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TLDR Book Review: Switch – How to Change Things When Change is Hard


Chip and Dan Heath’s book, Switch, explains why change is so difficult and what we can do to make it easier. This little book is a must-read if you’ve ever met inexplicable resistance addressing issues as trivial as buying a new brand of coffee for the break room or as significant as enforcing the mandatory use of hand sanitizer. Is anyone actually in favor of spreading communicable diseases? Do the absence of San Francisco Hazelnut Morning Blend really warrant a call to the department chair? Why would people be so opposed to undeniably positive changes? The answer lies in understanding Riders, Elephants, and Paths. And here’s a spoiler alert: you’ll need a lot of mango.

Why Change (and Rallying Elephants) is Hard

At its core, change is about influencing people’s ideas or thoughts. Plato likened humans to a charioteer trying to wrangle and control an unruly horse. The charioteer represents our reason while the horse represents our emotions. In this book the authors borrow a different metaphor. Instead of a capable soldier at the helm of a chariot, humans are more like a Rider on the back of a powerful and stubborn Elephant. The planning, analytical, rational part of us is the Rider. S/he holds the reins, and directs the Elephant… in principle. The Elephant represents our emotional, intuitive side who is under the control of the Rider… in principle. But as the metaphor suggests, it is the Elephant, not the Rider, who is stronger. At the end of the day, if the Elephant is not motivated and kept in check, then when the Elephant and Rider disagree, the Elephant will always win.

This metaphor helps explain why change is difficult. Too often, we’re shouting advice to the Rider, while ignoring the Elephant rampaging through the break room in search of the last French Vanilla K-Cup. We shouldn’t ignore reason entirely, but it can’t be the end of story.

1. Direct the Rider

Let’s begin with the part of change that we’re most familiar with as doctors and scientists: evidence. The authors agree that we are right to offer data and arguments to convince people rationally that a problem exists and that our solution is worth pursuing. However, 2 guidelines can improve the efficacy of our advice.

First, we need to offer specific, measurable goals. The authors use dieting as an example. We can present hundreds of pages of data showing the dangers of obesity, but if our concluding admonition is “Eat Healthy,” our audience will be left feeling less guidance than before. Is a low-carb diet healthy this year? What about fiber? Is that still a thing? What about red wine? Smoothies? Kale? Kombucha? The Elephant may be motivated to improve its health, but the Rider needs to know what exactly s/he should do or s/he’ll just give up and eat another 3 packages of Cheetos for dinner. Instead, the recommendation should be something specific like “switch from whole milk to skim milk to reduce your saturated fat intake.” Having a clear goal is something the Rider can work with.

Application in Medicine
The medical analogy would be a laudable goal like “improving safety.” Most likely, everyone in your department shares this goal, but it’s too non-specific. Instead, give them concrete actions to take, whether that means showing them screenshots of what this means for their workflow, or giving them a simple 3-step plan for moving forward. The bigger the change, the more important it is to “script the critical moves.”

Change can also be facilitated by “finding bright spots.” Instead of focusing on failures, find examples of success that can be replicated. Find out the underlying cause and disseminate it more broadly. The authors give a great example of researchers who were interested in improving growth and health of children in an impoverished area. Rather than coming in and imposing their ideas and their evidence for the importance of a balanced diet, many of which would probably not have worked, they looked for “bright spots.” They looked for children who, despite the poverty and circumstances, had higher than expected weights. What they found were simple solutions such as feeding the child 3 smaller meals a day instead of 2 larger meals, or incorporating small bits of meat and vegetable into the child’s starchy food, which was not considered a normal child’s diet. These were changes that other families could make within their contexts and budgets.  

2. Motivate the Elephant

Next, you have to motivate the Elephant. This means you need to show people why you are trying to create a change. Tell a story that illustrates the downsides of the current policy. Give concrete examples of how the change has produced benefits.

Application in Medicine
In medicine the focus is typically on patient care, safety, or efficiency. However, the motivation could be based on improved physician or staff well-being as well.

“An unmotivated Elephant can doom a change effort,” the authors write. So keep those Elephants motivated.

Elephants also need hope because “hope is Elephant food.” Elephants need to know that change is possible or they’ll give up. Celebrate small successes, even if they’re largely symbolic. Trainers apply the same technique to animals. If you’re training a monkey to ride a skateboard, you don’t wait until he can perfectly execute a flip on the half-pike before you give him a treat (in this case a piece of mango). Instead, you give him a piece of mango just for touching the skateboard. Then when he tries sitting on it you give him more mango. When he tries standing up on the board, he gets more mango. You incrementally and frequently reward him for each step he takes towards your desired behavior.

Did your spouse go to the gym for the first time? Give them positive feedback immediately. Did they put one pair of dirty socks into the hamper? More positive feedback. Did they only eat half a bag of Cheetos instead of tearing through all two-dozen “Mom’s Pack” snack bags and washing it down with Mountain Dew? You’ve got to start somewhere. And for any major change, you’ll need a lot of mango.

Identity is another way to motivate the Elephant. Changes are much more likely to take root if people perceive them as outworkings of their deepest goals and values.

Application in Medicine
Ask questions like: What kind of department do we want to work in? What type of faculty are we? What kind of doctor am I?

If you can tap into their identity as “We are the kinds of people who embrace change, who adapt and evolve.” Or “We are a group of people who want to create a culture of patient safety and transparency.” Or “We are the types of people who show up for each other.”

Find an aspect of their identity that resonates with your mission, and leverage it. For example, in motivating a change from plastic-containing K-cups to mostly recyclable materials, you could argue that, yes the flavor options are not as extensive, but we are the type of people who care about the environment and want to minimize our carbon footprint.

3. Shape the Path

You need to shape the Elephant’s environment. Most people will follow the path of least resistance. The Elephant is going to follow a well-worn trail, even if it leads off a cliff. Instead of dangling a peanut under its nose or whacking it with a pith helmet, you need to rope off the old path and pave a new one. If you make your preferred outcome the easier option, then more people will opt for it.

Application in Medicine
If you’re trying to make sure clinicians document part of the sepsis exam, try to build it into the EMR. They are more likely to do it if it is part of their workflow. Then once they build habits, it will start to happen naturally.

You can also alter the Elephant’s environment by “rallying the herd.” The Elephant will look for social cues to decide what to do.

Application in Medicine
If you are trying to encourage attendance at M&M meetings, the Elephants will look around and see that no one else goes, and conclude that it’s not really expected, or not really important. Rallying the herd can be done by creating smaller groups who are open to change and letting them lead, so that they are not unduly influenced by the rest of the naysaying herd. For example, you could start working individually with group members to try to build up a core of attendees. Then when a new elephant comes to try it out they will see that part of the herd is already there.

Rallying the herd could also mean publicly praising individuals who have made the change you are seeking, or providing feedback to the group on how well they are doing.  


Change is hard. Whatever change you may be trying to implement will likely be met with a combination of resistance, complacency, apathy, and statements about how it-all-sounds-very-wonderful-I-just-don’t-have-the-bandwidth-right-now. Not only is change hard, being the agent of change is hard. After reading the book, we were struck by how much easier it is for leaders to either maintain the status quo or adopt a simplistic carrot-and-stick approach to change. Figuring out how to direct the Rider, motivate the Elephant, and shape the Path takes time, creativity, and energy.

But you can do it! Start by buying this book [Amazon] and reading it one page at a time. Throw yourself a party when you finish each chapter. And join the thousands of others who have become agents of positive change in their organizations. Finally, be patient and plan ahead: you’ll need a lot of mango.

Christina Shenvi, MD PhD
ALiEM Associate Editor
Assistant Professor
Assistant Residency Director
University of North Carolina
Neil Shenvi, PhD

Neil Shenvi, PhD

South Durham School of Science and Math
(The Shenvi Homeschool)