Distinguishing Adaptive from Technical Work

 

Ronald A. Heifetz

 

The practice of medicine illustrates die distinction between technical and adaptive problems, and the dynamics these problems generate. Patients come to physicians with symptoms and signs of illness. They hope that their doctor will be able to “fix” the problem, but they do not know if their hopes are well-founded. Often, the physician can indeed cure die illness. If a person has an infection, there are many times when the physician can say, “I have an antibiotic medication that will almost definitely cure you without any effort or life adjustment needed on your part. The medication is virtually harmless. I can give you one shot, or a week of pills, whichever you prefer”. The purposes of our discussion, we can call these technical situations. Type I – situations in which the patient's expectations are realistic, the doctor can provide a solution and the problem can be defined treated, and cured on the basis of (1) using the doctor's expertise and (2) shifting the patient's burden primarily onto the doctor's shoulders. The patient appropriately depends on die doctor's know-how, and the doctor depends on the patient's trust, satisfaction, and willingness to arrange payment.

 

These Type I situations are somewhat mechanical; one can actually go to somebody and “get it fixed.” Many medical and surgical problems are of this sort, and many of them are life-saving. From the doctor's point of view, these provide gratifying moments when she can say, "Finally somebody has brought me a problem that I can solve!" Although the patient's cooperation is crucial in these situations, the weight of problem-defining and problem-solving rests with the physician. The patient looks to her to provide a prescription that at once will offer direction (take this medicine), protection (the medicine will overcome the infection), and order (you should be able to resume normal activity within the week).

 

Of course, many situations that bring people to doctors are not so technical. We can separate these adaptive situations into Types II and III. In Type II situations, the problem is definable but no clear-cut solution is available. The doctor may have a solution in mind, but she cannot implement it. And a solution that cannot be implemented is not really a solution; it is simply an idea, a proposal. The patient must create the solution in Type II situations, though the doctor may play a central role. Heart disease sometimes presents a Type II problem. The patient can be restored to more or less full operating capacity, but only if he takes responsibility for his health by making appropriate life adjustments. In particular, he will have to consider the doctor's prescriptions for long-term medication, exercise, diet program, and stress reduction. He will have to choose among these. Type II situations can be managed in a mechanical way only partially by the physician. She diagnoses and prescribes, but her recommendations will have side effects requiring the patient's evaluation of the tradeoffs. What new balance should he reach between cutting down the intensity of his job, getting exercise, or eating better? The patient has to recognise his own problem enough to provoke adaptive change. The responsibility for meeting the problem has to be shared.

 

In these situations, the doctor's technical expertise allows her to define the problem and suggest solutions that may work. But merely giving the patient a technical answer does not help the patient. Her prescribing must actively involve the patient if she is to be effective. The patient needs to confront the choices and changes that face him. The doctor's technical answers mean nothing if the patient does not implement them. Only he can reset the priorities of his life. He has to learn new ways. And the doctor has to manage the learning process in order to help the patient help himself. The dependency on authority appropriate to technical situations becomes inappropriate in adaptive ones. The doctor's authority still provides a resource to help the patient respond, but beyond her substantive knowledge, she needs a different kind of expertise – the ability to help the patient do the work that only he can do.

 

Type III situations are even more difficult. The problem definition is not clear-cut, and technical fixes are not available. The situation calls for leadership that induces learning when even the doctor does not have a solution in mind. Learning is required both to define

problems and implement solutions. Chronic illness and impending death from any cause often fit this category. In these situations, the doctor can continue to operate in a mechanical mode by diagnosing and prescribing remedies (and a “remedy” of some sort can usually be found). Yet doing so avoids the problem-defining and problem-solving work of both doctor and patient.

 

In Type II and III situations, treating the illness is too narrow a way for the patient and the physician to define the task. It applies a technical formulation to a non-technical problem. When critical aspects of the situation are probably unchangeable, the problem becomes more than the medical condition. For example, if the patient's diagnosis is an advanced stage of cancer in which the likelihood of cure is remote, it may be useless – indeed, a denial of reality – to define the primary problem as cancer. Cancer, in this case, is a condition. To the limited extent it can be treated at all, it is only part of the problem. To define cancer as the primary problem leads everyone involved to concentrate on finding solutions to the cancer thus diverting their attention from the real work at hand. The patient's real work consists of facing and making adjustments to have realities that go beyond his health condition and that include several possible problems: making the most out of his life; considering what his children may need after he is gone, preparing his wife, parents, loved ones, and friends; and completing valued professional tasks.

 

Table 1 summarises the characteristics of the three types of situations.

 

ChallengeX

 

Unfortunately, neither doctors nor patients are inclined to differentiate between technical and adaptive work. Indeed, the harsher the reality, the harder we look to authority for a remedy that saves us from adjustment. By and large, we want answers, not questions. Even the toughest individual tends to avoid that require adaptive work, searching instead for an authority, a physician to provide the way out. And doctors, wanting deeply to fulfil the yearning for remedy, too often respond willingly to the pressures we place on them to focus narrowly on technical answers.

 

Source: R. Heifetz: Leadership without easy answers. Cambridge, Massachusetts, 1994.