Tuesday, July 31, 2012

The Olympics, Doctors, the NHS, Transformation and Heroes: Why the Difference between the USA and UK, Part III

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.” 

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