What is healthy tension in decision-making?

Our culture often frames a discussion of tension in the negative. The concept seems to be, if tension exists, something must be out of balance and needs to be fixed. Tension has gotten a bad rap. Could it be we have that concept wrong in our culture and thereby, wrong in healthcare too?

Even cultural thinkers and leaders have dealt with the issue of healthy tension in their writingsGandhi is quoted as: "Honest disagreement is a good sign of progress.” Another leader, Nelson Mandela was cited for stating: “A good leader can engage a debate frankly and thoroughly, knowing that he and the other side must be closer, and thus emerge stronger.” F. Scott Fitzgerald stated: The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time and still retain the ability to function.”

So many times, during my 30-year leadership career, I shared with our leadership teams my belief that: “the right amount of healthy tension is a good thing.” The right amount of healthy tension is often necessary to move ideas and change ahead, especially in large organizations or industries. Imbedded in the concept of healthy tension is the observation that tension is necessary to advance an idea that may have multiple possible routes in achieving change. Again, to be objective, there is also a form of tension that is unhealthy; often it is a disingenuous effort to thwart change. Sometimes this masquerades as healthy tension, yet when offered with ill-intent, it is really an effort to stall, delay or obstruct the needed advancement. It is at the stage of discerning the healthiness of the tension that one can get led astray by the impure motive by someone who is looking to obstruct change.

Turning now to healthcare decision-making, when we look to individuals making health care choices it is often suggested that tension should not exist. Yet, framing individual decisions about health care choices in context of achieving healthy tension, it helps to further highlight the challenges of balancing decision-making between individuals and health systems and its many actors. The continuum found between the individual and health system ends of a decision-making scale should have a degree of healthy tension in order to effectively frame the decisions. That stated, the framing needs to be carried out with a neutral attitude of seeking the ideal outcome for the health condition being considered; importantly, in the unique individual in need of care. The healthy tension should assure that the individual’s values and goals are in healthy tension with the health system’s capabilities, expertise, clinical wisdom and pressures to move ahead quickly. That is the kind of healthy tension that advances an optimum decision for the individual making a health care decision.

Large organizations, health care systems included, dislike tension, or delay in decision-making. They perceive they become less efficient if decisions are delayed or vary from an algorithmic approach to disease or condition-based decisions. Since the corporatization of health care has impacted most health care organizations to focus on efficiency, delay in decisions to allow healthy tension is not valued by most inside the health delivery systems.

Once again, time is a valuable ally for individuals making consequential decisions about their health. The decision-making tension should be healthy even if they are not healthy physically.