5 October 2018
Dear Interested Readers,
Lean Fosters Critical Thinking
I loved medical school and my years as an intern, resident, and fellow. What really appealed to me was that the approach to the patient that I was taught seemed to be a pathway to managing uncertainty. I like a logical process to solving problems. The importance of the patient’s history was emphasized. I liked best the attendings that focused on “the softer” issues in the history. When I became a resident and was “teaching” interns and students I would erupt with annoyance when I read a work up where the “Social History” was “bus driver” or the “Family History” was “cancer.” I wanted details. If I was annoyed by a skimpy Social History or Family History, I was outraged when I would read an assessment that revealed no evidence of critical thinking or a clinical plan that suggested that the methodology was to “cast a wide net and see what comes back.”
Sloppy assessments, poorly considered diagnostic strategies, and scatter gun testing all seemed to me to be origins of error, waste, and misuse or overuse of medical resources. Of greater concern was that a lack of critical thinking was the origin of unsafe management and all of the risk associated with a “failure to diagnose or treat” the actual problem. I had been significantly impressed by a book that I had read in the late 60s, Sickness and Society by Hollingshead and Duff. If you click on the link, you will discover that this book focused on all of the biases and social issues that complicated the evaluation and treatment of hospital patients then and now. Critical thinking suffers from more than sloppy methodology and, it suffers from personal and societal biases that result in waste and injury. Sickness and Society is an old book and we have moved on, but if you clicked on the link you might have read an overview of the study. Here is the core of that assessment:
These authors studied the hospital and its clients within the relative social contexts impinging on its operation; medical school, community, and families. They trace the ways each of these contexts, separately and collectively, influence patient care and interpersonal relations within the hospital…conflicts among teaching needs, research interests, and patient care; the relationships between physicians and administrators; conflicting interests of the house staff and community physicians; factors affecting morale of nursing staff and others…The authors stress the degree to which the hospital tends to mirror the social structure of the community in which it is imbedded…The authors conclude that status within the community is as important as illness in determining treatment in the hospital… Another feeling of importance is the degree to which emotional and family stresses and problems…were systematically ignored or denied by the physician…Patients participated in this conspiracy by withholding certain important information. But even when this information was willingly offered physicians either denied or ignored its importance. The authors feel that this practice often leads to to poor treatment and sometimes to unnecessary treatment…A finding of particular importance is that although the object of hospitalization is patient care, no single individual had responsibility for the direction of hospital care to the patient. This fragmentation of treatment and responsibility…was particularly detrimental to the basic goals of hospitalization.
Not included in the review of this “ancient” book was the fact that impressed me most which was how often the diagnosis and treatment were wrong. On page 379, the authors write:
…for 26% of the semiprivate and private patients cared for on the medical service, the diagnosis applied had little or nothing to do with the patients’ problems. Moreover, these diagnoses were usually inapplicable, always led to complication of existing problems, and produced no therapeutic benefits.
The book did me the great favor of helping me realize that my own biases and social interactions were the origin of errors and that the critical thinking that I felt was so important was always going to be downstream from some fundamental upstream issues that included my own world view. The book reported information that constituted an indictment of the environment of current practice and values of its day. Much of its power came from the fact that it was the analysis of an elaborate study done at Yale over a six year period in the early 60s. Is it hard for you to believe that over 25% of the time at a exclusive academic medical center the working diagnosis during the hospitalization was wrong? Have things changed in the intervening 50 years? The book predates our language about equity in care or our understanding of biases that complicate our thinking. Are we in better control of these societal issues, the professional biases, or the coordination of care now than we were then? Observing the care of friends and family members in multiple institutions, which is obviously not statistically valid methodology, I would say that I fear things have not changed much.
Throughout the entirety of my practice life I have carried the findings of Sickness and Society with me as I have tried to live in the complex world of professional relationships, personal biases, and societal structure. It always felt to me that unless we focused on how we make errors, and how those errors are actually a by product of biases and systems that are unable to produce equity, we will continue to fail in our responsibility to many patients and never achieve the Triple Aim. Said differently, I think Hollingshead and Duff were reporting the substance behind the defects that were reported thirty years later when Crossing the Quality Chasm was published in 2001.
When I was first exposed to Lean thinking I was impressed with the similarity between the process and “scientific method.” As my experience with Lean grew and as I tried to “sell it to colleagues” I became convinced that the authors of Crossing the Quality Chasm were right when they advocated a “systems approach” to clinical improvement. Don Berwick further underlined that impression when he re emphasized the importance of continuous improvement as step 5 in the 9 steps of Era 3. What continues to discourage me is how slow healthcare as an industry and a collaboration of professions has been to embrace the wisdom of Lean despite its proven efficacy. Lean reinforces critical thinking. Lean moves critical thinking from an individual activity to a collaborative exercise.
We often hear that Lean is “transformational.” That always sounded pretty exciting to me. If what you are doing is hurting real people, wasting real resources, and causing you to suffer endless cycles of rework while angering your patients wouldn’t you think a little transformation would be good? Apparently, many of our colleagues conceptualize transformation as something akin to a frontal lobotomy. Since I was pretty sure that I wanted to be “transformed” into a better clinician and clinical leader I had a hard time understanding the resistance.
Having been exposed to Lean thinking now for most of a decade, I think I am changed in demonstrable ways. It’s a bit like using Pilates to improve my flexibility, core strength, and posture. Both improvement processes take a little effort and go faster with the benefit of an experienced teacher. The more I have learned about Lean and the more I have personally experienced the individual benefit of the philosophy, the more I am convinced that as we face the greater challenges that are coming at healthcare, the more we need Lean.
At the personal level I find that now I approach problems first saying, “Don’t jump to a solution!” I get into the analytic flow by asking myself what the reason for action might be. I think about what is wrong with the current state. I try to envision what a better state would be, or how closer to that state I might be able to get with a first effort. I pay attention to the “scope” of the problem. I try not to take on more than I can process. I think about all of the issues that might be upstream or interconnected with “my problem.” I think about what a reasonable solution might be based on all the considerations. I form a hypothesis. I think about how to effectively test my hypothesis. I begin to think about what the likely outcomes might be and how I will use that information to further my understanding of the problem. The process goes round and round. Things change. It occurs to me that the process of care that they tried to teach me as the “best practice” back in medical school and during postgraduate training was a pretty good facsimile of scientific method and of Lean thinking. I wonder whether many schools have extended their reach to include Lean. It would be nice to look forward to a new generation of Lean thinkers practicing medicine with improved processes of critical thinking.
The End of a Long Road
I took the picture that appears as the header for this post from the cliffs overlooking the Pacific in Brookings, Oregon. My wife and I were leisurely traveling down the coast from Portland, Oregon to Santa Cruz on Monterey Bay where we planned to be present at a party to celebrate the first birthday of our youngest grandson. After we settled into our room for the night I told my wife that I wanted to take a walk down a path that I had seen coming out of the back of the parking lot near our room.
I knew that the path was headed through some trees toward the ocean which was not far away. After going through a grove of trees I came to high bluff where there was a fence that was clearly meant to prevent people from falling onto the rocks far below. It felt a little bit like the time I stood on the “White Cliffs of Dover” where there is no safety fence. I was mesmerized by the scene before me and stood there for a long time lost in my thought and my concerns about my father.
The picture was taken a few minutes before a sunset that was obscured by a heavy late afternoon fog that was trying to lift. The combination of the ocean, the rocks, the elevation of the cliffs, the sunset, and the fog all came together to create what I thought was a beautiful and inspiring scene. The only sound I could hear was from the waves churning against the rocks far below.
Several hours after the picture was taken my sister called to say that to her surprise my father had died at 1:30 AM. He was a couple of months short of his 98th birthday. It would have been a big event. We knew that he was nearing death, but the actual day and moment of such an event are frequently a surprise. We were hoping for a little more. I had visited him after Labor Day and we had taken “a road trip” to his home town which was a two hour drive from Abernethy Laurels where he had moved into a nursing unit this summer. The previous several weeks had been complicated by trying to find the right mix of meds that would allow him to be comfortable and yet be alert enough to interact with family and friends. I had been on the phone most days discussing concerns with his wife and caregivers.
In life Dad always was a great example for all of us and was always in control. When it was all over I was not surprised that he surprised us. He always defined the moment, and made the critical decision that moved us forward. He always asked the critical question that would get you thinking about possibilities. When it was time for me to think about medical school he asked me where I was going to apply. I gave him a list that included some of the best schools in the South. He said, “You have an excellent transcript and a well rounded list of activities and interests. Have you thought about applying to Harvard?” I had not, but I did.
I have many wonderful memories of family trips, and individual activities like the day we hiked up to near the continental divide outside of Creede, Colorado near the headwaters of the Rio Grande. We caught our limit of rainbow trout in a beaver pond in a high meadow that day. A few years later we went back and discovered that something had destroyed the dam and the pond was gone. It was a lesson of some sort.
He always advocated for the best effort toward a stretch goal. When I got my first report card in junior high school I had an A in every course except physical education where I was given a C. My father looked at the report and asked, “What happened in PE?” I told him that the teacher gave everyone of the 85 boys in my class a “C.” The school was overcrowded and understaffed. My teacher was not even a PE teacher. Most of the time he taught “shop.” My father listened and then said, “Why don’t you stay after class, and ask your teacher what it would take to make an A.” I did. The teacher was surprised by the question and then said he would give me some extra assignments to write, and if they were good enough, he would change my grade. I did the extra work. For the rest of the year I made an A in PE, but most importantly I learned a lesson.
I wish that I could say that I never failed to meet his expectations. I can say that I always knew exactly what those expectations were, and there was always help when I needed it. I was very fortunate in my choice of parents. Now there is nothing that soothes my soul like being quiet in a beautiful place while trying to imagine the advice that they might want to give me. Good things happen when you quietly enjoy the beauty of the natural world. Wherever you are this long weekend I hope that you will have a chance to be quiet in a beautiful place.
I really appreciate the notes and calls that I have received from many “Interested Readers” who have heard that my father has died. Some commented that they felt that they knew him because of the comments that I had made about him in these notes recently and over the years. I feel like there is still more for me to learn from reflecting on my experience with him. My wife loves the show “This is Us” where the past and characters from the past keep showing up in new episodes. Don’t be surprised if you read more about Harold Lindsey in some future letter.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
