I think the one core lesson from the book, related to new year’s resolutions, would be to start small. If you’re wanting to exercise more (and maybe have already given up on that), start with just a minute of exercise a day or start with one pushup… and then move up and increase your workouts gradually from there.
Why start small, with goals that are less scary? Because big changes ARE scary. Maurer talked about that brain science in Podcast #153 last year. I now have a podcast of that episode to share for those who don’t listen to the podcasts.
Mark Graban: Hi, this is Mark Graban. Welcome to podcast 153 for July 24th, 2012. Joining me today is Robert Maurer, PhD. He is director of behavioral sciences for the family practice residency program at Santa Monica UCLA Medical Center, and he’s a faculty member with the UCLA School of Medicine. In this episode, we’re talking about an excellent book that he wrote called “One Small Step Can Change Your Life: The Kaizen Way.” Yes, that’s right, kaizen, and it’s a topic near and dear to my heart, of course. I discovered Dr. Maurer’s book when doing research for our book, “Healthcare Kaizen,” with Joe Swartz.
I blogged about the book. There’s a review posted. I’ll link to it here in the show notes at leanblog.org/153. It’s really interesting to hear Dr. Maurer write about and talk about applying this kaizen, continuous small change approach, in the realm of therapy instead of the workplace.
He writes about the brain chemistry that causes people to fear change, this is, if you will, our reptile brain, except when it’s small changes. It’s really fascinating stuff. I’m thrilled to have a chance to talk to him and to share our conversation with you. For this and all episodes, you can go to leanpodcast.org. Thanks for listening.
Mark: Bob Maurer, thanks for taking time to join us here on the podcast.
Robert Maurer: It’s a pleasure, Mark.
Mark: Going to start by introducing yourself and your professional background for the listeners.
Robert: Sure. I’m a clinical psychologist, and I work in a setting that’s unusual for psychologists, because most psychologists are in clinics or offices, and I work in a medical clinic where we train physicians who finished their four years of medical school and are now in three years of training to become family doctors. I spend about half my time in the exam room with the resident, giving them feedback on their communication skills, and then have the opportunity to teach them how to be more effective in their communication.
Mark: I just wanted to say, from a patient perspective, I think it’s great to hear that there’s more focus being placed on educating clinicians about communication. Is that becoming more common in health care education today?
Robert: There are a couple of answers to that. Within the medical school proper, the undergraduate medical school, it’s now become quite common, and many medical schools have actually the equivalent of an acting company, where the medical students get to practice on, essentially, actors that are presenting them with patient challenges. When they take their board examination, they have to do this in front of what they call “standardized patients,” so their communication skills are now part of their licensure. I’m in family medicine, and family medicine’s the only specialty in medicine that requires they have this training.
There’s someone like me at each of the family medicine programs in the United States, so it’s part of that unique specialty.
Mark: I’m really curious how you first go exposed to kaizen from your perspective. We think of kaizen and lean as being workplace improvement methodologies. You’re working with individuals focused on their lives. How did you get started with this?
Robert: In a very roundabout way, given this opportunity I have in family medicine, it presented some unique fascinations and some amazing frustrations, because most therapists sit in an office or a clinic waiting for people to create enough pain in their life, run out of excuses. Then they come in late in the process, whereas the average Americans go to the doctor three or four times a year for relatively ordinary kinds of concerns.
Here’s this amazing opportunity, Mark, to be in an exam room, seeing a patient before they get married and create marital problems, before they have children that they have problems with, before they become depressed, yet we had no tools on how to predict health in people who are essentially there for brief amounts of time.
Long story short, I began collecting studies from around the world on people who were succeeding in their jobs, their health, and relationship over long periods of time. There are about two dozens studies that have followed people anywhere from 15 years to 70 years to see, again, what predicts success in all three areas of life, health, relationship, and work.
One day, I was reading the newspaper, and there was a full page ad for the Toyota brand of Lexus. For the umpteenth year, they had won the J.D. Power customer satisfaction award.
A thought went through my mind, “Well, maybe metaphorically, there’s something about building a highâ€‘quality car consistently year after year that, metaphorically, I might be able to apply to human behavior.”
I started to look at the history of Toyota and Lexus, and there’s a book called “The Machine that Changed the World,” I think by a man named Womack, if I remember right. I thought it would be about computers, but as you probably know, it’s about automobiles.
In it, he talks about Dr. W. Edwards Deming, and the idea of small steps that they introduced in manufacturing in World War II, and that was then Dr. Deming and the concepts of small steps to improve quality products was incorporated into the whole Japanese philosophy embraced by Toyota, etc.
That was how I got introduced to kaizen, through trying to see metaphorically if there was something about a quality car I could apply to a quality life.
Mark: How did you get started with applying these ideas, then, with the patients in the realm of therapy?
Robert: In the clinic in which I work, our major focus is, of course, in terms of physical health. That was my first interest, although I’ll take you through a little bit of the research on the couples work, which has even more dramatic impacts for kaizen, because we see a lot of people, like a lot of your listeners, who are leading very busy lives, and have very little time to do the kinds of things that we know people need to do in terms of exercising an hour day, etc., etc.
We found that if we could get people to exercise one minute a day, every single day, all of a sudden we took away all their excuses, because if I ask you to exercise an hour a day, you’ve got all kinds of good reasons why you don’t have time to do that, but if I ask you to exercise in place while you’re watching TV one minute a day, then all of a sudden you’re developing a habit.
Years ago, Mark, before I heard of kaizen, there was this world famous expert at UCLA giving a two evening course on cancer pain. At the end of the night, he said to these cancer patients, “I want you all to go home and meditate for one minute.”
I waited for all these patients to leave, and I went up to the professor and said, “Sir, why are you asking them to meditate for one minute? It’s not enough to do them any good.” He patiently said to me, “How old is meditation?” I said, “Thousands of years old.”
He responded, “Correct. There’s a good chance everybody in this room has heard of it before tonight. Those who like the idea have already found a book or a teacher, and are doing it. For the rest of the people in this room, meditation’s the worst idea they have heard of.”
“I’d rather they go home and meditate for one minute than not meditate for 30. If they discover they like it, they may forget to stop,” which is what the research argues. It was a study done in Seattle, where they looked at people who, over the course of an entire, gardened or walked for just an hour.
That’s a total in the whole week, which is about 450 calories, and lowered their risk of cardiac death by 70 percent.
A study in the Journal of Clinical Nutrition, a couple of years ago we found, talked about the fact that if you exercise three minutes at a time for a total of 30 minutes a day, but just three minutes at a time, even climbing steps in your office building, you had the same reduction in cardiac risk as someone that was exercising 30 minutes a day.
The Framingham study, the most famous of the prospective studies, were in 1984, they began following 5,200 people, and they found if you took one pound off a year for four years, that is, again, four pounds total, and kept it off, you reduced your risk of hypertension by 25 percent.
My favorite study, and then I’ll talk a little bit about the couples research, was done at the Mayo Clinic, where they developed essentially a pedometer that you wore. It’s called a “data logging underwear” You have to see it to believe it. They looked at people who never set foot in a health club, but who were, in spite of that, either thin or quite heavy.
What they found from the data logging underwear is people who were thin simply moved more doing the day. On an escalator, they walked up instead of just standing there motionless. In their office, they would pace when they were on the phone. When they went to the Costco lot, they’d park at the very end instead of driving around, trying to find a space close to the door.
They simply moved more, which added up to, on average, 300 calories a day, and an average of 30 to 40 pounds of weight loss in a year.
I’ll give you some more of these studies if you want, but again, in our 70 millimeter Dolby, superâ€‘sized, extreme makeover culture, it’s just hard to believe these small steps could have such profound influence on the body.
Mark: Before moving on, talk about relationships and couples. There’s a story in the book where you talk a patient, a woman, I think, who you got to start exercising one minute a day, and those small steps really got her going to be able to take on more serious activity, building that new habit. Tell the listeners more of the details of that great story.
Robert: Sure. The inspiration to work with this woman came out of a study that was done in Pittsburgh, and then in Ireland, in which they went into a huge highâ€‘rise building, they went to the fourth floor, and found a dozen people that hadn’t exercised since high school, and they gave this group a lifetime membership to the fancy health club across the street. They gave them a gift certificate for their trainer and another gift certificate for workout clothes. They went to the 10th or 11th floor of that same building, identified another dozen people in a different business who hadn’t exercised since high school.
All they asked them to do on Monday was go into the stairwell of the building, go up one flight of stairs back to their floor, back to their desk, back to work. Go up the same stairwell, go up one flight, add a single step, back to your floor, back to your desk. You get the idea, every day of the work week adding one step to this ridiculous regiment.
Well, when they came back one year, three years, five years later, which group do you think is exercising better, better weight loss, cardiovascular fitness, lower cholesterol? Of course, the steppers. So, what we asked this woman to do, she was a woman that worked a fullâ€‘time job, had a mother in a nursing home that she wanted to visit at night. She had two small children, so the kind of busy lives that again, many of your listeners have. And so, asking her to go to the gym or follow the American Heart Association recommendations of 30 to 45 minutes, five to seven days a week, she just looked at us blankly.
But if I asked her to exercise in front of the TV set moving as fast as she can, walking in place one minute a day, could she do that? And of course, her face lit up, of course I can do that. And what you’re counting on is, if you do something one minute a day, at first of course it’s annoying, then it becomes tolerable, and then you develop a habit. And what we were counting on is like with that professor with people with the meditation is that at a certain point you assume they’re going to forget to stop, and you’ve developed a habit.
Mark: And I’m sure listeners are curious, how do we take what we think of probably as workplace improvement ideas of this kaizen, apply it to our relationships?
Robert: The best research we have on marriage is by a gentleman by the name of Dr. John Gottman who’s a psychologist previously with the University of Washington and now at the Gottman Institute. What makes this work so extraordinary, Mark, is he’s studied about 10,000 couples over the last two decades, and he’s a scientist, he’s not really a clinician. He can sit you and a fiancÃˆ down for a 15â€‘minute interview or less, predict the likelihood you’ll be happily married four years later versus miserable or divorced â€‘â€‘ ready for this? â€‘â€‘ with 93 percent accuracy. Now, basically, if I can summarize his research for you, it boils down to two things. One was how couples deal with conflict, which is not surprising, but some of what he found was common sense, some of it was quite uncommon. The second thing he found is positive attention outweighed negative on a daily basis by five to one when the relationship wasn’t going well, 20 to one on the days when it was.
Now, what’s he talking about? 20 candlelight dinners? 20 trips to the movies? You couldn’t physically accomplish it. It turns out to be small, trivial moments. When your mate calls you during the day, does your voice light up when you realize it’s them? Do you put down the remote control, the newspaper, the telephone when they walk through the door?
If they went to the dentist this morning, do you remember to ask them about it tonight? If you said you were going to be home at 6:00, are you home, or calling to say you’ve been delayed? Those small, trivial moments accumulating throughout the day were more predictive of success than anything else the couple could do. So, it’s probably the best example of kaizen in a relationship I can think of.
So, what we ask people to do who are in counseling, for example, is usually they’re going around during a day rehearsing all the arguments they had last night or the ones they anticipate today. We asked them to do through the day thinking one or two positive things about their mate, and we have evidence it changes your brain chemistry, and it certainly changes how you walk through the door that night.
Mark: Now, one other thing you write about in the book, there’s a lot of really interesting brain science about how people react to change. A lot of times people complain that people in the workplace, or employees, or others are resistant to change and that they hate change. What is it about our brains that impacts the way people react in these settings?
Robert: Sure. The thing that makes the human brain so complicated is that we literally have three separate brains in our head. So, the bottom of your head between the bottom of the head and the neck is a place called the brain stem, and it’s the oldest part of the brain, and thus we call it the reptilian brain, because from the outside it looks like the whole brain of an alligator. And it does very basic things, wakes you up, puts you to sleep, reminds the heart to beat. Sitting on top of it about the size of your fist is the midbrain, also called mammalian brain because we share that brain in general with all mammals, and it’s where all the emotions live and the survival mechanism in the brain lives, which we’ll come back and talk about. And then again, to add to the complexity we have the cortex, which is wrapped around the midbrain, and with it we’re all thinking, reasoning, logic, culture, civilization, all the magnificence of being human occurs there.
Now, on the bottom of the midbrain is a place called the amygdala, it’s about the size of an almond. And the amygdala is where something called the fightâ€‘orâ€‘flight response lives. It’s basically what we used to call fear, they now call it stress. But it’s basically the fear mechanism in the body, so that when you stepped out of your cave in the morning with a body that didn’t see well or smell well, couldn’t run fast, the first thing you did is you became afraid, because there were lots of animals out there that used to feed on us. So, any time you enter a new situation, fear shows up.
And so, if somebody says, it’s time to join the gym, or a doctor says you have diabetes, you’re going to have to change your lifestyle, or you’re trying to do anything new in your life that triggers the amygdala, and so the way kaizen works, we think in part is that because you’re making steps that are so ridiculously small like exercising one minute a day, it doesn’t stir up any fear. So, the amygdala stays quiet, and through the sheer repetition of simple steps you’re building in a habit.
The example I love to give in front of a class is, I’ll draw two golden arches and say, what does this remind you of? And of course, everybody in the world gives you the same answer, McDonald’s. Now, some of the people in this audience have never set foot in a McDonald’s, wouldn’t eat at McDonald’s. But they’ve shown you that logo in 15 or 30 second commercials over and over and over again. Watch an hour of Law & Order and you see the same commercial four or five times, because the point of the commercial is not to entertain you, it’s to build the image and the product into your mind. And repetition, of course, is the best way to do that.
So, any time we can get people to do something positive for just 15, 30 seconds at a time, it keeps the amygdala quiet, and then the brain learns a new habit. The bigger the steps you want to take in life, the more it triggers fear, that is, the amygdala, and the more you start going into resistance. So, that’s part of the trick of kaizen is the small, repetitive steps that eliminate fear and allow the brain to start building positive habits.
Mark: So then, how do we take these ideas, and what are your experiences or thoughts about how to apply this to change, and trying to lead change and improvement back in the workplace now?
Robert: Sure. The really important key to kaizen, and it’s not always something that’s made clear, because people think of it as small steps with the hope of course of reducing the price of the product, etc., etc. But kaizen really has two ingredients. It’s looking for very, very small, incremental steps, but it’s also a very small step â€‘â€‘ as Deming talked about, as Toyota talked about â€‘â€‘ has to be in the service to the customer. It isn’t just going to be, can we reduce the size of the package without the customers being able to notice? That’s a small step, obviously, but there’s nothing about that that serves the customer. So, it’s really anything that’s considered waste that doesn’t serve the customer has to leave. So, it’s that service component that isn’t always as emphasized.
There are a few other points. One is that when you look at the history of innovation, what you find, at least to our surprise, our research time, is that it’s very rare that some big bold step was responsible for the innovation.
Whether you look at the innovation of the microwave, you look at how Walt Disney got the idea for Disneyland, the credit card, I can give you multiple examples, each of these things were some small trivial moment that somebody got intrigued with.
The guy that invented barcodes, which, as you know, revolutionized so many industries, was a guy that was trying to help grocery stores with their checkout process, could not figure out what to do.
Feeling frustrated one day, he goes off to the beach feeling very sorry for himself, sticking his hand in the sand out of frustration. Took his hand out of the sand, saw the sand sticking to the grooves on his fingers, and got the idea for barcodes.
I can give you two dozen more examples, because we have this myth in organizational creativity that if you want a big result, you want an innovative result, you’ve got to take big, bold, high-risk steps, when there’s no evidence that’s the case. Often, somebody looking at something that at the time seems small and trivial turn out to be something large and profound.
The other thing that we’d see in hospitals all the time is, as you pointed out quite correctly, every hospital in the country is now investing millions, and as a society, billions of dollars in electronic health records, and there are many advantages to them, but in terms of life saving, if we could get everyone in the hospital to wash their hands as regularly as they need to, we would save more lives.
It’s much easier to take on the innovative process of electronic health records and spend the vast fortunes that takes, as opposed to getting people to do the mundane thing of washing their hands. When they introduced checklists into the surgery suite, four or five items that the physician nurse would check off before starting an operation, they reduced infections sometimes to zero, and saved millions of dollars, but the resistance to getting people to use a checklist in the operating room was huge.
We tend to accept big steps, sometimes, more than small ones, but often not to our advantage.
Mark: Can we use some of these kaizen principles if we think about trying to improve something, let’s say like hand washing? Rather than making a jump to 100 percent immediately, are there some small steps that we can try to take to allow people to build new habits and help closer to, or get to that 100 percent point eventually?
Robert: Yeah. In fact, there are a couple of wonderful books that look at this whole idea of how to apply small steps in social environments. One is called “Switch” and the other is called “Drive.” One of the examples they use, I forget which of those books, to tell you the truth, because they’re both so extraordinarily wellâ€‘written, is where they put up signs in the hospital, either, “Be sure to wash your hands,” or another part of the hospital, they put up a sign, “Please help your patients . Wash your hands before and after.”
The “please to do it for the patients” tripled the rate of participation and hand washing. Sometimes those kinds of appeals can be dramatically effective.
Mark: Like you said, that’s bringing things back to what the patient needs are, as opposed to, “I’m the boss. I’m going to make you do it because I said so,” and people react very involuntarily, and say, “Well, who says?” It’s understandable where that resistance comes from in a traditional topâ€‘down command and control environment, wouldn’t you say?
Robert: Exactly. All of the research argues that punishment just doesn’t work that well, because the minute the person punishing you is out of sight, you go back to the old behaviors.
Mark: Again, thanks so much, Bob, for talking today. I really recommend everybody go take a look at your book, which is called “One Small Step Can Change Your Life: The Kaizen Way.” Again, Bob Maurer from UCLA. Thanks for talking today.
Robert: It’s a real honor. Thank you, Mark. [background music]
Announcer: Thanks for listening. This has been the Lean Blog podcast. For lean news and commentary updated daily, visit www.leanblog.org. If you have any questions or comments about this podcast, email Mark at leanpodcast@Gmail.com.
About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as the new Executive Guide to Healthcare Kaizen. Mark is also the Chief Improvement Officer for the technology company KaiNexus.