Hey, Let’s ALL Change from the Inside Out!

7 Habits Stephen CoveySo I saw this JAMA article in which the authors, Berwick et al, use the term “change from the inside out,” and don’t attribute it to Stephen Covey, whom I’ve always thought originated the phrase, although I may be wrong [1]. I’m a big believer in change from the inside out rather than change from the outside in. One example I can think of for the latter is Maintenance of Certification (MOC).

There’s an almost glib and superficial commercial tone about the JAMA piece. There’s even a “rah, rah” at the end. I’ve noticed I get that feeling about many similar articles trying to sell an unpopular product or idea. It sounds a little on the slick side (thank you so much!). About the same time, I got an email advertising an MBA course. The header said “Fast-track your career with Iowa’s Executive MBA.” The sender meant well.

Stephen Covey Time MatrixI know Covey was a business maven [2]. But he didn’t act like one. However, one of the writers is a physician leader of the Institute for Healthcare Improvement whose web site looks–slick.

Anyway, Berwell et al start off talking about how well the Affordable Care Act (ACA) has worked out so far, which rang sour right away because it’s been controversial out of the gate. Coverage isn’t the same as care and, to be fair, I think the authors meant well by acknowledging that.

However, I take issue with “To borrow a phrase contributed by Splaine and colleagues, it is time to move from changed forced from the ‘outside in’ to change led from the ‘inside out.” Well, my bias is that Covey said it best in his book The 7 Habits of Highly Effective People.” Splaine’s paper was published in 1998 and my institutional library does not have access to an electronic form of the full article. However, the abstract certainly sounds like Splaine might have read Covey’s book [3].

Don’t get me wrong, I’m not against the Triple Aim, “simultaneous pursuit of better care for individuals, better health for populations, and lower per capita costs of health care.” I also agree that laws and regulations can’t fully realize the promise of the Triple Aim by themselves. And the authors acknowledge that context can make all the difference when it comes to implementing a redesigned health care system. They even use the word “blunt” to describe regulations and laws. They also seem to know what lingo to use; for example, “…public policy is no match for the patient-clinician relationship in helping people recognize and adopt healthier lifestyles.”

I have a few comments about the principles they outline that purport to revise care design principles originally developed by the 2001 Institute of Medicine in the Crossing the Quality Chasm report.

  •  Design and nurture systems that expect and embrace change, in the continual pursuit of improvement. Please include front line doctors when designing the systems. We’re all about embracing change, but the devil’s in the details and physicians are often the ones who get stuck with them.


  • Change the balance of power, so that health and well-being can be coproduced in partnership with patients, families, and communities. Share the power; don’t give it all to the certification boards. Empower doctors as well and avoid cluttering our busy days with busy work so that we can give more time to our patients, families, and communities.


  • Cultivate and mobilize the pride and joy of the health care workforce. Remember the best way to do this is to avoid burdening physicians with confusing and irrelevant regulatory hoops through which to leap ever higher and higher.


  • Make it easy. Continually reduce waste and all nonvalue-added requirements and activities for patients, families, and clinicians. Here’s a good idea, stop telling doctors that MOC is “easy” and really make it easy by eliminating busy work like Part IV. Cut the crap like joint ABPN/APA sessions at APA annual meetings that I don’t have time to attend anyway that have titles like “How the APA Provides Everything You Need to Make MOC Easy For You’ (Thanks to Dr. Phil Muskin again, Chair of this year’s free sessions titled “MOC: Why It Exists, What It Is About, and How You Can Do It” for trying to tell me (as he tried last year) how this is easy–my answer is still the same. Will someone please go to Toronto on May 19 and ask Phil why APA sent that ABPN-Letter (1) requesting Part IV of MOC be eliminated if everything is so easy?


  • Move knowledge, not people. Exploit all helpful capacities of the modern digital age, and continually substitute better alternatives for visits and institutional stays. Meet people where they are, literally. I’m right here running all over the hospital in my role as a psychiatric consultant doing all the things that MOC programs have left out of their empty Part IV modules. If you want to move knowledge, make academic library resources free and open access to hard-working doctors in private practice as well as to academicians.


  • Cooperate and collaborate, above all. Eliminate silos and tear down self-protective institutional and professional boundaries that impede flow and responsiveness. Wonderful; let’s start by tearing down the antique board certification silos which are as self-protective as bureaucratic organizations can get.


  • Assume abundance. Use all the resources that can help, especially those brought by patients, families, and communities. Boards already assume abundance; they’re picking the pockets of doctors every day on their wasteful MOC programs.


  • Return the money from health care savings to other public and private purposes. Aim for total health care expenditures at or below 15% of gross domestic product. Return my money I sent to the board for the MOC and we’ll call it good.

If we can hammer this out we might be able to stop this train.


1. Berwick, D. M., et al. (2015). “Change From the Inside Out: Health Care Leaders Taking the Helm.” JAMA.

2. Covey, S. R. (1990). The seven habits of highly effective people : restoring the character ethic. New York, Simon and Schuster.

3. Splaine, M., et al. (1998). “Looking at care from the inside out: a conceptual approach to geriatric care.” J Ambul Care Manage 21(3): 1-9.
Today, managing care from the “outside in” is the predominant model for changing health care. The risk of this outside-in approach is that the health care system may lose sight of the people and communities for which it serves and cares. In this article, an “inside-out” model for viewing health care in a geriatric population is presented from the perspective of patients and providers, placing the provider in a proactive rather than reactive role. By focusing attention on the outcomes or value a patient is experiencing, providers are challenged to consider new ways of managing care.