I am an optimist, and I think healthcare is getting better all the time and will be much better a decade from now. But after years of intense enthusiasm for one innovation or another (e.g., critical pathways or electronic medical records), I now tell my colleagues not to expect a breakthrough. No major innovation will solve our problems and make everything fine. Instead, what we should expect is door-to-door fighting for the rest of our careers. Every unit of organization in healthcare will need to work constantly against its organizational dysfunction, and try to make its care safer, more efficient and more reliable.

My message is not a pessimistic one. I'm actually saying that the right attitude is what some call the "Toyota culture" – the relentless pursuit of something better than we have now. The journey will never be over. I say that because I don't want to be a fraud and imply that if we just push for the adoption of electronic medical records, our problems will be solved. I don't want to hope no one remembers promises I implied about electronic medical records when I push for widespread use of patient portals, or pay for performance or bundled payments.

We will never be done. We have to settle in for the long haul. I actually feel that there is a nobility to that, just as, for physicians, there is a nobility to going in to work every day and seeing patients whom you can help. And then starting anew the next day. I am beginning to look at the work of improvement as a manager in just the same way.

I have been acquiring insights (e.g., how to use incentives) and skills (e.g., negotiation) along the way without any structured plan – often on a "just-in-time" basis when the skills were needed. I have watched my colleagues struggle with the same challenges that confront me, and tried to learn what makes some so effective, and others less so. I have learned a lot from managers and leaders in non-healthcare fields and from writings in other disciplines. My fond hope is that, for the next generation of physician leaders, the essays in this book will make that learning process faster and smoother.

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