Joining me for Podcast #153 is Robert Maurer, PhD, Director of Behavioral Sciences for the Family Practice Residency Program at Santa Monica-UCLA Medical Center and a faculty member with the UCLA School of Medicine. We are talking about his excellent book titled One Small Step Can Change Your Life: The Kaizen Way.
I discovered Maurer's book when doing research for our recently-published Healthcare Kaizen. Here is my earlier review and blog post about his book. It's really interesting to hear about applying the Kaizen approach in the realm of psychology and therapy instead of the workplace. Maurer writes about the brain chemistry that causes people to “fear change” – except when it's small change. Fascinating stuff and I'm thrilled to have spoken with him a few months back.
For a link to this episode, refer people to www.leanblog.org/153/.
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Transcript:
Mark Graban: Hi, this is Mark Graban. Welcome to episode 153 for July 24, 2012. Joining me today is Robert Maurer, Ph.D. 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 Schwartz, and I've 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 our, if you will, our reptile brain, except when it's small changes. It's really fascinating stuff. I'm thrilled to have had a chance to talk with him and to share a conversation with you. Bob Maurer, thanks for taking time to join us here on the podcast. It's a pleasure. Can you start by introducing yourself and your professional background for the listeners?
Robert Maurer: 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. So 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 Graban: Well, 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 healthcare education today?
Robert Maurer: There's a couple of answers to that. Within the medical school proper, the undergraduate medical school, it's now become quite common. 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. And 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. And I'm in family medicine, and family medicine is 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 Graban: So I'm really curious how you first got exposed to Kaizen from your perspective. You know, 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 Maurer: Well, in a very roundabout way, because 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, and then they come in kind of late in the process. Whereas the average American goes into the doctor three or four times a year for relatively ordinary kinds of concerns. So 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. And yet we had no tools on how to predict health in people who are essentially there for brief amounts of time.
So, long story short, I began collecting studies from around the world on people who are succeeding in their jobs, their health, and relationships over long periods of time. There's about two dozen 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 JD Power Customers Satisfaction Award. I thought, well, maybe metaphorically, there's something about building a high-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. I thought it would be about computers, but as you probably know, it's about automobiles. And in it he talks about Dr. Deming and the idea of small steps that they introduced in manufacturing in World War II. That was then incorporated into the whole Japanese philosophy embraced by Toyota. So that was how I got introduced to Kaizen, was through trying to see metaphorically if there was something about a quality car I could apply to a quality life.
Mark Graban: How did you get started with applying these ideas then with patients in the realm of therapy?
Robert Maurer: Sure. In the clinic in which I work, our major focus is, of course, in terms of physical health. So 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 who, like a lot of your listeners, 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 a day. We found 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 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 ever 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.” So 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? 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 is the worst idea they ever heard of. I'd rather they go home and meditate for one minute than not meditate for 30. They may, however they like it, they may forget to stop, which is what the research argues.”
There was a study done in Seattle where they looked at people who, over the course of an entire week, 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%. A study in the Journal of Clinical Nutrition a couple years ago talked about the fact 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 somebody that was exercising 30 minutes a day. The Framingham study, the most famous of the prospective studies, where in 1984 they began following 5200 people, found if you took one pound off a year for four years–that is, four pounds total–and kept it off, you reduced your risk of hypertension by 25%. My favorite study was done at the Mayo Clinic, where they developed essentially a pedometer that you wore, they called a data-logging underwear. And they looked at people who never set foot in a health club, but who were, in spite of that, either thin or quite heavy. They found from the data-logging underwear that people who are thin simply move more during the day. On an escalator, they walked up instead of just standing there. In their office, they would pace when they were on the phone, and when they went to the Costco lot, they parked 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. So I'll give you some more of these studies if you want, but again, in our 70-millimeter Dolby super-sized extreme makeover culture, it's just hard to believe these small steps can have such profound influence on the body.
Mark Graban: So before moving on talking about relationships and couples, there's a story in the book where you talk about 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. Can you tell us more, tell the listeners more the details of that great story?
Robert Maurer: 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 high-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. Tuesday, go into the same stairwell, go up one flight, 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 regimen. 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 full-time job, had a mother in a nursing home that she wanted to visit at night. She had two small children. The kind of busy lives that again, many of your listeners have. 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 the 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 Graban: I'm sure listeners are curious. I mean, how do we take these, what we think of probably as workplace improvement ideas of this Kaizen, and apply it to our relationships?
Robert Maurer: The best research we have on marriage is by a gentleman named 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. He can sit you and a fiance down for a 15-minute interview or less, predict the likelihood you'll be happily married four years later versus miserable or divorced, with 93% accuracy.
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 5 to 1 when the relationship wasn't going well, 20 to 1 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 that. 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 of 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, are you home or calling to say you've been delayed? Those small trivial moments accumulated throughout the day were more predictive of success than anything else the couple could do. So it's probably the best example of Kaizen and 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 the day rehearsing. All the arguments they had last night are the ones they anticipate today. We ask them to go through the day thinking one or two positive things about their mate. We have evidence that changes your brain chemistry and it certainly changes how you walk through the door that night.
Mark Graban: 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 or that they hate change. What is it about our brains that impacts the way people react in these settings?
Robert Maurer: The thing that makes the human brain so complicated is that we literally have three separate brains in our heads. The bottom of your head, between the bottom of the head and the neck, is a place called the brain stem. It's the oldest part of the brain in us; 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 the mammalian brain, because we share the brain in general with all mammals, and it's where all the emotions live and the survival mechanism in the brain lives. Then to add to the complexity, we have the cortex, which is wrapped around the midbrain, and where all thinking, reasoning, logic, culture, civilization, all the magnificence of being human occurs there.
Now, in 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 fight or flight response lives. It's basically what we used to call fear, they now call 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 anytime you enter a new situation, fear shows up. And so if somebody says, “Well, 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 a McDonald's, but they've shown you that logo in 15 or 30-second commercials over and over and over again. Ask an hour, watch an hour of Law and Order, 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 anytime we can get people to do something positive for just 15 or 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 Graban: 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?
Robert Maurer: Now, 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, of course, reducing the price of the product, etc. But Kaizen really has two ingredients. It's looking for very, very small incremental steps. But it's also every small step, as Deming talked about, as Toyota talked about, has to be in the service to the customer. That isn't just can we reduce the size of the package without the customer 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 is considered waste that doesn't serve the customer has to leave. So it's that service component that isn't always as emphasized.
The second is a few other points. One is that when you look at the history of innovation, what you find, much at least to our surprise, our research team, is that it was very rare that some big, bold step was responsible for the innovation. Whether you look at the invention 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, have 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 the bigger… 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 that's the case. Often somebody looking at something that at times seems small and trivial turned out to be something large and profound. So the other thing that we 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's 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. And so it's much easier to get people to take on the innovative process of electronic health records and spend the vast fortune that 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 and 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. So we tend to accept big steps, sometimes more than small ones, but often not to our advantage.
Mark Graban: So 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% immediately, are there some small steps that we can try to take to allow people to build new habits and help get closer to or get to that 100% point eventually?
Robert Maurer: Yeah. In fact, there's a couple of wonderful books that look at this whole idea of how to apply small steps in social environments. One's 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 well written, is where they put up signs in the hospital. Either, “Be sure to wash your hands,” or in another part of the hospital they put up a sign, “Please help your patients. Wash your hands before and after.” And the plea to do it for the patients tripled the rate of participation in hand washing. So sometimes those kinds of appeals can be dramatically effective.
Mark Graban: Like you said, that's bringing things back to what the patient needs are, as opposed to, “I'm the boss, I have the… I'm going to make you do it because I said so.” And then people react and involuntarily and say, “Well, who says?” And you know, it's understandable where that sort of resistance comes from in kind of a traditional top-down command and control environment, wouldn't you say?
Robert Maurer: Exactly. All 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 behavior.
Mark Graban: Well, 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 Maurer: It's a real honor. Thank you, Mark.
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