Rarely do you see a clinician, researcher, teacher, philosopher, ethicist and writer all bundled up in one person inside one white coat. Jerome Groopman has been such a person. Dr. Groopman and his wife Dr. Pamela Hartzband, an endocrinologist, are one of healthcare’s power couples. Together they are providing the world access to their insights and to their biases in popular books like How Doctors Think and Your Medical Mind: How to Decide What is Right for You.
Hartzband and Groopman frequently write articles in the New York Times like “How Medical Care is Being Corrupted” which was a denunciation of “pay for performance”. Dr. Groopman writes for The New Yorker, where he has been a staff writer since 1998. A recent New Yorker article by Dr. Groopman that I particularly enjoyed was his piece on Oliver Sacks . Over the last several years he and his wife have also written several articles in the “Perspectives” section of the NEJM.
Despite the reputation for clinical excellence, the contributions to the body of knowledge in AIDS and Oncology, the moving descriptions of what is important to patients, the insights that he has provided to us about how we falter in critical decision making as we fall into the traps that behavioral economists and psychologist warn us to avoid; despite all this, I fear that something about his current message is beginning to sound like a reactionary warning. Viewed collectively, some of the most recent articles written by Dr. Groopman and Dr. Hartzband come across as attempts to encourage rejection of the efforts of others to transform medical practice to provide more people access to high quality efficient and effective care at a cost we can all afford.
Until now I have kept my observations to myself and have felt that their opinions contributed to the discernment that is necessary for progress. The issues that face us are complex and the way forward will require debate and compromise. All points of view must have a voice: but after reading their article “Medical Taylorism” in the January 14th edition of the NEJM I am no longer reluctant to express disagreement with what they have published. The article may arise out of their misunderstanding of Lean. Perhaps unintentionally, it misrepresents Lean and therefore mistakenly creates a set of false impressions. Or perhaps it is an intentional attempt to derail an effective approach to clinical improvement because it offends some of their closely held values and is an intentional misrepresentation and a manipulation of a story and facts.
Either explanation is problematic and the publication of an article built on either errors of analysis and understanding or distortions and misrepresentations of facts raises questions about what is going on within the editorial processes of The New England Journal of Medicine.
I am not alone in my concerns. Since “Medical Taylorism” was published there has been much dismay and many people are talking about how to respond to the misinformation. Modern Healthcare does not have the academic panache of the NEJM, but their response– entitled NEJM Writers Confuse Taylorism With Lean by editor Merrill Goozner–is a scathing reply to the ignorance of the history of Lean and the misrepresentation of Lean that was obvious in the article. Ironically, at the end of the piece Mr. Goozner suggests that Drs. Groopman and Hartzband read Don Berwick’s classic NEJM article from 1989, “Continuous Improvement As An Ideal In Healthcare”.
The historical errors reported as facts in “Medical Taylorism” connecting Frederick Taylor (who was a stopwatch wielding efficiency fanatic from a hundred years ago) to Lean are a very good set of reasons to watch Don Berwick’s speech at the IHI in December 2015. Don traces the history of continuous improvement in his speech because he still sees Lean and other forms of “improvement science” as core to the future of healthcare and the Triple Aim. Taylor and his laudable and remarkable efforts at efficiency were employed by Henry Ford to efficiently and cheaply make the model T the “wheels” of the nation. To jump from that fact to making Lean the cause of the woes of patients and providers more than one hundred years later may make some literary sense to Groopman and Hartzband but I see it as an intellectual manipulation of a piece of history to serve their own purposes.
The picture presented is medicine driven by a stopwatch. Implied is that the stopwatch came from Taylor and that Lean is about stopwatches and having doctors run faster as they have less time with patients. Nothing could be more wrong. The time crunches that drive many clinicians to burnout are the gift of fee-for-service finance and volume-based reimbursement schemes and metrics and not the result of Lean. Lean tools and culture are the antidote to our poisoned delivery system. Lean was introduced to healthcare in 2001. The time crunches and the deterioration of the joy in practice that concern Groopman and Hartzband date back at least forty years. Blaming Lean for the loss of quality time with patients is like blaming EMTs for the accidents to which they respond.
Lean done well can improve both quality and finance by eliminating waste. Lean does not depend on stopwatches. Lean depends on trust that is the derivative of respect for both the patient and the provider. Lean seeks the path to harmonious flow that can be found by allowing the people who do the work to design the work. There is a Zen like quality to Lean culture and the workplace it creates that is antithetical to the wasteful hurry that is driven by a stopwatch trying to maximize the number of repetitive activities done in a defined period of time. A fair and unbiased presentation of Lean would never present it as a stopwatch-dependent activity of a demanding management that is oblivious to the true values of healthcare.
I want you to click on the link and read the article, but there are a few statements that I want to bring to your attention. The tone is set early in the article and they attempt to connect Frederick Taylor to Lean by saying,
Central to Taylor’s system is the notion that there is one best way to do every task and that it is the manager’s responsibility to ensure that no worker deviates from it. “In the past, the man has been first; in the future, the system must be first,” Taylor asserted.
Toyota, inspired by these principles of “Taylorism,” successfully applied them to the manufacture of cars, thereby improving quality, eliminating waste, and cutting costs. As health care comes under increasing economic pressure to achieve these same goals, Taylorism has begun permeating the culture of medicine.
Merrill Goozner points out in his editorial in Modern Healthcare that there is a subtle attempt to connect Lean to the dehumanizing impact of assembly lines:
Each worker in the first assembly lines was given a small and repetitive role, whose demeaning nature was best portrayed by Charlie Chaplin in his 1937 movie “Modern Times.”
It takes a gifted writer with an agenda to conflate assembly line manufacturing with Toyota’s radical implementation of a “human first” philosophy in manufacturing in the pursuit of quality, safety and affordability where any worker concerned about a defect can stop the line until the problem is solved.
I do not know where Groopman and Hartzband were in the seventies and eighties but in my practice we had all the clerical tasks to do then that they say computers and Lean have imposed on us now. In fact, we were trying to work computers into our workflows even as Deming was helping Toyota design a better way to create workflows that respected their workers and long before 2001, when Toussaint and Kaplan began to explore the use of Lean in healthcare. Assigning Lean as the cause of a problem that existed before Lean was used in healthcare does not seem to me like sound reasoning.
The most depressing and infuriating paragraph for me is an attempt to imply that those who seek to bring Lean to healthcare “…all want a different kind of health care for themselves and their families than they profess for everyone else”:
There is a certain hypocrisy among some of the most impassioned advocates for efficiency and standardization in health care, as Boston neurologist Martin Samuels recently pointed out. “They come from many different backgrounds: conservatives, liberals, academics, business people, doctors, politicians, and more often all the time various combinations of these. But they all have one characteristic in common. They all want a different kind of health care for themselves and their families than they profess for everyone else.” What they want is what every patient wants: unpressured time from their doctor or nurse and individualized care rather than generic protocols for testing and treatment.
I hope that I have misunderstood the intent of using this quote. My wife and I get our care, in exactly the same place where I once pushed the learning of Lean. I wish my children and extended family had the same opportunity where they live. The likelihood of hope being realized may be diminished by this article. I would be afraid to get my care where Lean was not the operating system of the delivery of care and where the principles and philosophy of Lean had not influenced the culture of the practice. I do not have any idea who Dr. Samuels may be talking about because I cannot think of anyone who promotes Lean who would fit Dr. Samuels’ description.
I believe that the article is dangerous because it may confuse many clinicians, practices, hospitals and health systems that are considering Lean or are still on the initial learning curve of Lean. I am very concerned about the damage that it may have caused already because Lean has the potential to be our greatest asset in the effort to return joy to practice as we strive to achieve the Triple Aim.
Care better than we have ever seen, health better than we have ever known, cost we can all afford, …for every person, every time.