But before long it becomes clear that he is really interested in a problem that afflicts virtually every aspect of the modern world—and that is how professionals deal with the increasing complexity of their responsibilities. It has been years since I read a book so powerful and so thought-provoking. Gawande then visits with pilots and the people who build skyscrapers and comes back with a solution. Experts need checklists—literally—written guides that walk them through the key steps in any complex procedure.
In the last section of the book, Gawande shows how his research team has taken this idea, developed a safe surgery checklist, and applied it around the world, with staggering success. It is neither. Teaching and Learning. Gutman Library. Alumni Services. Renew Books. Change of Address Form. Special Collections. Request for Library Purchase.
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Brittleness is the inability of a system to cope with surprises, and, as we apply computers to situations that are ever more interconnected and layered, our systems are confounded by ever more surprises. By contrast, the systems theorist David Woods notes, human beings are designed to handle surprises.
Last fall, the night before daylight-saving time ended, an all-user e-mail alert went out. The system did not have a way to record information when the hour from 1 A.
This was, for the system, a surprise event. The only solution was to shut down the lab systems during the repeated hour. Fetal monitors in the obstetrics unit would have to be manually switched off and on at the top of the repeated hour.
Medicine is a complex adaptive system: it is made up of many interconnected, multilayered parts, and it is meant to evolve with time and changing conditions. Software is not. It is complex, but it does not adapt. That is the heart of the problem for its users, us humans.
Adaptation requires two things: mutation and selection. Mutation produces variety and deviation; selection kills off the least functional mutations. Our old, craft-based, pre-computer system of professional practice—in medicine and in other fields—was all mutation and no selection. There was plenty of room for individuals to do things differently from the norm; everyone could be an innovator. But there was no real mechanism for weeding out bad ideas or practices.
Computerization, by contrast, is all selection and no mutation. For those in charge, this kind of system oversight is welcome. Gregg Meyer is understandably delighted to have the electronic levers to influence the tens of thousands of clinicians under his purview.
He had spent much of his career seeing his hospitals blighted by unsafe practices that, in the paper-based world, he could do little about. A cardiologist might decide to classify and treat patients with congestive heart failure differently from the way his colleagues did, and with worse results. That used to happen all the time.
But those processes cannot handle more than a few change projects at a time. Artisanship has been throttled, and so has our professional capacity to identify and solve problems through ground-level experimentation. The answer is that the two systems have different purposes. Consumer technology is all about letting me be me. Human beings do not only rebel. We also create. We force at least a certain amount of mutation, even when systems resist. Consider that, in recent years, one of the fastest-growing occupations in health care has been medical-scribe work, a field that hardly existed before electronic medical records.
Medical scribes are trained assistants who work alongside physicians to take computer-related tasks off their hands. This fix is, admittedly, a little ridiculous. We replaced paper with computers because paper was inefficient. And it sort of works. Not long ago, I spent a day following Lynden Lee as he scribed at a Massachusetts General Hospital primary-care practice.
Lee, a twenty-three-year-old graduate of Boston University, is an Asian-American raised in Illinois, and, like many scribes, he was doing the job, earning minimum wage, while he applied to medical school.
He worked for Allan Goroll, a seventy-two-year-old internist of the old school—fuzzy eyebrows, steel-wool hair, waist-length white coat. Goroll can spend more time with you instead of typing at the computer. Goroll, in private, I can certainly leave the room. The first patient was Zoya Shteynberg, a fifty-seven-year-old immigrant from the Soviet Union with copper-red hair and red-rimmed glasses.
Goroll faced Shteynberg across his desk. To his left, his computer sat untouched. To his right, Lee stood behind a wheeled laptop stand, his fingers already tapping at the keys.
The story Shteynberg told was complex, and unfolded, as medical stories often do, in pieces that were difficult to connect.
She had been having sudden, unusual episodes. They sometimes made her short of breath, at other times nauseated. While driving her car, she had an attack in which her heart raced and she felt so light-headed that she feared she might pass out. She had a history of high blood pressure, and she had frequent ear congestion. Goroll probed and listened, while Lee recorded the details.
He paused to tell Lee how to organize the information: to list faintness, high blood pressure, and ear congestion as three separate problems, not one. When it came time for a physical examination, Lee and I stood behind a curtain, giving Shteynberg privacy. Goroll called out his findings for Lee to record. We returned to the room, and the doctor summarized his observations for Shteynberg. He listed a few possibilities and follow-up tests.
Underpaid and minimally trained, they learn mostly on the go, and turn over rapidly most within months. Research has found error rates between twenty-four and fifty per cent in recording key data; Goroll still spends time after clinic reviewing the charts and correcting errors.
But Lee spared him many hours a week, and Goroll was thrilled about it. He got back enough time to start work on the eighth edition of a textbook he has written on primary-care medicine. And, because of his scribe, he was able to give his patient his complete attention throughout the consultation.
Goroll will come right up in front of my eyes, and he listens. We are already seeing the next mutation. IKS Health, which provides the service, currently has four hundred physicians on staff in Mumbai giving support to thousands of patient visits a day in clinics across the United States.
The company expects to employ more than a thousand doctors in the coming year, and it has competitors taking the same approach. Siddhesh Rane is one of its doctor-scribes. A thirty-two-year-old orthopedic surgeon from a town called Kolhapur, he seemed like any of my surgical colleagues here in Boston, direct, driven, with his photo I.
He explained the virtual-scribe system to me when we spoke via Skype. In India, Rane listens to the visit and writes a first draft of the office note. One, Nathalee Kong, a thirty-one-year-old internist, was based at an M. For a week, Rane listened to recordings of her patient visits and observed how she wrote them up.
A note for a thirty-minute visit takes Rane about an hour to process. It is then reviewed by a second physician for quality and accuracy, and by an insurance-coding expert, who confirms that it complies with regulations—and who, not incidentally, provides guidance on taking full advantage of billing opportunities. IKS Health says that its virtual-scribe service pays for itself by increasing physician productivity—in both the number of patients that physicians see and the amount billed per patient.
Kong was delighted by the arrangement. Let me check that off in the computer before I forget. Before working with Rane, Kong rarely left the office before 7 P. Kong manages a large number of addiction patients, and has learned how to use a list to track how they are doing as a group, something she could never have done on her own.
Her biggest concern now? That the scribes will be taken away. Yet can it really be sustainable to have an additional personal assistant—a fully trained doctor in India, no less—for every doctor with a computer? Big technology companies are already circling to invest in IKS Health. They see an opportunity for artificial intelligence to replace more and more of what Rane does.
Yet they also reported no significant change in their job satisfaction. With the time that scribes freed up, the system simply got doctors to take on more patients. Studies of scribes in other health systems have found the same effect.
Squeezing more patients into an hour is better than spending time entering data at a keyboard. More people are taken care of. But are they being taken care of well? As patients, we want the caring and the ingenuity of clinicians to be augmented by systems, not defeated by them. In an era of professional Taylorization—of the stay-in-your-lane ethos—that does not seem to be what we are getting.
Putting the system first is not inevitable. In their factories, front-line workers were expected to get involved when production problems arose, instead of being elbowed aside by top-down management. By the late twentieth century, American manufacturers were scrambling to match the higher quality and lower costs that these methods delivered.
Some people are pushing back. Neil R. Malhotra is a boyish, energetic, forty-three-year-old neurosurgeon who has made his mark at the University of Pennsylvania as something of a tinkerer. He has a knack for tackling difficult medical problems.
In the past year alone, he has published papers on rebuilding spinal disks using tissue engineering, on a better way to teach residents how to repair cerebral aneurysms, and on which spinal-surgery techniques have the lowest level of blood loss. Together, they convened an open weekly meeting, currently on Thursday mornings, where everyone in the neurosurgery department—from the desk clerks to the medical staff to the bosses—could come not just to complain about the system but also to reimagine it.
Epic heard about his plans to fiddle around with its system and reacted with alarm. The hospital lawyers resisted, too. But he managed to keep the skeptics from saying no outright. Soon, he and his fellow-tinkerers were removing useless functions and adding useful ones. Before long, they had built a faster, more intuitive interface, designed specifically for neurosurgery office visits. It would capture much more information that really mattered in the care of patients with brain tumors, cerebral aneurysms, or spinal problems.
Now there was mutation and selection—through a combination of individual ingenuity and group preference. One new feature the department embraced, for instance, enlists the help of patients. The data on mobility before surgery turned out to predict which patients would need to be prepared for time in a rehabilitation center and which ones could go straight home from the hospital.
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