22 January 2016
Dear Interested Readers,
What’s Inside This Week’s Letter
It is rarely true that I know what next week’s letter will be about before this week’s letter comes to you, but that was the case last Friday. About the time I finished writing last week’s letter I discovered that the NEJM had published an article by Pamela Hartzband and Jerome Groopman that was provocatively entitled, “Medical Taylorism”. I have had a week to think and I have exchanged numerous emails with many others who felt that the article was a misguided offensive move against improvement science in general and Lean in particular. Given the size of the readership of the New England Journal, the respect that many have for the authors based on their previous contributions, and the way in which any article published in “The Journal” influences the opinions of many healthcare professionals, I feel obligated to respond. I hope what you read will cause to to think deeply about the utility and purpose of Lean and realize that the “diagnosis” that Groopman and Hartzband made implying that Lean was at the root of much of the dissatisfaction of clinicians and patients because it robs them of vital time together is just wrong.
The presidential primary season is quickly coming to its first moments of decision. Last Sunday the Democratic candidates spent a significant amount of time discussing the next steps in healthcare reform. This is an important moment and without endorsing any candidate I spend a little time talking about what they are talking about.
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This week’s piece on strategyhealthcare.com is yet another return to Don Berwick’s brilliant speech at the 27th Forum of IHI held in Orlando back in early December. If you missed previous reviews, here is another chance to get the “Reader’s Digest” condensed version. The piece also contains the link to the real speech. I hope that you will check it out and also show it to your friends and encourage them to sign up to get the weekly letter. To those of you who are new readers this week, welcome!
I Really Disagree!
It is hard to disagree with people for whom you have great respect. At any moment in medical history there have been great clinicians who thought about more than just disease and new and more effective treatments. There have always been a few who were remarkable clinicians and also could hold their own as philosophers and writers. 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. They both have years of clinical experience and alone as well as together they are providing the world access to their insights and to their biases in popular books like "How Doctor’s Think and Your Medical Mind: How to Decide What is Right for You.” You may remember a television series back fifteen years ago, Gideon's Crossing; it was based on Dr. Groopman and his book The Measure of Our Days.
Hartzband and Groopman frequently write articles in the New York Times like “How Medical Care is Being Corrupted” which was a denouncement of “pay for performance. Dr. Groopman also publishes articles in 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 that was published last August. Over the last several years he has continued to publish articles in his field but he and his wife have also written several articles in the “Perspectives” section of the NEJM.
Dr Groopman seems to be the complete package. He is renowned as an AIDS pioneer and oncologist, author of more than 180 scientific papers, and an esteemed Harvard Professor. If his research and patient care are not enough, he is a writer who communicates with grace about behavioral economics, ethics and the interface between medicine, the art, and medicine, the business. He can interpret medicine and doctors to patients and gives physicians deeper insights as they seek to help patients make decisions. Those abilities alone should make him one of our most valuable contributors. The patient stories in his first book, The Measure of Our Days: New Beginnings At Life's End should be on every caregiver’s reading list.
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 a reaction to much of the attempts to transform healthcare toward more efficient and effective care at a cost we can all afford.
My opinion is based on the feel that I have had after reading the last few Perspectives articles like “The New Language of Medicine” and “There Is More To Life Than Death” plus the New York Times piece mentioned above. These articles contain a little bit of an edge, a hint of some disagreement with attempts to improve healthcare by a focus on some of the realities of population health, outcomes measurements, new payment methodologies and collaborative care that are forcing new ways to solve problems that could erode classical clinical autonomy. I began to think as I read each article that I did not totally agree with Groopman and Hartzband and wondered what their motivation was behind the recent articles. Initially I respected the fact that they presented the feelings of many and were entitled to their opinion. I appreciated the civility of their presentation and could understand where they were coming from, even if I did not agree with the destination of their opinions. I progressed from asking myself whether they were defending values that they felt were under siege to being quietly convinced that they were using all of their creativity to undermine programs and a movement that was a big exercise in adaptive change that they refused to accept.
Don Berwick’s speech gave me a new way of asking questions about what has been happening over the last five years or so of their writing. Do they fear the passing of what Don Berwick would call Era 1? Are they frustrated by the carrots and sticks of Era 2? It feels like they are beginning to function (write) like modern day “medical Jeremiahs” who, like Jeremiah from the ancient biblical text, are predicting some new manifestation of professional doom. With the article “Medical Taylorism” I am no longer confused and fearful of commenting least I have it all wrong and have misunderstood their motivations. “Medical Taylorism” makes me feel that I must vociferously disagree. It is an article that either arises out of their misunderstanding and unintentionally misrepresents Lean and therefore mistakenly creates a set of false impressions or it is an intentional attempt to derail an effective approach to clinical improvement and is an intentional misrepresentation and a manipulation of a story and facts in a way that serves their purpose.
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. At a minimum there should have been a companion article with a differing point of view. The article that followed, “History of Medicine: Mr. Gilbreth’s Motion Pictures-The Evolution of Medical Efficiency” was not such an article. A point of view that is supported by a misrepresentation of facts without a balanced chance for the presentation of an alternative analysis does not serve the best interests of healthcare, the practice of medicine, or the interests of the community.
I am not alone in my outrage. Since last week there have been several blog postings expressing dismay and many people are writing “Letters to the Editor” in response to “Medical Taylorism”. 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 response to the ignorance of the history of Lean and the bias against 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 to Lean are a very good set of reasons to watch Don Berwick’s speech at the IHI in December. Don spent a lot of time tracing 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. Frederick Taylor was a contemporary of the Wright Brothers. 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. With his assembly lines Ford cut the cost of a model T from over $1000 to less than $300.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. Taylor’s contributions to the fundamentals of Lean are less visible than the contributions of the Wright brothers are to the sophisticated systems of our most advanced commercial airliners.
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. There are rare moments that occur occasionally during a Lean kaizan event when a stopwatch may be used to measure improvement of a time sensitive part of a workflow, but I have never seen a stopwatch used to set a limit on the time a patient has with the doctor or nurse. The time crunches that drive many clinicians to burnout are the gift of finance and the volume based reimbursement schemes and metrics of fee for service medicine. I knew Don Berwick in the seventies and eighties before he knew Lean. Long before Lean we both worked on schedules with fifteen and thirty minute appointments that were often a joke because of double bookings. Lean did not create the focus on volume or time. Lean tools are not the cause of the distress and burnout in healthcare today. Lean tools and culture are the antidote to our poisoned system, or as John Toussaint and Patty Gabow infer by the titles of their books, Lean is the medicine or the treatment for the damage done by a focus on finance that has destroyed the joy of practice.
Lean done well can improve finance by eliminating waste, including over processing and wasted human effort. 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. Lean does consider time because time can be wasted. A fair and unbiased presentation of Lean and the good that it has already brought to healthcare would reveal that Lean is about respect, problem solving, a focus on value as defined by the patient, and the prudent stewardship of scarce resources as the path to restoring the joy of being a provider or a patient and not as a stopwatch dependent activity of demanding management that is oblivious to the true values of healthcare.
Ironically, Lean is an asset to any clinician who fears, as do Groopman and Hartzband, the loss of time with patients and the erosion of other closely held professional values. Understanding Lean should have been possible for Groopman and Hartzband if they had wanted to know the truth. They work at the Beth Israel Deaconess Medical Center where Lean has been effectively used to sustain and improve the culture of care for which the BIDMC is famous.
I do not want to dissect the article. I want you to read it, 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.
Advocates lecture clinicians about Toyota’s “Lean” practices, arguing that patient care should follow standardized systems like those deployed in manufacturing automobiles. Colleagues have told us, for example, that managers with stopwatches have been placed in their clinics and emergency departments to measure the duration of patient visits. Their aim is to determine the optimal time for patient–doctor interactions so that they can be standardized.
Merrill Goozner points out in his editorial in Modern Healthcare that this a subtle reminder of 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 Henry Ford’s approach to assembly line manufacturing to Toyota’s radical implementation of a “human first” philosophy in manufacturing in the pursuit of quality, safety and affordability. To then imply that a process or philosophy that arises outside of medicine is not worth considering on the basis of its merits in healthcare is also short sighted. Would they also exclude fiberoptic scopes and echocardiography? How would they feel about Interest Based Dispute Resolution. I think we know how they feel about computers because they are linked with Lean.
Encounters have been restructured around the demands of the EHR: specific questions must be asked, and answer boxes filled in, to demonstrate to payers the “value” of care. Open-ended interviews, vital for obtaining accurate clinical information and understanding patients’ mindsets, have become almost impossible, given the limited time allotted for visits — often only 15 to 20 minutes.
I do not know where Groopman and Hartzband were in the seventies and eighties but in my practice we had forms to be filled out, patients were given questionnaires and again all that information was gleaned and processed in fifteen minute follow up appointments and half hour initial visits and consults. 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. Assigning cause to an event that occurred long after a problem arose does not seem to me like sound reasoning but rather the sort of factless assertion one might hear during this rather depressing presidential campaign season.
The most depressing and infuriating paragraph for me in the paper quotes Martin Samuels who is a respected Boston neurologist:
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 have tried hard to stay away from “inference” or the assumption that I knew and understood the motivation of Groopman and Hartzband because I do not. I actually hope that I have misunderstood what they wrote, but this quote suggests and their use of it to make a point leads one to believe that they agree with the fact that advocates for Lean and other forms of improvement science are trying to force onto the public care that they would not want for themselves. That is over the top.
I get my care, and my family gets their care in exactly the same place where I once pushed the learning of Lean. 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. Among advocates for the utility of Lean in the search for the Triple Aim I am not alone in this attitude. In fact 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. Samuel's description.
So what is the repair of this effective attempt to bring doubt down upon Lean and those who see it as a path to 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.
I hope that there will be many letters to the editors of the NEJM. Letters to the editor can only be 175 words long so this missive will not make it, but Patty Gabow, Paul DeChant and I have already sent one. You could also send a letter. Perhaps the NEJM should review its editorial policies for the “Perspectives” section. I hope to coauthor or hope to see someone write a Perspectives article in the near future that presents Lean as it functions in the institutions that are effectively using its principles to improve care. The benefit of Lean to healthcare is an accepted fact in many institutions. It has been the central focus of the progress made by IHI as anticipated by Berwick’s 1989 NEJM article and demonstrated again so obviously almost thirty years later in his recent speech. In other quarters like JCAHO there is an understanding that demonstrating some proficiency in the use of continuous improvement science will be necessary as JCAHO encourages hospitals in their pursuit of “zero harm”.
Those that are threatened by Lean for whatever reason may have felt relief by reading “Medical Taylorism”. I sense that their anger and dissatisfaction with the quality and joy of practice is ill placed when they blame Lean for their troubles. Lean is a potential solution for those who are willing to try to understand its principles. Those that need a foe are not choosing wisely when they focus their ire on Lean. Their pain arises from the inadequacies of Era 1 and Era 2 and they will never find relief until they explore the possibilities of Era 3. The journey to Era 3 requires a process of giving up what does not work and moving toward possibilities that offer proven advantage:
To move away from Era 1 and 2 - Stop excessive measurement
- Abandon complex incentives
- Decrease the focus on finance
- Avoid professional prerogative at the expense of the whole
To embrace the possibilities of Era 3
- Recommit to improvement science
- Embrace transparency
- Protect civility
- Listen, really listen
- Reject greed
I would love to See Dr. Groopman and Dr. Hartzband apply their communication skills to the promotion of Era 3.My Vote Counts This Time Around
One of the sad realities to be balanced against a very long lists of positives of being a citizen of Massachusetts is that your personal vote rarely counts in the presidential primary selection process or even in the final election. The primary in Massachusetts is always too late to have much of an impact. In years past it has occurred long after the momentum from the states that vote earlier have gone a long way toward the final answer. In the November election all of the candidates focus on the battleground states. Since McGovern carried only Massachusetts in 1972, it has been conceded to the Democratic candidate just as Alabama is usually a sure call for the Republicans. I always added my vote to the process but I never felt that there was any chance that my vote made any more difference than another grain of sand makes on a large and beautiful expanse of a tropical beach. One of the first things that I realized when my wife and I finally decided to move to New Hampshire was that now I would be a real player in the process of selecting the next President. My vote suddenly has a chance to make a difference in the candidate selection process and could make a difference in the final election! Oh, how great is the joy and responsibility of the power!
I have paid close attention to all of the “debates” produced by both parties. Until recently the Republicans were taking the Emmy for the most entertaining presentations. It is easy to see how experience with “reality” TV can contribute to the entertainment quotient of a group shouting match. I have been constantly surprised by what I have heard, and just when I think I have heard either the crudest or silliest comment I could ever hear, I am surprised when the next vituperous shout tops the last comment that led me to say to my wife, “Can you believe he/she said that?” While the Republican “Debates” have often been a series of entertaining snarls, the Democratic Debates have come across with no more sense of controversy or disagreement than many of the Sunday school discussions that I have attended over the years.
Last Sunday night was the exception. For about eight dramatic minutes that you can view courtesy of Mother Jones, Bernie and Hillary slugged it out. Throughout the evening I was as uncomfortable as a small child witnessing an argument between two parents. When they launched into healthcare my anxiety levels peaked. I cared about the conversation between Hillary and Bernie because I see merit in both of them and I am not sure yet which one of them will receive my very “decisive vote”.
The discussion was largely precipitated by the fact that Bernie Sanders had released details on the scope and funding of his single payer health program just about two hours before the debate. Single payer is not a new idea for Bernie. He has been strongly in favor of healthcare as an entitlement, not a mandate, for his entire political career. This is a position held by many liberal members of the Democratic party and can be traced back to FDR and Truman. FDR always regretted not including healthcare or at least something like Medicare in the New Deal. Both he and Truman tried to fix it. Johnson finally got Medicare and Medicaid passed. Ted Kennedy tried for years, but the best we have ever achieved is the Affordable Care Act which is a huge accomplishment but leaves almost 30 million without access and the coverage is so incomplete for many that cost is still a barrier to care for many millions more.
Hillary’s point was it is pretty good and we should do nothing to harm it like trying to make healthcare an entitlement by moving to the “Medicare for all” program that Bernie favors and in so doing risk all that has been gained. In short, Hillary focused on all that we had gained that made our glass half full. She was somewhat successful in the implication that Bernie would negate the good of the ACA by pursuing “Medicare for all”.
Clearly Bernie was concerned that the glass was half empty, if almost thirty million do not have care and millions more have inadequate coverage or are flummoxed by the cost of their drugs. Bernie’s usual demons, corporate finance controlled by Wall Street billionaires who pay inadequate taxes, and campaign finance laxity that allows billionaires to buy elections are a major add up in his mind to why things are the way they are in healthcare. Hillary pointed out that those were just the realities that should make us happy and protective of what we have. Her bottom line was something like, “Bernie, if we can’t fix it, let’s not make it worse. Why don’t we just continue to press for incremental improvement.”. Bernie’s best arguments were 1) the lack of fairness in the moment, 2) the correctness of an entitlement (a human right) over a mandate (obligation to buy or be at variance with the law and subject to penalty), 3) our variation from the rest of the developed world, 4) “the urgency of now” for those who can’t afford or are excluded from care and finally, 5) the high cost that we are paying because of the insurance and drug companies.
I really did not learn anything. It was a good discussion and I think both candidates scored points. I would decrement Hillary a little bit for twisting Bernie’s message in a way that was self serving. I was actually leaning toward her before she did this. She knew that he was not suggesting the repeal of the ACA, although she implied several times that he was. But hey, it’s politics, it’s hardball. Bernie made his case and held his ground about the way things should be and that is worth points even if the realities of the world are harsh and pragmatism often trumps idealism.
I still do not know whose lever I will pull. It is a serious responsibility. Who knows, the future I want for my grandchildren may depend on how I vote? It is a scary feeling and I feel a responsibility to give making the best decision my full attention.
It is Cold!
The roads are clear in my little town. We have only about four or five inches of snow on the ground from two small storms so it is easy for me to shuffle along on my daily exercise trips. The challenge has been temps in the single digits and low teens. Yesterday’s shuffle took me “downtown” where as you can see by the picture that there are children braving the cold to skate on the rink that sits on the town green. The gazebo where brass bands play on balmy summer evenings has no point or purpose this time of year. It is just waiting for warmer times to come. I had a good shuffle and finished with icicles in my beard. I was back and forth in my mind the whole way: Bernie versus Hillary. On the other side I am amazed to discover that I am rooting for Bush or Kasich. They both have demonstrated competence and they also project civility. Civility and respect for others and the process would seem to be a given at the level of a presidential election, but then things seem to often not be what they should be. I think I have about eighteen days or ninety miles of walking left before I must decide which lever to pull.
The obvious big issue for this weekend is not whether a storm will hit New England but whether the Patriots will survive Denver. I have a plan to record the game, go for a walk, and then come back and fast forward through all the ads. The approach represents effective Lean thinking. I hope that you will give enough forethought to your weekend so that you will find time to treat yourself to some exercise. |
