Difficult or Different?

You work with a huge variety of people. Different nationalities, different cultural backgrounds, different sexes, different colours, different professional groups and different inner humans. However, frequently we don’t experience ‘difference’ so much as feeling we are experiencing ‘difficult’ when in fact difference is the underlying driver of that outward behaviour. This brief educational article is about what I will term ‘positional difference’ and how this is underpinned by a far more complex set of drivers than you might imagine.

Commencing with a story

Bob is a laproscopic surgeon working with two others in a small, new, NHS-style provider, established under Any Qualified Provider and accepting patients who choose their practice when offered choice by either GPs or surrounding Trusts. The group of three decided early that they would be remunerated on a case-based approach i.e. a fee for an episode, as that was how the practice itself is remunerated under AQP. Initially, they agreed schedules across 6 days, whereby each of them effectively ‘acquired’ their case load over the two days they were ‘on service’.

However, what became apparent was that your service day markedly affected the number of patients you might find being referred, with some days clearly ‘hot’ and others decidedly tepid. This was raised by one of the team at their regular practice meeting, with a suggestion that they needed to revisit how patients were allocated as the current arrangement was leading to bias and disproportion. As it stood, Bob was quite happy with the existing arrangement because he actually had what constituted an ‘average’ caseload. However, he could see that Jenny appeared to be constantly busy and Peter appeared to be frequently quiet. There was certainly no professional reason for this, as all three were highly respected individuals.

So Bob agreed to chair the process of examining other arrangements and asked the other two to come up with alternative suggestions.

The suggestions

The first back was Jenny. She proposed that they didn’t change the way they allocated patients as she had worked hard to build practice. However, she did suggest that perhaps Peter might benefit from engaging in some marketing and promotion of his services to increase his patient load, including informing potential referrers of his availability. She said she favoured this slightly competitive approach, as it would keep all of them on their toes and benefit the group as a whole.

Peter took a very different view by proposing that they cover the schedule as they had been but they allocated the patients evenly across the three i.e. they accepted them as a practice and handled them so that each caseload was roughly even. He said that the scheduling suited him because it allowed him to plan family arrangements but it was unfair that sheduling itself left him with fewer patients.

Bob considered both of these suggestions and his own practice, as well as doing some investigating on how others approached the same issue, as he formulated his own ideas. In the end, after careful analysis of the likely effects, he thought that the best approach would be to randomly allocate the schedule, so that individuals did a variety of days and over time it should result in a fair allocation of patients.

The meeting

They started with each individual presenting their solution and agreed no comments until all three were out on the table. However, at that point, all three sat there in the realisation that they had managed to produce not one better solution but three completely different approaches.They set about discussing them and the relative merits and disadvantages as each of them saw them.

Jenny said that hers was a business-focused approach that respected the principle that we shouldn’t compromise one person’s hard work to compensate for gaps elsewhere and instead we would be better competing harder to fill the gaps i.e. bring the others up, not simply give her caseload away. She said she didn’t like Bob’s suggestion or random scheduling because she used her off days to pursue other professional opportunities and she couldn’t do that if she couldn’t plan.

Peter said that Jenny hadn’t actually offered a change and currently the allocation was unfair. She had simply benefited from a reality they didn’t know at theĀ outset. It wasn’t down to extra hard work and they had all worked at promoting the practice. He didn’t like Bob’s random scheduling either as he said that one of the reasons for going into the venture was better work-life balance and that meant planning around the children etc.

Bob, who thought that both alternative suggestions were wrong, also found himself wishing he hadn’t offered to chair because it was clear that if they adopted his suggestion he could see potential for accusations of bias and yet he was fundamentally against each of the others. Even allocation of patients introduced the problem that someone could ‘coast’ and still end up with the same caseload as others. If the issue was truly a day issue, then the extra promotion effect would disproportinately benefit the busy and would almost certainly not fix the imbalance, even if it improved the practice volume as a whole. He shared these thoughts in a matter of fact manner and said “so what shall we do?”.

The degeneration

Jenny said straight out that she wasn’t giving up her case load and she didn’t go into the venture to ‘carry’ the others. If they wanted more work, work for it. She did say that if random was acceptable to the others, why didn’t they randomly cover their four days and leave her two as they are.

Peter became upset and pointed out they went into this as equal partners and every one of them had lifestyle or life plan reasons why it was beneficial. He accused Jenny of being self-interested and suggested Bob didn’t appear to want the same work-life balance and hence why random was fine by him.

Bob re-stated his concerns about the first two suggestions and pointed out that they had no evidence at all that either would fix the issue. He said that in the absence of any evidence to the contrary, random allocation would definitely even the case load and that if Peter wanted the problem solved, he had to be prepared to compromise his home arrangements for his professional obligations. If home was more important, then he could just accept the current arrangements. He said he had no objections to Jenny’s solution per se except that he wouldn’t agree to it as a fix to this problem because it added cost and would not necessarily fix the issue.

The meeting degenerated into what can only be described as an argument with each individual accusing the others of being difficult. Or are they just different? With no means by which to rationalise that difference to move forward?

The differences

These individuals have been characterised to exhibit behaviour and thought patterns of three rather polairsed but nonetheless common sets of underlying drivers. The purpose of the article is not to explain that in full (we doubt you have the reading tolerance) but to identify them and their impact, along with profound long term consequences. I would also suggest that you encounter these differences daily, not just in a specific story such as this.

Each individual adopted a POSITION. My position is we should… However, those positions are underpinned by experiences, beliefs, values and other psychological factors which we will collectively term your inner human. In truth, the only common behavioural pattern, common to us all, is that we view the other suggestions through what we call a risk radar – a background, largely subconscious process of evaluating all of our experiences for risk and threat. However, our individual interpretation of risk is also heavily influenced by our inner human.

For instance, you can see Peter’s position and reactions being driven by a wide range of factors that in part are associated with his Altruistic Nurturing drivers or behavioural profile. These include:

  • His attitude to and the importance he places in family
  • Fairness as a personal value
  • His dislike of self-interested
  • His belief that they are a team, with a shared responsibility to each other

Jenny has what we’d call an Assertive Directing motivation, often exhibited as high drive, high competitiveness and a tendency to want to lead. We see this in:

  • Competing to keep the case load she has built up
  • Pursuing multiple opportunities concurrently
  • Refusal to go backwards

She absolutely doesn’t see self-interest as a character flaw and she believes that each individual has a responsibility to self, which goes hand in hand with “don’t moan about something, do something about it”. Equally, she wouldn’t understand why, if the workload increased for all, it was still considered wrong by the others that she may still be doing more.

Bob is what we’d describe as Analytical Autonomising, which you’d recognise by his methodical, if somewhat detached approach and his tendency towards upholding principles, even if a practice is acceptable. You can see this in his:

  • Not wanting to adopt a solution without knowing it solves the problem
  • Reliance on evidence over emotions or opportunity
  • Tendency to notice the problems with suggestions, rather than the benefits

He would be particularly fearful of disrupting a ‘working’ status quo in favour of a gamble fix, based on no certainty. Whereas Jenny might be persuaded to ‘give it a go and see what happens’ this is unlikely to persuade Bob. He’d be all in favour of a limited trial, carefully evaluated but you don’t get to trial without first being pretty certain that the solution is a robust, risk-free one.

The costs

Whereas it is easy to understand the differences, in an almost obsersvational ‘how interesting’ manner, it should be vital that we all appreciate the costs. I would break this down into both the interpersonal costs and the lost opportunity cost i.e. the outcomes they achieve. For instance, where could this go?

At an interpersonal level, typically, we switch from something that looks like a professional difference of opinion to a far more personal attack, even if indirectly. These three are in business together. They have the perfect set of differences with which to excel. However, with no understanding or mechanism for working with their difference, they see each other as difficult. Even in my brief story, Peter is judging Jenny as self-interested (read selfish, in Peter’s mind). Jenny is viewing Peter as a lightweight (being carried). Bob is viewing Peter as inflexible. Jenny is probably viewing Bob as obstructive.

These viewpoints are tinted by each of our inner humans. The individuals become those judgements in our eyes – Peter the Inflexible, Jenny the Selfish and Bob the Obstructive. There isn’t a ‘right’ solution or right person within this story. However, I am interested to know who you aligned with or thought was ‘most reasonable’? If you even had some of those thoughts i.e. any leaning towards or away from one individual versus another, you have to accept that interpersonal difference affects your judgment. I would hazard a guess in which case that you work with people who you see as difficult.

These three see no common ground. This is because they are problem-solving at the level of positions, not needs. They will find common ground and better solutions when they learn how to switch. If they don’t, the risk here is that their business venture with huge potential, falls apart. Peter may go along with it for a while but will then likely pull out. Jenny may well find herself having to work other days anyway to compensate, undermining her other opportunities. Depending on Bob’s own personal position, he may or may not engage in the extra work, leading to a divide between him and Jenny. It can be amazing how something successful can be turned on its head by something so apparently benign (humans who think a bit differently).

Every day in the NHS, with clinicians working with managers, nurses with clinicians, theatre staff with surgeons, different behavioural profiles, nationalities, cultures and more, decisions are difficult, consensus is elusive, conflict is pervasive, change is complicated and people fall out. It creates intransigence, higher costs, lower productivity and ultimately threatens the security of all. And the true irony? They call the training it takes to address this ‘soft’ skills. We tend to call them mission critical.


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