Change is just more of the same
Department of Biomedical Imaging, University of Malaya,
Kuala Lumpur, Malaysia
��Modern skulls still have a stone age mind� 
�This Quality Assurance programme is a total waste of
�Why change the roster if it was working just fine before?�
�If it isn�t broken, why do you want to fix it?�
�The bosses never tell us what�s going on, but they expect
us to follow them!�
�Why can�t they make up their minds about how they want to
improve the standards in our academic department instead of changing things all
�It�s just another new Dean of the faculty who thinks he
knows it all and wants to change things.�
�Don�t you remember the previous attempt by the
Vice-Chancellor to change our university? It ended up in a total failure,
�All this stuff about change management is an excuse for
the consultants to make lots of money.�
�The only way we are going to survive is if we destroy
everything and then, like the proverbial phoenix, we rise from the ashes.�
Type the word �change� into Google and you get 1.4 billion
hits. �Change management� gets you 71.8 million hits, �coping with change� 2.6
million and �books on change� 302,000 hits. In short, change is BIG.
Think of a change that you recently experienced. Did you
like that change? Or were you unhappy with it? Did you take a long time to come
to terms with it, or was it a breeze? Or did you forget about it for another
time and place? Were you able to stop the change? In the end, does it really
matter whether you liked it or not? After all, it has already happened.
Change is all around us, and it is close to impossible to
define because it can be seen from so many different perspectives. We find
change disorienting as it fills us with an anxiety similar to the loss of
something that had defined our lives. With an established routine, we don't
have to think! And it is so easy to forget that thinking is really hard work,
especially if everything needs to be thought out every day! It is akin to
experiencing a �culture� shock where we experience the unease of a different
culture with different customs, values, and language. This is due to the
absence of the recognisable cues or signposts we took for granted in our
�familiar� culture. Add death to the scene and change is never easy. The death
of a relationship is almost worse than the physical death of a loved one.
Yet each of us craves change that brings benefits.
Businesses want to be more profitable, more efficient, faster to market and
more innovative. Athletes want to run faster, jump higher, throw further, score
more goals and break records. Educators are always looking for more effective
best practices and processes. Doctors are always looking for more effective
treatments, better outcomes, less morbidity, faster reports, quicker scans and
more resources to do be able to do more. Researchers are looking for the
breakthroughs that will win them the Nobel Prize. Entrepreneurs are looking for
the next big trend that will be the next iPod and make them millions. Children
want to grow up and become adults sooner so that they can buy their
Lamborghinis. In other words, most people want CHANGE when it is in their
interests, the only caveat being that everything else stays the SAME!
Many people wish to freeze the present and hold things
static in the mistaken belief that by resisting or ignoring change they can
control the world around them. We wish to do our barium enemas the same way as
we have always done; we do not want to learn about that new MR colonography, or
get sucked into all the hype about PET/CT! Teleradiology is not my cup of tea
as I have enough work already!
However almost everything we experience is alive: our
ideas, our values, our passions, our families, our friends, our colleagues, and
our communities. All these things need �movement� to continue to be alive. They
change every day, very often in subtle ways that we do not notice, until one
day we find that the ground under us has shifted. The reason we work is to
create similar movements, to produce change for ourselves, our colleagues, our
patients, our hospitals and our communities. Without movement towards some
predetermined acceptable goal, life will be a drag and we will all suffocate.
What are the consequences of inability to change? Entropy. Slow certain death.
At the same time, we cannot steamroll blindly towards
change. Contrary to the emphasis on change, the importance of stability amidst
all the change is very often overlooked. Without a certain degree of stability,
most things would exist for no longer than a split second. Without specialities
in medicine, healthcare would be a free-for-all which would make life for
patients a total chaos. Conversely without a certain amount of continuous
change, things would remain the same forever. For instance, there would be no
MR guided ultrasound which transcends imaging, intervention and surgery or targeted
Stability and change complement each other and should be
treated as interdependent conditions. Both of these states existing alone raise
serious problems. Excessive change leads to chaos while too much stability
results in inertia. However, when we put stability and change together,
possibilities open up. Without the continuity provided by stability � without
connections between the past, present, and future � and disruption provided by
change, there would be no reason to grow, learn or have dreams. Change only
benefits an individual, a family, an organisation or a community if stability
is also part of the change. Indeed, these connections provide the basis for
trust, durable social relationships, the rule of law, and robust communities.
Stability is the keystone of human identity .
Unfortunately stability is often perceived as a lack of
change or even as resistance to change. Change, on the other hand, is always
perceived as positive and to be pursued. It is no wonder that the call for
change is a top priority every time a failure occurs or a new challenge comes
along. Suggestions for change are easily funded and readily implemented but
often with poor results. This tells us that we should not view stability in the
same way as stasis or paralysis.
Stable systems, contrary to common belief, must be highly
adaptive and flexible. This is exemplified by our human body and homeostasis.
Homeostasis is the property of open or closed systems in an organism that
regulate its internal environment so as to maintain a stable, constant
condition. Multiple interacting dynamic adjustments and feedback mechanisms
make homeostasis possible. However when too many of its systems collapse, the
organism is unable to maintain itself and succumbs. Therefore systems must have
the capacity to change in order for it to stay the same. The challenge, albeit
easier said than done, is finding the right balance between stability and
change; the �yin� and the �yang�.
So, why is the change process so scary? Because change
upsets people. It changes the goal posts, changes the rules we have become so
familiar with. It disrupts our routine and habits. It can be very unnerving
when the familiar packaging of your favourite coffee is changed, or when
someone takes �your� seat on the restaurant, train or bus or even when �your�
toilet at work is occupied. Change demands constant adaptation. But imagine
everything changing at the same time: how you work, what you work on, the
principles on which your work is based, your work rules, how success is
measured, what is socially acceptable, the cost of living, the way of living �
this is change multiplied manyfold. Even though change is inevitable and
essential the acceleration of the pace of change is frightening. But while we may
not be able to control change, we can certainly control our attitude towards
We tend to respond to change the same way we respond to
anything we perceive as a threat. We go through denial-resistance-anticipation /
exploration- commitment (Figure 1). There are those who categorise people in
the change process zoologically , for example:
- Ostriches - They work on the principle that if they cannot see the
change then it�s not there. They seal themselves off from those around them,
i.e. they cocoon themselves and try to ignore what is happening.
- Moles � They disappear when change is going on and then they pop up when
they think everything has been completed.
- Tigers � They fight tooth and claw all the way in the change process.
They are extremely sensitive and if you hurt them only a little, they will seek
to hurt you a whole lot more. Their motto is �Go make your change elsewhere
with little people but don�t mess with us!�
- Dogs � They tend to be more powerful in a pack. They seek one another
out and attack en masse. They are not fearless but they know that together they
create even more fear and damage.
- Owls � These people know better than you and are not slow to point this
out. They enjoy pointing out all the little faults in your change project which
for them is below their level. They ooze negativity, destructive criticism, and
even conduct plain sabotage.
- Snails - They go so slowly that change does not really affect them,
since by the time they get to their destination, the posts may have shifted
somewhere else. Basically they hope that you will leave them to their own
Do any of your colleagues fit any of the above
When we are not comfortable with change, we often
rationalise why the proposed change is bad. We wish to stay where we are
because we feel that our needs have already been met; we justify it by saying
that we have invested heavily to get where we are or that we are in the middle
of something important. Alternatively we do not trust the person driving the
change, we think that the proposed destination or journey is not right and
looks worse than where we are now, too much relearning is required, or there is
nothing to attract us forward. The more horrifying the scenario, the more
likely we are to believe in the reasons not to change, e.g. the end of a way of
life, the vested interests behind the change, the loss of some moral high
ground, the end of a speciality, or the loss of �territory�. This becomes a
rallying cry for different groups of people who have a variety of reasons to
resist change, which often have little to do with the change itself. But in
resisting change, we forget how we arrived at the current state that we
consider to be sacrosanct � it evolved from some other state that those before
us had resisted too!
What about doctors? How well do they cope with change? Are
we doing a good job of changing? The answer is: not really. A physician�s
background, ethics, and beliefs strongly mould his or her opinion and influence
his or her practice behaviour. As human beings, physicians are motivated by
multiple interests: the patient�s interests, their own interests, society�s
interests, and, increasingly, the payor�s interests. Physicians must balance
their multiple motivations with a professional ethos that demands
accountability; competence, if not perfect performance; willingness to admit
mistakes that occur; maintenance of requisite knowledge and skills; and
willingness to admit ignorance and ask for help. These special features of a
physician�s background makes practice behavioural changes very complex . New
diagnostic techniques and advanced therapies are vital in improving the quality
of healthcare but these technologies, in themselves, are insufficient.
Traditional approaches to address physicians� lack of
awareness and lack of familiarity, such as continuing medical education and
dissemination of evidence-based guidelines, have proven ineffective in changing
practice behaviour . Generally single interventions, such as educational
materials, reminder systems, audit and feedback, have modest or almost
negligible effects when used alone. However, the use of combined intervention
strategies can result in significant changes in physician behaviour and
improved health outcomes . In a cohesive, balanced approach to planning
successful interventions for improving practice, behavioural theories must be
supported with consideration of the organisational dimension. Any intervention
designed to have an impact on behaviour must be considered from a multidimensional
Whose responsibility is it to manage change? Is it the
heads of government or ministers, the industry, the leaders of organisations,
professors, professionals, the staff, parents, or the institutions of learning
like schools and universities? As much as we would like to transfer
responsibility for change to others, everyone must be part of the solution.
Leaders have a greater responsibility to facilitate and enable change (not to
instruct and impose) especially to understand the situation from an objective
standpoint and help employees understand why, how and when to respond
positively depending on individual situations and capabilities. Managing the
change process is no easy task! The best organisations learn externally as well
as internally, and successful adjustment to change is not just movement, but
movement with predictability.
There have been numerous management tools which have been
formulated by management gurus with their �theory of the decade�, to assist in
managing change in organisations (Table 1). The complexity of some of these
constructs makes any sensible use impossible. The tendency is to apply one of
these techniques over a time frame and expect change to happen � a
one-size-fits-all approach that often backfires . Change is a process and
not a one-off event or even a series of events. Even though events help to
focus people�s attention, they are only one part of the change equation. It is
the ongoing practice that enables long-term success.
Most management theories concerning change and stability
are in their infancy. Most theories still focus on change management, with
little reference to the need for, or benefits of, organisational, stability
. The most successful organisations are the ones that value both stability
and change, and try to balance the divergent practices. Even though change
costs money, it is the stability that earns money. Successful organisations,
such as Sony and GE have an organisational culture that promotes stability, but
at the same time stays innovative by institutionalising change.
Change should be seen as a journey, not a blueprint, where
change is non-linear, loaded with uncertainty and excitement, and produces
sometimes perverse outcomes. Personal change needs to precede organisational change
and acceptance requires a change in attitude. The more complex the change, the
less we are able to force it. We should stop focusing on the individual parts
but try to see the issues in totality. The issues/challenges we face should not
be seen as attempts at problem-solving, because problem-solving is reactive and
often functions as a way of maintaining the status quo rather than enabling
fundamental change. Labelling an issue/challenge as a �problem� allows us to
distance ourselves from the �problem�, which subsequently inhibits our ability
to see the true situation. Instead, we should view challenges as learning
The toughest part, though, is to learn to love ambiguity:
simultaneously pushing for change while allowing self-learning to unfold and
being prepared for a journey of uncertainty. If we can simply allow ourselves
to be comfortable with all the seemingly unrelated bits and pieces of
information � most of which are contradictory, ill-fitting and plain confusing
� we can discover new ways to understand a situation which can eventually
At the same time, we also need to create a personal vision
but not be blinded by it, while focusing on what we can do as individuals
rather than on what we can�t do. It is also helpful to develop a perspective of
looking at problems/challenges as sources of creative resolution with a
willingness to learn and develop. Other measures we can take are: to try to
value the individual and the group, incorporate centralising and decentralising
forces, and be internally cohesive but externally oriented . Change is too
important a task to be left entirely to the experts and the individuals in the
change process must be actively involved in its execution to achieve the
The long-term costs of failed change efforts include lost
time, energy, revenues, employees, increased cynicism, depression, anger, fear,
increased resistance to change and misperceptions about change management.
Therefore, it is vital that organisations desiring change must be committed to
the efforts, otherwise the result of a failed effort to change is an
organisation that is worse off than when it first started.
"The more things change, the more they are the
Figure 1 Phases of going through change.
Table 1 The numerous tools for change.
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|Received 30 July 2008; accepted 31 July 2008
Correspondence: Department of Biomedical Imaging, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia. Tel.: +603-79492069; Fax: +603-79581973; E-mail: email@example.com (Basri J.J. Abdullah).
Please cite as: Abdullah BJJ, Ng KH,
Change is just more of the same, Biomed Imaging Interv J 2008; 4(4):e36