Lean arrived a little late for me. Even now, the Triple Aim is still more of a goal than a reality. When I think back over the system of waste in which I practiced medicine, I am left with the regret of the lost time spent licking envelopes, making calls for approvals, make calls to cajole a consult when the system had not been staffed to meet expected demands, and using my one-off problem solving skills to make it through the day. I am also left with the regret that I too was often a waster of resources.
Trying to improve practice without a culture of Lean thinking is much like the work of Sisyphus. You push the stone up the mountain again and again. The time I spent figuring out a solution one day rarely had a continuing return on investment the next day. My solution did not create new “standard work”. I knew that tomorrow the same problem would be there needing a different solution because there was also no standard work in the work of others, and the various suppliers of the services I needed for my patients each had their own autonomous way of viewing the world.
I do not think that I ever experienced burnout but I can remember great personal stress as the result of being embedded in a system of waste. I regret the fact that I surely transferred some of that stress to my close family and some dear friends. Work-related stress was not the only factor in a marriage that did not last; but it was surely a contributor. Time wasted in an inefficient system was a burden for my patients, a loss for me and a loss for my family. I understand why it was the way it was; but I still feel that I am justified in my regret of the past reality.
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During a recent conversation with Anita Ung about the success at Atrius Health with quality metrics, she surprised me by describing a senior clinician whom I respect greatly who is dismissive of participating in the efforts to improve quality metrics because he “has too much to do”. He works in an environment where there is Lean but apparently he has decided just to continue to work as he always has worked. It is sad indeed that he is not alone. Accepting changes in work flows and a redefinition of your “standard work” requires a great deal of adaptation. This physician and I did practice in simpler times when clinical autonomy was mistakenly conceptualized as an asset. The best doctors were the most individually creative in the ambiguity of clinical practice. When clinical supports are not optimal, knowing or inventing what to do in an inadequate environment does require resourceful utilization of what is available and some creativity, even as it generates waste.
Ironically, as I have said before, solving problems is a satisfying exercise but when the whole day is full of problems that return again and again to be solved and solved again, that can be stressful. I envy those clinicians who now have the ability to solve a problem once in a Lean environment and expect it to stay solved.
If I could turn back the hands of time almost forty years to July 1, 1975 and make one small change to the moment when I walked into the Kenmore office of Harvard Community Health Plan to start practicing, it would be that through some miracle I walked into a practice where my arrival had been preceded by the establishment of the Lean environment that does exist at Kenmore in 2015.
I was born too soon. I was born before we had Lean. Sure, I did get a taste of TQM in the mid-nineties; it helped me and the system did get a little better. Despite being attracted to “quality in daily work life” and making many efforts at self directed improvement, my reflections now suggest to me that I could have done more for my patients if I had just had Lean.
The patients did not get the best that they might rightfully expect. Sadly, I also realize that I could have enjoyed practice even more than I did and I would surely have had less stress to take home with me if I had worked in a Lean culture and been able to practice in an environment of continuous improvement. It is painful for me to realize that for at least a decade now it has been possible for every medical professional to have the joy of better support working at the top of his or her license in a continuously improving environment, but very few are doing so. There are huge opportunities to be realized.
