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For nearly 18 years of our marriage, my wife and I had a game. I would say “I love you” on the phone to her, especially when I knew she would be among a group of her
coworkers.

She would reply giggling, as if I were tickling her, “Me too,” too embarrassed to return the reply in public.
“Me too what?” I would prod her.
“You know . . . .”
“I am not getting off the phone until you say it,” I would insist.

Sometimes I would win the battle, and she would whisper “I love you.” At other times, I would have to settle for “Me too.” Either way, the encounter always added that special charm to our relationship.

But somewhere along the way, things had changed.

My “I love you” would be greeted with an indifferent “Yaa . . . yaa,” a sign of the low point that our relationship had begun to touch.

Recently, after months of getting the cold shoulder, I ventured to ask her, “So, what did I do wrong?”

“You know exactly what you did,” she replied dismissively. Was it that I took a 2-day break in the middle of our 2-week vacation to deliver a lecture to senior executives? Or that I did not help the kids with their homework during exam week? Or that I was 3 days late in picking up her prescription medications?

I feared opening Pandora’s box, but my wife did not. After our 3 children were asleep, lists of reasons poured forth.

“Where should I start?” After some 15 minutes, her bottom-line was, “Your priorities are screwed up—your kids and your wife are simply not in the top 3 on your to-do list anymore.”

I reassured her that on my to-do list, I had “home,” under which I listed “pay bills, call the accountant, basketball practice pick-up . . . ” She watched me coolly. I realized that I had, at best, invested in minor logistics for the family and not in the more nuanced quality time and ownership that all relationships thrive on.

Then I asked my wife if she could think of anything positive I had done in the past 18 years.

“Not right now—I’m not in that state of mind,” she said, unrelenting.

That was exactly my point. I tried to convince her that my failings were her perceptions, her state of mind, and not reality. I retreated for another 15 minutes of hard listening. Finally, when my turn came, I stuck to one issue.

“The family is my priority.”

“Lip service,” she replied bluntly.

Perceptions are hard to change with words alone. Action was required. As a medical director for quality improvement, I had delivered scores of lectures on improving care and taking corrective action. Now it was my turn to improve the quality of care I was providing to my family. What better way than to go into a quality improvement

cycle using the Plan-Do-Study-Act (PDSA) cycle?

This meant that I would take small steps of change, while using performance indicators and data feedback for myself along this new path.

Early the next morning, I developed a computer spreadsheet and titled it “Family First,” avoiding negative titles, such as “Changing Her Perspective.”

The Plan of the PDSA cycle has 3 steps. First, I asked myself, what am I trying to accomplish? My aim was to demonstrate to my wife that I cared about her and the kids: a change in perspective (because the reality, according to me, was that I did care, but somehow that was not being conveyed).

Second, I asked, how will I know that a change is an improvement? I needed to measure my improvement. I thought back to the early years of our marriage, and our teasing phone conversations came to mind. A simple test could be to float the words “I love you” and see if she would reciprocate with that precious “I love you, too,” that

I had not heard in awhile.

Third, I asked, what changes could I put in place that would result in improvement? I listed 10 concrete changes that would reassure my wife that our family is a priority for me. Each day I would do as many of these activities as possible: get home early, drop off or pick up the kids from school or sports practice, help with dishes and home clean-up each evening, spend more quality time with kids, and get feedback from my wife.

The Plan had been laid out in the first 3 steps, and now I had to Do. The PDSA cycle was in full gear. I took a deep breath and started that morning.

I made sure to Study what I was doing. Each change measure had a case definition. For example, coming home early meant arriving at home before 5 p.m. Each day, I would track myself on the spreadsheet, crediting myself with 1 point for each activity.

A measurement tool was critical to my change process. It provided quantitative data, not opinions, such as, “I said, you said.” When you turn subjective opinions into facts, you can measure them, and subsequently you can improve them.

Although I had not measured my baseline, I estimated that I was scoring a 4 out of the potential score of 10. The first week of my intervention, I averaged a 7. I decided not to discuss my intervention with my wife and let my actions speak.

One evening, as I rose from the dinner table so that I could start on the dishes, my wife encouraged me to stay seated with the family. I continued toward the sink. “Is this your attempt to redeem yourself?” she joked. “How long will it last—a week or two?” I resisted a rebuttal in my defense. I could see that I was faltering in my performance:

I could not reach above a 7 on most days. The second week’s average was 7.7, only slightly better.

I persisted. But my wife had not flinched from her perception. I avoided detailed conversations. I achieved an impressive 8.8. At this stage, I had mastered the art of washing dishes. I had the kids hanging up their jackets and putting their shoes in the closet.

“What’s up with Dad?” the teenager asked, eyes rolling in defiance.

“Just do it,” I replied.

My policy was clear. No dish left behind. No paper unturned. The buck stopped here (all dishes, newspapers, and clutter must be put away). Taking full responsibility made me proud to see a clean living area and kitchen. I did not want praise—just a change in perception and perspective from my wife. But I was still far from it.

My action plan had brought one more quality benefit. I was now fully engaged with the details of my kids’ lives.

Car conversations revealed my teenager’s soap opera life in school. “Beth-Ann did not invite Kyle to her party. . . . Margaret is dating Josh.” I learned about tween fads from my 11-year-old, along with the lyrics of “High School Musical.”

And finally, I commiserated with the fears of my second grader: “Can the police really put you in jail for not washing your hands?”

I was uncertain whether my work suffered. Clearly, I had to gear down my load, set a lower bar, and make fewer commitments. I was not shy to talk about my new priorities. I told my colleagues of my noble New Year’s resolution of spending more time with my family. I did not mention that I was using the PDSA cycle.

The critical aspect of my 10-point change plan was getting feedback from my wife by asking her, “Have I been deficient?”

After 3 weeks, she became annoyed by the question. “Can you stop asking me that meaningless question?”

While I believed I was being genuine, she felt I was being condescending.

I took a more subtle approach: “Anything else you need help with?” Now the answer was a more pleasant

“No.” In the course of change, it is important to get feedback and quickly readjust. It is not necessary to get all of the components right at the first shot.

I pressed on with my spreadsheet chart. My wife now seemed impressed with my persistence in being engaged with the family. I enjoyed my new priority. The PDSA cycle had helped me make focused, appropriate improvements, rather than random stabs at change.

Two months later, I offered “I love you” while on the cell phone.

“Me too,” she said. It hadn’t come automatically. She was signaling that something had changed for the better.

“Me too, what?” I coaxed.

With a giggle she replied, “I love you, too.”

I’d made it.

Manoj Jain, MD, MPH

QSource, Tennessee’s Quality Improvement Organization

Memphis, TN 38115

Requests for Single Reprints: Manoj Jain, MD, MPH, QSource, Tennessee’s

Quality Improvement Organization, 3175 Lenox Park Boulevard, Suite 309

Memphis, TN, 38115;

e-mail, mkjain@aol.com.

Ann Intern Med. 2008;149:209-210.