This blog post
originated in my surprise that the Opening Ceremonies of the Olympic Games
honored both the National Health Service and Tim Berners-Lee. Watching the doctors and nurses
and patients dancing in the Olympic Stadium made me wonder why health care
reform united the United Kingdom and seems to be tearing apart the United
States. I also started to wonder
why so many physicians in the United States seem to defend the status quo that
has resulted in the “inconceivable” outcomes documented in Part II of the
blog. How can professionals defend
a system that is so costly and results in such low quality by any objective
measurement? The short answer is that doctors are human beings.
Arrogance and power and
social standing make it hard for any professional to exhibit the humility,
courage, and existential strength that are needed to continuously improve one’s
craft. In examining journalism’s
response to the ongoing News International surveillance, phone hacking, and
bribery of police officers scandal in Great Britain, David Carr wonders why the
offenders are seen as “outliers;” he wonders why there have not been
“deeply
reported investigative articles about how things went so wrong: the failures of
leadership, the skewed values and willingness of an industry to treat the
public with such contempt. The Guardian correctly suggested that the arrests
were unprecedented in the history of newspapers.”
Carr examines the many
reasons why 66% of the public no longer trusts newspapers to be accurate, and
he zeroes in on why journalism as an industry has lost its way.
“The
news media often fail to turn the X-ray machine on themselves because, in part,
journalists assign a nobility to the profession that obscures the flaws within
it. We think of ourselves as doing
the People’s work, and write off lapses in ethics and practices as potholes on
the way to a Greater Truth.” (http://www.nytimes.com/2012/07/30/business/media/holding-up-a-mirror-to-journalism-the-media-equation.html?ref=business)
I started Part I of this
blog by discussing one of my heroes, Tim Berners-Lee, but now I have to reflect
on one of my heroes who recently passed away: Joe Paterno. A sociology
professor stated,
“It
makes sense that the catastrophic fall of Paterno correlates with the degree of
hypocrisy people have identified between Paterno – the moral do-gooder – and
this really ugly underbelly of the program he ran that was so morally
contemptible.” (http://blog.pennlive.com/patriotnewssports/2012/07/joe_paterno_provides_a_caution.html)
The Penn State football
program and its coach achieved unparalleled success on the field, and Paterno
became the most powerful person in the entire university. Arrogance and an inbreeding where
leaders were recruited internally created a culture that valued “protecting”
the reputation of the athletic program more than protecting the safety of young
men being abused by Jerry Sandusky.
Like journalists serving
the Greater Truth and Paterno extolling the Grand Experiment of melding
athletics with academics, physicians see themselves as part of a noble
profession ably taking care of patients.
Physicians are famous for not appreciating advice or oversight from
non-physicians. When physicians
and nurses are found to have done the “inconceivable” things we discussed in
Part II, the outlier concept is quickly articulated.
Dr. Kevin Pho criticizes
policy wonks in “The Tension Between Physicians and Health Policy Experts” for
not deferring to physicians on how to reform the American health care delivery
system.
“Yet,
to successfully reform our health system, doctors need to be at the forefront,
not policy experts. And I’m not
saying that because I’m a physician myself.” (http://www.kevinmd.com/blog/2011/05/tension-physicians-health-policy-experts.html)
The good doctor doth
protest too much.
This idea that
physicians need to always lead any effort to improve health care delivery does
not make sense. Physicians,
patients, nurses, hospital administrators, legislators, health plan executives,
and employers all have part of the answer to the health care delivery
problem. Robust, long-term
solutions to the complicated problems of health care delivery can only be
crafted when all of the listed players truly understand how the problem looks
and feels to each of the others. Theory U: Leading from the Future as It Emerges
by C. Otto Scharmer (San Francisco:
Berrett-Koehler, 2009) offers a way to gain the wisdom and insight from
all concerned when trying to come up with lasting solutions.
Physicians, like
journalists and football coaches, are human beings. They are no more or less likely than other human beings to
act rationally, irrationally, bravely, cowardly, or ethically. This tension between the idealized view
that many physicians have of themselves and reality was nicely captured in a
series of letters between Arnold Relman, MD, the former editor of The New
England Journal of Medicine and Princeton economist Uwe Reinhardt. Relman thinks physicians are special
and he asks Reinhardt the following question:
“Do
you really see no difference between physicians and hospitals on the one hand,
and ‘purveyors of other goods and services,’ on the other?”
Reinhardt is ready with
a long answer that should be read in its entirety. The short answer is that doctors act like any other human
beings. A portion of his
answer includes the following:
“Surely
you will agree that it has been one of American medicine’s more hallowed tenets
that piece-rate compensation is the sine qua non of high quality medical
care. Think about this tenet, We
have here a profession that openly professes that its members are unlikely to
do their best unless they are rewarded in cold cash for every little
ministration rendered their patients.
If an economist made that assertion, one might write it off as one more
of that profession’s kooky beliefs.
But physicians are saying it.” (http://content.healthaffairs.org/content/5/2/5.full.pdf+html)
Physicians are human
beings who try to do their best in a complicated, dysfunctional, rapidly
changing health care system that too often results in the bad outcomes
documented by Millenson and the ProPublica journalists cited in Part II of this
blog. I agree with Dr. Thomas
Smith of Johns Hopkins who was quoted as saying, “Most doctors are
sleepwalkers, not evildoers.” (http://www.usatoday.com/news/health/story/health/story/2012-01-30/Doctor-exposes-the-dangers-of-overtreatment/52893278/1)
Human beings, including
doctors, are not good judges of their own performance and behaviors. Self-deception is part of being human
and has been called “one of the most puzzling things that humans do.”
“Researchers
disagree over what exactly happens in the brain during self-deception. Social psychologists say people deceive
themselves in an unconscious effort to boost self esteem or feel better.
Evolutionary psychologists, who say different parts of the brain can harbor
conflicting beliefs at the same time, say self-deception is a way of fooling
others to our own advantage.” (http://online.wsj.com/article/SB10000872396390443343704577548973568243982.html)
What is not
controversial is that human beings deceive themselves and are not good judges
of their own behavior. Children as young as three have a “positivity bias”
where they see themselves as smart regardless of their abilities. Nobelist Daniel Kahneman’s Thinking, Fast and Slow (New York: Farrar, Straus and Giroux, 2011)
catalogs and analyzes the false beliefs that we humans automatically think are
true. The illusion of validity is
the false belief that our own judgment is accurate, and Kahneman admits that
even he cannot escape the cognitive illusion that his own judgments are
reliable. Although he won the
Nobel Prize in Economics for developing the field of behavioral economics, Kahneman
is a still a human being, and human beings harbor cognitive illusions. Another scholarly book on
self-deception worth reading is Robert Trivers’ The
Folly of Fools (New York: Basic Books, 2011).
And that is why doctors,
being human, need all the help they can get from check lists, social
scientists, empowered patients, patient families, employers, spouses,
government regulators, individual and group report cards, nurses, and
others. The last word goes to
President Ronald Reagan, “Trust, but verify.”
