevent the body epidemic rather than to cure it as they floated down toward them. In my mind that is some sense of all show, but somebody who had a lot of go.
Now finally, I want to comment on the sixth characteristic and that is the vital importance of believing that what you are doing makes a difference. This is what keeps leaders going in the face of adversity. I will admit that it may not pay to be like the workaholic, who was offered a two month paid vacation in recognition of his really exceptionally good work. He declined however telling his boss, “Sir there are two reasons why I won’t accept your offer. One, the business might suffer while I’m away, and two, it might not.” (laughter)
I will also admit that it helps to have two or three very loyal supporters within the organization who sort of agree with what you do. It also helps to have one or two close friends outside the organization for those times when criticism seems to outweigh applause. On the other hand, President Harry S. Truman said while in Washington, D.C., “If you want a friend in Washington, you ought to buy a dog.” Now, there have been times when I thought I ought to buy a dog, but not very often.
Now, I ask you to recall my premise that change is inevitable. It always brings tension and dis-ease. That people and attitudes are more important to success than organizational efforts and organizational charts. Then recall the six qualities of leadership I have suggested. One, adaptability; two, the ability to make decisions; three, the ability to risk; four, have a vision or plan; five, involve others in the plan and give them credit; and six, the believe that what you are doing is really going to make a difference.
This is not rocket science. It does not take a Margaret Thatcher, a Bob Dole, a Bill Clinton, or any combination of names that you can put together that you see on the TV to manage change. It does not take this caliber of person to lead the way toward restructuring and more importantly to make a difference. We are the people who have these qualifications on the home front. We are the ones who will lead the way. Most leaders do not play a Christ-like role, nobody said that leaders have to be perfect in order to make a difference.
I’m reminded of the story of the preacher who had a fiery pulpit stance against sin and he preached for a long, long time. But finally, he succumbed to temptation and he went out and sinned. His congregation found out. He tried to explain his fall from grace by saying that since he had sinned, he was much more knowledgeable and better able to preach about it than when he was inexperienced. Now, those who lead the way are just ordinary people, people who occasionally learn by sinning. People who work in fairly small fish ponds. People who plug along trying to make a difference. This is leading the way. Many clear opportunities are brilliantly disguised as problems. The critical skill is to strip away the disguise and know when you have an opportunity rather than a problem. In the end, we will be able to look into the mirror and say to ourselves, I couldn’t do everything, but I did do something and my world is a better place because of it. I made a difference.
So, who will lead the way? You Mark, you Pat, you Joe, you Mary, you John, you David, and you, and you, and you. You in your own way will manage the turmoil of change. You will cope with downsizing, which is really what right sizing is, you will restructure the medical school, the residency, the community health center. You will work with people so that the organizational changes that are needed, will work. You will, at the bottom line, make a difference.
Finally, remember that a little sense of humor always help. So when you begin to feel that you have more brilliantly disguised problems than clear opportunities, look for something funny. And since the role of tenure is a big issue in the survival of US medical schools and it’s a hot topic about whether we can downsize, I want to close with something that tickles my funny bone every time I hear it. In a talk by Senator Orrin Hatch, given at the University of Utah Conference on the Cost of Depression in the Hospital, he revealed the thirteen reasons why God never received tenure in any University. I share them with you.
First, God only had one major publication. Second, it was in Hebrew. Third, it had no references. Fourth, it was not published in a peer review journal. Fifth, there is some doubt that God actually wrote it. Sixth, God may have created the world, but what has She done since. Seventh, the scientific community cannot replicate the results. Eighth, God never got permission from the ethics board to use human subjects. Ninth, when one experiment went awry, God tried to cover it up by drowning the subjects. Tenth, God rarely came to class, and just told the students to, quote, Read the Book, unquote. Eleventh, God expelled the first two students. Twelfth, God’s office hours were irregular and classes were sometimes held on a mountain top. And thirteenth, although there are only ten requirements, most students fail.
Well, I want to thank you for the opportunity to present the Sixth Gayle Stephens lecture and share my thoughts with you on who will lead the way. As I look around the room, it’s clear that many of you are long term colleagues, we’ve been friends for a number of years. Some of you are more recent colleagues. Yet, there is that sense that all of you are committed to lead the way. Not by being a Margaret Thatcher or a Robert Dole, but by being you, yourself and I. So, who will lead the way? You in the front, you in the middle, and you in the back are not excluded either, you also have to lead the way. Thank you very much.
Last Updated (29 January 2005 16:36)