The Jigsaw Puzzle in the Lunchroom
Almost a year ago, IHR staff members began to bring jigsaw puzzles into the office. Someone would select a puzzle and spread the pieces on a table in our lunchroom. I watched with interest as the puzzle began to organize. Border pieces were sorted, then assembled. Shapes and colors were aggregated. Some days, nothing changed. Some days, whole images emerged. There was occasionally progress between Friday night and Monday morning. Each puzzle seemed like a multi-authored scientific paper, but with no first author, no senior author, and unknown contributors.
As the IHR director, I feel an obligation to lead by example. When I am stuck on a research problem or need a break from meetings, I’ll fit in a few pieces. To my surprise, I found that I like assembling boundaries, borders, and big splotches of color. Some of my colleagues start with borders as I do, creating form but delaying realization. Others start with a striking feature – a mountain, a boat, or a face. Some of us cluster similar pieces even if we don’t connect them, while others fit a random piece while passing by.
Most of us in the IHR are introverts. We sit in cubicles or in offices with closed doors. A good day is one with plenty of uninterrupted time to think, write, or analyze data. We emerge for nutrients, caffeine, hydration, and (reluctantly) for meetings. While we’re not averse to working on puzzles with others, we’re also content to work alone.
I particularly enjoy the times when I’m peering at a puzzle, and someone walks in and begins a conversation. We may talk about research projects, but we also talk about family, home repairs, current events or movies. Great ideas have emerged from such conversations.
A puzzle can be a mirror. When all the pieces resemble each other, I’ve learned that I get stubborn. I’ll stop by for a few minutes after work to fit more pieces before I leave. On the way home, I reflect that this stubbornness is a legacy of my clinical training. When patient after patient was admitted to my service with no end in sight, I would examine each person and their clinical puzzle. If I couldn’t solve it in the middle of the night, at least I could group the pieces, and wait for daylight and other eyes.
Sometimes a puzzle bogs down. Day after day, no progress. Some reasons are predictable: grant deadlines, holidays, Wednesdays when most people work from home. But the diagnostician in me begins to wonder: Are there too many pieces? Do the pieces look too much alike? Are the cut shapes too uniform? And the leader in me begins to wonder: what, if anything, should I do to help? I have also learned to recognize when puzzle-building is going well. The jumble of pieces diminishes rapidly. Someone is always hovering over the puzzle. People talk about emerging patterns, and are pleased that the product is so much more vivid than its components.
One puzzle in the lunchroom is stored in a plastic bag because the box with the picture was lost. I’m curious to see if we’ll ever unpack it. In bleak moments, I worry that this puzzle is a metaphor for the health care system - a jumble of pieces with no image for us to refer to. I worry that all of us inside that system – clinicians, staff, administrators, researchers and policy makers – are working on small, disconnected problems. I worry that we continually mistake our part for the whole.
Thinking about the jigsaw puzzles in our lunchroom restores my optimism. In the IHR, we work on hard problems. We try to understand how people deliver health care and how they use that care. We try to identify ways to help systems serve their members and patients, improve quality, and contain costs. We have learned that to do our job, even we introverts must band together – clinicians, economists, epidemiologists, social scientists, programmers, project managers, statisticians, and administrative staff. When we agree on an underlying question and on a strategy for addressing it, answers emerge like the image on a jigsaw puzzle: gradually, anonymously, without claims of ownership and with shared satisfaction in the final product.
There are plenty of good, hard puzzles in health care, even if we can’t see the picture on the box. We don’t lack for problems, but we may not have enough lunchrooms. If we can build learning communities where people with disparate perspectives can bring their puzzles, who knows what new methods we may develop and what new images we may discover? It may not matter which puzzles we start with as long as we learn how to convene.
Watching the IHR solve jigsaw puzzles increases my confidence that there is a big picture, and that all the pieces fit. If we create the right work space, we will gravitate to shared puzzles. If our instincts are sharp, we will choose the most promising puzzles to solve. If we are patient and persistent, we will solve them.
To finding that next piece,
John F. Steiner, MD, MPH