Rethinking The Abilene Paradox

This entry is part 1 of 2 in the series Elephant in the Room: The Role of Shame in HIT Resistance

Forty years ago, management literature referred to a story demonstrating how organizations “frequently take actions in contradiction to what they really want to do and therefore defeat the very purposes they are trying to achieve.” That story is now known as the “Abilene Paradox.”

The story describes a Texas family who enjoys each other’s company by simply sitting on the porch on a hot afternoon, but collectively decides to take a trip to Abilene – despite individual unspoken misgivings. When they return, each family member admits they really had a miserable time – but in order to please the others (or so they thought) each agreed to a trip no one actually wanted to take, suggesting that people are often “very averse to acting contrary to the trend of a group where there is real risk of displeasure and negative consequences for not going along.” 1

The volume of social science research on organizational behavior in the forty years since its original publication may deepen the significance of the Abilene Paradox, especially in healthcare. Social work researcher Brené Brown poignantly described some of this research in a 2010 TED Talk. 2  Brown focused her research on the most powerful human desire – human connection. She discovered that the drive for connection was very often unmet. Her study subjects described disconnection as a major fear. And this fear then led to a deep sense of vulnerability. In western society, we see vulnerability as weakness or failure. Given this, a person feeling vulnerable then may develop a deep sense of shame.

This TED Talk hit a nerve. In a subsequent 2012 TED Talk, 3 Brown said she initially thought “perhaps six or seven hundred people” would watch her original talk on YouTube. As of today, the video has over 16 million views. If Brown herself grossly underestimated the response to her talk – that her observations on shame and vulnerability resonated with tens of millions of people around the world – it seems obvious that we would also face this significant challenge in healthcare. In other words: are shame and vulnerability driving organizational forces in the healthcare environment? Are these forces that people working in these environments never admit or talk about? If so, what are the implications? Brown argues that equating vulnerability with weakness is a major misunderstanding. She proposes instead that vulnerability is not a weakness, but an act of courage. Our willingness to makes our vulnerability open for all to see is necessary, even a requirement, for innovation, creativity and change.

Most healthcare research looks at clinicians – individually and collectively. We know, for example, that during their training, physicians undergo an acculturation process where invulnerability is a core theme. More importantly, we now know this cultural norm is a key factor contributing to medical error. 4 Similarly, research on physician-nurse relationships examines the “culture of blame and shame”. “Bullying” behavior between other clinical professionals – doctor to nurse and nurse to nurse – even clinician to patient” is well documented.

With an understanding of how shame and blame work for doctors and nurses, can we assume these emotional barriers also exist throughout our healthcare organizations? What about managers and executives? Those who work in Healthcare Information Technology (HIT)? Although we are not aware of any research in these areas, we propose that shame and vulnerability affect those beyond the bedside. Brown notes that shame is a universal human experience (an elephant in the room). This scope extends much further than focusing exclusively on physicians and nurses.

Assuming this is true, what is the significance to healthcare, particularly HIT? Few would disagree that our industry is in a dramatic state of flux that seems certain to introduce faster and more significant change in coming years. Dr. David R. Masys, former Professor and Chair of the Department of Biomedical Informatics and Professor of Medicine at the Vanderbilt University School of Medicine and now an Affiliate Professor of  Biomedical and Health Informatics at the University of Washington School of Medicine, notes “Health care is being overtaken… by colossal changes in the environment in which it delivers its services and in the knowledge base of science upon which medical reasoning and health care decisions are made.” 5 Of course, a primary driver of this change is the cost of care – but there are many other motivators, such as quality and access.

In general, the direction of this evolution suggests the system is taking shape: paying for value not volume, caring for patients from birth to death, coordinating care across the continuum, engaging patients as co-creators of health. The common thread is a need for data and information. Without robust, usable, interoperable HIT, none of this evolution is fully realized.

  1.  Abilene paradox. (2014, August 23). In Wikipedia, The Free Encyclopedia. Retrieved 16:18, September 3, 2014, from http://en.wikipedia.org/w/index.php?title=Abilene_paradox&oldid=622424716
  2. Brené Brown. (2010, June). The power of vulnerability (video file). Retrieved form URL: www.ted.com/talks/brown_on_vulnerability
  3.  Brené Brown. (2012, March). Listening to shame (video file). Retrieved from URL: www.ted.com/talks/brene_brown_listening_to_shame
  4.  Peter Rivard. Accountability for Patient Safety: A Review of Cases, Concepts, and Practices. Massachusetts Coalition for the Prevention of Medical Errors. September, 2003. Retrieved from URL: www.macoalition.org/initiatives/docs/Accountability%20%LitReview%0@Final_Rivard_new%20%copyright.pdf
  5.  David R. Masys. Effects of Current and Future Information Technologies on the Health Care Workforce. doi: 10.1377/hlthaff.21.5.33, Health Aff September 2002 vol. 21 no. 5 33-41. Retrieved from URL: content.healthaffairs.org/content/21/5/33.full
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Posted on October 1st, 2014 in Innovating Health Care IT
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