Framing Traps

Framing is a way for people to organize and sort their views on data. In some ways it is just another way of saying "perspective" or "frame of reference." However, as a metaphor, framing works better when we talk about their limitations.  Here is a picture frame:

It is kind of a detailed frame, rather heavy on decoration. It is rather large, probably heavy if made from solid wood...but it is still just a frame. Inside of this frame we can imagine a painting, maybe a Renaissance painter of some renown or a landscape:

Look at that! A whole mountain in a frame. A great many things happen on mountains so this frame could have a great deal of information in it. Landslides, herbivores, carnivores, trees, clouds, hikers, meteorology, and a host of other things can exist within this frame. But it's still just in a frame.

Here we have a great many frames and also a good depiction of our trap. There is a great deal of wall space between those frames and someone on those benches would have to turn around to see all the frames on display. So it is with framing traps in the managerial sense.

One of the best ways, that I know, to avoid a framing trap is education. I have been fortunate to pair my education with time spent developing a career. I feel that this has overlapped at least two of my frames. Education, when done properly, forces one to challenge the border of our frames and to include other ideas or perspectives. Just as I see our mountain in the picture above as a rather boring landscape for a picture, someone else may see it as a still life that represents shrinking natural spaces in our environment. We are both right, however my frame of "boring landscape" is just an opinion while "shrinking natural spaces" can be substantiated with research.

This is another way to avoid a framing trap. Think of the meaning behind data and points of reference. There is generally a message behind the data that goes beyond the data itself. If a department has low turnover and low productivity there may be story behind it. Maybe the employees are loyal to each other but less so to the company. If draconian measures are taken to improve the production those bonds could be severed and the turnover will increase...as will cost.

Seeking perspective and dissenting opinions can also go a long way towards avoiding a framing trap.

Here is another mountain in a frame. It looks different than the mountain in our second picture. This picture seems to be teeming with life. It is a matter of perspective yet somehow I feel this second mountain picture is "fuller" with more to learn from. 

As for dissenting opinions, it is useful to have people that do not always agree with you to provide opinions on what your frames are showing. It takes a leader with a great deal of ego strength to be able to hear that he or she is incorrect but it is invaluable in ensuring that details that may otherwise be missed, aren't. Thin skinned narcissism is not a desirable trait when looking to avoid a framing trap.

All in all, a frame only shows what it is in the frame. Placing many frames side by side still leaves gaps between the frames themselves. If one chooses to use frames as a tool one will have to find ways to color the spaces between them with a great deal of critical thinking and help from one or two devil's advocates. This is yet another reason why leadership training is critical. It is very easy to only view life from a frame but it is yet another thing to learn to move those frames around and challenge what it is in them. A trained leader is much better at the latter. 

Complex Decisions!

Decision making for a modern manager seems to be turning into learning how to sort wheat from chaff with regards to data. Although most data can have a use, that use can vary from the merely handy (the employees like the new yogurt bar) to the incredibly useful (the spending habits of our customers on our websites). All of it can serve a purpose, knowing that employees are happy can lead to other ways to keep them happy and thereby increase productivity and knowing buying habits is a power unto itself. However, all this data makes for a complex environment in which to operate. In previous weeks we spoke of decision support systems that are adaptive and can learn to make decisions on their own. However, these systems have their own peril as seen in the 2010 Flash Crash of the stock market. In the end, humans are involved in a great deal of the decision making process and most likely will be for the foreseeable future regarding company operations. At least until Skynet does its thing.

There a few strategies that are available and three areas of decision making layed out in Hoch et al's "Wharton on Making Decisions". Two of them are similar, environmental and complexity wherein the environment plays a role in complex decision making. For simplicity I have added environmental in the setion "do something about the weather" which is taking directly from Hoch. We will look at them from the perspective of my organization which is the largest integrated healthcare system in the US.

1. Complexity

A) Data-Rich Environments-Patient data can be overwhelming. A given provider can access medication histories, illnesses, treatments, demographic data, and even draw conclusions on socio-economic status by looking at billing and priority. It sounds like a great deal but the data is broken up into smaller sections which means that a person need not sort through all of it to find some answers. On the other hand, there are portions that are mired in useless data and make it difficult to find what you are after. For example, I work in rehabilitation, housing, and vocational services which is a subset of Behavioral Health. We are required to use a program that creates treatment plans and allows other providers to access the plans and add their treatments as well. This way all the treatment planning is on one living document which sounds just lovely. It's not.

The plans become gigantic and they publish data that is useless to our department such as medications from a year ago. This wouldn't be a factor if the data was published in a way that was easy to read. Instead we have to sort through reams of superfluous information to get to the treatment narratives. To make things worse the program is not user-friendly and was obviously built by the lowest bidder.

Complexity need not be as complex as it seems if there is a way of easily organizing data. Even large amounts of data and be sorted by programs however the user still needs to be intuitive enough to draw conclusions between seemingly unrelated data points. What makes matters worse than they need to be are systems that impede almost as much as they help.

B) Do Something About the Weather (Environmental)

The weather affects healthcare in many obvious ways. The homeless are at risk of freezing to death in my state so that is something that is planned for. But as for the day to day operations of the hospital we are required by law to keep supplies on hand, back-up power sources, and personnel ready at all times. Where Coca-Cola may lose money if their trucks are delayed, running out of something as simple as saline can cost lives so there are contingencies in place for stocks of supplies. Healthcare operates from a different mindset when it comes the environment. While it is possible for us to be overwhelmed by natural disasters the day to day weather isn't something that affects us a great deal.

C) Optimizing Power Pools

Going along with weather and complexity, we have the capability to provide our own electricity for critical machines and operating suites. Naturally we use commercial power for the day to day of the operation but energy independence can be gained as long as fuel supplies last in our generators. Should the fuel become an issue there are also battery backups for certain machines as well. If it all fails there are bigger concerns over just optimizing a power pool, it means the power pool is no longer there.


2. Multiple Stakeholders


A) Listening To Stakeholders- This seems obvious! However our major stakeholders are the patients and also taxpayers. And the messages they sometimes send are colored by not having all the information or in some cases a belief in alternative facts, which seems snarky but misinformation and lies do color some of the perceptions of the public regarding my organization. Managing out stakeholders is a very fine line and even now, writing a blog to be published, I am aware of how my words can be used. For such a large organization as mine it is imperative that the people within the organization are aware of the ambassador status they hold to the general public.

B) Behavioral Approaches-This, so far, does not seem to be something used by my organization. One doesn't need a strategy for removing a kidney and in mental health the prevailing illnesses often preclude being able to have predicted outcomes. We can come close, as mental illnesses do have symptoms but in the end it is still an art from different from a straightforward surgery. So for now this approach may not have much application though being able to model behavior has significant advantages. That being said, the flaw in this model is that is it predicated on the other parties behaving as you think they should.

Change via Tribes

In this week we explore a concept of driving change via tribes as outlined by Seth Godlin in his Ted talk.  In short, groups of people begin to coalesce and then those groups begin to push forward a movement that encapsulates their views. I am not so sure that this is exactly groundbreaking research but he does raise an interesting point. Leaders of movements tend to crowd-source their work. There is nothing particularly wrong with that as to get most anything of note accomplished in terms of major change one has to have others buying into the concept of change. The questions posed this week are below and rather than answer them is list form I'll attempt to address them in a larger narrative of tribes, change, and barriers.

The questions are:

1. How do you react when you hear colleagues using some of the excuses listed in the 50 Reasons Not to Change graphic?
2. Do you ever use any of these excuses yourself?
3.How can you overcome the thinking that creates those responses to change efforts?
4. Do you agree with Seth Godin’s concept that change is driven by tribes?
What can you take away from this exercise to immediately use in your career?

The 50 Reasons to Change graphic can be found here and short of listing all 50 I took a few from the graphic that seem to infect my organization. For the most part, my organization is mired between the past and future and seems to pay little attention to the present. By this, the current state of the world seems to have no affect on how my organization operates. This is, of course, perception and in an organization of over 200,000 employees I am not a major player so I admit I may be missing something. That being said, I am directly involved in program management and our program is not operating with an eye to the future. 

We are, on paper, to provide re-integration opportunity for patients with addiction, mental health issues, and/or homelessness. This population typically lacks skills that many take for granted. There is a lack of computer skills, budgeting skills, behavioral problems such as an inability to give or receive feedback, and even basic hygiene (at times). Our program, to my constant annoyance, does not mandate that participants attend classes or groups designed to address those concerns. Instead we focus on finding housing and employment however how can one find employment in a digital world without computer skills? What good is the job (if you find it) if you lack insight into communication skills needed to work with others? I could go on. In the past, and I hear it constantly, "we've done it this way," this worked to a certain degree. In 1987 you didn't need to know how to use web-tools to gain an education. You didn't need to know how to use complex software to do a great many jobs. And most of out patients stopped in 1987 and stayed there. One of the things I teach the patients on my immediate case load is that you have to force yourself to stay relevant. 

When changes were tried the patients complained and management backed off which leads to the "been tried before" excuse. Well yes, change isn't always comfortable. And now we've moved into a paralysis by analysis mode where we use the excuse of "talking about changes" as a way to avoid actually making those changes. 

One can tell by my tone that it is exceptionally frustrating to know changes are needed yet to run up against significant barriers. In some ways, my role was created to help drive those changes but it seems as though it was thought that simply creating a role was change, never-mind providing the support that role needs to accomplish one of its fundamental purposes. 

Godin's idea of tribes is interesting but he leaves out the tendency of tribes to fight one another. My organization knows it needs a change, but they are still groping in the dark on how to do that. There is a large body of "old guard" that makes up a tribe that actively fights any change no matter how useful or small. Overcoming that level of entrenchment is not an easy task. I have made small changes that were easily digested (my immediate supervisor is supportive) and am now seeing how those changes play out. It looks as though I may have to make a change to my change but by doing so I am building a certain level of change tolerance among the organization. Small changes...observe...small change...observe. Rinse, Repeat.

Making Better Choices

One has to like the Harvard Business Review, all the charm of PBS with the glamour of C-SPAN to really drive it home. All snarky comments aside the Business Review offers insightful and useful information. In this week it is an interview with a leadership professional and consultant named Marcia Blenko who offers some of her take on leadership and decision making.

Marcia Blenko argues that decision effectiveness correlates positively with employee engagement and organizational performance. How do you think that employee engagement relates to decision effectiveness?

I think people like being part of a winning team. Additionally, companies get better results with an inclusive decision making process. This can become a cycle of positivity where good choices bring better performance and then inspire more inclusion. When working with patients in recovery it is stressed that plan needs to be patient's plan and not one just given to the patient. The same works for providers as well. Give providers a buy-in to the plan and the plan becomes better. Additionally, this imparts a sense of ownership between the plan or decision and the affected parties.

What are some impediments to good decision making?

Leadership is a learned art. There are very few natural, charismatic leaders that can inspire people to great works and even those sometimes have tragic ends; Joan of Ark comes to mind. A gifted orator may not make a good leader nor a business man make a good president. Leadership isn't something that just exists, it has to be created within a person. I think the biggest impediement to good decision making is hubris coupled with an inability to see your blindspots. Hubris is fairly self-explanatory but blindspots refers to a leaders inability to see where they are lacking in information or allowing biases to cloud judgement. This is were inclusive decision making is helpful. It colors in those blindspots and adds perspective to issues requiring a decision. By learning about leadership and its often subjective issues a leader can start to understand themselves. This will hopefully reduce hubris as well.

Blenko suggests that there are four elements of good decisions: quality, speed, yield, and effort. In your opinion, is there anything missing from this list?

Good decisions are no bigger than they need to be in order to get the job done. I would argue that precision would be a fifth element of decision making. To elaborate I feel that some decisions can be too sweeping in scope. In order to overhaul an entire system one must fully understand all the variables in play. It may be that smaller, more targeted decisions towards one variable can have bigger ramifications down the road. The Law of Unintended Consequences should always be considered when making decisions. There are times bold strokes may be needed but careful leadership will always encompass the downstream effect of decisions. In other words, make a change, measure results, make a change, measure results. If one does not measure the results of an action before taking another you can wind up chasing the gauges.

Choice Overload!

Sheena Iyengar in her excellent talk on choice highlights the problem of choice overload. Iyengar's research is part of a school of behavioral economics that seeks to address how people behave with making economic decisions. This is a departure from schools of thought such as classical economics where the phrase "all other things being equal" often appear. In life many things are equal and even our moods can affect choice. Going deeper, behavioral economics seeks to explain how the brain functions with choice. It is a blend of psychology and economics and it's also one of my favorite topics!

Iyengar's research states that with too many choices people are like to experience one (or all) of three things:
1) Less likely to choice- people are less likely to make a choice when they feel overwhelmed by choices. This can be subtle as even innocous items can create choice overload. Iyengar used jam for her experiement however it can be applied to most any item.
2) Less quality of choice-When a choice is made, the quality of choice is of less quality for the chooser. Iyengar saw people making poor financial choices the more choices for retirement funds they had.
3) Less satisfaction with choice-In the end people are less satisfied with what they choose.

She offers a few ways to mitigate choice overload and they are:
1) Less is more-Fewer choices leads to more choices being made.
2) Concretization-Make the choices relevant to life
3) Categorization-Group choices together
4) Condition for Complexity-Go from less choice to more choice over time.

These aren't overly complex coping mechanisms and they go well with the brain's tendency to want to group things together for quicker sorting. Prejudices and bias can be negative outcomes of the mental sorting but it is a handy tool. Mental health workers often group mental illnesses into groups to make them easier to treat. It also is handy as a way to explain to other providers what a given patient may be experiencing. If a provider tells that a patient has an "axis II" disorder I know I am working with a personality disorder and can plan appropriately and may know what to look for when I observe a patient's behavior. Because of this, categorization is one of favorite coping mechanism for easily sorting choices and information.

I do believe that less is more. I have never been the type to use 10 words when 5 will do and I see no need to sort through thirty types of shampoo when I know the one I use does the job. Perhaps this is part of other favorite idiom..."keep it simple." I recently decided to buy a new phone. I have a S6 from Samsung but it's a little old, there is a small crack in the screen, and the battery seems to be wearing out a tad. I looked at the S7 as a possible upgrade and it has a few improvements over the S6 but then I thought what I actually do with my phone on a day to day basis. I take a few pictures, argue on Facebook, play a handful of apps while waiting around for things, text, check email, and maybe if I'm unlucky actually have to talk on the phone with someone. The S7 comes with a close to $700 price tag and I while it's cool to have a great phone my current phone still does the job I need it to do. I don't really need the little extras the S7 brings. This is a blend of keeping it concrete and less is more and I tend to think I blend those quite a bit.

Choice is a funny thing and we like to think that more we have to choose from the better we will be. I tend to think that as  Western Society that is free from most existential threats we've decided we have so little to actually fear that we need to obsess over a phone having megapixels. Research suggests we all want SOME choices and it's nice to a variety of teas in my pantry and a couple different shoes to wear to work but there is a tipping point for such things. Iyengar's techniques for dealing with choice can serve as a way to better handle that tipping point.

21st Century Enlightenment (Updated)

I've posted on this video during my undergrad it still remains one of my favorites and I highly recommend it. Below are the questions that came with the assignment and I will attempt to answer them but I hope that you, the reader, take away something of your own from the above video. I've re-used some of my original work on this subject but I've added the perspective that a few years of experience can bring as well as what I have learned managing programs. Lastly, in the context of the recent US election and some of the divisive issues it brought to the surface I will attempt to bring a timely perspective to this argument.

1. Why do you think the talk is titled 21st Century Enlightenment?

Global societies are undergoing quite a bit of change and not all change is always good. 21st Century Enlightenment means that as people we need to change the way in which we think and interact within the societies that sustain us. One-tier concepts such as freedom, progress, or technology are great for breaking down complex concepts but they carry with the the trap of simple answers. Quite frankly, getting your philosophy from a bumper sticker means that you lack the relationships needed to be aware of your overall place in society. Additionally, this trap of simple thinking disconnects the individual from the society that provides the individual with the tools for success. Nothing ever happens in a vacuum and enlightenment is no different. 21st Century Enlightenment means that we govern ourselves with empathy and self-awareness and not just concerning ourselves with the individual. It will be a profound shift in thinking for many.

In many ways my answer to this question has not changed and it may have been re-enforced recently. It seems that simple platitudes have replaced critical thought. It is easy to promise jobs to a beleaguered area but it is much harder to do in practice. Where I have changed is I have given a great deal of thought to how a population gets to a point where they stop questioning the deeper variables behind an issue. The recent US election highlighted  a problem in the US that should have been obvious to anyone paying attention. Midwest areas and areas outside of large US cities have seen declines in earnings as well as a loss of jobs and the economic recovery has largely skipped these areas. So while it is great to expect an expansion of empathy it is difficult to do when you are looking at foreclosure and a shrinking portion of the economic pie. It is hard to think of others if your own children cannot be properly fed.

The spiral comes from thinking that simple answers that can be summed up in a Tweet are somehow going to fix very complex problems. The jobs in the rust belt are gone, victims of globalization and shifts in technology. No amount of empty air from a politician will bring back what it is no longer needed to keep a company profitable.  

2. What does Matthew Taylor mean when he says "to live differently, you have to think differently"?

We cannot solve new problems with old thinking. Any fundamental shift in society comes from new modalities of thought. In order for us to create a more empathetic society we need to start to think in more empathetic ways. It isn't enough to ask "is this right for me" but to look past ourselves to how others view the world and attempt to reach across those boundaries.

I still stand-by this answer. Speaking only for the US, the focus has always been individualism and that may not be the best answer to move forward into a different, and more encompassing society. Changing an entire nation's culture of individualism is not an easy task, indeed my personal opinion is that the US is too entrenched in this idea of "rugged individualism" to really fully shed it. However, it may be possible to shift into a blended philosophy of individualism and collectivism. It isn't a binary choice after all. I can still work hard in school and my career (advancing myself in the process) while voting to protect the rights of other groups of people and dedicating time and effort to helping others. I feel like too many people view life as a zero-sum game; like as if someone else's gains means that one person is missing out. That may be true for things such as job promotions but it isn't true for things such as marriage rights or ensuring access to health care.


3. At one point in the video (4:10), Taylor argues that we need "to resist our tendencies to make right or true that which is merely familiar and wrong or false that which is only strange". What is he talking about? Can you think of an example within your company or your life that supports this point?

To make something right that is merely familiar means to ascribe logical fallacies to things that make us feel better. Some call this confirmation bias. You see this quite a bit in arguments such as gun control. Person A defended his home from an invader therefore we are safer with weapons in our homes. However the math does not support this argument. It just makes a person feel better to have a weapon in the home; thus it is true because it is merely familiar. On the other side of the coin we can look at the current gay-marriage debate in the US for an example of people attempting to make wrong what is merely strange. Current attempts to modify the Constitution to ban these marriages are people taking this argument to its absurd ends.

In my areas of patient care there are those that subscribe to the idea that things are wrong for being different and it can be rather infuriating to overcome. When it comes to addiction rehabilitation certain amounts of empathy are called for however this does not mean that there cannot be natural consequences for actions. For example, being intoxicated at work could lead to termination and this is a natural consequence. Empathy does not mean shielding those effects but to understand why one would see their actions as justifiable.

These examples still hold true. And the statement listed in the question is one of my favorite from the whole video. It is comforting to hold to ideals and norms that are familiar. However, we cannot claim to celebrate diversity if we do not also allow for a diversity of ideas. One thing I have come to learn since I last answered these questions is a growing fallacy of thinking opinion equals fact. The truth is that an informed opinion bolstered by supporting facts, reasoned judgements, and experience is worth more than one that isn't. Tom Nichols posted an excellent article that can be found here and it expands on the idea that reason seems to be taking a back seat to ignorance. I find it hard to disagree with him.

4. Taylor argues that our society should eschew elements of pop culture that degrade people and that we should spend more time looking into what develops empathetic citizens. Would this be possible?
I think we should but I am not so sure that it is possible. I've largely dropped most of pop culture from my life; I don't even have cable or antennae service. This allows me to pick and choose my entertainment through streaming or getting out and enjoying the arts. However, I have reached a point in my life where I can afford to make those choices. Not everyone is that fortunate or has that freedom. For many, entertainment is taken where it can be found and it would be understandable for peoples that are disenfranchised to experience a certain amount of schadenfreude over other's suffering. I wager most of you reading this has taken a fleeting pleasure at watching a Lindsay Lohan-type meltdown. Sure, we might feel guilty afterwards and the thoughts themselves are most likely fleeting but they are there.

I do believe that is a goal towards which we should all strive. There can be no harm come from less degradation and more empathy. If everyone already thought this way we wouldn't need an enlightenment in the first place.

To expand on this thought I think that developing empathetic citizens isn't something that is possible unless a level of living has been reached where people can spare the time and effort to develop empathy. The US child poverty rate is one of the highest in the developed world. This level of dysfunction in a country that likes to advertise itself as a model to the rest of the world would be darkly ironic were not its hubris so disturbing. A shift to a more empathetic model of humanity could well lead to a change in the policies that allow such poverty to exist in a county of plenty. However hungry people have little empathy to spare.

5. At the end of the video, Taylor talks about atomizing people from collaborative environments and the destructive effect on their growth. What is the implication of these comments for organizational change efforts?

Overall organizations must seek collaborative environments. Even simple change mechanisms such as Lewin's Model state that collaboration and buy-in are key to successful change. The simple fact remains that we all need something from each other. Simplistic thinking and rugged individualism often leave out that a person's success is dependent on using the protection and resources the group provides. People cut off from adequate protection and resources do not grow as well as those that are provided those tools. Go to any impoverished school district and see how growth is stunted in areas cut off from the fruits of society. This paradigm can be scaled to sub-units in an organization and even down to the individual. Without support people are doomed to fail.

I see little to add here expect to state that more experience in my field has even further entrenched the idea that collaborative environments are better than every man for himself. Diverse and collaborative environments are even better!

6. What can you take away from this exercise to immediately use in your career?
This has re-enforced my need for a global perspective. The myth of rugged individualism is just that...a myth. We live in an increasingly global environment, we cannot isolate from it. It affects everything we do and buy. Typhoons in China raise prices on goods in the US. Shady investment practices in the US cause bankruptcies in the United Kingdom. Faster communication means we are more aware of the world around us than ever before. Hiding from this change does not make it go away, it just means you get left behind.

As with question 5, I see little to add. For individualism to work the individual needs to be able to control a great deal of the variables that affect the individual. Globalism makes that increasingly difficult and removes the control an individual has. A line worker has little control over the company moving jobs to Mexico and it can be argued that groups of workers also do little to prevent this as the policies that allow these things to happen are written at the federal level. However, groups of workers can negotiate wages, benefits, and safer working conditions. Individualism plays well on the surface but the truth is that we all depend on one another to some degree or another. Developing empathy allows for deeper and more productive connections with those we rely upon and in turn rely upon us.

Multi-Stage Decision Making

Wharton, in “Wharton on Decision Making” describes a multi-stage process for decision making and offers a few questions one can ask themselves to enhance the likelihood of a desired outcome (John Wiley & Sons Inc, 2001). The questions are fairly handy and since I work in mental health, and my job is directing patients towards their own best outcomes they good tools that I can use to give a patient the ability to reflect. They are:

1) Am I being myopic?

2) How appropriate is the starting analogy I am using to solve the problem?

3) What are penalties for making an error?

4) What am I learning from the feedback I am receiving?

Taken in order these are fantastic “self-checks” one can use to slow down a decision making process. One of the biggest barriers that I encounter when attempting to decide the best course of action to take with a given patient is myopia. I work in addiction, homelessness, and with the severely mentally ill. It is normal to look at patient’s past behavior and attempt to draw conclusions about their future behavior. Addiction recovery is a process that is often shot-through with failure. Not only are the organic changes in the brain difficult to revert but the thinking errors that arise lead addicts to repeat a series of bad choices. It becomes a bit of a self-directed spiral; thinking errors lead to relapse which undue any organic brain recovery which then leads to more thinking errors.

As for myopia, it is easy for a provider to not see past the information directly in front of them. We often tend to ignore possible factors “down the line” as we know patients typically can only handle one hurdle at a time. However, this a trap. If a provider does not have supports in place for a patient that does move ahead the patient can be left in a bit of a lurch.

However there is a flaw in this process; it assumes that a patient is thinking rationally, or even a manager for that matter. People in addiction rarely demonstrate clear thinking and the sufferers of a severe mental illness face immense hurdles in apply a clear process to any decision. There are managerial techniques such as developing one’s own emotional intelligence that allow for a manager to begin to set aside some of their bias and prejudices but once again it comes back to the capability of a given manager to apply these tools.

For me, decision making professionally is often based more on intuition and how I’m reading a patient’s ability to commit to a process. At the risk of sounding like I am discounting the text, which I am not, this skill cannot be based on equations or applying a set model. One has to read a chart, engage with the patient, and learn to use active listening and motivational interviewing to get a feel for where a patient is at in their minds. And of course, patients are not always honest so a great deal of intuition is required.

In any other aspect of my decision making, from personal life, to managing a program itself, the multi-stage process is quite handy! It allows for a methodical approach to looking at an issue and provides a foundation of assurance that you’ve covered options while approaching a decision.