Heroes and Vigilantes
Jeff Brown - June 2010
Most hospitals are designed for the nineteenth century. Most doctors don’t know how to share power. Most patients with complicated problems don’t receive coordinated care.
So rang the clarion in April’s Harvard Business Review. Kindly sent to me by a CEO. To enlighten, convert, inform or seek debate? The premise of three opinion pieces is that doctors are not natural team players, that stories of heroism reinforce autonomy at the expense of patient outcomes, that we must strive to simultaneously address predictability and ambiguity and, most of all, that any reforms must come from within us.
Our health system measures the hard work of hard workers by how many patients they manage to see or tests or procedures they call for. How well patients eventually do is often only measured by the touchstone of sentinel events or the Health and Disability Commissioner. These monitors repeatedly show that individual clinicians, and even hospitals, have only limited control over the fate of their patients. Thomas Lee argues that superior coordination, information sharing, and teamwork across disciplines are required if outcomes are to improve, but that medicine’s altruistic core values actually reinforce practitioners’ resistance to change.
He goes on to claim that a profession that attracts idealistic people who want to do good, and selects out the smartest, hardest-working and most competitive people in society, is hobbled by their fierce autonomy. Doctors have historically seen themselves as their patient’s sole advocates, with the rest of the world divided into those who are helping and those who are in the way. And people prefer binary options, as Koechlin’s recent work on frontal lobe function illustrates, which may explain much of our dichotomous approach to even complex decision-making. We debate dilemmas, not trilemmas. We seek second opinions, or our patients do.
In fact, says Atul Gawande, the second opinion is a tremendously flawed institution. You do not get to pick the best outcome, just to pick from two different options. What you really want is for those two doctors to talk to each other. He also argues very strongly for checklists, and for changing the stories we doctors tell ourselves about what it means to be great. Change from the fables of heroism of infallible lone healers to tales of great organisations and brilliant teamwork that make for great care. But moving toward teams collides with the image of the all-knowing, heroic lone healer. Doctors must accept that to be all-caring is different from being all-knowing or all-controlling.
Yet if our medical schools did not train us in leadership and teamwork, can we be expected to have naturally assimilated the skills and attitudes required? Those of us now asked to lead teams and serve teams are the products of a medical mindset twenty to forty years out of date - it was current when we were selected and trained. When medicine was a cottage industry of autonomous artisans. That is how our beliefs and morals were formed. And when we are challenged to change we argue from what we know.
Yet many of the reasoned arguments we make about why we have certain beliefs are mostly post-hoc justifications for gut reactions. The social psychologist Jonathan Haidt says, although we like to think of ourselves as judges, reasoning through cases according to deeply held principles, in reality we are more like lawyers, making arguments for positions that have already been established.
There is hope. In our collective stories. In our collective intelligence. This notion from economics is that what determines the inventiveness and rate of cultural change of a population is the amount of interaction between individuals. We are sharing and telling our stories in the modern medical age at an unprecedented rate. Which holds out hope that we will prosper mightily in the years ahead because ideas are having sex with each other as never before.
Our medical culture will evolve because, as Matt Ridley espouses, exchange makes cultural change collective and cumulative. It becomes possible to draw upon inventions made throughout medical society, not just in your health neighborhood. The rate of progress depends on the rate at which ideas are having sex.
In the recent past we have forced ourselves into silos of specialisation, or been forced into silos of geographical isolation. Our CHE then DHB boundary riding, or primary vs secondary vs tertiary territorialism, has made any innovation as vulnerable as island species, suspended in webs of significance we ourselves have spun.
In the modern medical world, innovation is a collective enterprise that relies on exchange, swapping things and thoughts. As Richard Bohmer elegantly outlines, modern health care organisations must be capable of simultaneously optimising the execution of standardised processes for addressing the known and learning how to address the unknown. Health care providers need to excel at performing three discrete tasks simultaneously: (i) vigorously applying scientifically established best practices for diagnosing and treating diseases that are well understood, (ii) using a trail-and-error process to deal with conditions that are complicated or poorly understood, and (iii) capturing and applying the knowledge generated by day-to-day care.
We cannot excel at this as lone heroes, as doctors, as craft groups, as organisations. Our collective intelligence has more chance when we take a stance for national services, for national clinical networks, for regional solutions. Provided we are always vigilantes for the complexity of patient care in which predictability and ambiguity exist side by side.
Our cumulative innovation is driven by ideas having sex, and by the new heroes who use checklists, who tell stories of great organisations and brilliant teamwork that make for great care, who drive national and regional solutions. Vigilantes who enable ideas to be a whole lot more promiscuous.
Jeff Brown
NATIONAL PRESIDENT
