Understanding Problems

Ever feel like your problems are so big that you can’t even understand them, much less deal with them? Ever feel impotent to grasp others’ problems, much less help them with them? Approaching the topic first from a medical and then from a larger perspective, the attached article may provide some insight.

A fellow student from the public health program at Johns Hopkins came to me with a research idea many years ago. Performing publishable research is a requirement of the program, and we were struggling with the most fundamental issue; thoroughly understanding the problem that you wish to address. Our team wrestled with the possibilities, explored lots of dead ends, and sought guidance from more experienced researchers. Eventually a reasonable, although not groundbreaking, plan took shape.

Defining the problem can be hard in clinical medicine. For example, suppose a 45-year-old plumber presents to a physician for low back pain which began after lifting a heavy pipe three days before. The subjective severity was 6/10. He has had intermittent back pain for several years and sometimes has lancinating pain down the back of his left leg to his calf. He is overweight, does not exercise outside of work, suffers from depression, and has poor core strength and lower extremity flexibility. The patient is able to work but only with difficulty. The doctor in this case could define the problem as acute low back pain, prescribing pain medications and relative rest. He could define it as an acute exacerbation of chronic low back pain with intermittent sciatica, doing the above, and giving him medications for the nerve pain. The doctor could define the problem but add that it is complicated by biomechanical issues (overweight, weak core musculature, tight hamstrings) and psychosocial problems (depression). In that case he could add physical therapy, a weight loss program, an exercise program, and an antidepressant to the plan. Lastly the doctor could do some combination of the above or send him to a subspecialist to figure it out.

Let us consider variations on this clinical vignette to learn how to define a problem. Problems have several characteristics, among which are size, shape, complexity and color. The size of a problem is how big it seems to those affected by it. Patients do not often assign a size to their problem except for small, medium or large. It is usually up to the clinician to ask the patient to assign a specific value to it. Also, the size of a clinical problem includes how the problem impacts function. The plumber in this case may be unable to work or even sleep with this level of pain, or he may have few limitations.

The shape of a problem refers to how the problem will change over time. Some problems will resolve on their own and so their shape may be visualized as an inverted pyramid. If this patient was 25, fit, flexible, trim, and without mental health concerns, this problem would probably resolve itself over a few days, and the physician would need to do little. In this patient’s current situation, the acute problem should get a little better, but the overall issue may be steady over time, at least for a while. If this patient were unable to function, the problem would worsen. His lack of activity would weaken him further, adding to his weight and poor flexibility. His inability to work would introduce money problems and probably add to his depression.

Problems can be complex or simple. A diaper rash in a healthy infant is usually simple, while metastatic cancer in an elder is usually complex. Problems can be deceiving. The plumber in this clinical vignette seems at first glance to have a simple problem; back pain when he lifted a heavy pipe. As noted above, however, with further digging the doctor realized that this patient had an underlying problem of significant complexity. Also, the complexity of a problem is usually related to size, but not always. An otherwise healthy family whose house was just hit by a tree has a big problem, but not necessarily a complex one.

The color of a problem refers to how those people involved see it. Our patient above may see his problem as a temporary setback, an aberration in his overall good health. If we use the colors of a stoplight as our paradigm, where green is “good” and red is “bad”, the resilient plumber may see his current medical state as light yellow. Conversely, he may perceive this problem as deep, lasting, and unremitting. In that case the color might be dark red. Others can influence how the stakeholders of a problem see its color, but ultimately each person decides for himself what color, and how light or dark, a situation is. Sometimes a “green” problem, such as a financial windfall, can turn red, as many lottery winners have discovered. Sometimes a “red” problem, such as a cancer diagnosis, can turn green, with the cancer cured and the family closer together as a result. Sometimes good circumstances turn out to be very bad, as on 6 August 1945 when Hiroshima boasted beautiful sunny skies while Kokura, Nagata and Nagasaki faced clouds.

Other Examples

Problems in other areas also have a size, shape, complexity and color. A man whose car has a flat tire generally faces a small and simple but steady problem (since the flat tire will not fix itself). Depending upon the man, he may color it as “no big deal”, perhaps light yellow, or a great tragedy, dark red, because he fears that it will make him late to work again and he will lose his job.

In the late 1990s Microsoft was probably the dominant computer company in the world, but it was in danger. The Internet was expanding, and more and more work was done in interconnected environments rather than on individual computers. Mobile computing was growing as well. The company’s problems probably looked small and self-limited, albeit complex. Many in the business may have ignored the warning signals altogether. How could they have known that Apple, a company that they thought they had beaten in the late 1980s, would come back? Today the market capitalization of mighty Microsoft is $327B, and that of little Apple is $467B.

The Ottoman invasions into southeastern Europe were a huge and worsening problem to the eastern Europeans. After the Battle of Nicopolis (1396) and the fall of Constantinople (1453), the Turks controlled the Balkans. After the Battle of Mohacs (1526) they controlled Hungary and they were even able to besiege Vienna (1529, 1683). However, because of their slow movement, rough terrain, poor roads, weak logistics base and limited annual campaign seasons, they never had the power to move further into Europe. Contemporary Western European chronicles spoke of the Turks occupying Germany or marching through Paris, but this was not a realistic possibility at the time.

Application

Why is it important to thoroughly understand each problem that we face? Because mankind is notorious for judging problems wrongly. Either we catastrophize, fearing and even expecting the worst possible outcome, however unlikely it may be, or we minimize, underestimating things that can cause real and lasting harm. People tend to overestimate the likelihood and severity of the unknown, as when a woman with mild fatigue and nonspecific pain for a week assumes she has cancer, and to underestimate the likelihood and severity of the familiar, as when a man with a beach house in South Carolina doesn’t board up his windows in the face of an approaching level 4 hurricane.

Late in life, Mark Twain wrote “I am an old man and have known a great many troubles, but most of them never happened.” Thomas Jefferson voiced a similar sentiment when he wrote “How much pain have cost us the evils which never happened.” These poignantly speak to man’s tendency to misunderstand the size and shape of problems, to color them darker than they actually are, and to imagine some when they don’t even exist.

By carefully and objectively evaluating problems and understanding them better, we are more likely to deal with them rationally and effectively. The woman with mild fatigue and nonspecific pain might wait another week to see if her symptoms resolve, which they probably will. The man facing a natural disaster might board up his windows and even evacuate his family.

Conclusion

We have seen that all problems have size, shape, complexity and color. Each characteristic is related to the others, and the skilled problem solver will address all of them. The skilled doctor, pastor, counselor, or leader will keep their problems in perspective, noting their real characteristics, not exaggerating or minimizing them, and deal with these problems appropriately. Such people will help other people, and their whole organizations, to do the same.

For further discussion on how to understand problems in health care, please read Discovery and Innovation in the Business of Health Care at http://mdharrismd.com/2014/01/20/discovery-and-innovation-in-the-business-of-health-care/. For further discussion on what to do about them, please read Getting Things Done in Military Medicine at http://mdharrismd.com/2013/03/31/getting-things-done-in-military-medicine/.

Author: MD Harris Family Institute

MD, MPH, MBA, MDiv Colonel, US Army (ret)

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