This Just In: Systems Designed to Fail, Fail

By Steven Lewis

First there is the disaster that comes to light long after the fact. Then there is the inquiry. Then there is the scathing report that meticulously unearths the causes of the disaster. Then there is the apology (they’re allowed now – it’s the law!). Then there is restitution. Finally there is the commitment: never again. And then the same thing happens, somewhere else, again, and again, and again.

Canadian medicine – it is quite different in some other jurisdictions – is organized around four fundamental premises. First, doctors are highly trained professionals whose license to practice needs no expiry or renewal date. Second, initial certification exams are reliable guarantors of lifelong competence and consistent, high quality practice. Third, it is both unnecessary and unsporting to subject the autonomous judgments of professionals to rigorous and regular scrutiny. Fourth, professional self-regulation is the ideal mechanism for preventing harm.

To quality improvement and harm reduction experts in every other industry, these premises are not merely dubious, but laughable. Yet they persist in medicine, and the inevitable result is that people get hurt. Radiology and pathology are high-stakes diagnostic professions where errors can kill. When massive failures occur, as in the Newfoundland and Labrador breast cancer testing debacle of 1997-2005 (!), or the Charles Smith forensic pathology fiasco of 1981-2005 in Ontario (!), the root causes turn out to be depressingly pedestrian. That’s what makes them as pathetic as they are tragic.

Even more damning is the repetition. The lid has just come off Quebec’s breast cancer diagnostic breakdown. Saskatchewan is cleaning up after a pathologist who may have put thousands of people at risk over 5 years. It will cost millions of dollars to have every one of his 70,000 images reread out of province, and perhaps tens of millions to settle the malpractice claims (the notorious Regina lawyer Tony Merchant has already launched a class action suit). The only difference between these jurisdictions and those so far untouched by the contagion is that the time bombs are on different schedules.

Despite the repeated revelations of system errors that demand system solutions, nothing has fundamentally changed to guarantee safer health care and prevent the birth of gestating misadventures. When push comes to shove, the right to practice shoddy medicine trumps public safety; no one gets to cancel the flight or shut down the assembly line without definitive proof of repeated incompetence. A health region or regulatory body that moves aggressively to suspend a practitioner pending investigation of suspicious results will be harassed and condemned for violating due process. The first reflex will not be to acknowledge the problem or seek mentorship; it will be to lawyer up. The medical association with go to bat to keep the practitioner in the saddle. Physicians and others in the know who would not send their own kids to an incompetent colleague either can’t or won’t stop yours from ending up in his care.

It’s not just a conspiracy between the guilds and the law; it’s a systematic failure to manage risk. Built in redundancy, rigorous peer review, structured continuing education, and mandatory recertification are cornerstones of safety. The higher the stakes, the greater the need for vigilance and tightly organized quality control systems. Geographically isolated professionals are obviously at risk, and many will fail without carefully designed, reliable supports in place. But everyone needs audit, feedback and peer support to perform reliably over time. In medicine it is well-documented that performance declines with age. The response to this chilling reality has been to let the chips fall where they may – the pathology of denial.

The Saskatchewan case is especially instructive. There were suspicions about the radiologist’s competence 3 years ago. With the regulatory noose tightening around his neck, he volunteered to go for remedial education. No educational program in western Canada stepped up to the plate. After he spent 3 months at McMaster, the Saskatchewan College received a perfunctory and brief report on his progress and skills that it rejected as inadequate. He returned to practice, and on the evidence to date, his interpretation of every 20^th image may have put someone at risk.

The system is designed to fail, and it must be redesigned to succeed. The solution is not to expect physicians to look furtively over their colleagues’ shoulders and snitch to the authorities. The remedies must be systemic, obligatory, and woven into the fabric of medical education, ethics, and organization. Among the obvious requirements are:

• Mandatory review of randomly drawn samples of diagnostic interpretations. The frequency and intensity of the scrutiny should be commensurate with the complexity of the practice, known error rates, and the consequences of mistakes.
• A formal, standardized protocol for addressing competency problems. The first signs of problems should trigger mandatory supervision and intensified case reviews until performance is demonstrably up to snuff.
• Beyond certain thresholds of error, automatic suspension followed by the launch of a remediation algorithm.
• Specific additional support, review, and continuing competency assurance procedures for isolated practitioners.
• Transparent reporting to the public of performance results.

It is delusional to believe that everything is now out in the open, with nothing more to uncover. It’s not just the outliers who cause harm; because medicine is so fraught with unjustifiable variations in practice, it is certain that the errors resulting from “satisfactory” practice far outnumber the misdeeds of the visibly incompetent. The graveyards are filled with anonymous victims whose stories will never surface in a public inquiry. Until professionals take their collective obligations seriously and embrace a culture of safety, prevention will fail, detection will be late, and the victims will pile up. If they view peer review, recertification, and remediation as violations of sacred entitlements, sleepwalking through mandated processes won’t accomplish much.

Sad to say, for radiology and pathology our salvation may come from machines. It is foreseeable that computerized pattern recognition software will be able to diagnose more accurately and consistently than specialists in all but the most unusual of cases. If that day comes, we can be sure that these highly reliable machines will be programmed to self-diagnose and identify anomalies in their own findings and performance at regular intervals, and will be examined, refurbished, and re-tested according to strict protocols. In other words, we will treat them and their needs with care and respect, governed by the duty to put patients first. Too bad that we don’t do the same for fallible diagnosticians and their victims.

Don’t Make Me Gag

By Steven Lewis

Would you commit in writing not to slag your physician on the internet? A US company called Medical Justice (MJ) is hawking a waiver form that gets patients to foreswear anonymous posts to doctor rating websites. I'm your doctor, you're my patient. If you have problems with me or my staff, tell us, tell your friends and family, tell anyone you want through the usual channels. But put it in writing that you won't post it to the internet.

The internet is a pretty big windmill to tilt against, but MJ claims 1000 doctors have signed on. The pitch is that the muzzle pact protects doctors from anonymously posted and inaccurate portrayals of their courtesy, promptness, morals, and clinical skills. The lawyer in the MJ website video recounts the story of an anonymous post implying that a physician was a child molester. Though the post was a malicious plant from a competitor, not a patient, apparently US law exempts Internet Service Providers from liability in such cases, and they cannot be compelled to remove the alleged defamation.

This is ugly and outrageous stuff. But the proposed remedy is ethically objectionable in principle and foolish in practice. The flaws are as follows.

First, Medical Justice argues that rating doctors is not the same as rating barbecues. This is formally true: I cannot libel the barbecue, and in any case the barbecue doesn't care. (The manufacturers do, but somehow they have not yet demanded censorship in return for the privilege of purchasing their goods.) MJ goes on to describe the doctor-patient relationship as a precious union of equals whose sanctity and trust are violated by the specter of anonymous rating. This is patent nonsense: there is a major power imbalance between the parties. The rating sites are popular precisely because the vast majority of patients don’t have the nerve to challenge their doctors face-to-face and fear the consequences if they do so.

Second, the internet free-for-all has been with us for a decade, and it has created an endless stream of opinion, advice, and rating. Of course it is full of garbage, lies, rantings and ravings. It is also a treasure trove of facts and shrewd observations that skewer privilege and reveal truths absent from the increasingly concentrated mainstream media. The bees have burst from the hive and there is no getting them back inside. There is no better advertisement for doctor rating sites than the attempt of doctors to suppress them.

Third, like Othello and Lear, MJ mistakes a friend for an enemy. Most people think better of their doctors than their doctors' performance warrants. The overwhelming proportion of assessments on www.ratemds.com are positive. An avalanche of evaluative literature shows that overall physician performance is in fact mediocre by the standards of evidence-based practice. Misprescribing is rampant, it takes weeks to get an appointment, adverse events abound in hospitals, and mental health problems are underdiagnosed and ineffectively treated. Physicians come off far better on the web-based rating sites than in scientific practice profiles. They should be demanding patient ratings, not proscribing them.

Fourth, the public can learn something from the ratings. Themes tend to repeat in both the critical and laudatory commentary. When 8 patients tell you that doctor X prescribes penicillin for everything, I doubt they’re lying. When 20 of 40 assessments of doctor Y mention misdiagnosis, I’d bet the farm that there’s a lot of misdiagnosis going on. When every one of 32 posters says Dr. Z cares, listens, and explains, I believe that of Dr. Z. Many of the postings are balanced, nuanced, and thorough. The critics in particular tend to give reasons for their judgments. Some are scathing and even cruel, but the savage commentary is usually reserved for those who have committed truly barbaric acts.

Fifth, physicians should welcome the feedback, especially if it is anonymous. Patients are disinclined to ruffle their doctors' sensibilities. I like my family doctor, Mick Jutras of Saskatoon, as do 29 of 32 raters here. He is intelligent, thoughtful, and a good communicator. I did not change my mind because one patient wrote, “He sucks. Totally ignorant. Rude.” But I have never had the jam to tell him that same-day access should be the norm*, that the lab test result communications are erratic, or that it is perplexing that Toyota summons my car for screening but his highly automated practice doesn’t invite me for the tests that are supposed to be so vital to my well-being. (My optometrist and dentist pester me relentlessly.) Nor has he ever surveyed me. Both he and I have let him down on the quality improvement front. If I thought he and his partners would read the internet ratings carefully and recognize that the negative feedback is the wellspring of improvement, I’d log on and write.

MJ claims to be in favour of objective physician rating systems, meaning, no doubt, rating systems that they control or endorse. Their real fear is that patients will pay more attention to each other than to the insiders’ guild. Don’t pay attention to the unwashed who have the gall to write about a condescending ass who interrupts after 20 seconds and can’t tell a virus from a bacterium. We’ll do the rating and ranking of our own.

But what about malicious content? Yes, it's a problem, and potentially harmful to the innocent. There are remedies aside from squashing your patients' freedom of expression. The rating sites open their doors to physician comments and rebuttals. Smart ones, like Saskatoon urologist and medical blogger extraordinaire Kishore Visvanathan, have actually embraced the concept and the technology as a learning tool. Patients can respond to others’ posts. Site surfers should be invited to report suspicious content to the administrators or directly to their doctors.

Above all, keep some perspective. False positive opinions far outnumber false negatives. A patient bent on vengeance has many ways to sully a reputation. And the public are not idiots: if they are at all open-minded about the merits of a doctor, they will read all of the posts and judge on the basis of the body of evidence presented.

If I ran a doctor rating site, I would add a new category: has your physician ever asked you to sign a MJ-type gag order? If the answer is yes, go elsewhere if you can.
________________
* Except for the time we were both at a fundraiser with excellent and abundant alcohol

The End of Professional Snobbery

By Neil Seeman

Imagine if no prestige attached to professions. Nobody cared about old-world credentials…MD, PhD, JD, MBA, MPH, MHSc: the letters would mean nothing, zip, in this alternate world.

It’s not so far off. Welcome to 2015, the year the Facebook generation is married with kids. This is when Mark Zuckerberg, 24-year-old billionaire, Facebook founder and Harvard dropout, turns 30.

The era of post-professional snobbery will be a very agonizing time…for boomer-generation grandparents. How will they boast about their over-educated children’s accomplishments as quantifiably as they can today? For the rest of society, it will mean a boon to human creativity.

The End of “Perfect Outputs”

In one of the most downloaded videos on the Web – Sir Ken Robinson explains, to roaring applause at a TED conference, how our educational system kills creativity in young people. Our system, he says, is geared to producing one “perfect output”: the university professor. Robinson blames the post-industrial age educational model for vaporizing creativity from children, promoting a culture where test-taking ability, rather than intellectual agility and ingenuity, reigns.

Young people under 30 – the Google Generation, the Facebook Generation, whatever title you fancy – really are different. They care more about social good, and less about status. This is not an original hypothesis. Leading thinkers on innovation - Gary Hamel, Don Tapscott and Jeff Jarvis – have written books on this. What has been less explored is what this means for healthcare.

In the era when newspapers drove the climate of public opinion – about two years ago – OpEds on healthcare were written by PhDs and MDs. Nowadays patient-experts write many of the most popular blogs (with clinically accurate content). Google controls health-seeking behaviour, with at least 70% of all searches on healthcare information originating from the Google search box.

When MDs and PhDs carry less prestige…

Today, the only job titles that earn real respect at cocktail parties are “social entrepreneur” and “artist” (though I admit I attract a fair deal of intrigue when I tell people that I’ve taken up boxing). Why does this matter for healthcare? Why does it matter for governments?

As Gary Hamel has trenchantly written, “Thanks to Enron, WorldCom, Adelphia, FEMA, Lehman Brothers, AIG, Fannie Mae, et al, the generation now joining the workforce has an extraordinarily jaundiced view of authority. They are deeply (and often rightly) suspicious of large organizations and those who run them. In their view, it’s not titles and credentials that make a leader worth following, but mission, self-sacrifice and world-class competence.”

Line management in both the delivery and organization of healthcare will need to get flatter. This means wider scopes of practice – for all members of the care team, which includes patients and their families. Further, CEOs will need to learn how to admit their mistakes. This is the signature virtue of the Facebook generation: humility. I always laugh when people tell me that social networks such as Facebook and MySpace and micro-blogging tools like Twitter show that the “younger generation” is self-centered. In fact, the average age of a user on Linkedin is 41; Linkedin is the fourth-most popular social networking site on the World Wide Web, with 40 million users. People under 30 demonstrate both humility and ego in equal measure. These are not mutually exclusive personality characteristics.

They can chest-thump like the rest of us (witness the scores of Facebook pages boasting about winning beer-chugging contests). But they can also confess to being wrong. Mark Zuckerberg, Facebook’s CEO, did exactly this when he responded to a storm of user protest and removed Beacon, a Facebook application. Zuckerberg famously wrote on his blog in December 2007:

“About a month ago, we released a new feature called Beacon to try to help people share information with their friends about things they do on the web. We've made a lot of mistakes building this feature, but we've made even more with how we've handled them. We simply did a bad job with this release, and I apologize for it. While I am disappointed with our mistakes, we appreciate all the feedback we have received from our users. I'd like to discuss what we have learned and how we have improved Beacon.”

…we will start to measure innovation and good governance differently

Today, we measure “innovation” through reference to numbers of publications, the impact factor of journals, academic citations, numbers of degrees after one’s name, and other proxies of knowledge translation. But if ingenuity and agility are what matters – we are currently preparing our children for jobs that may not exist as we know them. The US Department of Labor predicts that the average learner will have 10-14 jobs by the time they are 38. Niche licensing, already commonplace in healthcare, will intensify. At the same time, there simply won’t be enough people with the requisite prescribed credentials (e.g. health records, information management, and health information technology) to satisfy the HR managers.

And so we will need to recruit very differently. Memo to management: drop the “fast-track executive model”; reward the curiosity-seekers, even if they fall flat-footed on their first, second, or third time round. Beware job applicants who have had perfectly linear career paths.

What is more, we may need to measure innovation capacity in the workplace differently, especially in healthcare (where the jobs will be) by qualities such as tolerance for failure; willingness to admit mistakes; and, most crucially, ability to learn from those mistakes.

Few will ever accuse Facebook’s Mark Zuckerberg of modesty, but his apologia for his Beacon debacle is emblematic of the new age. Imagine if a hospital admitted in a CEO’s blog that its big-budget technology implementation failed miserably? And then have the CEO tell her clients how she had learned from her mistake? That is good governance, Facebook-style.

About the Author

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

It’s Good to be Alive: Limericks in Bloom

By Neil Seeman

The economy crashes, and falters, and fails
You utter the wildest, most hair-raising wails,
“Should I buy, should I sell?”
But there’s no one who’ll tell.
It’s chaos around you and panic prevails.

Yet holiday weekends were meant to have fun
To warm weary bones in the heat of the sun
To soak aching toes
Forget all your woes
And bask in successes laboriously won.

Forget the travails; you are, thank God, alive
You know that, no matter, you’ll always survive
You know you have friends
Who will go to all ends
To be there for you till your spirits revive.

I’d always liked poking some innocent fun,
Joking when others were morbidly glum.
My friends would be crying
I’d smile at their sighing
And tell them that grieving was clearly “too dumb.”

So welcome the spring, when the world is ablossom
The view from my window’s amazingly awesome
Pansies, impatiens
In stunning variations
I think I will go and attempt now to grow some.

It’s spring, and you look, and you can’t fail to notice
That purple-blue buds have come out into focus
When the first bluish hue
Makes its yearly debut,
It’s time to rejoice at the birth of the crocus!

I exult at our hedge with its gorgeous azalea
It brightens our garden in splendid regalia
It’s pink, red and milky
Luxuriant and silky,
Each spring it parades its new paraphernalia.

When you see that your garden’s outfitted in frocks
Whose beauty just happens to knock off your socks
I bet that you’ve planted
Something enchanted -
Polychromatic and plentiful phlox.

Like gardens, we humans are, thank God, alive
We’re fruitful, productive and yes, we’ll survive!
We’ll laugh at our ills and our trifling distress
With humour and beauty we’ll battle our stress
It’s springtime, the season to thoroughly thrive.

It’s the springtime of hope and it’s time for good cheer
Now is the loveliest time of the year
Forget your finances
And broken romances
It’s time to rejoice with the ones you hold dear.

About the Author

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

India On My Mind

By Neil Seeman

I have never visited India. I know little of its culture, geography, history, or politics. One thing I know is that lots of smart people are writing about healthcare innovation in India. In Canada, more smart people have been thinking about how best to measure innovation. To be sure, measuring innovation is slippery: it’s hard to quantify “accidental triumphs” or “successful failures” in healthcare. We often revert to measuring interesting, but limited, output indicators: patents, publications, citations.

What if we could measure a country’s agility to innovate? This leads me to India.

India’s Healthcare Innovation Pivot

A pivot is the central point, or pin, on which a mechanism turns or oscillates in a new direction. Can we measure a region’s ability to “pivot” – to bridle the horse and gallop off in a new direction? The Indian healthcare economy is pivoting.

As the Wall Street Journal’s Peter Wonacott reported last month, rural India is defying the global economic slump. He wrote: “In poor and largely rural states from Orissa in the east to Rajasthan in the west, many new leaders have invested in health, education and infrastructure. That has set the stage for the creation of industry and consumer markets and enabled upward mobility.”

Nitish Kumar, chief minister of Bihar, India – where only one in ten people can read – has recruited private-clinic doctors from rich regions to public hospitals in the country’s poorest state. In an alliance led by his Janata Dal party, Mr. Kumar champions “Government 2.0” – the low-tech variety. He hosts Monday open houses at his home, where ministers must respond to public complaints. Bureaucrats travel with him to town-hall meetings across the most impoverished areas of the state, where they pitch tents in mud fields.

India’s economy is standing up boldly athwart the global downturn, and pockets of innovation in rural India are leading the country forward. Speaking at a recent meeting on “India's Future” organized by the Confederation of Indian Industry in Coimbatore, Gurcharan Das, author of India Unbound and former CEO of Procter and Gamble (India), said India’s economy will recover faster than others’. The International Monetary Fund projects India’s economy will grow 5.1% in 2009 (versus 0.5% for the rest of the world).

In Bihar, there are auspicious signs: The number of people migrating out of the state dropped 27% in the 2006-08 period compared with 2001-03, according to the Bihar Institute of Economic Studies. This, despite the fact that more than half of Bihar’s 83 million residents live below the international poverty line of about $1 dollar (US) a day.

Writer Vijay Vaitheeswaran has noted how India is better-equipped than many richer nations to embrace healthcare innovations. Fewer than 20% of US surgeons in America use health information technology (HIT). In contrast, according to Technopak Healthcare, a consulting firm, nearly 60% of Indian hospitals take advantage of HIT. India is fast becoming a hub for clinical research. Admittedly, India has a long, long, long way to go: tens of millions of Indians go without healthcare despite the country being a global hotspot for “medical tourism.” India owes much to its destitute: the level of malnourished children is higher than that of sub-Saharan Africa.

Yet, over the last decade, India has also emerged as the destination of choice for US healthcare organizations that take HIT seriously, in part because of India’s low-cost labour force – but also because of the ingenuity the country has shown in its embrace of new business processes. Recognizing the scarcity of trained e-health professionals in America, India has jumped in. The Nittany Institute in Chennai is suddenly overflowing with Indians taking courses in medical coding, IT Infrastructure management, even “e-talk” – the jargon of e-health.

The Diaspora Returns to Lead the Pivot

“India has always had access to intellectual capital,” says my colleague Amol Deshpande, “but it has lacked good infrastructure and abundant early capital funding.” Amol recently returned from Mumbai where he met Indian-born entrepreneurs at healthcare expos. He recalls some revealing conversations. “I was born in India,” conference attendees would tell him, “but I just came back after 12 years in Silicon Valley.” “The return of non-resident Indians with entrepreneurial minds, their own capital (from the US) and relatively cheap access to good technological infrastructure has begun to change the innovation landscape,” Amol tells me. “Combined with increased demand from a growing middle class and rising rural economy, innovation will begin to flourish.”

The Indian healthcare economy is pivoting thanks to money, brainpower and raw ingenuity. The poorest regions of India are leading this bottom-up revolution; they have the most to gain.

Can Canadian Healthcare Pivot?

It is the “bob and weave” of the Indian economy that impresses me. As the global economic punch arrives, India bends its legs quickly and simultaneously shifts its body. Will Canada pivot or buckle? I don’t know. Manny “Pac-Man” Pacquiao, the Filipino boxer who is emerging as the next all-time great, “slips” from opponents with beauty; hand-speed is what makes him special. Ali’s magic was in footwork, not his punch. My own boxing trainer, Theo Asante, always tells me “anyone can throw a punch”; it’s avoiding the punch that matters. People who measure innovation should consider how to measure agility. Look to India.

Some additional links of interest:

• www.strategy-business.com/press/freearticle/06306
• www.canada-indiabusiness
• www.ideas-innovation.blogspot.com
• www.principledinnovation.com/blog
• www.endlessinnovation.typepad.com
• www.howardwright.com
• www.innosight.com/blog/353-cherish-failure---paul-saffo-world-innovation-forum.html
• www.mootee.typepad.com/innovation_playground/2009/05/the-new-age-of-innovation-when-every-global-industry-will-be-restructure.html
• www.blog.julielenzerkirk.com
• www.getfreshminds.com
• www.innovation.fleishmanhillard.com/?p=3071
• www.pbconnect.com/blog
• conferences.ted.com/TEDIndia/program

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

p.s. More on ‘I don’t Know’
Last week’s essay on “I don’t know” was “tweeted” on Twitter. Trisha Torrey, a globally renowned patient advocate and writer for About.com, picked up the discussion and asked her readers if their doctor had ever told them, “I don’t know”. See the results of the poll here.