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It is Time for Clinicians to Engage: Let’s Criticize Less and Dare Greatly More

John Haughom MD whiteWhen I write or speak about healthcare transformation, I am often asked why I do not criticize more. Criticize health system leadership. Criticize governmental policies. Criticize burdensome regulations. It’s a long list. Why avoid criticism? The answer is simple. Discerning emerging solutions is much more productive and fun.

We are living during a very interesting period in the history of health care. No doubt, it is a time of great transition. We are passing from one time to another. Transition periods are important, yet they are hard to define because it’s difficult to determine exactly when they start and when they end. To understand the transition healthcare is now experiencing, we must do our best to understand what is on either side of it.

The traditional approach to delivering care has served us well and accomplished great things over the past century. Yet, it is also being overwhelmed by complexity and producing inconsistent quality, unacceptable levels of harm, too much waste and spiraling costs.

The traditional method of delivering care is struggling and another is emerging to take its place. Because the traditional approach has served us well and accomplished great things, we want to believe that the present state will continue forever. Because conditions have changed, this will not happen. We are in need of a new approach. An approach that carries the best of the past forward, yet also addresses present day challenges. It just might be that on the other side of this current transition is potentially a time unmatched by any other in the history of healthcare. Thanks to visionary clinical leaders at institutions across the country, there is growing evidence this is not only possible; it is likely.

Who does the future belong to? If we look closely at other transition periods in history, two groups of people are apparent. The first are what we recognize as critics. They are people whose response to the need for change is criticism. Critics always exist, but in a time of transition they tend to multiply. What do they criticize? They criticize the new, they criticize the change, they criticize the change for being unnecessary or too fast, or they criticize the change for being too slow. They criticize anything and everything. Critics are abundant. The question we should consider is, “Will criticism solve problems?” Typically, it does not.  While constructive criticism has its place, it alone is not likely to accomplish much especially when the world is yearning for innovative solutions.

The second group of people that major transitions yield is leaders. They are men and women of vision, courage, persistence, integrity, creativity and enthusiasm. They see transitions as periods of opportunity. They have the ability to ignore the turmoil, confusion and difficulties that characterize transitions, and remain focused on the task at hand. They look into the future and imagine new possibilities.  Yet, they spend the majority of their time in the present working tirelessly to bring a new vision to reality.

They eagerly share their vision and enlist the support of others in pursuit of the vision. They tend to be excellent communicators both in word and action, and their presence alone energizes and inspires people. No matter what the odds, doubts, and criticisms, they carry on, and eventually, they are recognized as heroes. Is there evidence of this happening now? Yes, there are many. Let’s examine just two.

With the help of good data and modern quality improvement methods, clinicians at North Memorial Health Care reduced elective inductions by 75% within just six months. In the process, they improved the quality of care, reduced harm and received a six-figure payer partner bonus. Using advanced analytics, team-based processes and evidence-based best practice, clinicians at Texas Children’s reduced appendectomy postoperative length of stay by 36 percent, dropped average variable direct costs by 19 percent, increased evidence-based order set adoption by 36% and increased the percentage of patients receiving recommended antibiotic as first antibiotic by 53 percent. There are hundreds, perhaps thousands, of other examples.

The future belongs to people such as these. They are leaders. One rarely hears them criticizing anything or anyone, because they are too busy getting the job done, deigning a new and better way of delivering care. In the process, they are defining what is on the other side of the transition.

The future will be what we make of it. Leadership is not a special class. It is a role each of us can assume. It is a position of influence. No doubt, some people are able to exert more influence than others, but all of us can have an impact, especially collectively. The voice of clinicians can be profound, particularly if our sincere goal is improving care for patients.  People will hear what we say. They will listen and be affected. Many are eager for clinicians to act in this fashion. They need us to be confident, optimistic and visionary. Let’s not disappoint.

We should not fear the proclamations of critics. In the face of criticism, I like to carefully reflect on a quote from a 1910 speech by Theodore Roosevelt.

 

“It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.”

 

It is time for leadership in health care. Let’s criticize less and dare greatly more.

 

John Haughom, MD, former senior vice president of clinical quality, safety and IT for PeaceHealth, is a senior advisor to Health Catalyst and the author of Healthcare: A Better Way. The New Era of Op

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  2. “Yes, it’s called “have your cake and eat it” conservatism.”

    Saurabh, again you are generalizing and using that binary mind. People are not necessarily consistent nor must they follow a consistent political line. Are you trying to sound like a raving Liberal in drag using soundbite generalities rather than appropriate argument? (This remark is not intended to criticize the normal Liberal mindset.) In general the right does not follow in lockstep as some presume the left does. We need to discuss concepts rather than soundbites.

    “government, hands off my government.”

    I am sure you recognize the people not of the left believe in government, just not to the same extent. Government is needed for a strong marketplace to exist, but it doesn’t have to make one lose their liberty or their economic freedom.

    You talk about revealed preferences. Are not your primary preferences liberty and economic freedom? Your preferences seem to indicate a different mindset though perhaps that is only in this venue. Do you want lockstep adhesion to a philosophy? If one wishes that type of lockstep adhesion they ought to be thinking about a socialist totalitarian state that I don’t think anyone here desires.

  3. “For many reasons a man can vote and intellectually support conservative or classical liberal ideas, but might still want the Medicare he paid for or want to support a pet idea inconsistent with those philosophies. ”

    Yes, it’s called “have your cake and eat it” conservatism.

    Or “government, hands off my government.”

    I do not underestimate the ability of some conservatives to justify why their slice of the government is morally earned and slice of others,
    handouts.

    It has the GOP in a bit of a bind. They know not of any free market solutions which would keep social security solvent in the long run but which would not inconvenience their traditional supporters in the short run.

    The left have the same problem with their champagne socialists, which is why the democrats stayed away from single payer and the public option in the ACA.

    Revealed preferences are more revealing than stated preferences, allan.

    I am not willing to rob people of their moral agency.

    I await with baited breath the debates and results of the next presidential election to see what, in the aggregate, people really want.

  4. “allan, whether I am a juvenile, puerile, … “

    It does matter because you have been engaging in the use of logical fallacies along with a bit of clever deception and I believe you know it. Again, maybe I am wrong and could be giving you too much credit.

    Let me give you an example of just one of the logical fallacies you used.

    Tea Party: “Government hands off my Medicare” You might have seen a few signs that said that exact quote and from that you drew your conclusions regarding the Tea Party. You generalized the few to the many creating a false generalization that you then used in argument. Your training tells you what you did was wrong.

    Most of the members of the Tea Party do not have Medicare.

    Just because a very few of those carrying the sign were amongst the Tea Party members doesn’t mean they were part of the group, nor that the vast number Tea Party people there agreed with them.

    You generalized figuring it sounded good in argument when you knew or should have known that such a generalization is a logical fallacy.

    We have no significant argument over “a”. “b” is another story as it to leads to a logical fallacy. I think in a way Don Levit was close when he pointed that out to you “ how the world is, and how it should be.”

    For many reasons a man can vote and intellectually support conservative or classical liberal ideas, but might still want the Medicare he paid for or want to support a pet idea inconsistent with those philosophies. If I am correct when polling the American population with regard to the usual use of the term left and right it has been found that the American public is center right.

    You don’t have to eat dirt and wrap yourself in drama. Many conservatives and classical liberals would object to ridding our country of Medicare a promise made to the American people and one that all too many are now dependent upon. Before you commit another logical fallacy recognize that these same people did not support or would not have supported Medicare in its present form. Likely if given a choice many would have preferred the King-Anderson Bill or other bills targeted only to those in need.

    “This thread is the best example of how the American right is unable to distinguish the normative (ought) for the descriptive (is), and shoots the messenger!”

    I disagree totally though the above might apply to you. I believe that disagreement occurs because you think with a binary mind that you accuse others of. Your personal perception of right and left seems to neglect the possibility of other philosophies that leaves the door open to alternative explanations of how differing individuals act and react. If you weren’t stuck in such a mindset you would have seen other alternatives that exist.

    Saurabh, relax and have a pleasant day. You are a smart and decent guy.

  5. allan, whether I am a juvenile, puerile, socialist, Satan’s spawn or even the devil himself.

    That does not change the reality which is:

    a) A constitution is only as restrictive as democracy and culture permit.

    b) Your country men love, adore, can’t get enough of big government.

    If the GOP produces a challenger who wins the next presidential election on a platform of privatizing social security and creating vouchers for Medicare, I will forever eat dirt and prostrate before thee oh Lord!

    In the meantime if there is anything I can do to convince you that I am a communist who eats Irish babies, please let me know!

    This thread is the best example of how the American right is unable to distinguish the normative (ought) for the descriptive (is), and shoots the messenger!

    I think it should be retained permanently for future historians.

  6. “You do have one advantage, allan: you hear what you believe. I have one disadvantage: I see what I see.”

    This is a bit simplistic and tripe coming from an educated man. We all color what we hear and see. This exchange is in black and white so I need not repeat what has already been written, but I do note your tendency to change the context of what was said and how it was said. In fact some of the things you state as your ideas in this reply are in fact mimicking those words of mine you reviled.

    Maybe what has transpired is a good thing for you as now you might have a better understanding of democracy and what constitutes a Constitutional Republic. You even seem to have learned what Jefferson and others taught us and that is the public will determine the future of the Constitution. I have no argument with you there. Maybe you knew all this before, but how am I to know one way or the other with all the soundbites and simplistic tripe you have been peddling in this particular conversation.

    Your responsiveness has mostly been juvenile while making all sorts of claims in this latest one that sounds like something you pull out of a book of insults and list without regard to substance. Should I answer this list of insults one by one? No. It should suffice that I told you where I stood and stand on particular issues.

    Yes, I believe in free markets because that has made the world richer and this country strong, but I also believe in compassion. I believe in individual rights. As I stated before I favor the utilization of the marketplace and because a marketplace can be thought of as apolitical I don’t find the need for big government or a lot of politics where soundbites are directed to win the heart rather than the mind.

    Where you stand, I really don’t know. At times you seem to sound like an ideologue and have contempt for America and Americans that are just normal people trying to get by. I’ll get to the chase and skip the direct reply to all the insults and let you correct those impressions about you or alternatively you can leave them stand.

  7. The simple statement that we ought to “criticize less” (NOT criticize ever or criticize never) – just criticize less and constructively build more certainly generated a lot of interest and comment!!!

  8. Saurabh and Allan:
    I was directed to this blog, but Saurabh’s comments were not posted.
    Allan, if you received them, if Saurabh is close to being accurate in his comments, I would leave it as it is.
    Saurabh:
    I hope you can hold 2 contrasting ideas in your head at the same time: how the world is, and how it should be.
    As far as the extremists on the left and right, if one goes too far right, he sees the same idiots coming around from the left.
    Don Levit

  9. Alex

    Thank you for commenting and sharing the link. It was very interesting. In the future, focusing on nutrition and prevention will be huge. One of the most interesting aspects of Big Data Analytics in healthcare is that it offers a very real potential to understand and influence behaviors.

    One of the most-cited statistics in public health is the imbalance of
    social investments in medical care compared with prevention activities. Approximately 95 percent of the trillions of dollars we spend as a nation
    on health goes to direct medical care services, while just 5 percent is allocated to population-wide approaches to health improvement.5 However, some 40 percent of deaths are caused by behavior patterns that could be modified by preventive interventions as I discuss in my book. Genetics, social circumstances and environmental exposure also contribute substantially to preventable illness. It appears, in fact, that a much smaller proportion of preventable mortality in the United States, perhaps 10–15 percent, could be avoided by better availability or quality of medical care. Thus, one could question a funding scheme that places so much emphasis on medical care rather than prevention.

    The fact that medical care historically has had limited impact on the health of populations has been known for many years. The data clearly indicates we could achieve a much greater impact on total health by going after behaviors than by delivering care.

    To put this in perspective, a study published in the British Medical Journal tracked approximately 35,000 people over about 20 years. The study looked at 4 behaviors related to health (tobacco use, appropriate alcohol use, diet and exercise) and demonstrated that people who did well on all 4 compared
    to people who did poorly on all four accounted for a 14-year difference in life expectancy. Compare this to all of healthcare delivery accounting for approximately 3.5 to 7 years of additional life expectancy.

    Preventive health has huge potential. As I said at the outset, Big Data Analytics offers many advantages here. Hence, Google’s recent announcement that it is seeking 100,000 volunteers to study this possibility.

  10. You do have one advantage, allan: you hear what you believe.

    I have one disadvantage: I see what I see.

    That aside you seem incapable of distinguishing between someone pointing out reality (this is the way the world is) and justifying reality (this is the way the world should be).

    I point out that your fellow citizens love the security from big government (the way the world is). You defend by giving me a lecture on the virtues of free market (the way the world ought to be).

    I point out that the constitution is only as good as the democratically elected leaders and the supreme court justices appointed by the leaders decide (reality). You give me a lecture on mob rule and the difference between republic and democracy.

    I point out the fact that the free market champion, Paul Ryan, in the last presidential campaign appealed to seniors that they may lose their Medicare benefits under Obama, shows how advanced your country’s dependence on government is. You defend by calling me a socialist.

    Were I to point out that a building is on fire, and someone retorted by saying “so you think fires are good for buildings, do you, it would sound absurd, would it not?

    That is exactly what you are doing.

    This is worse than shooting the messenger because you don’t like his message.

    I have encountered this malady before, but never with such defiance that I see in your responses.

    I really find it difficult to believe that you don’t get the difference.

    Why so? I suspect you are unwilling to hold two seemingly contradictory thoughts in your mind at the same time. The pain of reality is too much for you to bear.

    Yes, I do think all idealogues converge. The far right and the far left are more similar than they think.

    This is a well known phenomenon in political science, in the understanding of which you claim to be better endowed.

    http://en.wikipedia.org/wiki/Horseshoe_theory

    Idealogues are not extremists, they may be that as well.

    Idealogues are hypocrites.

    “Hands off my Medicare” is the perfect poster child, though not the only example, of that utter hypocrisy.

    I do not believe free markets, limited government and a constitutional republic are a joke. I do believe that the BELIEF that in modern America these elements run through the veins of its citizens is a joke.

    I hope you will not insult your intelligence by failing to acknowledge the difference between these two statements.

    In short, I think your country men love big government. They just can’t admit it.

    Here is something from the right winger, Mark Steyn.

    http://www.ocregister.com/articles/percent-379256-government-spending.html

  11. Saurabh, I missed the Vox reference because it was neither clear, equatable nor exclusive. It also misses the fact that the mainstream news media are considered by many to be left of center and that is where the comparison would have been clearer and perhaps should have been made. Vox Media at the present time is a near nothing.

    I favor the marketplace. That is economic and not really political. Because I favor the marketplace I require less government and less politics. I believe in the Constitution because it acts or should act as a consistent anchor to keep the ship midstream. I don’t necessarily agree with everything in the Constitution but I will abide by it because it creates stability and has proven value. I believe in balanced budgets because I don’t believe it ethical to spend on myself and force someone else to pay for it.

    I don’t know much about you though from your writing I know something about your feelings towards America which don’t sound very positive. Based upon your words it seems you think the American Constitution somewhat of a joke and the belief in small government, the Constitution and balanced budgets are extremist thoughts. You act as if you are solidly locked into the concept of democracy which means that 51% of the people can vote the other 49% into slavery. Is that what you believe or perhaps you never looked at things that way.

    You talk about a binary mindset and reality. My suggestion, stick to radiology because you don’t know very much about psychiatry. You talk about ideologues, theory and a whole host of other things. Again my suggestion is for you to stick to radiology because you don’t know very much about political science and have not been able to make a coherent argument to enhance your position.

    I think you have to take a step back and consider what you have been saying in the context of the discussion. Then I think you should start anew.

    Yes I recognize your profile is open while mine is unknown to you, but not unknown to many on this blog. By having your profile open you have the advantage. You can demonstrate your degrees and education and assume people will consider you a learned man. I have a much greater obstacle to overcome. I can only use my words on this blog and people have to determine who I am through those words. Thus I have given you the white king and I have taken the black one.

  12. allan, do bear in mind one thing.

    My profile is open. You know where I work. But I know nothing about you.

    That’s fine. But remember: it is you ducking under the safety of anonymity not me.

  13. allan, you missed the Vox reference because it didn’t occur to you that a person criticizing the right can also find the left equally pretentious.

    This is a function of your binary mindset. All evil lies on one side, or the other.

    You are unable to deal with the complex thing called reality because like the Marxists, progressives you reduced cause and effect to one deterministic theory.

    There’s a theory in political science, the horseshoe theory, which states that the far left and the far left are not terribly far from each other.

    You are exemplar of the theory, and also of the fact that the most dangerous people in the world are ideologues, whether they are unwavering religious fanatics, Marxists or free market (but government-sucking) fundamentalists.

    I will argue them. All the way.

  14. “ why would I be talking about German media when I’m referring to American -across the spectrum-media bias?”

    Because you could have used the three major broadcasting networks in your example and you chose not to. You chose something more obscure, but I am more familiar with Vox smart phones and Vox German TV than I am with a brand new tiny digital media company that is more similar to Glen Beck TV though Beck’s might be a more stable media company.

    “Are you auditioning for Saturday Night Live?”

    Absolutely not. I have seen what you have written and there is no way I would try to compete with you in the realm of fiction and comedy.

    “Constitutional Republic? How is the “constitutional” bit working out for you?”

    Far better than what we are seeing in other countries. How does dictatorship sound to you?

    “ You really can’t grasp this, can you?”

    You are starting to sound like my grandchildren. Grow up.
    I am looking at your follow up questions and along with being inaccurate they have no content and are out of context with what I stated above. I expected this type of talk from my children in grade school, but not from someone at U of P. In this exchange you have made a total reversal of who you were in other exchanges and on other blogs. I suggest you review what was written so you better understand what is and is not being said. I suppose you are now revealing your true character or is this just a trial audition of another personality.

  15. Don,

    I saw little evidence of majority dissent against the fiscal, economic and healthcare policy of the preceding four years during the last elections, to the extent that people found the policies so objectionable that they wanted to change the chief executive of their country.

    But let the next GOP challenger run on a platform that remedies the policy failures you cite. Specifically on a tight monetary policy, reduced and specified government spending and privatization of social security because of future insolvency and a complete voucher system for Medicare.

    Go on! I dare the GOP to put forward such a candidate! What are they fearing in a country which has market principles and limited government running through its veins?

  16. Our thought leaders have brought us the PCMH, pay-for-performance, and assumption of risk by physicians. The recent Health Affairs article shows that none of these correlate with a low rate of preventable hospital admissions: that desirable goal is seen only with physician-owned small primary care practices, which our thought leaders are trying to destroy.

    Is it any wonder that we “criticize the new, criticize the change, criticize the change as unnecessary or too fast . . . ?”

  17. “The ACA represents insurance coverage reform. It does little to substantively improve the process of care for the patients we serve.”

    Well, that is for sure. Why can’t we leave the poor government out of all this?

  18. FGS allan, why would I be talking about German media when I’m referring to American -across the spectrum-media bias?!

    Are you auditioning for Saturday Night Live?

    “No. America is a Constitutional Republic. There is a difference, something that you seem unwilling to recognize or unwilling to learn.”

    Constitutional Republic? How is the “constitutional” bit working out for you?

    You really can’t grasp this, can you?

    It doesn’t matter whether you have convinced yourself that I understand the nuances (I can’t vote and am too insufferable to run for office), if those who are elected, those who vote and those who comprise the judiciary do not understand the nuances of a constitutional republic.

    What next allan?

    Are you going to restrict democracy to those who understand the difference between a democracy and a republic?

    Or are you going to restrict voting to those who understand the difference between a democracy and a republic?

    Or just run to the supreme court like whining ninnies saying “look the President broke the constitution?”

    You are shooting the messenger here. A messenger who is stating, and will state again, your country loves big government and there’s absolutely nothing you can do about it.

    “Perhaps it deviates from your more socialistic tendencies that are always associated…”

    So I’m either with allan or the socialists! Oh, the intellectual depth of the binary mind!

  19. “It wasn’t me guv, the government made me dependent on the government…”

    Saurabh, are you back to believing that America’s basis for existence is the singular democratic vote? No. America is a Constitutional Republic. There is a difference, something that you seem unwilling to recognize or unwilling to learn. Perhaps it deviates from your more socialistic tendencies that are always associated with governments that believe they give rights to the people instead of this country where the people gave rights to the government.

    I know it is tough to envision that some people believe that government gets its rights from them, but that is how America’s founders saw it. That is why they liked things that you seem to disdain, balanced budgets, the Constitution and small government. I so happen to stand on that side rather than on the side of political despotism where one’s vote is determined by how much they can suck off the government’s largesse. Each to his own.

    Yes there are many that want the government in every aspect of their lives and to provide for them to such an extent that they depend upon future generations to pay for it. They are too foolish to recognize that as a step towards devolution into that vast ocean of despots and poverty from whence they came. It is from that ocean that that some people decide to immigrate into the United States.

    This is a nation of immigrants. Why are we here? The culture of the old country didn’t provide freedom, economic and otherwise. Why change the culture back to the one from which one is escaping?

    You say: “Go on. I dare ya! Put your free market principles where your votes are!”

    Those free market principles are what made the United States into the strongest nation of the world. Knowingly or unknowingly you are trying to tear it down.

    “Have you really not heard of Vox news run by Ezra Klein? I think you need to get out more.”

    You are not talking about Vox, but Vox Media a very recent entry into the digital media world which is even a worse comparison than Vox tv, a German company that has been around for quite awhile and has proven itself being one of the largest of its type in Europe. [for your edification: There are a lot of entities carrying the name Vox because Vox in Latin means voice.] Go back to Jon Stewart and Saturday Night Live. At least they are funny. … You are suggesting others need to get out more? You are laughable.

  20. Saurabh says that government does nothing unless the people support or tacitly approve
    Would that include Quantatative Easing and bailing out the big boys?
    Would that include keeping interest rates at zero for five years so that savers suffer the loss of legitimate time value of money?
    Would that include forcing the stock market to rise while the median household income dropped from $51,000 to $46,000 over the past three years
    Those who support Medicare and Social Security
    Do so either because they do
    Not know the trust funds are filled with debt instead of the excess FICA contributions which were used to pay other federal expenses
    That would be like an insurer using its reserves to buy back their stock to artificially increase the price
    An insurer that depleted their reserves to enrich the stockholders would have a cease and desist order issued by the state department of insurance
    The federal government is not able to accumulate money for future use
    Don Levit

  21. “It might seem that way based upon what our government has been doing in recent decades”

    Robbing moral agency, allan! How very progressive!

    “It wasn’t me guv, the government made me dependent on the government and vote for that dependence.”

    The government does nothing the citizenry do not actively support or tacitly approve.

    Once again I’ll say: your country loves big government, including denizens on the right.

    I dare the GOP to put forward a free marketeer against Hillary that in his/ her manifesto privatizes social security and Medicare.

    Go on. I dare ya! Put your free market principles where your votes are!

    If you do not find the Tea Party placard “Government hands off my Medicare” or Paul Ryan’s appeal to seniors that they might lose their slice of big government absurd precisely because these exemplars of free market, then you are devoid of even single strand of irony.

    What’s their next placard? “Government, hands off my Obamacare!”

    Have you really not heard of Vox news run by Ezra Klein?

    I think you need to get out more.

  22. Touchy? Perhaps, watching a great country be consumed by guilt and stupidity.

    The use of Fox has already become more than just a comparison, but perhaps I should forgive you because you might be unaware. Vox which I believe is German is not comparable to Fox. Maybe you were just trying to make things rhyme, without any rhyme or reason.

    “The same country where the Tea Party, that beacon of free market capitalism, used as its battle cry “government, hands off my Medicare?”

    Nice soundbite, but it is demonstrative of a feeble attempt to use innuendo instead of how did you put it? Adult discussion. The Tea Party supported three major ideas. A balanced budget, the Constitution and smaller government.

    In every group people might have divergent ideas from the basic principles of the group so if just one person diverges the opposition can turn the unsophisticated with a simple soundbite. This seems to be an example.

    Your tone could lead one to believe you don’t like what the Tea Party stood for or might stand for today (The movement has a multiplicity of groups, some with different agendas) . That would mean you don’t like the Constitution, balanced budget or a smaller government. I leave any clarifications that might be necessary up to you.

    I am not quite sure what your point is about Ryan. He proposed his ideas. This country is a pluralistic society so we expect many different points of view, discuss them and hopefully come up with a rational resolution of whatever problems exist. Maybe you don’t realize this. Maybe you watch too much Saturday Night live or Jon Stewart and get your news from them. I don’t know.

    My country likes big government? It might seem that way based upon what our government has been doing in recent decades, but it is founded on the principle of federalism and small government with limited powers. I’m guilty. I like the basic principles this government was founded upon and appreciate that certain distasteful things were abandoned.

    You are right markets are messy, but effective. Dictatorship is much more organized. No discussion needed. Wood choppers abound. You portray the healthcare system in a black and white sense when it is a hybrid so some of the things you say are true though a bit on the hysterical side.

    I’ll take the markets with a compassionate people over the wood choppers and poverty every day of the year.

  23. You’re a little touchy allan! Which is why you picked up on my questioning Fox, not Vox!

    “Yes it is true and I live in a country where the market economy thrived.”

    The same country where the Tea Party, that beacon of free market capitalism, used as its battle cry “government, hands off my Medicare?”

    Or government, hands off my government! That’s not Saturday Night Live!

    So Paul Ryan, the free market musketeer, warns seniors that under Obama that leftie they could lose their Medicare benefits!

    Is this your free market knight appealing to his foot soldiers, allan?

    Live free or die, eh!

    oh, allan don’t make me laugh!

    Your country loves big government, can’t get enough of big government, runs to big government, even more than the Europeans!

    Do you even realize that much of what big pharma produces would never have arisen were they not guaranteed to make a killing, guaranteed by big government, guaranteed by a myriad of regulations.

    Markets are messy. Talk is cheap. No one has had to face them in healthcare in the US. You wouldn’t be able stand to them for a second.

  24. “ I have a parsimonious view of markets.”

    That is fine and probably good in the long run, but under certain circumstances not pleasant. We might want to a bit extra where significant unpleasantness exists, but we don’t have to destroy the marketplace to do so. Nor do we have to destroy the Constitution or remove individual rights.

  25. Hypersensitive bore? …And you go off the handle because someone asks what is wrong with Fox after your whine?

    I am glad you recognize that I have a bias towards markets. Yes it is true and I live in a country where the market economy thrived.

    Yes the sale of iPads is different. So what? Every sector of the economy has its differences. I am sorry that you don’t recognize that.

    We have more than just right and left in this country, but perhaps that is too difficult to understand so you consider anything that is not to the left as being to the right. Not very sophisticated, but I guess it will have to do.. I have news for you Saurabh just like there is a difference between healthcare and iPads there is a difference in political philosophies on the right and the left.

    Next time you want to fix a label of hypersensitive take a look in the mirror.

  26. In this day and age we can no longer be content to criticizes, but DARE to DISRUPT. The economic environment is changing quickly and no business including the healthcare industry will need to change also

  27. You are making a good point, Merrilee. In the first Appendix of my recently published book, I talk about the role of complexity theory in healthcare and how healthcare is very much a complex adaptive system. As a result, you need to be careful when you try to fix one problem, you do not cause a worse one. As a complex adaptive system, healthcare requires an entirely different style of leadership. Much more sophistication and much, much better control of data to be sure you know what you are doing and the consequences of your actions. There is a lot of interesting and exciting work going on in this area right now. Thanks for sharing your thoughts.

  28. Very well said.
    Health care is like a balloon. Squeeze one area and another bulges…but if you aren’t looking or cannot measure all areas simultaneously you will miss the “equal and opposite effect”.

  29. Even amongst patients, what has “value” for one, may not for another. Witness end of life/advanced care plans. They will differ from patient to patient.
    A red flag goes up for me when I see “value” being used to determine what path a patient should follow. Consider the “value” of the Liverpool Care Pathway in the UK. Just say’n.

  30. Oh allan you’re turning out to be such a hypersensitive bore!

    I know you have a considerable bias towards markets to the extent that you cannot seem to fathom why and how healthcare is different to buying Ipads.

    But surely you cannot miss the bipartite media bias in your country? Right & left. That’s right allan, right as well as left.

  31. Charles… I agree. Very well said. We have used value stream maps in virtually every improvement project I have ever been involved in, and every single time, the care teams have measured value in terms of outcome metrics that matter to patients. In fact, we often included patients on the improvement teams to assure that we did a good job at it. One could argue effectively that we should not measure value in healthcare in any other way.

  32. Fair enough but when I think of a value stream analysis it is focused on what is best for the patient. So if we look at a value stream for uncomplicated low back pain, for example, we focus on the patient from start to finish — what is the patient pathway throughout? With a value stream analysis we can identify what steps are added value for patient and what steps are not — and then figure out a way to eliminate the steps that do not add value for the patient. In the traditional lean management approach the value stream is nearly always patient focused.

  33. “It is Time for Clinicians to Engage: Let’s Criticize Less and Dare Greatly More”

    I’ve learned a lot in life and one of the things I learned is when people want others to withhold criticism they generally have something to hide or they are trying to sell something.

  34. “value-stream analysis”

    Value depends on what had you wear. Value for a patient will be different from value for a provider or value for a payer. Be careful with that.

  35. The solutions that are being presented in health care currently in the US and Canada are creating a more complex system that will not help the population overall.

    Only a small part of the health of a population is due to the care provided by MDs.

  36. We definitely agree on these points. We need clinical leaders involved not to be cheer leaders or to rubber stamp, but to use their knowledge and expertise to lead healthcare in a new direction. I believe that is critically important, necessary and it is happening.

  37. I’m not suggesting that MDs avoid leadership positions. I’m suggesting they must be cautious NOT to fall prey to supporting unproven agendas when they don’t make sense, even if they are being paid to do so. A dose of healthy skepticism is needed otherwise we delude ourselves into supporting programs created by consultants and bureaucrats who have limited understanding about the complexities of patients.

    Physicians are best suited to provide an insightful perspective of what ails health care but more and more I’m hearing from MDs who do not support the government’s chosen approach. The voices of these MDs are ignored. That is a big mistake.

    MDs are highly intelligent, observant people. They should not simply become government cheer leaders.

  38. In the movie Ratatouille, Anton Ego, the food critic, states the following about critics:

    “In many ways, the work of a critic is easy. We risk very little, yet enjoy a position over those who offer up their work and their selves to our judgment. We thrive on negative criticism, which is fun to write and to read. But the bitter truth we critics must face, is that in the grand scheme of things, the average piece of junk is probably more meaningful than our criticism designating it so. But there are times when a critic truly risks something, and that is in the discovery and defense of the *new*. The world is often unkind to new talent, new creations. The new needs friends.”

    The new needs friends, which generally does not occur in healthcare unless its going make someone a whole lot of quick money. The art of innovation in most healthcare organizations is only driven from the top by senior management with the authority to allow for change, so that their new ideas can live and breath. If you do not have a friend in senior management, most of your “new” ideas will die before they have seen the light of day, especially if they threaten the status quo of cash flow, billing, or JCAHO.

    As to the critic, let us remember the only difference between a consultant and a critic is that you are paying the consultant to criticize you. As senior management are the only ones to hire consultants, and therefore allowed to use the phrase “Our consultants recommended that we do x, y, and fire Z”, the idea of great daring is a little much to swallow, especially when it comes from a consultant.

    If you want great daring, I believe that you need to foster a climate of innovation at an organization from the top to the bottom so that the “new” has friends at any level. Since I am not seeing most healthcare consultants or senior managements pushing such an agenda, it is unlikely that “daring greatly more” will be possible in such a confining atmosphere.

  39. No kidding! There is no doctor shortage, just a shortage of doctors who actually want to see patients. There is a whole ocean of committees, consultants, board members, observers, cheerleaders, desk surfers, quality talkers and general morons. Get a job for cripes sake! These parasites are going to run out of places to attach to the host.

  40. That anyone can think that the growth of CNOs is a good thing totally beyond comprehension.

  41. Rather than grapple with the fundamental issues underlying the criticism that bothers him, Dr. Haughom criticizes the act of criticism itself.

    I think the word we’re searching for is “irony.”

    I’ll also throw in “straw man” since I don’t think anybody believes criticism alone solves problems. But it does identify problems, which is the first step in solving them. Dismissing or belittling criticism will lead inevitably to festering problems, not solutions. Witness the VA’s recent crisis. Remind me, how did the VA deal with its internal critics again?

  42. “The growth in clinical leadership roles has skyrocketed in recent years (e.g., CMOs, CMIOs, CNOs, etc.). The demand greatly exceeds the supply for these positions”

    And most of us in the trenches would refer to this as ever-increasing administrative bloat, taking time, money, and human resources away from true patient care.

  43. Love the dialog! Some appear to think the current health care system is the “evil empire” that will either implode or be beheaded by the people. Others like the post author are arguing that we should look on the bright side because there has been progress over the last 100 years when compared to the previous 6000, and that we are moving into an era of potentially huge changes as incentives of providers and payers moves into closer alignment. Either way, there is an exciting road ahead for the future of health care, but I think the path of continuous improvement is most credible view.

    The example that John cites related to advances made via Accountable Care Organizations (ACOs) are inspiring. However, I can see that much more work will be needed to make the incentive alignment successful because powerful losers exist in the ACO model. This model includes physicians, hospitals and payers. But what about big pharma and medical device industries? How will their incentives be aligned with the payers. As a medical device designer for 17 years, I have to say that although we used world class medical design process when designing products, I would much prefer to find ways to help people avoid needing them. I accept that in a free economy there will always be winners and losers, but we will need to be wary of big losers and their efforts to spike the punch.

    One other comment, I would love to see one more virtue added to your list for leaders and that is compassion. Maybe this goes without saying but it is one the chief elements needed in our system of health care. Healthcare providers are so comfortable with institutions that they forget how alien an environment it is for patients, and how insecure it can make them feel. many things are done to benefit the provider (and maybe even improve “efficiency”) that actually end up hurting the patients. The inverse relationship that often exists between cost and quality, will be a challenge to navigate without a good strong dose of compassion, in particular for the elderly.

  44. Savings in length of stay, when examined critically, are turning out to correspond to increases in the cost of post-acute care. Often, these so-called improvements are simply pushing the balloon in and then watching it bulge out in another spot. As a clinician working 100% of the time in the trenches, my suspicion and distrust of “thought leaders” grows by the day. They’ve supplied me with disposable laryngoscopes that are so bad I can’t intubate with them, and have had to go back to carrying my own with me. They’ve decreed that sutures and other necessary OR supplies have to be kept in a central core rather than in each OR, so that the nurse has to run out of the room every single time a surgeon requests something. They act as though the physicians and nurses who are at the bedside are criminals just waiting to be caught breaking some new rule. They seem to care only about numbers and processes, and very little about the individual patient that I face on the OR table every day. This isn’t criticism; it’s reality. Yes, I work with great teams. But we aren’t allowed, let alone encouraged, to do things better in our own innovative ways. It’s the Joint Commission way and the CMS way or the highway, with the blessing of our chiefs and administrators. How long has it been since you loaded any of the trucks, Dr. Haughom?

  45. So, basically, you are admitting that clinical care is one-third as effective in prolonging life at many, many multiples the cost. Such value!

    Let’s all be grateful that our vaunted healthcare leaders don’t run the auto industry or the technology sector. If they did cars would be bigger, slower, and less fuel efficient than in 1985, and computers would now be twice as large as they were in 1985 and four times as expensive.

    The next revolution in public health will be the public’s rejection of the medical care system’s screen today, screen tomorrow, screen forever and make a perpetual patient out of everyone mentality.

  46. Leslie… In my response above, I made on key typo. Here is what I meant to say.

    Thanks for your comments, Leslie. I agree with you and this is why we need to have more clinicians in leadership. Once again, the data shows we are headed in this direction. The growth in clinical leadership roles has skyrocketed in recent years (e.g., CMOs, CMIOs, CNOs, etc.). The demand greatly exceeds the supply for these positions. Increasingly, these roles are by necessity focusing on value which inevitably makes the process of care the center of attention. Value absolutely requires the meaningful involvement of physicians and nurses. I was amazed by a recent survey reported in the last issue of Health Affairs. Among the rapidly growing number of ACOs in the country, 50% are led by physicians and another 30% are collaboratively led by a physician and an operational leader. I knew this would happen, but I did not expect it to happen so fast. As the movement toward value in healthcare unfolds, the need to effectively manage care will only accelerate. I believe that is necessary and important. [NOTE: Managing care does not mean managing physicians and nurses. It means we need to engage clinicians in effectively managing care. Only clinicians are equipped to do that.]

    By the way, I agree with you about the dialogue. Whether we agree or not, this type of dialogue is important. Thanks for your comments. John

  47. Thanks for your comments, Leslie. I agree with you and this is why we need to have more clinicians in leadership. Once again, the data shows we are headed in this direction. The growth in clinical leadership roles has skyrocketed in recent years (e.g., CMOs, CMIOs, CNOs, etc.). The demand greatly exceeds the supply for these positions. Increasingly, these roles are by necessity focusing on value which inevitably makes the process of care the center of attention. Value absolutely requires the meaningful involvement of physicians and nurses. I was amazed by a recent survey reported in the last issue of Health Affairs. Among the rapidly growing number of ACOs in the country, 50% are led by physicians and another 30% are collaboratively led by a physician and an operational leader. I knew this would happen, but I did not expect it to happen so fast. As the movement toward value in healthcare unfolds, the need to effectively manage physicians will only accelerate. I believe that is necessary and important.

    By the way, I agree with you about the dialogue. Whether we agree or not, this type of dialogue is important. Thanks for your comments. John

  48. Thanks for your comments, Bobby.

    Which care system is “better” depends on what you look at. In terms of rescue care and specialty care, the US system is substantially better than other industrialized nations. However, we do worse in terms of primary care, behavior modification and prevention. In those areas, the US has to do much better and I believe there are very promising options on this front going forward. Once again, it will require engagement by clinicians as well as society in general. These issues are covered in Chapters 1, 2 and 8 of my book.

  49. This comment thread is terrific. Dr. Haughom, my experience has been that leaders often don’t give physicians a lot of time to create solutions…we are told to make things better but not given the time or resources to do so.

    I think this often creates a certain cynicism within the front line.

    I will also add that when I was starting internship, we had a touchy-feely orientation in which we repeatedly told how concerned they were for our wellbeing and that we should let them know if we need help. Two days later, I found myself in over my head. I asked for help, and was basically ignored…really, I was told to just keep moving.

    So…there’s what the leadership says, and what they do, and often there’s a big gulf between. I think closing that gulf will help clinicians step up and leverage their criticisms into problem-solving.

    Historically, productivity has been the number one priority. That’s what the actions show so far.

  50. “For decades, experts have puzzled over why the US spends more on health care but suffers poorer outcomes than other industrialized nations. Now Elizabeth H. Bradley and Lauren A. Taylor marshal extensive research, including a comparative study of health care data from thirty countries, and get to the root of this paradox: We’ve left out of our tally the most impactful expenditures countries make to improve the health of their populations—investments in social services…”

    http://www.amazon.com/The-American-Health-Care-Paradox/dp/1610392094/ref=sr_1_1?ie=UTF8&qid=1409782304&sr=8-1&keywords=American+health+care+paradox

  51. Charles… Thanks so much for your comments. I could not agree more. As I said, criticism has its place. My point is simply that you have to balance the act of criticizing with at least an equal measure of thoughtful and innovative thinking regarding solutions. You do an excellent job of highlighting what we need more of in healthcare, especially as a group of clinicians. We need to engage in meaningful process improvement, including the use of value stream mapping. We need to eliminate unwarranted variation and waste (I view avoidable harm as simply a form of waste). Why don’t we have a consensus around the Triple Ai8m especially among clinicians? In my view, the future will be all about value (i.e., higher quality, safer, less wasteful and more cost effective care). It is not possible to realize value in healthcare without focusing on and improving the process of care. Achieving value will require engagement by healthcare’s frontline workers — clinicians. This is pretty much what my book is about.

  52. John I appreciate your effort here but I also understand much of the reaction. We need thoughtful criticism of the current system. What we need much more of — and I do agree with you here — is an effort to subject every process in health care to a rigorous value-stream analysis to identify defects and build new approaches. Why so much unwarranted variation? Why so much waste? Why so many patients falling through cracks? Why isn’t there a national consensus that the Triple Aim must be our collective goal? It strikes me that there is too much acceptance of the status quo and in some parts of the country far too much focus on acquiring the kind of dominant market share that drives up costs and does little or nothing to improve quality. The best criticism is fuel to drive us toward solutions.

  53. Vik… You are correct that Public health measures have mattered a great deal, but so to has clinical care. The evidence shows that public health added about 3.5 years to life expectancy per decade between 1900 and 1960. However, the big advances offered by public health largely reached a plateau. Since 1960, clinical care has added about 1.3 years to life expectancy per decade.

    In the last 60 years have we been able to show that clinical care
    can make a difference. This is in the lifetime of many people involved in
    healthcare today. We can do more than just predict whether a patient will live
    or die. We can actually change the outcome. We are the first generation
    of clinicians that can make that claim. That’s something that I’m proud and
    excited to be a part of.

    We stand on the foundation of 100 years of science that has massively
    improved our understanding of the human organism in health and disease
    and given us thousands of ways to improve the well-being and life expectancy
    of patients.

  54. The great public health accomplishments of cleaner water, safe food supplies, food fortification, vaccinations, indoor plumbing, lead paint abatement, education about tobacco use, and improvements in motor vehicle and workplace safety have done much more than any clincal intervention to prolong lifespan. In fact, I don’t even think you understand the irony of what you wrote. Cancer, heart disease, and stroke are predominantly diseases of aging and in earlier ages people rarely lived long enough to develop them.

    So, what you are saying really, is that as living has gotten better, easier, and, thus, longer, people now survive to become old enough for their bodies to decay and die from a chronic disease and medicine bravely steps into the breech to let them draw a different Ace of Spades. That’s all well and good, but let’s see it for what it is. Heart disease is the number 1 cause of death ONLY because it’s the easiest thing to record on a death certificate. No one does post mortems on 80 year olds who die in their sleep; they had a “heart attack.”

  55. Thanks for your comments, Rob. I never said not to complain or criticize. I just believe that the act of criticizing needs to be balanced with at least an equal amount of time discussing and creating meaningful solutions.

    With respect to EHRs, I agree with many of your points. While clinical care needs to enter the digital age and we need EHRs, current EHRs need to be vastly improved. This is slowly happening, once again with meaningful and heavy involvement from responsible clinicians. We will see many changes and improvements over the next two or three years.

  56. Vik… See my comments on the progress we have made over the past century. It has been huge and unrivaled in the past 6000 years. Still, there is no doubt that as the complexity of care has grown, so too have the problems related to quality, safety, waste and cost. All of these can be largely remedied by attention to improving the process of care. This is something clinicians understand and need to engage in. The ACA represents insurance coverage reform. It does little to substantively improve the process of care for the patients we serve. As responsible clinicians, we need to engage in that important work.

  57. I was once one of the biggest EMR proponents. I did so because I was able to use computers to make my office run better and make the care I gave better. It did that. I was the opposite of a critic: I was an evangelist, telling others the benefits and potential of this great tool.

    Now I am one of the greatest critics of EMR, as the potential to improve care has been co-opted, turning it into something that worsens care. I speak as loudly as I can, given my status as a PCP, but I also act, trying to build a different/better option on my own. My activity to change things, however, is absolutely a criticism of what’s out there.

    We always need to be critical, as a lack of it makes us simply gullible. The person who simply complains but does nothing may be doing so to get the people who can change things to do that. But many just complain because they want to blame others for the hard problems they are unwilling to take on.

    Still, I think that sending the message for people to not complain is often equated with silencing critics. We should never do so. Critics (including our own self-criticism) are the guardrails that keep us on the road. Change doesn’t happen without criticism. Change doesn’t happen until the few voices of complaint become many. Criticism, which is the illumination of what is wrong, is a necessary (but not sufficient) condition for change.

    But I think the characterization of doctors as non-doers when it comes to changing health care is off the mark. There are many of us working to make things change. Surely the monolithic system can’t with its “wicked” problems won’t come down easily, but just like the death star, a few well-placed blasts can disrupt everthing. It’s hard, but it’s not impossible. I used to bull’s-eye womp rats in my T-16 back home, and they’re not much bigger than two meters.

  58. Bobby… I am not talking about “balancing criticisms.” I am talking about balancing the act of criticizing with at least an equal amount of focus on creating solutions.

  59. Let’s consider the facts. Over the past century, lifespan has increased by over 30 years. This is after remaining relatively stagnant for about 6,000 years. In the industrialized world, infections that used to kill people by the tens of thousands have either been irradiated or are tightly controlled. Since 1960, age adjusted mortality for heart disease (the number one cause of death) has decreased by 56%. Since 1960, age adjusted mortality from stroke has decreased by over 70% Over the past twenty years, many cancers have become either curable or a essentially a chronic disease. There is a huge amount of evidence that the outcomes that matter most to patients — a healthy, functional and long life — has improved dramatically over the past several decades. By no means does this mean we can ignore the problems, but the fact that we have the best healthcare the world has ever seen is pretty indisputable based on criteria that most patients care about.

  60. Bobby is right. No serious person makes that claim with a straight face. The system is great for people like me, who are connected, savvy, and have resources. Most average Americans, hmmm, maybe not so much.

    And, please explain then, how, if it is the best in the world it required the massive and complex overhaul known as the Affordable Care Act? Was that just supposed the few finishing touches needed to really round things out?

  61. To play with your metaphors a bit, I don’t want American healthcare consumers to find common ground with their healthcare leaders (if you can could identify them, which, as I wrote in a post with General Healthy, you cannot). I want them to punch them in the mouth. For the 50 year ascendancy of the physician-as-expert-in-all-things-health, we have gotten a dithering class of professionals who yammer incessantly now about how tough their lives are. Poor babies.

    You think the problem is EHRs? Good grief, we still can’t agree on giving everyday consumers access to data from state medical boards so that they see which physicians have had claims of malfeasance brought against them and the results of those investigations. I can find out more about registered sex offenders living suburban St. Louis than I can about any physician caring for my family.

    The healthcare system is being hoisted by its own petard. In its endless mewling for more (money), more (power), more (complexity), we now have a system that is slowly choking to death on all that excess. I won’t be sending flowers to the funeral.

  62. You don’t properly “balance criticisms.” You address and refute them. Those that are simply cynical and/or otherwise fatuous can be debunked relatively quickly.

  63. “There is a great deal of evidence that we currently have the best healthcare system the world has ever seen.”
    ___

    Depending on your definition of “best.” There is also a tsunami of evidence to the contrary.

  64. Thank you, John. I agree with your comments. I do not see an issue with criticizing. I do see a problem with not balancing that criticism with productive conversations about solutions. The world is eager for solutions. I also believe that as clinicians we have a meaningful and powerful role in creating solutions. There are problems. They need to be fixed. Most of them are related to the process of care. Clinicians understand the process of care better than anyone. It is time for us to move on to that productive discussion.

  65. So, I can’t figure out how to reply to your cool aid comment below.
    This goes here.

    Actually, I’m not sure your comment is fair. There is a difference between kool aid and trying to keep a conversation on productive ground.

    I think John’s point is that when you go beyond a certain point criticism generally causes more problems than it solves and tends to distract from more positive uses of one’s time …

    In this particular conversation, there’s a huge opportunity cost.

    We spend a lot of time freaking out and bemoaning our fate that could be used for problem solving, for finding common ground, for constructive action.

    The usability concerns around EMRs and the problems people have with some of the new quality measures are great examples.

    Do the critics have a point? Sure. That’s obvious to anyone that’s remotely paying attention. There are problems. They need to be fixed.

    Let’s fix them.

  66. There is a great deal of evidence that we currently have the best healthcare system the world has ever seen. I review some of this evidence in my book. However, it has also become increasingly complex, leading to the quality, safety, waste and cost challenges we currently face. These challenges can all be managed but we need to find creative solutions to address them. This will require clinical thought leaders and innovators, and the collective involvement of clinicians.

  67. While we might disagree on some of the details, I certainly agree that there are many exciting and powerful solutions to the challenges currently facing healthcare. There are amazing possibilities just over the horizon, and I believe the future has the possibility of being exciting, rewarding and meaningful. Whether it is or is not, is largely up to us. We do not have to be pawns in this process. We can play a powerful and meaningful role in the future. Let’s hope we do.

  68. As I said, I agree that criticism has its place. However, the world needs solutions. If we do not balance criticism with solutions, it is highly unlikely we will have a voice or an impact. Based on the engaged groups of clinicians I see around the country, I believe this is starting to happen and it is long overdue. Clinicians are at the center of the care process. We need to use our knowledge and position to effect meaningful change that benefits patients. If we do not figure out how to do this collectively, it is likely we will get more of what neither we nor patients want.

  69. I am not sure I agree, Merrilee. Over the years, I have worked with many teams of dedicated clinicians on improving care, and almost always found that the efforts of a well trained, committed team results in the whole being greater than the sum of the parts. That is what good teams do. In addition, it is not likely clinicians will have a voice in coming changes if we do not speak collectively about what we know best — patient care. Because we are not doing this, we are leaving a void to be filled by others who understand care far less than we do. There is truth in the old saying, “United we stand, divided we fall.”

  70. We are in agreement. As I indicate in the essay, criticism has its role, but it needs to be balanced with effective solutions. Criticism alone is not likely to accomplish much. Healthcare is blessed with the most intelligent, well educated and committed workforce in the world. We need to engage them in solutions. They understand the process of care and how to make it higher quality, safer, more efficient and more cost effective. No insurer can accomplish those goals. As clinicians, we need to understand the value of our extensive knowledge, as well as our strong commitment to and relationship with patients, and use it to improve care for everyone.

  71. Saurabh and Perry are on to something here, I think.

    Healthcare is clearly a super wicked problem.

    Snip =

    “Wicked problem” is a phrase originally used in social planning to describe a problem that is difficult or impossible to solve because of incomplete, contradictory, and changing requirements that are often difficult to recognize. Moreover, because of complex interdependencies, the effort to solve one aspect of a wicked problem may reveal or create other problems.

    Rittel and Webber’s (1973) formulation of wicked problems specifies ten characteristics, perhaps best considered in the context of social policy planning. According to Ritchey (2007)[2], the ten characteristics are:

    There is no definitive formulation of a wicked problem (defining wicked problems is itself a wicked problem).

    Wicked problems have no stopping rule.

    Solutions to wicked problems are not true-or-false, but better or worse.
    There is no immediate and no ultimate test of a solution to a wicked problem.
    Every solution to a wicked problem is a “one-shot operation”; because there is no opportunity to learn by trial and error, every attempt counts significantly.

    Wicked problems do not have an enumerable (or an exhaustively describable) set of potential solutions, nor is there a well-described set of permissible operations that may be incorporated into the plan.

    Every wicked problem is essentially unique.

    Every wicked problem can be considered to be a symptom of another problem.

    The existence of a discrepancy representing a wicked problem can be explained in numerous ways. The choice of explanation determines the nature of the problem’s resolution.

    The planner has no right to be wrong (planners are liable for the consequences of the actions they generate).

    Seeking to generalize the concept of problem wickedness to areas other than planning and policy, Conklin identifies the following as defining characteristics of wicked problems:[3]

    The problem is not understood until after the formulation of a solution.

    Wicked problems have no stopping rule.

    Solutions to wicked problems are not right or wrong.

    Every wicked problem is essentially novel and unique.

    Every solution to a wicked problem is a ‘one shot operation.’

    Wicked problems have no given alternative solutions.

    And then there are ‘super wicked problems’:.

    Kelly Levin, Benjamin Cashore, Steven Bernstein and Graeme Auld introduced in 2007 the distinction between “wicked” and “super wicked problems”.[23] They first presented International Studies Association Convention in Chicago, February 28 – March 3, 2007. They presented a revised version of the paper to the Climate Change: Global Risks, Challenges and Decisions Congress, 10–12 March 2009, Copenhagen, Denmark.

    They defined super wicked problems as having the following additional characteristics:

    Time is running out.

    No central authority.

    Those seeking to solve the problem are also causing it.

    Hyperbolic discounting occurs

    While the items that define a wicked problem relate to the problem itself, the items that define a super wicked problem relate to the agent trying to solve it. Global warming is considered as super wicked problem by others.[1]

  72. Agree with all four points.

    We need an adult discussion on air.

    Not Vox. Not Fox.

  73. My fanciful list:

    Artificial Intelligence enters EHR so that diagnoses is improved. Na of 132 has little flag : “Inappropriate ADH may be occurring on your patient.” Migrating large joint arthritis brings up “This can occur in Meditarranean Fever”…

    Vans with small labs and imaging equipment and GPs or PAs or NPs begin making house calls again.

    More emphasis on home care, in general.

    Whenever one lab is ordered, all are done…on a few lamdas of blood. (Within reason)

    Indemnity returns so that patient receives payments from insurers and thus begins to learn charges and controls ultimate reimbursement.

    Experiment with county hospitals going free without billing where they would manage or admit all people who 1. Have illness that might kill them or 2. Might disable them or 3. Illness that might bankrupt them. No business records kept, only medical records. No clerical employees, only clinical. All docs on salary. Ambulatory banal care is left to patient to manage in any way desired.

    Full genome determined on every citizen in US., with new profession “genome translators” GTs becoming part of medical profession specialties.

    Affirm criterion of “useful” in granting US Patents so that post marketing clinical research does not have to determine usefulness so often.

    Try to arrange some way for the public’s democratic voice to be expressed in health care policy. Eg what should be covered in a health plan offered by the government? Who should decide influenza vaccine priorities in epidemic situations? Drug policy of the US? Some input into research priorities of NIH?

    Incentives for insurers to weigh heavily on mental health and drug rehab have got to be studied and in place.

  74. Then again, maybe Healthcare is more of a Super Wicked Problem:
    1.Time is running out.
    2.No central authority.
    3.Those seeking to solve the problem are also causing it.
    4.Policies discount the future irrationally.

  75. Healthcare is a wicked problem.

    http://en.wikipedia.org/wiki/Wicked_problem

    There are no solutions, only trade-offs.

    A critic is one who points out the upside and downside.

    A cynic is one who only thinks of the downside.

    A woolly optimist is one who throws his/ her toys out of the pram when someone points out the downside.

    There is a very thin line between a woolly optimist and a snakeoil salesman.

    I took the red pill. I gulped it down with Talisker 18.

    I wish I had taken the blue pill.

  76. ” If it is heeded in time, danger may be averted; if it is suppressed, a fatal distemper may develop.”

    Yes, that distemper is here. We should have given those puppies their vaccines.

  77. The dismissal of criticism as a communicatoin form, common amongst our dear healthcare leaders, demonstrates a real intellectual limitation and a certain tinge of cowardice. In my view, it is long past time for Americans to become a lot more critical of, and a lot more combative with, their vaunted healthcare industry which has “served us well and accomplished great things.” Yes, served us so well and accomplished so many great things that it did not need an incoherently complex reform that will cost the nation a small fortune to implement and will do more to codify dysfunction than to fix it.

    Everyone of the commentors above has it right. And so, too, did Churchill: “Criticism may not be agreeable, but it is necessary. It fulfils the same function as pain in the human body; it calls attention to the development of an unhealthy state of things. If it is heeded in time, danger may be averted; if it is suppressed, a fatal distemper may develop.” The fatal distemper is the addled notion that our healthcare industry has any meaningful “leadership” of any kind. It doesn’t.

  78. I am with you there, Merrilee.
    Individuals are generally pretty ethical.
    It is groups, particularly groups led by dynamic leaders, that raises red flags.
    Think of Moses, the greatest Jew who ever lived, was also the humblest Jew.
    Don Levit

  79. “They tend to be excellent communicators both in word and action, and their presence alone energizes and inspires people . . . The future belongs to people such as these”

    Very dangerous way of thinking. It’s brought us:

    Jonestown, the Iraq war, lousy EHRs . . .

  80. There will be no long term solutions found for health care unless the cheer leading stops and more diverse perspectives are sought out and appreciated.

    To find the very best solutions critical thinking AND criticism are required. “Groupthink” is dangerous to innovation and open minds.

  81. This is a tactic know as branding and marginalizing. The thought leaders and innovators of yesterday produced the horrific mess of a system we have now. Shouldn’t there been some consideration of the dissent instead of riding the bandwagon of consensus momentum to the next level of “ooops, we blew it!”?

  82. I agree wholeheartedly with Datum.
    One must first recognize the shortcomings, and be passionately critical of some of the present system’s failings.
    This passion needs to be transformed into positive action.
    As the author suggested, we need to carry forward what works, and discard what doesn’t.
    Change is hard for everyone, but change is the natural rhythm of life.
    For far too long insurers have been able to control the natural rhythm in their favor.
    Now, it is time for insurers to provide products in which all parties win, in the short term, and particularly, the long term.
    Let’s stir up some trouble to promote efficient and fair changes to our health care system.
    Don Levit

  83. It would be helpful if you included your definitions of “critic” and “innovator” to assist the reader as they navigate your essay …

    Many innovators begin life as critics.

    Many critics are thoughtful. Many leaders are not.

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