Category: book

On Three Doctors

Note: This is old, an assignment back from when I was still in undergrad. It’s interesting reading old things you’ve written and seeing how you have and have not changed.

The arrival of the Enlightenment throughout Europe during the 17th and 18th centuries heralded the rise of large bureaucracies in European governments that were meant to rule the people with the ideals of reason and justice. As the bureaucrats become more powerful in the 19th century, the logical ideal became closely associated with the government’s power, and therefore also became tainted by its corruption and incompetence. In Charlotte Perkins Gilman’s “The Yellow Wallpaper,” Leo Tolstoy’s “The Death of Ivan Ilyich” and Sir Arthur Conan Doyle’s “Scandal in Bohemia” doctors become symbols of authority and reason. Because of their training in the sciences and logic, they command great respect from the community and are characterized as infallible, their decisions being final. For Gilman and Tolstoy, however, because the doctors often make their patients more ill, the absolute authority of the physicians is largely undeserved. Doyle, however, portrays the character of Watson as a physician who uses his training in reason to do good deeds through solving crimes during his adventures. Seeking reform in their societies, Gilman and Tolstoy urge the reader to question the authority held by the physician and to think for himself, while Doyle emphasizes the physician’s heroism and his dedication to justice. This difference in views shows the difficulty faced by physicians to connect with their patients and the importance of communication in health care.

In “The Yellow Wallpaper” Gilman writes the diaries of a woman who is suffering from an unnamed malaise, and is made worse by her physician husband who insists that the only cure is more rest and that she must not worry about anything. Initially, Gilman’s character submits herself to the authority of her husband.  The narrator emphasizes that her husband, John, is a “physician of high standing,” and that her brother “is also a physician, and also of high standing, and he says the same thing” (Gilman 29), demonstrating how the two doctors represent a center of power that she must obey. It is important that her physician is also her husband, emphasizing that she submits to his judgment not only as a patient, but also as a wife, showing how completely overpowering is his influence over her. Although John “laughs at [her]” (29), despite her illness, she claims that “of course one expects that in a marriage” (29). John’s dual role as husband and doctor creates a scenario where, in addition to the husband mocking his wife, the doctor is mocking his patient. John treats her like a child, addressing her as a “little girl” (36) and patting her head. This condescending behavior creates a distance between the doctor and the patient, and the narrator withdraws emotionally, deciding that she will hide her thoughts in her diary. In addition, the description of her treatment of “phosphates and phosphites –whichever it is – and tonics” (29), reveals an intellectual barrier between her and John. The doctor doesn’t respect her enough to properly explain the treatment, and when she doesn’t seem to get better, he threatens to send her to yet another notorious doctor, Weir Mitchell, who is “just like John and my brother” (33). Although all these men are in agreement about the proper course of treatment, over time the narrator becomes more ill psychologically, turning mad at the end of the story. She becomes obsessed with the pattern of the yellow wallpaper in her room, which has “a lack of consequence, a defiance of law, that is a constant irritant to a normal mind” (37). The narrator is attracted to this pattern because it defies logic, and is the opposite of her physician husband, who “is practical in the extreme” (29). Because the yellow wallpaper unlocks her imagination, she can escape the strict limitations imposed on her by her husband’s treatment. She expresses a desire to creep around with disregard to how society perceives it, revealing the desire for action and freedom (42). When the wallpaper ultimately takes over her mind, the narrator locks the door and begins creeping along the walls of her room. She tells her husband defiantly that she has “pulled off most of the paper, so you can’t put me back” (42). John, who was portrayed as always in control, is so baffled by this that he faints, while the narrator continues creeping. John fainting is symbolical of the failure of reason to treat her malaise. In fact, her husband’s rest cure was detrimental to her condition. Gilman’s short story showed the need for reform in the way society treated women, starting with the need to question the absolute authority of physicians and a look at the impact their ineffective treatments had over women’s lives.

In “The Death of Ivan Ilyich” Tolstoy paints a similar portrayal of physicians and their futile treatments. All of the doctors are considered to be famous, with each new physician being more renowned than the one preceding him. Ivan is constantly visited by “yet another celebrity” who says “almost the same thing as the first, but put his questions different” (Tolstoy 64) with the only effect that “his questions and conjectures confused Ivan Ilyich still more and increased his doubts” (64), which reveals how in Tolstoy’s eyes the physicians protect each other’s authority, but fail to improve the condition of the patient who comes to them seeking help. Tolstoy’s physicians also create an intellectual distance between themselves and their patients. When Ivan goes for the first time to see a doctor about his pain, he finds the process to be “the same as it was in court” (61). The doctor is dismissive of the patient in the same way that Ivan, a judge, would be dismissive of a man on trial. When Ivan finally asks the doctor to explain the seriousness of his condition, he is met with a pompous “I’ve already told you what I consider necessary and appropriate” (62). Such mistreatment by the physicians causes Ivan to develop a resentment towards them that grows into a feeling that it’s a “lie, a lie for some reason acknowledged by everyone, that he is merely ill and not dying, and that he needed only to keep calm and be treated” (75). The famous doctors put him on a strict regimen and at first Ivan’s “main occupation since his visit to the doctor became the precise following of the doctor’s prescriptions” (63), showing how the doctor’s absolute authority can consume a person’s personal life. The treatments fail to improve his condition and ultimately the doctors can only give him increasingly “large doses of opium” (83) to control the pain. Ivan’s deteriorating condition symbolizes the failure of medical science, and therefore the failure of reason, to save not only his life, but also his soul. Despite being trained in logic as a judge, when Ivan runs the logical exercise that “Caius is a mortal” (70), he refuses to accept the logical conclusion that he himself is a mortal, and that he also will have to die. Tolstoy’s view of medicine criticizes doctors for not being able to connect to their patients on an emotional level and he seeks reform in the increasingly bureaucratic Russian society to solve social problems from a merciful Christian perspective instead of only using cold logic. This is shown when Ivan’s pain is comforted only by the peasant Gerasim, who “alone did not lie…he alone understood what it was all about” (76).

Sir Arthur Conan Doyle was himself a professional physician, and out of the three authors is the most positive about the characteristics of a doctor. In the story “Scandal in Bohemia” the Dr. Watson is portrayed as an adventurous man who dutifully serves the powers of reason and uses it for justice. To Watson, the character of his friend Sherlock Holmes represents logical perfection, because of his exacting “process of deduction” (Doyle Part I) with which he is able to uncover the most obscure truths. The attraction that Watson feels towards Holmes’ mind is almost erotic at times, with their interactions often being flirtatious in nature. Watson “could not help laughing” at Holmes’ brilliance and the two men communicate “with hardly a word spoken, but with a kindly eye” (I) like two lovers exchanging secret glances in public. Doyle goes on to show Watson as a courageous man who isn’t even afraid of “breaking the law” (II) in his quest to aid Holmes. Doyle also has Holmes emphasize that Watson’s help “was all-important” (II) and that none of his exploits would be possible without Watson. With this Doyle emphasizes the role of doctors as individuals who sacrifice themselves in order to enable others to succeed. Dealing with deadly diseases on a daily basis means physicians are constantly surrounded by danger, which is why they must have adventurous personalities much like Watson. Doyle also emphasizes the humanity of Watson, showing that the physician is an empathetic character in contrast to the cold Holmes who is so rude that he even insults a king (II). In addition, the choice to write the Adventures of Sherlock Holmes in first person shows the very personal impact each of these adventures have on Watson, much the same way each patient would have an impact on the doctor.

For Gilman and Tolstoy the physician represents how reason can become corrupted by its own power.  They portray doctors as centers of authority that are respected by the society but don’t deserve such praise because they often do more harm than good to the patient. For Doyle, however, the doctor is a heroic character who seeks to use reason for purposes of justice despite his own human flaws. The great difference between these two views of doctors as villains and heroes reveals the importance of doctors’ ability to communicate empathetically with their patients. Tolstoy and Gilman are frustrated that the physician doesn’t listen earnestly to the patients’ complains, and seek to reform that. Doyle approaches the divide between doctor and patient from the opposite perspective, showing that doctors aren’t the ideals of reason that society makes them out to be, but have their own human desires and fears that they have to overcome. These short stories demonstrate that because the doctor is placed in such a respectable position by society, they have a duty to offer the best care possible. They also show that such effective care can’t be achieved by only applying drugs and surgeries, but requires an honest connection between the doctor and his patient that makes the patient comfortable with his treatment.

Bibliography

Tolstoy, Leo, Richard Pevear, and Larissa Volokhonsky. “The Death of Ivan Ilyich.” The Death of Ivan Ilyich and Other Stories. New York: Vintage, 2010. Print.

Dock, Julie Bates., and Charlotte Perkins. Gilman. Charlotte Perkins Gilman’s “The Yellow Wall-paper” and the History of Its Publication and Reception: A Critical Edition and Documentary Casebook. University Park, PA: Pennsylvania State Univ., 1998. Print.

Doyle, Sir Arthur Conan. “A Scandal In Bohemia.” The Adventures of Sherlock Holmes. N.p., n.d. Web. 9 Dec. 2012.

On Taylorism, Healthcare, and The Goal

This was prompted by Kim Sullivan’s review of Jerry Muller’s The Tyranny of Metrics at The Healthcare Blog. Drs. Accad and Koka also had Mr. Muller on their podcast. Both are worth going through.

It’s always been unironically fascinating to me how primitive systems thinking is in healthcare. Frederick Taylor was a turn of the 19th century industrial engineer credited with the development of scientific management, known as Taylorism colloquially. Taylor’s main idea as described in his Principles of Scientific Management was to apply the scientific method and experimentation as a management tool to figure out what’s really going on inside the organization and what processes work best instead of relying on impulse, intuition, and habit. This on its own should not be controversial. Discord about Taylor arises from the way Taylorism has been applied in practice, through the meticulous measurement of employees in order to justify the creation of onerous compensation structures and unrealistic performance expectations. As Mr. Sullivan and Mr. Muller point out, this is increasingly a problem in healthcare through the rise of pay-for-performance measures and evidence-based medicine requirements that are detached from reality. Taylor himself is not entirely guilt-free of this association, as he did have a consulting business through which he showed a willingness to advise exactly this type of tyrannical measurement as long as it would sell his consulting product.  Unfortunately villains in the real world are rarely straightforward. In addition to proposing the scientific method and measurement as management tools, Principes of Scientific Management also instructs managers to treat employees as human beings by considering employee capabilities and motivations when assigning work  and for managers to be actively engaged in the training and development of their employees.

That being said, although Taylor was instrumental in introducing the scientific method to the practice of management, industrial engineering theory was already evolving beyond Taylorism and its flaws at the time of his death in 1915, and has made significant advances in both theory and practice since then. This is to say that Taylorism in industry has been out of fashion for 100 years already, so it’s both interesting and frustrating to see it so earnestly adopted in healthcare only now and in such a chimeric form. The work of W. Edwards Deming, Peter Drucker, Taiichi Ohno, and even Taylor’s contemporary Henry Ford made great strides to humanize and correct the errors of Taylorism. This work remains unknown and misunderstood in the healthcare field, but of course everybody must start somewhere.

However, although healthcare systems engineering is still in its nascent stage, there is little reason for optimism or hope for actual clinicians that the situation in general will change for the better, regardless of their attempts to fight this problem of tyrannical measurement. While industrial engineering advanced significantly beyond Taylorism, most of this knowledge is not being put in practice widely despite being around for quite some time. Bob Emiliani dives into the question of why this is the case in “The Triumph of Classical Management over Lean Management“. Mr. Muller is correct to point out that manager expertise is an issue, but this is only a symptom of the problem. Low level managers are less affected to do this problem insofar as they are directly engaged with the work, so even if they were not previously experienced or taught they are bound to learn quickly. The root of the problem lies in the scale of organizations and the implications that this has for increasingly higher levels of management. As you go up the levels of management, the managers are paradoxically vested with increasingly greater levels of resources while at the same time increasingly less knowledgeable of how to properly utilize those resources due to being more removed from the actual work. As the Russian proverb wisely says, God is high above and the Tsar is far away. This is compounded by the fact that high ranking management needs to justify its existence to their employees and the organizations funders (whether public or private), needs to manage conflict between different departments vying for the same resources, and has a perfectly human (surprisingly, managers appear to have limbic systems) need to minimize risk to the self from mistakes made downstream. Is it surprising then that the solution management uses to negotiate all these stresses are dumb, objective measurements that they can point to when something goes wrong? Downstream employees say they were following instructions to explain why a mistake is not their fault, upstream managers say they were following best practices.

This is all colorfully illustrated in Eli Goldratt’s “The Goal“, a delightful book that I highly recommend. It’s a cult hit among industrial engineers and operations consultants, butit’s also a good bridge for clinicians who have a visceral reaction to the specter of  Cheesecake Factory management insofar it shows that their frustrations with administration are shared in other industries and explains what good scientific management can look like. The book itself is a novel and not especially well written, the characters are blunt and the events can feel conveniently orchestrated, but the plot moves along at a rapid pace making one always wonder what happens next. In many ways it reminded me of a Dan Brown novel. The story follows Alex Rogo, an industrial engineer who is the head manager of a struggling factory producing a variety of widgets. Alex is a humane character in that it’s obvious he cares deeply about his factory and the employees that work there, but he is also limited in his ability to be patient, to keep promises, and to fully understand his situation. These challenges extend to his personal life. Alex’s main challenge in the story is that he did everything that he was supposed to: he went to the right schools, got the right internships, and once he became manager made sure that his factory did well on all the metrics that the central corporate offices believe to be important. Why, then, is his factory failing? Why are his costs always increasing? Why are his orders always overdue? All this should be a familiar setting to healthcare professionals.

Without spoiling the novel itself, and leaving Alex’s adventure for you to discover for yourself, the main point of the book is that blind measurement is not only ineffectively, but actively harmful to organizations’ ability to achieve their eponymous Goal. Measurement has to be intelligent and strategic, designed to analyze and solve specific problems in the organization rather than be applied haphazardly trying to use the measurement to find problems to solve. For frontline practitioners the book implies two key pieces of advice. The first is that although the Tsar is far away and measuring foolishly, this does not mean that you can’t use measurement appropriately within your local context to help you solve problems that you as a person immediately affected by these problems, the person with that dasein to use Heidegger’s term, are facing. The second piece of advice is to stop trying to convince whoever is making you do ineffective measurement to change, because the odds are that they are incompetent and won’t change until proven wrong. To that effect, rather than asking for permission, the frontline practitioner needs to take the initiative (and responsibility) to make the necessary change and then let the results speak for themselves.

I recommend reading Mrs. Muller, Emiliani, and Goldratt’s books for the rest.

Lessons from “How Doctors Think” for Hospital Operations

Dr. Jerome Groopman is the Chair of Medicine at the Harvard Medical School and staff writer for the New Yorker. His 2007 book How Doctors Think seeks to inform lay readers through a collection of medical case studies about the training that physician receive and the thought process through which they gather information and formulate the diagnosis. Most importantly, however, the book emphasizes the cases in which the logical process through which the diagnosis is developed fails and the physician misdiagnoses the patient and puts their life in danger. Sometimes the diagnostic process repeatedly fails to correctly identify a condition across multiple physicians. How Doctors Think begins by presenting the case of Anne Dodge who had been misdiagnosed for fifteen years by psychiatrists, internists and dietitians as suffering from bulimia and irritable bowel syndrome until a gastroenterologist finally identified celiac disease as the cause of her weight loss. Dr. Groopman also recounts how three renowned Boston-area surgeons had misdiagnosed the hand pain he was experiencing, including one diagnosis that was not a real medical condition (pg. 170). Diagnostic errors like these provide a stark contrast to the idealistic public image of physicians as precise and evidence based practitioners.

The book argues that most of these errors are not due to malice or incompetence, but are a natural byproduct of the mental heuristics that physicians must use to treat patients in a timely and efficient manner. Although physicians are trained in medical schools to carefully record the patient’s narrative and consider all possible options, the operational realities of the healthcare environment such as time-consuming electronic medical records and decreasing appointment durations force physicians to increasingly rely on shortcuts that are vulnerable to cognitive errors.

Dr. Groopman concludes by urging patients to participate more in the diagnostic process by asking physicians key questions such as “Are there any other possible causes?” and “Does any of the evidence not match the diagnosis?” The purpose of these questions is to force the physician out of their diagnostic autopilot mode and give them a chance to recognize any logical fallacies they may have committed. This collaboration would ideally improve physician decision making, decrease the frequency of medical errors, and improve patient outcomes.

Implications

The transition of payment systems from fee-for-service to pay-for-performance through programs like DSRIP and MACRA will inevitably put pressure on providers to standardize processes in order to reduce variability and improve population health outcomes. How Doctors Think reveals the significant variability that exists in physician decision making caused by individual practice preferences and errors during diagnosis, which is a major challenge for large healthcare organizations trying to meet their performance targets. Because “as many as 15 percent of all diagnoses are inaccurate” (p.24), organizations that can control and reduce this variability will be increasingly rewarded by programs such as DSRIP for standardizing their care. Safety net hospital are more vulnerable to such variation because they are more likely to face the resource constraints that force physicians to reduce their time with patients, which Dr. Groopman identifies as a major cause of diagnostic error. Fortunately analyzing the types of errors that physicians make provides a framework to understand how physician processes need to be adjusted and what changes can be made in the organization to reduce the occurrence of these errors. It is therefore recommended that all providers, but especially safety net hospitals, address the problems presented in How Doctors Think by implementing three operational reforms: communication standardization, diagnosis standardization, and treatment standardization.

 Communication Standardization

Dr. Groopman emphasizes that good medicine relies on effective communication between the patient and physician. This requires the standardization of physician’s communication practices to ensure that they are obtaining as much information as possible from the patient.

Physicians should be trained to ask open-ended questions when interviewing patients, which avoids leading the patient towards a diagnosis that the physician is already thinking of, and “maximizes the opportunity for a doctor to hear new information” (p.18). The physicians should also be able to interview the patients quietly and uninterrupted, as distractions can cause the physician to miss important information (pg. 75). When the patient makes a statement that conflicts with the physician’s clinical judgement, the physician should make an effort to not dismiss the patient (pg.264). To maximize trust, the physicians must explain the condition and its risks in a clear manner, but also be prepared to spend more time with the patient when it is clear to the physician that the patient is still nervous or uncertain (pg. 88). Accordingly, the hospital should make it easy for physicians to extend their time with the patient or to schedule a follow-up appointment. Physicians should also explain why they are performing any tests and specifically what they are looking for (pg. 172) to engage the patient and give them a chance to express their own opinions and concerns. Finally, the physician needs to clearly explain all possible outcomes, the positive and negative features associated with those outcomes, and the likelihood of those outcomes (pg. 173) to enable patients to make the choices most consistent with their preferences. This discussion should always be framed within the context of the condition to minimize the risk of patients fearing the treatment’s side-effects more than the disease itself (pg. 246).

Diagnosis Standardization

Safety net hospitals should implement a diagnostic checklist that physicians must review at the end of each case to ensure that they are not committing a logical fallacy in their diagnosis. Common errors that physicians make include:

  1. Representativeness – assume the symptoms correspond to a standard case (pg. 44)
  2. Availability – diagnosis affected by ease with which options come to mind (pg. 64)
  3. Search satisficing – stop searching for problems once you find one diagnosis (pg. 169)
  4. Vertical line failure – thinking inside the box when data and symptoms disagree (pg.171)

To avoid these logical failures, after the physician decides on a diagnosis they should be required to go through the following questions that Dr. Groopman recommends in the epilogue of How Doctors Think:

  1. What else could it be?
  2. Is there anything that doesn’t fit?
  3. Is it possible there’s more than one problem?
  4. What is the patient worried about?
  5. Review the patient’s story from the beginning.

In addition, patients should be encouraged to ask these questions and should be trained to do so through informational materials available to them in waiting areas and posters around the hospital. The benefit of this strategy is that it engages the patient in their health and prevents the physician from ignoring the checklist by going through it carelessly to save time.

Finally, this diagnosis verification process can be further enhanced by implementing systems of physician peer monitoring, such as radiologists reviewing a sample of each other’s slides and discussing the diagnoses that are found to be incorrect (pg. 188). This allows physicians to identify mistakes in a safe environment and collectively improve their skills. The knowledge that they are being peer reviewed also encourages physicians to more careful in their decision making.

Treatment Standardization

Treatment protocols should be standardized across physicians practicing in safety net hospitals to reduce variation and ensure equity in the treatment that patients receive. Dr. Groopman highlights how two very different procedures can be believed to be the optimal treatment protocol at the same time simply because they are both championed by a prominent physician who “did it that way” (pg. 163). Physicians are also susceptible to influence from the industry to prefer treatment plans based on non-clinical incentives that may not put the patient’s interests at the forefront, which may be the case with spinal fusion surgeries (pg. 228). As much as possible, treatment protocols should be directly based on the available clinical evidence and physicians practicing at the safety net hospital should be expected to conform to them. This has the benefits of reducing variability, increasing the rate of physicians’ expertise gain, increasing NYC Health + Hospital’s ability to negotiate with insurers, and makes it easier to explain and justify treatment plans to patients.

Conclusion

Although How Doctors Think was published in 2007, experience with the healthcare system today quickly reveals that few of the lessons this book contains have been addressed. In fact, many providers have made the situation worse by continuing to put physicians under time-pressure without developing the physician workflows necessary to maximize patient-physician interactions or redesigning organizational processes to improve diagnostic quality. This fundamental gap in understanding between management and physicians demonstrates why How Doctors Think should be required reading for healthcare administrators.