Tossing and turning, tossing and turning
Dr Jeff Brown, National President - article in the Specialist, Issue 89, December 2011
[Below is Dr Jeff Brown’s Presidential Address to the 23rd ASMS Annual Conference delivered on 17 November]
Over the last 12 months and over the last few days and nights, tossing and turning has been my life, and I’m going to lead you, not on a ramble but maybe an amble, through three stories. Stories of heroism, stories of endeavour and earnest hope, and a story that tries to explore why things unravelled, how we might grasp on to the tail of what has unravelled a little more than we had hoped, and build a future out of it.
Over the course of the next couple of days we’re going to spend time here in workshops trying to work out a direction forward for the thousands of senior medical and dental officers that help run this marvellous health system of ours. We have, as you know, the lowest number of specialists per head of population of any OECD country and yet we have one of the best health systems. That means you, and your colleagues that have let you come here, are working bloody hard and working very well. We may lose sight of that because botches and dramas make the front pages. The other thing that makes the front pages is disaster, and we’ve had a few, haven’t we?
My first story: of other heroes
My first story of tossing and turning is a personal story but a story of other heroes.
On 22 February this year 182 people lost their lives in Christchurch. Many more were injured, some very seriously. Thousands have had their lives disrupted and will never be the same again. I had the dubious privilege of being on the 14th floor of the Grand Chancellor when it happened. I and those around me were incredibly lucky to get out without serious injury. I have subsequently seen some of the footage of where we were, it made me cry, and realise how lucky we were and how unlucky other people were.
However, over the next 20 hours I was privileged to work with and observe some amazing human beings in an absolutely unplanned reaction to a disaster. Now, if you look into the literature and read about crowds, or if you hear commentary about crowd behaviour, you get quotes like this: “crowds obliterate reason, sentience and accountability”, “a crowd reduces its myriad individuals to a single dysfunctional persona”, “crowds are stupider than the averaging of component minds”.
But delve a bit deeper, as John Drury from Sussex University has done, searching for the evidence behind those sorts of statements, and you find they are not substantiated. Disasters in soccer crowds and people getting crushed are actually more about physics than morality. Non-linear dynamics means that if you have a little push somewhere, it’s like you’re encountering a sudden stop on the M6. Not due to an accident, it’s just a crowding. You get people pushing up against others. And when you are against a door or a balustrade you might get crushed. It isn’t a crowd going wild, it is merely physics.
What we know is that people in crowds and in disasters can do things that they normally would not do. Maybe what is happening is they’re finding neglected parts of their personality. They are performing heroic acts for strangers. What I saw, and was fortunate enough to take part in, was human beings doing acts of heroism for other human beings that they had no knowledge of beforehand. They risked their own lives for others. You may say they were stupid doing so. But that was crowd behaviour that showed what we as humans can do for each other. Not just what we can do, but what we will do. I was extremely privileged to be part of that.
This story has more specific implications. I was with a bunch of medics, mainly doctors and some nurses and an ambulance officer. What I saw were amazing skills but, more importantly, amazing behaviour. The behaviour I saw and was privileged to be part of was behaviour which you do not learn by being a productive unit in a hospital, by producing more widgets, by increasing your elective surgery or churning out more patients or reducing your average length of stay.
The skills I saw were teamwork skills, were human factor skills, were skills of leadership, were skills of ability to toss your ego out and get on and do what you could do as part of teams that formed and re-formed as the situation needed. These skills have been learned and honed, away from what some of our leaders would say is the core business of your job. These are skills that were learned on things like the Advanced Paediatric Life Support course that we were on. Three days away from the hospital, three days away from the patient, three days in a 2 to 1 student to teacher ratio environment. Honing the behaviour and skills that we then saw in action in Latimer Square.
These are the “extras” that we as ASMS have argued for in varying MECA negotiations. Presidents well before me have argued for time away from patients to learn the things like leadership, like team work, like human factors that are essential to cope with the unknown in front of you. We saw in Latimer Square, and in the rest of Christchurch, people putting those skills, attitudes, behaviours into practice in the most extreme circumstances. You also know that in our everyday SMO lives we are constantly challenged to use those things that we learn, not just by sitting down with a patient or cutting into them or prescribing for them. To use those very important things learned in non-contact time your union has fought for you to have. These came to the fore. That’s one of my stories of tossing and turning.
A second story: the MECA journey
Another story of tossing and turning is our MECA journey.
I want to wind you back a little bit to 2008. Time for Quality with the then Minister of Health, David Cunliffe, shaking hands on behalf of ASMS and the DHBs, endorsing a partnership between managers and SMOs. One step on a journey.
Then 2009, In Good Hands. The new Minister of Health, Tony Ryall, wanting to encourage clinical leadership. Having spent months exploring the health system around the country he realised that he needed clinicians to take more charge. However, he wanted something concrete, in five weeks, over Christmas. Leading a small expert group I submit we delivered a document which is still Government policy, which is still extant, In Good Hands. Clinical leadership from bedside to boardroom. Distributive clinical leadership. We’ll have some presentations tomorrow about success stories of distributive clinical leadership.
2010, another year. The Business Case. I am obviously presuming that all of you have read this several times and tuck it under your pillows at night to make you feel better about the world. This business case which was developed in a new way with some honest individuals from DHBs and honest individuals from ASMS who believed in what they were doing. A business case that agreed some targets and agreed a level of investment which would be necessary. A level of investment equivalent to building a new hospital. But a level of investment that would be necessary to produce the medical workforce of specialists who could then implement changes that were necessary within our health system, to bring us up from the bottom of the table of specialists per population.
This is a process that was entered into in good faith and continued over many months. One year ago standing here I could tell you we had a business case which we had to be slightly secretive about because of certain sensitivities. It has since been broadcast and generated a degree of DHB antagonism. However, we made a further effort this year to try and stay in the same room with DHBs and develop a Joint Quality and Patient Safety Improvement Plan - the implementation document. A worthy document, a blueprint, not just lots of nice words. This plan has three interconnected components - quality and safety, clinical leadership and a stable SMO workforce. The point about this plan, which I emphasise has been developed in agreement between DHBs and ASMS, is that all these three things are interconnected - you cannot get one of them without the other two.
Quality and safety improvement - you all know about that. Reducing variance where you can, improving outcomes for patients and freeing up resources. Economists and accountants, including the Ministerial Review Group, state that approximately $800 million per annum is spent on error, and of that maybe $590 million per annum is avoidable error. And about 80% of that occurs in hospitals. That’s a lot of money spent on fixing up error. So just by entering the health system, and especially a hospital, you have money spent on you to fix things that go wrong. If a proportion of that $590 million could be saved, it could be spent elsewhere. There is possibly more money to be reinvested from these savings than in the next great cancer drug or next great surgical technique. It’s a challenge for all of us.
The challenge is to unlock that money. To find it and prevent it being wasted, we need clinical leadership and we need a stable SMO workforce. We need clinicians stepping forward and particularly SMOs stepping forward. We need time freed up for that leadership. We need SMOs being upfront and central in setting quality and safety agendas, not being dragged reluctantly into a room to be token champion of the next best thing. And to do that we need a stable and sustainable workforce. We cannot do it languishing at the bottom of the OECD table. We cannot do it by not having enough of you. We need an investment and we need a significant investment so that the people who want to be specialists want to be specialists in New Zealand and don’t disappear over the ditch. And if they do disappear for some extra training, they will want to come back
So what your negotiating team and your Executive have tried to do over the last 18 months is find a way of making it more attractive for the young specialists-to-be to come here. And argued that we need to keep the older specialists whose families have grown up and are at a place in their life where they can travel the world and work where they want, to encourage them to want to stay here. Whether we have succeeded or not is yours to call over the next two days. I challenge you to help us.
Tossing and turning. I’ve lost sleep over unravelling. We had an agreement with DHBs about an investment. What has happened over the last few days, weeks and perhaps months for that agreement to unravel?
Last Story: something forensic
My last story to share with you is trying to do some forensic - not psychiatry - but forensic economics and try and look at behaviour and why perhaps we are where we are now and what our challenges are over the next couple of days.
One thing we started off with almost two years ago was blue sky thinking. We tried to start with a fresh approach, we tried to sit round and agree on things rather than being adversarial. When you think about blue sky thinking it sounds great, as if everything’s an option.
But blue sky thinking itself does not really encourage limitless imagination. It rather embeds in its own metaphor our absolute inability to think outside our own perceptual and conceptual limitations. We as humans perceive the sky as blue only because of our peculiar physiology and the arrangement of our senses. We think we are doing blue sky thinking but we are constrained by who and what we are. We can’t help but do it our way. Perhaps your negotiating team and the DHB representatives were constrained by the very people we are and the way we think.
Chicken sexers, plane spotters and being risk averse
I read a paper recently about chicken sexers and plane spotters. Chicken sexers from Japan and plane spotters from England. Trying to explain perceived wisdom, that mysterious and ineffable expertise that some people just have. It’s very difficult to sex chickens, I understand, when they’re little, and decide whether they’re males that should be tossed out or females that are going to produce eggs.
Experts in Japan in the 1930s could tell very quickly, by looking for a particular part of their rear end, whether it’s male or female. The problem is, they couldn’t say why they knew and they found it very difficult to train someone else. You can send them to a skills lab, you can send them to a simulation suite, you can send them to a course on chicken sexing - they don’t know how to sex chickens. The only way to learn is by apprenticeship, by actually having the master there and the pupil or apprentice saying “male” and being told “no, female” and over a period of time learn that mysterious and ineffable expertise. A lot of what we learn in medicine is more like chicken sexing than a skills lab.
It was the same with plane spotters in England in the Second World War. There are certain people who have a personality that enabled them, before the days of sophisticated radar, to pick an enemy plane from a friendly plane as it flew over. But they couldn’t explain why and when you tried to train the next plane spotters, because obviously you wanted more of them, it became very difficult. It took months and months of apprenticeship with a master. Does that sound a lot like medicine?
However, and here’s the danger, we believe as SMOs, as specialists, as wise old, or not so old, heads, that we just get it right. That our instincts are right. Some of our own have shown, however, that that’s not quite so. Atul Gawande has written about the dangers of doctors who place too much faith in their intuition. The Checklist Manifesto argues that just because you’re a doctor doesn’t mean you can remember everything; in fact you do better with checklists.
I was very glad the pilots who flew me here yesterday through the washing machine of cloud formations, circling round and round with no sense of horizon, had checklists so they knew whether the plane was upside down or not. Yet how many of us use checklists in our everyday medical life? Or do we just trust some of our instincts?
A very interesting physician, Donald Redelmeier from Toronto, has researched what confronts us in medicine and life. He has looked at the determinants of emergency department crowding, what makes us not achieve the 95% target. It’s not about alternate primary care or patient preference or community education or the weather or the season, but it was about whether there were local rest home services. It’s not about patient co-morbidities or complexities, it’s not about access to labs or staff morale but it’s more about the staffing characteristics, how many ED doctors and nurses you actually have and about availability of afterhours radiology.
Some of his other research is about mobile phone use. As a doctor who didn’t like the fact that people were coming in dying or dead into his trauma room, he has established that mobile phone use in a car is as dangerous for producing motor vehicle accidents, or deaths in motor vehicle accidents, as being drunk. He has showed that changing lanes in busy traffic produces no actual real benefit in terms of getting to your destination quicker but increases your chances of having a collision threefold. He has also shown that over five years from 2004 to 2009, if you were an applicant to enter medical school, you were much less likely to be accepted if you were interviewed on a rainy day.
One of the reasons for recommending his research is that along with Tversky, a Nobel Laureate in Economics, he found that doctors making a decision for a single hypothetical patient favour more expensive treatments and more expensive investigations than when making a decision for a group of hypothetical patients with similar symptoms. So you and I, when faced with a patient in front of us, will make expensive decisions for that single individual. Yet if we back off and make a decision about a group of individuals, we’ll be more parsimonious, we’ll use the health dollar better. It’s a challenge for us to try and understand why we behave one way with a patient in front of us and another way when we’ve got our hands on some of the purses of the health dollar. As we step into clinical leadership roles, how are we going to mix and balance those two behaviours?
When we look at our agreed MECA pathway, the tossing and turning that went on to produce a business case, to produce an implementation document with an agreed level of investment, why was there a sudden backing away. A backing away by some of the health bosses, backed by health politicians? Why did that happen?
I wonder whether some of Tversky’s work with Kahneman actually gives us an answer. The idea of behavioural economics or prospect theory, which has, over a generation, managed to unravel some of the beliefs of utility theory which said that the market was open and transparent, which said that people are fully rational when they make decisions, that they are completely selfish when they make decisions, and that they have stable tastes. Tversky’s work which won him the Nobel Prize undid all that, and introduced behavioural economics - how you and I assess the probability of an event. We search for memories of relevant examples, things that we can easily remember. But that leads to a completely faulty assessment of risk. If we don’t have “like” events in front of us, we have nothing to absolutely compare with.
The MECA process that we’ve been going through, the business case development, the thinking of investment of the size of a new hospital in a medical workforce, was an event which no Minister, no health boss or Ian Powell had even thought of before. This was new supposedly blue sky thinking. It was a challenge, yet whilst it remained a theoretical undertaking, we all worked with it. When it became practical, rubber-hitting-the-road reality, all of a sudden human behaviour took over.
What we then saw, and what Tversky showed, is that human beings are risk averse when they are making a decision that has hope of a gain. Even stock market agents are usually bad at investing themselves. When there is hope of a gain, we as humans are risk averse. And yet we take risk when we’re making a decision that will lead to a certain loss. I wonder whether our health bosses and those behind them, when confronted with a chance to make a real gain, to make a substantial investment in the SMO workforce for the next generation, behaved as only humans behave - risk averse. And maybe we have been led to a decision which may be a certain loss.
So your job over the next two days, as delegates representing the SMOs who have let you get away to this Annual Conference, is to help us work out how to go down a path which may be a loss or may be a gain for the health of the citizens of New Zealand. I look forward to tossing and turning with you, to having robust discussions and finding direction from you. To find wisdom in the crowd, in those you represent. And to champion a future for the people who, in their everyday lives, perform the sort of miracles and heroism which we saw in Christchurch earlier this year.
