The Power of “I don’t know”

By Neil Seeman

Saying “I don’t know” can be a deeply liberating experience. People in healthcare – and in virtually all service industries – do not say this nearly enough. The client ends up suffering.

I learned the power of this phrase in law school; I hadn’t read the course notes, and, upon being fingered by the lecturer for an answer, I couldn’t fake it. Saying “I don’t know,” then pledging to the teacher to learn the answer, made me feel at once authentic and committed.

Trouble is, “I don’t know” is an alien phrase for many information elites – including everyone from lawyers to accountants to insurance salespeople to what Deepak Chopra calls “Medical Deities” (aka MDs). My colleague Carlos Rizo has suggested an entire course be taught in medical school on how and why and when to say “I don’t know.”

In a talk called “Empowering Patients” at a spectacular conference – “One Patient, One Record,” organized by Kevin Leonard and colleagues of the University of Toronto and patientdestiny.com – speaker Doug Gosling twigged me to the power of “I don’t know.” When chronically ill patients have access to their full medical record, Mr. Gosling explained, it is very hard to hoodwink them. If a clinician fails to say “I don’t know,” a patient detects evasiveness.

Perhaps “lie” is the right word. Lawyers will make a fancy case that in rare instances “saving” a patient from the truth is worth the lie. Maybe so. But here’s our reality: In 0.2 seconds – the time it takes to blink – it is possible for anyone anywhere with access to the Web to type in a health term into Google and for Google to send back a solid answer.

When you’re chronically ill, you are Googling about your illness several times a day. There are many who say we still need “information curators” to sift through the “noise”. Not always. I believe Google is making most of us a whole lot smarter about our healthcare. I think most people with chronic illness can learn enough accurate information online in 24-48 hours about any disease to be able detect whether their care provider is faking an answer.

An example: It is difficult at first to distinguish between obsessive compulsive disorder (OCD) and ritualistic behavior in young children. Many young girls (and boys) like to line up their dolls and pillows in a pre-ordained way every evening before bedtime. Insisting that food be organized in a circumscribed pattern on their dinner plate is also normal for a child. OCD is very different, and research published last year in the Journal of Psychopathology and Behavioral Assessment suggests the condition can develop in children as young as four.

When I asked a pediatrician to explain the difference to me one day, his eyebrows rolled sideways, he touched his left upper brow with his forefinger, and gave me a song and dance about how absurd it was to imagine that a four-year old could exhibit signs of OCD. I lost trust in him because he failed a basic humility test: to say “I don’t know but I’ll try to find out.”

Memo to doctors (and lawyers) everywhere: we pretty much always know when you don’t know (especially when it comes to our children or aging parents). This was probably true before 1995, when there were a few thousand websites, but far more so today when there are billions. And yet, in a paradox, many professionals today – perhaps to legitimize their existence in an age of ubiquitous information – feel they have to know *everything*. To say “I don’t know” is an unthinkable utterance, as if to break honour with a fraternal pledge of feigned knowledge.

True knowledge begins with “I don’t know – but I’ll try to find out.” Ask a patient.

About the Author

Neil Seeman is Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College, University of Toronto.

My Evening with the Future

Steven Lewis

Throw away the crystal ball and spend an hour with Google Health: the future will be right in front of you. Providers who prefer the pedestal to parity and see themselves as traffic cops on the health information highway are in for the shock of their lives.

I intended to compare the on-line personal health records of both Google and Microsoft, but I couldn’t convince Microsoft that I was Phyllis Diller from Scottsdale AZ (you have to be a US resident to sign up). Google let me in, and in a few minutes I had my own record. Well, not quite my own. (Health record privacy purists, skip the next paragraph.)

Touch wood, I’m a healthy guy. I don’t have any chronic conditions (unless you count seasonal hay fever, a cat allergy and a severe reaction to sopranos), have never had surgery, take no prescription drugs, and, having read too much quality and outcomes research, am a bit of a fatalist. There will be no colorectal cancer screening bazooka shoved up my behind unless I get to watch a video of my doctor smiling happily through the procedure. With so little data to enter, I made stuff up – gave myself type 2 diabetes, angina, arthritis, and added 25 pounds – to test the ingenuity of the architecture.

Hello Frank Gehry. The software leads you through a consumer’s garden of neurotic delights – and I mean that in a good sense. You can input your own remarks and notes, set permissions for access, amend or delete entries. You can second guess the diagnosis or advice you got from your doctor in the seven minutes he spent with you. You can get drug price and therapeutic equivalence comparisons – your own reference based pricing program is at your fingertips. You can catch contraindicated drug combinations. You can learn your odds of falling prey to various health breakdowns by linking your profile to web-based risk calculators. You are handed the key to a cornucopia of safe information injection sites tailored to your profile.

But, dammit, this is America, and in America nothing good happens unless money changes hands. Some of the featured partner sites offer free advice, but they’ll also sell you drugs or other products. Others are more brazenly mercenary: at the Cleveland Clinic site it’s cash for counsel. Want a second medical opinion from MyConsult? That’ll be $565, and it’s not insured. The web site supplies a sample report so you can see what you’re likely to get: mainly of a summary of what the patient sent in, and a 3 paragraph opinion. I figure a good senior resident could knock one off in half an hour, an hour tops. Bargain-hunters can score a nutritional consult about your gout (honest) for a mere $95, or 2 sessions on high blood pressure for $165.

Perhaps you’re more inclined to Blueprint for Wellness, which offers a package of 29 lab tests, a wellness questionnaire, and a personal wellness report for $134. TrialX.org will match your condition to a database of 25,000 clinical trials and help you find clinical investigators expert in your condition – all free. It’s essentially a dating service for researchers and a potentially vast pool of trial recruits.

To those of us of a certain age for whom a long distance call was a special and costly luxury, this is all a bit disorienting, even creepy. Google has an incentive to choose its partners carefully – it doesn’t want to jeopardize its carefully cultivated we’re-not-like-the-other-megacorps image. No filter is foolproof, and no interaction is risk-free. Nonetheless, the methodologically innocent are far better off with Google as the quality control overseer than heading off solo into a cyberspace full of charlatans.

Still, there are reasons to pause and reflect. Will the model undermine the doctor-patient relationship? Will it fuel an even greater obsession with tests and assessments, luring millions more to the already-vast army of the worried well? What happens if providers act on inaccurate or misleading patient-created information? What jurisprudence will arise from the inevitable litigation when something goes wrong?

Yeah, whatever. Quibble all you want; it’s here, it’s growing, there will be no pausing and precious little reflecting. It’s a predictable workaround, an evening up of the odds against Fortress Healthcare that keeps patients in the dark and puts a firewall between them and their health record. Some enlightened health care organizations, such as Group Health Cooperative in Seattle, put patients at the centre of their e-health strategies. How strangely foreign to the Canadian Way.

Canada’s e-health leaders can either ignore it or embrace it. Ignoring it risks dooming the provider-oriented, paternalistic plans to rapid obsolescence. They should take what’s good about it – joint production and ownership of health information, the potential to create networks of trustworthy information sites, the linkage to self-management tools tailored to individual profiles, the fantastic communications capacity – and revamp their e-health plans, fast.

The democratization of knowledge and the desire to be treated like an adult in health care transactions are irresistible forces. It’s a near-miracle that Canadians for the most part continue to put up with the arrogance, inconvenience, secrecy, and error build into the existing system. We could have seen this coming a decade ago, but we are too often a nation of deer in a world of headlights. Google and Microsoft have set off the alarm. Pushing the sleep button won’t cut it much longer.

Pay for Performance: The Wrong Time, the Wrong Place?

Steven Lewis

It sounds like such a good idea: don’t pay people to show up and scurry about, pay them for proven performance. It’s the new Big Thing in health care financing. As usual, the Brits have pursued it most vigorously. Some Canadian health care executives get bonuses for achieving certain targets. The US Medicare plan has quit reimbursing hospitals for the costs of dealing with avoidable mishaps such as falls and bed sores. Health care cheques should come with performance strings attached. About time, right?

Well, yes, if your overlook the P4P track record. Renowned British health economist Alan Maynard found lots to be cautious about in his review of experiences to date. The Hay Group believes that even 5% to 10% of income at risk is insufficient to produce a significant effect, let alone the 1% to 2% typically on the table in such arrangements. In the UK, the vaunted GP bonus schemes – which can add tens of thousands of pounds to physician incomes – have turned into base pay. The average GP practice scores 95% of the bonus-triggering points available and virtually all get 90% or more. But the number of complaints per practice – one reasonable measure of satisfaction – varies considerably.

On examination, the very essence of P4P is troubling. It is a profoundly pessimistic concept of what makes people tick in health care: we can’t rely on organizational culture, professionalism, devotion to public service, or commitment to excellence to get the desired results, so let’s just concede that it’s all about the money. Managers and practitioners are hardened cynics for whom pecunia vincit omnia -- cash conquers all. So let’s tell them what to accomplish, ring the economic bell and watch the Pavlovian throng stampede to improvement via the cash-stuffed trough.

Dishearteningly, P4P writ large becomes a self-fulfilling prophesy. Adopt its assumptions and fund or pay accordingly and you will indeed turn civilized people into econocentric shadows of their selves. Set up the game and people will learn the rules and play accordingly. Moreover, the game will inevitably lack sophistication, because to dole out the rewards, the goals must be clear and simple; the results easily measurable and immediate; and the reach modest (no one will play if it’s too hard to win). All nuance and complexity are obliterated by the basic algebra of the payout. So it’s hardly any wonder that British GPs are walking away with the dough. Ask not for what the bell tolls – it tolls for fee.

But what if we’re just learning, and eventually get it right, particularly if we learn from our masters in the private sector? You’re doubtless as inspired as I am by the corporate CEOs with incomes almost entirely driven by the value of their (occasionally back-dated) stock options and the quarterly earnings statements. They sure knew how to tally up the performance points. You get what you pay for, and the denizens of Wall Street decided to pay for scams so absurd that they make the Nigerian please-be-my-agent-for-millions howler look like Protestant-ethic capitalism at its sober best. IKEA CEO Anders Dahlvig refuses to take his company public precisely to avoid the tyranny of get-rich-quickism that makes a virtue of impatience and myopia and rewards Ponzi schemes over substance. But he never claimed to be as smart as the guys who ran Lehman Brothers.

For the hundredth time in a seemingly infinite series, the world is learning two key lessons: you don’t get something for nothing, and appealing to baser instincts will improve neither humans nor their achievements. Health care is a uniquely fraught enterprise that deals with uncertainty, vulnerability, tragedy, hope, and trust. Of course it involves great amounts of money and to which neither individuals nor organizations can be indifferent. Health care takes place in a messy world, not a monastery. But money is a resource for achieving other ends, and if it defines us or crowds out nobler preoccupations, the means become the end, the aperture narrows, and the golden calf beckons.

Doesn’t it seem odd that we would have to coin the notion of “pay for performance” in the first place? What the hell else are we paying for? When did “doing one’s job” uncouple from “doing one’s job well”? Suggesting that ordinary performance – not spectacular, but merely satisfactory, like being nice to your patients or doing Pap tests at the recommended interval – deserves a bonus debases the entire enterprise. It creates a cultural norm in which lousy performance is the natural state and the passable is redefined as extraordinary. It dumbs performance down and leaves out the hard parts.

Show me a P4P system that rewards first class care of the frail elderly, life-enhancing management of multiple chronic conditions, reduced need for surgery fifteen years from now, or ending one’s career with sunny disposition and compassion intact, and I’m all ears. But in my preferred world, the first dollar and the last pay for excellence across the board, an ethos of care, devotion to the public good, and the perpetual search for knowledge. Pay individuals well and fund organizations fairly. Settle the money issues swiftly so all can focus on what the money is supposed to achieve. Do this well and we’ll have pay for performance – not as cause-and-effect, but as a harmonious feature of a thriving culture.

Providers who practice to chase income targets and dangled bonuses are different from providers who want a reasonable income to pursue their callings out of love for what they do and a drive to serve people better. For those who crave the buzz of the financial transaction, there is a vast world beyond health care to explore. Health care that takes its cues from the rantings of the Chicago School and the MBA culture imperils its values and its practitioners. If those twin intellectual frauds can take down an economy, they can easily corrupt health care. Health care culture needs more than a behaviourist tweak and tuck. The worst imaginable outcome would be that P4P as currently conceived actually worked as intended, for that would prove just how far we have fallen.

Bottom-Up vs. Top-Down Innovation – and Hot Air.

Neil Seeman

“Hot Air” by Marjorie Priceman is a delightful children’s book about the first hot-air balloon – invented by brothers Joseph-Michel and Jacques-Étienne Montgolfier. In September, 1783 their Aerostat Réveillon reached 1,500 feet, its passengers being a sheep, a duck and a rooster. The Montgolfiers thought that smoke propelled the balloon. Years later it was discovered that hot air rises because it weighs less than cool air.

More than two centuries later, the debate over the source of innovation rages on: Does change come from daring researchers (the Montgolfiers)? From the throngs of people who cheer on the invention and send forth news of the sensation (in this case, to Paris)? Or from the monarch (it was King Louis XVI in 1783) who champions the invention?

Health policy wonks – especially those interested in the transformative power of health information technology (HIT) – are fixated on whether innovation comes from the “bottom up” (the patient/consumer) or the “top down” (government or the hospital).

Author Vijay Vaitheeswaran describes the bottom-up/top-down debate in the Economist Magazine’s current special report on health care and technology. Denmark is perhaps most cited as the showpiece for top-down HIT innovation, with almost all Danes having regular access to an electronic health tool to manage their appointments, track medications, and to ensure they don’t take the wrong kind of medication, too much medication or drugs that should not be used simultaneously.

So here’s one top-down formula for the successful adoption of HIT: Mandate common security standards, data-sharing protocols, and consistent interpretations of privacy law.

On the other side of the debate, many “health 2.0” or “peer-to-peer” enthusiasts tend to believe in bottom-up innovation: Give patients the tools (e.g., their complete online medical records), and the doctors and hospital CEOs and government leaders will step into line. I used to believe this. I now understand things are a bit more complex.

Too much focus on the bottom-up/top-down debate misses the real goal: making sick patients healthier faster, or managing and preventing illness altogether. This may happen bottom-up, top-down, or, more often than not in my opinion, by combination or accident. In many cases (as with the hot air balloon) we don’t really know why for years to come.

The management and health policy communities tend to ignore the reality of the happy accident. We are trapped in a cognitive bias: we think that if quality or outcomes improve within any organization, this must be by dint of “process improvement” or because of a charismatic leader who “just got things done.” From the hot air balloon to Twitter to Viagra, history abounds with accident as the seat of innovation. Perhaps the most we can do is make the ground fertile for more accidents to happen: hire lots of smart, diverse people willing every so often to bonk senior management on the head to experiment.

I don’t pretend to know the answer to why innovation and adoption of HIT takes off more quickly in some jurisdictions than in others. I am skeptical of those who think they know the answer to this very difficult question, given the deep socio-cultural differences among neighborhoods in the very same city, much less among countries or continents.

But I do say this: all the energy the academy, consulting firms, large companies and governments spend on debating this question could be channeled into something more productive: curiosity-seeking, idea-generation and free-form debate among patients and providers and others working in the system. Consider parking 15 percent of your organization’s time into tinkering with how to improve healthcare for everyone.

Sometimes a competitor will steal your idea. (Some claim that the hot air balloon was invented some 74 years earlier by the Portuguese priest Bartolomeu de Gusmão.) Sometimes a monarch or government official will take all the credit. Never mind. If just once we soar high, then it will all have been worth it.

Neil Seeman is Director and Primary Investigator of the Health Strategy Innovation Cell, based at Massey College at the University of Toronto. neil.seeman@utoronto.ca