Our Healthcare Iceberg Is Melting:

What would John Kotter Do?

"The hardest part of change isn't making the first move—it's sustaining the momentum. In a changing world, you must learn to lead change." — John P. Kotter

Setting the Stage: New Cracks in Our Iceberg

When John Kotter wrote about Emperor Penguins facing an existential crisis as their Antarctic home began to crack beneath them, he created a powerful metaphor that applies perfectly to our healthcare system today. We're standing on increasingly fragile ice.

Like the colony in Kotter's parable, our healthcare system appears solid from a distance. We have world-class medical schools, remarkable technologies, and dedicated professionals working tirelessly. But beneath the surface, troubling fractures are spreading.

The signs are everywhere if we're willing to look. Clinician burnout has reached concerning levels across all specialties. Rural hospitals continue closing at an alarming pace, creating healthcare deserts across America where patients must travel hours for basic care. Administrative costs consume a disproportionate share of healthcare spending compared to other developed nations, while staffing shortages—from nursing to primary care to specialized medicine—stretch remaining personnel thin. And despite leading the world in healthcare spending as a percentage of GDP, American healthcare outcomes lag behind those of many peer nations.

These aren't just abstract concerns—they represent real pain points. In conversations with healthcare leaders, I hear the same concerns expressed in different ways: "We're working harder than ever just to stay afloat." "Our margins keep shrinking while demands increase." "Our people are exhausted." "The complexity is overwhelming."

Like the subtle signs of ice thinning that Fred the penguin noticed in Kotter's fable, these warnings appear in daily operations: increasing staff turnover, declining patient satisfaction, growing backlogs for appointments, and expanding regulatory requirements that seem impossible to fully meet. The ice beneath our feet isn't just cracking—it's melting faster than many realize.

The Seagull Has Landed: AI as the Unexpected Messenger

In Kotter's penguin colony story, change began with Fred, a curious penguin who noticed the problem, and a seagull who offered an outside perspective that initially seemed threatening. Today's healthcare has its Freds: forward-thinking clinicians, administrators, and patients who recognize the system's fragility. But our seagull? Increasingly, it appears to be artificial intelligence.

Like the seagull in Kotter's story, AI comes from a different world. It speaks a language many find strange. It represents the unknown. And it's easy to dismiss as irrelevant to the serious business of healthcare. Yet just as the seagull offered the penguins vital information about new possibilities beyond their melting home, AI presents healthcare with perspectives and capabilities that might help us navigate beyond our current constraints.

Consider how AI is already transforming other industries. In finance, it's revolutionized fraud detection and risk assessment, identifying patterns across vast numbers of transactions. In manufacturing, it's optimizing supply chains and predictive maintenance, reducing downtime by anticipating equipment failures before they occur. In consumer services, it's personalizing experiences at scale, allowing companies to understand individual preferences and adapt offerings accordingly. These aren't just technological changes—they represent fundamental shifts in operating models.

Healthcare's initial AI implementations have been promising but largely incremental: improving scheduling efficiency by predicting no-shows and optimizing provider calendars; helping detect patterns in medical images to flag potential abnormalities for radiologist review; streamlining documentation through voice recognition and automated summarization. While valuable, these applications mostly focus on making existing processes more efficient rather than reimagining care delivery.

The real potential, however, lies not just in making our current iceberg more comfortable, but in helping us envision and build entirely new models of care delivery. AI could enable:

- Truly continuous care monitoring rather than episodic visits

- Predictive interventions before conditions become acute

- Personalized treatment plans that account for genetic, behavioral, and social factors

- Knowledge democratization that empowers patients and extends clinical expertise

- Resource allocation that maximizes impact rather than following historical patterns

The question isn't whether AI will impact healthcare—it's whether we'll recognize and leverage this moment of transformation thoughtfully, or merely react to changes as they happen around us. As Kotter wrote in Leading Change, "Whenever you cannot describe the vision driving a change initiative in five minutes or less and get a reaction that signifies both understanding and interest, you are in for trouble."

The Colony's Reaction: Understanding Resistance to Change

In any major transformation, resistance is natural and often rooted in legitimate concerns. In Kotter's penguin colony, NoNo represented those who resisted change out of fear and attachment to tradition. Today's healthcare has its share of NoNos—but their objections deserve our empathy and understanding.

When speaking with healthcare professionals about AI, I hear remarkably similar concerns across organizations:

"We've seen technologies come and go before. Remember when [insert previous technology] was going to revolutionize everything?" This skepticism often comes from veteran clinicians who have witnessed multiple waves of promised transformation that delivered more disruption than improvement.

"Our patients need human connection, not more technology." This concern emerges from professionals who have already seen screens come between them and their patients, with EHRs creating what some call "desktop medicine" rather than relationship-centered care.

"We barely have time to implement the systems we already have." This practical objection reflects the reality of change fatigue in organizations still struggling to optimize electronic health records or quality reporting systems implemented years ago.

"AI might work elsewhere, but healthcare is different." This perspective comes from those who recognize healthcare's complexity and the stakes involved when algorithms influence care decisions.

"This feels like one more thing being done to us rather than with us." Perhaps the most important objection, this reflects clinicians' experience of having changes imposed without meaningful input or consideration of frontline realities.

These aren't irrational objections. They reflect genuine concerns about preserving what matters most in healthcare: the human connection, clinical judgment, and ethical practice. They also reflect change fatigue in a sector that has experienced waves of disruptive technologies and policies, often implemented without adequate support or clear benefits.

What's more, healthcare professionals have witnessed firsthand how technology can create as many problems as it solves. Electronic health records promised efficiency, but often increased the documentation burden. Patient portals promised better communication, but sometimes generated overwhelming message volumes. Telehealth expanded access but created new challenges in care continuity.

The most powerful resisters aren't those who openly oppose change but those who appear supportive while quietly maintaining the status quo. As Kotter observed through characters like Louis, the head penguin, public support without genuine commitment can be more damaging than outright resistance. In healthcare, this looks like leaders who speak enthusiastically about innovation while failing to allocate real resources or create psychological safety for experimentation.

Building the Guiding Team: Who Needs to Lead Healthcare's Transformation?

In "Our Iceberg Is Melting," the colony's salvation came not through a lone hero but through a diverse team that brought different strengths to the challenge. Alice provided empathy and emotional intelligence, Professor brought analytical rigor, Buddy offered coalition-building skills, and Louis eventually provided formal authority.

Healthcare's AI transformation requires a similarly diverse coalition. We need:

1. Clinical Innovators– The Freds who see both the problems and the potential. These frontline physicians, nurses, and therapists understand patient needs and can identify high-value use cases where AI truly addresses pain points rather than creating new ones.

2. Technical Translators– Modern-day Professors who understand both healthcare operations and AI capabilities. These individuals bridge worlds, translating clinical needs into technical specifications and explaining AI concepts in accessible terms.

3. Change Navigators– The Alices who recognize that transformation is as much about emotions as logic. These leaders excel at addressing fears, building psychological safety, and helping teams navigate the discomfort of learning new approaches.

4. System Thinkers – Healthcare's equivalents of Buddy, who understand how changes in one area impact the broader ecosystem. These leaders consider how AI implementations affect workflows, team dynamics, and patient experiences across care continuums.

5. Authorizing Sponsors – The Louis figures who control resources and formal authority. These executives must not just permit change but actively champion it, removing barriers and creating consequences for maintaining the status quo.

6. Patient Advocates – A voice often missing from Kotter's original story but essential in healthcare transformation. These individuals ensure AI serves patient needs rather than merely organizational efficiency.

The most effective guiding teams I've observed bring together individuals from across organizational boundaries—breaking down silos between IT and clinical departments, between administrators and providers, between startups and established institutions. Like the penguin scout team, they combine curiosity, diverse perspectives, and a shared sense of urgency.

As Kotter reminds us, "Because major change is so difficult to accomplish, a powerful force is required to sustain the process." That force comes from a guiding coalition with the right composition, level of trust, and shared objective.

Communicating the Vision: What Does an AI-Enabled Healthcare System Look Like?

In Kotter's story, the scout team had to help the colony visualize a different way of living before penguins would leave their familiar iceberg. Similarly, healthcare needs a compelling vision of AI-enabled care that inspires action rather than merely building technology.

What might this vision include? I imagine healthcare transformed in several ways:

From reactive to proactive care: AI helps identify patterns in population health data, allowing interventions before conditions become acute. Instead of waiting for the patient with congestive heart failure to arrive in the emergency department, AI-enabled remote monitoring flags concerning trends days earlier, triggering outreach from care coordinators.

From scarcity to abundance in clinical resources: AI augments clinician capabilities, allowing them to practice at the top of their licenses. Nurse practitioners supported by AI diagnostic tools deliver primary care comparable to physicians in routine cases. Specialists use AI to extend their reach across geographic areas, serving more patients without sacrificing quality.

From standardized to personalized approaches: Treatment recommendations incorporate not just clinical guidelines but individual patient characteristics, preferences, and social determinants. Medication dosing, rehabilitation protocols, and educational materials adapt automatically to patient needs.

From isolated to connected care journeys: AI helps coordinate care across settings, predicting needs before transitions and ensuring no patient falls through the cracks. Information flows seamlessly across the ecosystem, with AI helping to translate and prioritize data for each care team member.

From burdensome to invisible technology: Documentation becomes ambient, with AI capturing and summarizing conversations rather than requiring manual entry. Interfaces adapt to user needs rather than forcing humans to adapt to technology.

The most powerful aspect of this vision isn't what AI does, but what it enables humans to do. When clinicians spend less time on administrative tasks, they can devote more attention to complex diagnoses, therapeutic relationships, and patient education. When barriers to access fall, care becomes more equitable. When technology becomes invisible, the human connection returns to the center of healthcare.

Like the scout penguins who saw a new home before others could imagine it, healthcare needs pioneers who can make AI's potential tangible through small but meaningful wins. Each successful implementation builds confidence that larger transformation is possible.

Kotter emphasizes that "Without credible communication, and a lot of it, the hearts and minds of the troops are never captured." In healthcare, this means translating technical capabilities into meaningful improvements in care delivery that resonate emotionally with clinicians and patients alike.

Culture and Courage: Maintaining Momentum Through Uncertainty

"We're constantly at risk of losing our courage," Kotter wrote, describing how easy it is for communities to revert to old patterns even when they know change is necessary. This rings especially true in healthcare, where the stakes are high and the pace of change often feels overwhelming.

Courage in healthcare transformation takes many forms:

- The courage to acknowledge that our current approaches are unsustainable, even when they represent decades of investment and identity.

- The courage to experiment and sometimes fail in a field where perfection is the expected standard.

- The courage to redefine professional roles when AI can perform certain tasks that once required human expertise.

- The courage to invest in future capabilities even while managing present crises.

- The courage to maintain human values of compassion and dignity while leveraging increasingly powerful technology.

What happens if we delay? The consequences extend beyond organizational performance to real human suffering. Without transformation, we face a future where healthcare access becomes increasingly inequitable, clinician burnout accelerates, and innovative talent leaves the field. The iceberg doesn't stop melting because we're uncomfortable moving.

Building a culture that sustains courage requires intentional leadership. It means celebrating early adopters rather than rushing to criticize when initial implementations aren't perfect. It means creating psychological safety where team members can express concerns without being labeled resistant. It means connecting technological change back to healthcare's fundamental mission of healing.

The most successful transformations maintain this dual focus—embracing innovation while honoring tradition; leveraging technology while amplifying humanity; challenging the status quo while respecting legitimate concerns. This balance is what Kotter's penguins achieved as they honored their past while adapting to new realities.

As Kotter reminds us, "Culture is not something you try to change. Attempts to grab it and twist it into a new shape never work because you can't grab it. Culture changes only after you have successfully altered people's actions, after the new behavior produces some group benefit for a period of time, and after people see the connection between the new actions and the performance improvement."

From Survival to Sustainability: Healthcare and Continuous Adaptation

The penguins in Kotter's fable didn't just find a new iceberg—they fundamentally changed how they thought about home. Rather than seeking a permanent replacement, they became a nomadic colony, developing capabilities to identify new homes before old ones became uninhabitable.

Healthcare faces a similar opportunity. Rather than seeking a new static model, we can build systems designed for continuous adaptation. AI offers unique advantages here, creating platforms that learn and evolve rather than remaining fixed.

Imagine healthcare organizations that:

- Continuously analyze patterns in their operational data, identifying inefficiencies and testing improvements without massive reengineering projects.

- Adapt staffing models dynamically based on patient needs rather than rigid schedules and roles.

- Customize care pathways in real-time based on individual patient responses rather than following standardized protocols.

- Evolve payment models based on actual outcomes and value created rather than predefined service categories.

This isn't just about implementing AI tools—it's about building organizations with the capabilities to identify signals of change early (like Fred noticing the initial cracks), rapidly test new approaches (like the penguin scout team), and scale successful innovations (like the colony's eventual migration).

The organizations that thrive won't be those with the most advanced technology today, but those that build the muscle memory for continuous transformation. They'll recognize that in a world of melting icebergs, adaptability itself becomes the sustainable advantage.

As Kotter observed, "The biggest impediment to creating change in a group is individual resistance to giving something up. People are generally OK with adding something to what they do. But real transformation requires taking something away from them, and that's when they resist." In healthcare's AI transformation, we must acknowledge what we're asking people to surrender—certain aspects of autonomy, familiar workflows, perhaps even elements of professional identity—while helping them see what they gain in return.

Call to Action: Finding Your Path Forward

As I conclude this reflection on healthcare's melting iceberg and AI's potential role in transformation, I want to ask you—yes, you specifically to consider:

Where is your healthcare iceberg melting? What cracks are appearing in your organization's foundation that might not be widely acknowledged?

Who are your Freds—the insightful observers noticing problems before others? Are they being heard or dismissed?

What guiding team might you assemble that brings together diverse perspectives—clinical, technical, operational, and patient-centered?

What small, concrete step could you take this week to begin scouting new possibilities?

Perhaps it's launching a discovery initiative to understand where the administrative burden is highest for your clinicians. Maybe it's creating space for front-line staff to share their observations about system challenges. It could be bringing together unusual combinations of team members to imagine care delivery without current constraints.

The journey from a melting iceberg to a sustainable future doesn't begin with grand strategies or perfect technology. It begins, as Kotter showed us, with awareness, urgency, and the courage to look beyond familiar shores.

What will you do today to help your organization take that first step?

As Kotter writes, "People change what they do less because they are given analysis that shifts their thinking than because they are shown a truth that influences their feelings." What truth about healthcare's future will you help others see and feel?

The time for waiting is over. Our healthcare iceberg is melting, and the next move is yours.