Saturday, March 31, 2018

EHR - Smart Regulate, Don't Deregulate

Who's to blame for the Electronic Health Record debacle? And a debacle it certainly is, at least for clinicians. The latest bite of criticism has hit the oped pages of the Wall Street Journal. Drs. Mass (pediatrician) and Fisher (nephrologist) from the Massachusetts General Hospital do a good job of chronicling its ills. MGH uses Epic, the near monopoly of enterprise-level EHRs. I call Epic “by engineers, for engineers,” so unintuitive that the pathways rival those of the old city in a European capital where only the natives or the guides can find their way, who use their special knowledge for fun and profit. With this and other EHRs, doctors become unproductive data entry clerks typing and clicking away to fill up the boxes and navigate the menus, often at home late at night finishing up charting the day's patient notes. The indictment goes on: the software design often causes errors rather than preventing them. The content of the notes is frequently filled with garbage designed to gather more money according to coding rules and to protect the practice legally. For instance, in pediatrics we are used to receiving ER notes that assure us that our three year old patient has attested that he does not smoke, and the pages and pages of verbiage makes finding what actually happened at the visit a needle and haystack adventure. And of course we often receive these notes not by computer but by fax, because the EHR programs are most often not interoperable as they were envisioned to be. The promise of all patient information available everywhere all the time? No way. Everyone looks at the same record within the system, generally hosted by a large medical complex, but you can't see the record if you are outside the system, as smaller independent practices and other units are. So why did we go through all this investment and work for a more troublesome and less productive state of affairs?

It's a familiar catalogue of frustration and vitiated hopes that we all share. What makes the article particularly congenial to the Journal, however, is its attribution of blame and the proposed solution. Blame goes to the government, for funding, encouraging, and requiring that the work of doctors be computerized before the programs were ready for mass consumption. Subsequent blame comes to government also for requiring far too much certification by vendors which, they claim, inhibits innovation. If only this vendor protection were removed, the authors aver, Amazon and Apple and other consumer electronics companies would invade the medical space and bring it up to speed and down in price. In other words, deregulate. WSJ red meat.

But I have to say to these doctors and WSJ, not so fast, my friends. It's not so easy and it's not so simple. For one thing, consider if the medical field and the field of consumer electronics are really so compatible. Medicine is far more complex than the stereotypic tasks of ordering a household item, and the market is far more constricted. The big tech software companies make their money on volume, and there are a lot more ordinary people in the world than there are doctors. How much money would it take to really attract the A team? Is the profit possibility really there?

But that's not the major objection I have; maybe they would come in, maybe not. My major objection is that I think the source of the problem is deeper than it appears. The physician authors might want to think of their medical training. Sometimes a rash is pretty simple and can be cured with a simple cream. But sometimes that rash is the harbinger of a deeper disorder that needs far deeper intervention. I'm afraid that this is one of those more serious situations, where the symptom of the poorly functioning EHR emerges not only from clunky governmental functioning and their less than acute ministrations to the health care system, but also from the organizational structure and political-economic interests of those we call “stakeholders.” Thus, I would not be drinking the Journal deregulation Kool-Aid just yet.

Should the federal health officials and the other pezzonovante who make up the health care establishment have pressed the Obama Administration to include EHR funding in ARRA, taking advantage of a unique time when big time money would be available? Were EHRs shovel-ready? Probably yes, they should have, and no, the EHRs really weren't completely ready. If they hadn't taken the cash opportunity when it presented itself, how could the medical world be computerized? It would have taken a lot longer time, and the money to buy and install and maintain the EHR systems could only have been raised by the institutions that were already predominant. So, the government's getting into the game seems well founded to me.

But did the government, under the Office of the National Coordinator of Health IT (known as ONC) screw the pooch in their administration of the program? To me, unequivocally, yes. They went for micromanagement of what was “meaningful use” (MU) of the EHRs that the practices and institutions bought – making sure that they weren't ripped off, that the government got what it paid for, it seems. He who pays the piper calls the tune, and the ONC didn't want to be accused of a giveaway to industry, understandably. Understandable.

But what the ONC screwed up was in hitting the wrong notes. What they should have concentrated on was interoperability, not every little use modality that took so much effort to document, prone to such error and inconsistency. What they didn't understand was that interoperability is the key. They should have mandated that all EHRs be absolutely interoperable, and then let the smaller details take care of themselves. This was their cardinal sin. Was it a sin of ignorance or one of influence? Were they not sophisticated enough about the usual pathway of progress in free market systems, or were they influenced by the most powerful pezzonovante in the EHR world, and the world of medical institutions?

I can't answer that question because I don't know how the process went. But we do know that interoperability is technically quite feasible, and that lack thereof is a political rather than technical issue. And it's quite clear that the ONC decision to go easy on interoperability only reinforced the controlling forces in our health care system. I detailed in a blog post last November why this is so important, as I described how large organizations have essentially weaponized the EHR.

Seeking business dominance by patient and clinician capture, the large medical centers and enterprise level software manufacturers have essentially weaponized the EHR by keeping it private and unsharable. When patient information is available only within an EHR network, the patient is “nudged” to access only in-network providers and facilities. Likewise, the externally impenetrable EHR pressures clinicians to renounce their independence and join the network not only to defray EHR costs, but also to achieve “featured” status for referrals on the EHR as the networks “nudge” referrals inward, and to utilize data in treating patients that they would have only laborious access to otherwise.

Maintaining strong EHR boundaries for network commercial advantage is regrettable. If large networks are to achieve dominance, they should do so by lowering costs and raising quality, which has been difficult for them, rather than using the EHR as a cudgel. Closed networks and closed EHRs provide diminished incentives to improve efficiency and quality, as services need to be just “good enough” rather than truly excellent to attract captured patients. A closed system even presents an ethical problem, since the primary care provider, who is ethically bound as a medical fiduciary to seek the best and most efficient referral resource for the patient, is nudged by the system to respect instead the financial needs of the network.

The search for root cause leads us inexorably to the organizational structure of health care. Although you wouldn't know it from the density of the propaganda cloud emanating from the large corporate networks, there is a good argument that smaller, decentralized units strung together by modern communication capabilities would deliver better and cheaper care than the large networks. But fighting to remain dominant is typical of economic behavior in any society. That's what is going on now. For a 2,000 word explanation of this argument, see:

So, to return to the start and Mass and Fisher's capitulation to WSJ ideology, what would be the effect of deregulating EHRs? Unfortunately, deregulation would not lead to interoperability. Since interoperability would simply give ammunition to the competitors of the large integrated enterprises, it is likely that they will be content to keep their systems closed.

What is needed is not deregulation, but smarter regulation. A legitimate role of government in our mixed system is to regulate the marketplace so that competition occurs on a level playing field and benefits accrue to the public. Smart regulation would recognize Epic as a dominant platform and regulate it as such, much as the government regulated Microsoft, another dominant platform. If the government made interoperability mandatory, and if they were to require the EHR to display referral opportunities equally, the playing field for clinicians inside and outside the system would be more level. If they also mandated that Epic and other platforms be open to module substitution, EHR competition would be improved. For instance: in pediatrics we have some EHR programs that work fairly well for us because they are specifically designed for us. Other specialties have something similar. If these practices join a big network to help them gain access to referrals, they must give up their more functional module and accept the more generic and inferior Epic module. If plug-in capability were required of the platform, all the EHRs would be subject to competitive pressure and would improve. It is even possible that Amazon, Apple and other A-list companies would enter the field.

That's it in a nutshell. For a more discursive treatment, check this out also, my best effort to describe the organizational structure dilemma facing our system:

But for the smallest nutshell at all, here is the letter I wrote into the WSJ and, mirabile dictu, they published it.

Budd Shenkin

Thursday, February 22, 2018

What Is The Place Of Doctors In Medical Care?

There's a lot of loose talk in medicine, a lot of loose talk by people who don't know what they are talking about, by people who are casually referred to as “thought leaders.” They say that the days of doctor dominance are over, that teams are the important thing, that doctors need to recognize how replaceable they are by algorithms and technicians, such as Advanced Practice Nurses, who are pushing legislatures all over the country to be able to practice independently. After all, they are professionals, too, and how much anatomy and pathophysiology and clinical training and wide knowledge and candidate selectivity do you really need? How much do you use in the day to day? And how smart do you really have to be?
They say, look at the quality statistics, and who does better, a doctor or an APN, a private practice or a Retail Based Clinic? They look at “consumer acceptance,” and they say, doctors aren't nearly as necessary as they think they are, because “public opinion” seems to indicate as such. Doctors, they say, are simply protecting their turf to the detriment of the public, and to the detriment of those alternative “providers.”
As my college roommate from Caribou, Maine, used to say: “bull-diggy.” Just, bull-diggy. You can always build a cheaper mousetrap, it's true, but it's just as true that you can always sacrifice quality for price, that there is always someone who will work cheaper and provide worse, and therein lies the rub. Sit atop the policy pyramid and all you can do is rely on statistics, no matter how misleading they may be. You watch the quality indicators and you think you are seeing something real, because if you are not a careful observer with a clinical background, you won't detect that “did you run a strep test before you treated with antibiotics?” doesn't mean that the strep test was positive, it just means did you run the test. It doesn't indicate if you did run the strep test (or, rather, that you charged for running one) and then decided to ignore a negative result and tell the patient, “Well, the strep test doesn't pick up some real strep infections that don't test positive, so we're giving you an antibiotic.” Such bull-diggy.
If the policy “thought leaders” ventured forth and looked at reality, they might get another picture. I wonder if they have doctors of their own, personally, or if they consult APNs and algorithms and the internet and their local RBC staffed by an APN with no backup. It reminds me of the 1960's in Washington, DC, when all the liberals (my friends, including George Silver and Phil Lee) were pushing “pre-paid health care,” and large group practices, before they were labelled as “HMOs” by Paul Ellwood and the Nixon Administration and thus became adopted by the corporate community. At that time there was an internist in Washington named Michael Halberstam, the brother of the soon to be famous journalist David Halberstam. These liberal DC docs, the cognoscenti pushing prepaid group practice, used Halberstam as their PCP (another term yet to be invented.) He was a wonderful guy and a wonderful doctor and he wrote a wonderful article in the New England Journal that really pissed me off, because I had had those same thoughts and he beat me to it, although I could never have reached his level of argument and eloquence.i But the point I'm making is this: Halberstam asked these elite patients, if you guys are pushing this prepaid group idea, and we have such a group right here in Washington, how come you are all visiting me, a solo practitioner?
Exactly. They knew what the best really was. Not that they were hypocrites, because they weren't. It's perfectly possible that for the average patient, given the burden of a large population, and given the average abilities of doctors, and given the disorganized nature of medical care, on average, for the average person, putting your health care in the hands of a prepaid group might have made the most sense, on average. Everybody can't be special. But, if you are an insider, and you really can evaluate good health care because you yourself are a professional in the field, then seeing the best of the best might trump the best of the average. So, it's a complicated proposition, this choice of to whom you entrust your health care.
An Example
Let me show you an example of what someone entrusted with your health care faces. This is not in some fancy place, the Peter Bent Brigham Hospital and Partners Healthcare, for instance, whence cometh many a prescription for health care improvement, and ever increasing size of the group. This comes from averageville, where the institutions are what they are on average in America. But in this case, not with an average PCP, but one who is Halberstamesque, the redoubtable Suzanne K. Berman of Plateau Pediatrics in Crossville, Tennessee, a distinguished member of SOAPM, the most distinguished unit of the American Academy of Pediatrics that concerns itself with actual practice, and a gifted writer. Here is what she contended with the other day:
A 24 day old baby has a fever and is feeding poorly, so the mother takes her to the ER. A fever in a neonate is very concerning, and in this case especially so, because the mother had a Group B Strep positive culture pre-delivery, and was not treated for it in the hospital, which constitutes a strong risk factor for serious infection in the baby. Any competent ER doc should know this is a life-threatening emergency, do the cultures and a spinal tap and admit the child for iv antibiotics. But this doctor and this ER just does some blood work and sends the patient home. This is pure and simple malpractice, but truth to tell, it happens. In fact, Suzanne says that it happened just this same way for another patient at the same ER a few weeks before. The next morning the mother visits her PCP, who is Suzanne:
Baby comes back to our office for f/u. We do the spinal tap on the baby in our office, do a catheterized urine culture, give antibiotics and ship baby to children’s hospital.  Baby arrives safely, stable.
1.5 hours later, after cerebral spinal fluid has been hand-delivered by our medical assistant to the lab, and after arrival and tucking in of baby at children’s hospital, CSF results still not reported.
Why, do you ask? Because:
1. The lab can’t run the specimen until there’s an order in the computer in the patient’s name to process the specimen, and
2. There’s no order in the computer to run the specimen, because
3. Registration “can’t” put the baby in, because we say that baby’s name is “Maria Ochoa” and their records show that the baby’s name is “Maria Fernandez.”
  1. And, WAIT FOR IT:  lab can’t enter results on Maria Fernandez when the CSF tubes are labeled Maria Ochoa.
  1. Supervisors leave at 3:30 pm on Friday 'evenings.'”
Holy, holy cow! Make no mistake, this is a question of life or death. If the baby hadn't come to see Suzanne, it could have been curtains, easily, very easily. And here is the lab dicking around with a crucial test that would determine whether or not it was a case of meningitis, and if the proper antibiotics were being used.
OK, all you fancy pants health care policy analysts. Do you still object to the picture of the pediatrician in charge, or would you want a comprehensive team with APN's in charge, or trust in the bureaucracy of the lab which seems caught in its own downward spiral, or the ER that persists in pediatric malpractice?
I remember my own experience when I was Chief of Pediatrics at Summit Medical Center in Oakland, and we were confronted with poor pediatric practice – not to this extent, but clearly poor – in the ER. I informed the Chief of the ER of the poor practice, and instead of his receiving our help to improve their performance, he successfully moved to ban our ability to review pediatric charts in his department. Amazing, but true, so I don't disbelieve Suzanne's account of her ER for a single moment, not one.
There are a number of observations that flow from this scenario applicable to current health policy issues. Let's let them fly.
One, as they say in the seminal text of Ghostbusters, “Who You Gonna Call?” Are you going to your local prepaid medical care group, or are you going to Michael Halberstam? Are you going to trust in the standard operating procedures of a bureaucratic operation, or do you want your Lone Ranger? And is your Lone Ranger going to be a doctor, or a nurse, or a technician of some sort, or maybe some algorithm and computer? Call me an elitist – go on, do it! – and I'll agree with you. I am. I have always aspired to be outstanding, and I want to trust my care to someone who has done the same. I want to have someone who knows what he or she is doing, in depth, and someone who will move a bureaucracy even when it's his or her time for lunch or time off, because he or she cares as a professional should care. I want someone, male or female, with balls. I want someone who has progressed through a rigorous training program not just for the knowledge garnered thereby, but who knows what it means to insist upon high performance from oneself and from others. Which, if you think about it, is a major function of education at any level.
Corporatists may disagree. They might say that with care, bureaucracies can be perfected, that organizations can learn, that not everyone can be outstanding, that care for the average person is best entrusted to a system, and that system engineering is really the key to high performance. To which I reply, this is not either/or. The best clinicians function best within high performing systems, and it is crucial for them to have such systems, because otherwise their functioning is compromised and in fighting the endless fight they will burn out. But for a system to be genuinely high-performing, the clinicians themselves need to have had a strong voice and a strong hand in creating it. A counter case in point would be Electronic Medical Records, those systems designed to decrease clinician productivity by transforming health care provision into data entry activity. The health care system accepts what Boeing would never tolerate, or rather what the pilots and airline companies would never tolerate from Boeing.
Are corporations and high performing individuals incompatible? Sometimes. Within corporations, something there is that doesn't love an individualist, and for their part high-performing individuals need to give unto routine procedures and other “providers” that which is routine, and to reserve for unique treatment that which demands uniqueness. A corporation has difficulty with the individual who knows what is right for the individual patient. Within a corporation, if you know what the individual needs, you often have to “fight for it.” “Fight for it?” Fight for the lab test result here and now, despite the lab techs being rigid and the supervisor taking off early? You have to “fight for it?” What kind of SOP is that? And yet, I bet you can't find me a practicing doctor who hasn't had to fight to get a lab test, or an imaging study, or a specialist report, or to find the crucial element of an ER visit in 200 pages of boiler plate in an EMR report. Is the Lone Ranger doctor dead? Well, if you want excellence, he or she better not be, because you show me any system, and I'll show you elements that need to be fought. The bigger you get, the less control you have.
And yet, large size is what is happening. Large size is not only accepted, but lauded “because coordination is easier in larger vertically integrated companies.” Merge CVS and Aetna and expect improved services say the corporate apologists. Right, vertical integration for improved services. "We can coordinate better when we're all under one roof." Not! Vertical integration is pursued in the great majority of cases to further market dominance rather than improve service or reduce price. Larger units provide larger lacunae. See the brilliant relevant essay:
Size is an impediment to productivity and responsiveness. In general, the farther away anyone is from the actual patient, the more the work is impersonal, and the less actual caring goes into actions. This is "off my plate" syndrome. Labs don't see patients. Administrators don't see patients. Neither techs nor administrators have to look a patient in the eye and say, I'm doing everything possible for your welfare, not my own personal agenda. Neither needs to lie outright when they favor their own interests or indulge their own laziness over the welfare of patients. “This is the way we do things” reigns in large organizations. Large organizations spawn more and more personnel not personally responsible to the patient.
And yet, it is not right, obviously, to lionize doctors excessively. After all, for all the Suzanne's who put the patient first and know what they are doing, there are all the others who persistently do the wrong thing in the ER, who are mal-trained and underperforming and self-indulgent and who resist improvement. It is the clinician's responsibility to make a diagnosis, and the Institute of Medicine estimates that more than 10% of the time, clinicians have have made an incorrect diagnosis on a patient, and what could be more important than a correct diagnosis? (And for those of you with faith in how we evaluate quality, please note that there is no attention paid in quality measurement to correct vs. incorrect diagnosis. What could be a more serious indictment of the present state of quality assessment than that?).
But, even given that serious caveat of the fallibility of doctors, it is still important to contrast the eons-old ethical burden of the physician with the ethical burden assumed by less qualified personnel (techs) and by administrators. Given the state of business ethics he observed, Arnold Relman, late editor of the New England Journal, concluded that all medical organizations should be run by doctors, and that all such organizations should be non-profit. Although he cast this as a serious proposal, I view his prescription as more a cri du coeur than something practical. But it is hard not to believe that as organizations get larger and dominated by non-practicing personnel, the ethical responsibility gets very diluted. Who is going to be more upset by lab intransigence, the hospital administrator or Suzanne?
Size and leadership inevitably play a part. If Suzanne were running the show at the lab, if it answered to highly motivated doctors, would the do-si-do of this patients specimen happen? When I had a Kaiser option with my health insurance years ago I thought I would scout the opposition and get a checkup there. The receptionist was nice and the doctor was nice. The scowling medical assistant, however, wore a badge that didn't say “Kaiser Permanente” but rather “SEIU,” and when my appointment ended during her lunch time, it was my doctor who had to go out to the station and do the MA's job herself. Is this really where we want to go, big and bureaucratic organizations, with less and less control on average for the patient and the PCP who takes care of that patient?
We can discuss quality of care all we want, but the individual doctor taking care of the individual patient is where the rubber hits the road. I severely doubt the capacity of ordinary measurements to comprehend the reality of these encounters in any organization. Anecdotal they may be, but the stories we hear from docs and patients are probably as close as we will be able to get to understanding what is going on. As of now, it seems to me that the most important variable in a patient's care would be, how good is your doctor, and secondarily, how well does the system support him or her? And if that is the case, what we should emphatically not be doing is figuring out how to supplant the doctor with less-trained personnel,ii and we should not be building ever larger units where poor quality and patient unresponsiveness can hide out.
Cowboy on a white horse? Maybe not a good idea. Team leader? Maybe a better idea. Large units with lesser-trained personnel or independent lesser-trained personnel? Doesn't sound like progress to me.
The independent opinion, advocacy, and concern of a highly-trained physician backed by a system that enhances his or her capacity to act intelligently should be the goal. Defining medical deviancy downward to save costs and preserve large organization preponderance isn't something doctors signed up for, and America shouldn't either.
Budd Shenkin

iHalberstam MJ, Liberal thought, radical theory, and medical practice.  N Engl J Med 1971; 284:1180-1185.

Thursday, February 15, 2018

What's The Matter With Parents Today?

Discussing the Florida gun outrage, from my pediatrician friend Glenn Schlundt in Pasadena, in a post to the SOAPM listserve:

In my area, the children, and the parents, are so different now than they were even 10 years ago. So many parents are adult children themselves. Many of them - even those in their 30's - have the coping skills I associate with teen parents. In some cases, it is due to exhaustion from working full time and then coming home to a child that has been left to fend for itself in a daycare setting, and who understandably has more needs than its predecessor twenty years ago. Some of it is from an apparent inability to see what their child needs, and - fundamentally - to set limits in a calm, warm, consistent manner. So many young parents in my practice react with frustration when their child seeks limits, and then are mystified when their child gets anxious.

In our area, the cost of living has exploded. I can't even use the word "soared," as it would be inaccurate. Growing up, homes in my neighborhood went for ~$25,000. This would have been about 1970. Those homes now have bidding wars and sell over the $1.2 million. The public school system is legendarily awful, so those who can send their kids to private school. The average tuition for kindergarten (yup, you read that right) is $25,000.00. High schools are in the $50,000 per year range. Those who can't get their kids in (there are not enough spaces), end up moving to a more expensive neighboring city.

Working parents are drowning.
The kids get less time with their parents now than they ever did. Some of them are simply orphans with a bedroom.

The amount of time and energy I spend counseling parents and teaching basic Skinnerian behavior modification, discussing tenets of Bowlby, referring to Jack Shonkoff's website, and helping parents with concepts like their child's magical thinking and regression in the service of the ego has also skyrocketed. The part that is often most difficult is that many of these parents cannot listen until they have been given a chance to talk, and there are not that many hours in the day. When they come back, everyone is often sad to find that their carrier now does not cover any F codes, so they get stuck with their bill, so there is more frustration. Every psychiatrist in our area is $650 per hour. None that I know of worth seeing takes insurance, and they all have wait lists.

What does this have to do with gun violence? I think it has a lot to do with it, and with road rage, and a lot of other things to which those of us in L.A. have long since become inured.

What to do about it?  Rearranging priorities and making time to listen to people, establishing and enforcing rules,  realizing that too much permissiveness, either individually or societally, can makes people of all ages feel as unsafe as easy access to weapons does. 

That would be a wonderful start.
Glenn Schlundt, MD
Rose City Pediatrics
Pasadena, CA

Pediatricians have an advantageous viewpoint; we see the soil from which outrages stem. Tension and anxiety, arising from economic stress, have always been linked to suicide rates. Given a militaristic culture – note how all the ballgames feature military themes with flags along with the national anthem, which is itself military, no “O Canada!” or “Sveriges nationalsång” (Sweden) for us – and gun access, aggression on others replaces aggression upon self. Poor educational institutions arise from poor funding and poor educational training institutions and dead end bureaucracy, and not enough attention to emotional needs. In our area in Alameda county in the lower grades there is a student/teacher ratio of 31:1, and no aides. Unconscionable and just stupid, really. So, this is what pediatricians like Glenn see in the offices.

Social policy and individual psychopathology are linked, and it's not just gun control, although that's involved, surely. Yes, the Right is right, personal psychopathology is important and should be attended to. I have yet to see, however, any Right proposals to do just that, which means money and mouth aren't meeting.

Myself, I see it as an infrastructure problem. “Infrastructure” isn't just asphalt, bricks and bridges; human infrastructure, human capital is the more important infrastructure in the modern world. Paying more for education and social support, more social capital investment, more true long term investment instead of eating the seed corn, less investment in luxury and military. Ojala!

Oh, yes, and more money for patients to visit people like Glenn down in the trenches. Pediatrics is more important than people know.

Budd Shenkin

Saturday, February 10, 2018

Ellsberg's Doomsday Machine

I have been hit like a ton of bricks by Daniel Ellsberg's new book, The Doomsday Machine, Confessions of a Nuclear War Planner.i It reminds me of a book I read over ten years ago, Confessions of an Economic Hit Man, by John Perkins.ii Like Ellsberg, Perkins had been trained in a discipline, was fascinated by it, and then used his abilities in the service of what turned out to be Establishment evil. In Perkins' case, it was selling loans to the governments of developing countries that he knew would be a disaster, but he went along with it until he awakened and wrote his exposé. We all know what Ellsberg did with the Pentagon Papers, his rather more famous turning against The Machine than is the current book. But it turns out that this later revolt is the more startling and compelling one. Like, ton of bricks compelling.

One of the reasons for my “ton of bricks” reaction is what I learned in graduate school in the field of public policy, first at the Goldman School at Cal, and later at Yale. At both universities we looked at public policy in a multidisciplinary way, which was key. We used economics and cost/benefit analysis, strategic rationality and decision making theory, political analysis, sociology, and – most eye-opening of all – organizational theory and behavior. (Given our current Trump-time, it seems we could have used personal psychology as well, but they did pretty well with the disciplines they had. Unfortunately, the Goldman School has abandoned organizational theory in favor of more quantitative work, alas.) The art of policy analysis is putting them all together to see why what happened did happen, and to try to craft policies with an eye to all these different points of view. Policy making is art – you can't just say “this program would be good,” you have to look at who would sponsor and support it, who would take it over, who would distort it, how it would be implemented, and could it pass. There was a debate as to whether or not a policy proposal should include all these aspects. I thought it should include as many as possible, especially politics and organizational analysis, and I wrote my book on the federal program of providing health care for migrant workers using economics, politics, and organizational theory.iii I thought it worked well putting it all together, and in a real world test, I used that book to get a whole new version of the Migrant Health Law passed by Congress, and today the program is working pretty much as I had envisioned it so far as I know. Amazing, I know.

At an exponentially more important level is The Essence of Decision, by Graham Allison, which I read at Yale after I wrote my little migrant health book. E of D looked at the Cuban Missile Crisis from the standpoints of rational decision making, political theory of interest groups within both American and Soviet governments, and organizational theory.iv This is a fabulous book that anyone serious about public policy should read – I rarely say anything that sweeping, but there it is. Here is an example of how organizations affected the Crisis: when Kennedy tried to control how the Soviet ships headed to Cuba would be blockaded (the term they used, “quarantined,” was intended to seem less bellicose) the admiral in charge of the Navy told Kennedy to back off. “Mr. President, the Navy will run the blockade,” was pretty close to what he said. They had their standard operating procedures, the modus operandi, and fine-tuning was not possible. Kennedy was concerned that if they didn't do it right and avoided being too strong-armed, you know what could happen. When you deal with organizations, you can try to get it to make fine distinctions, but you will probably fail. See also, for instance, the difficulty of having soldiers in Iraq or Afghanistan, trained killers, becoming peacemaking nation builders instead. It can sometimes work to some extent with prolonged effort, but it's hard.

So, the ton of bricks is this. Ellsberg looks not just at the theory of nuclear war, to which he contributed as a decision theory analyst, but what it meant in practice. He was present at the creation of MAD – Mutually Assured Destruction – a standoff that still persists. But, since he existed in the real world, and crucially, because his loyalty to America was completely assured and he could gain clearances way beyond Top Secret, since he was totally credentialed, he could go out and see and verify beyond theory, beyond the games and simulations and reliance on rationality that university guys like Herman Kahn and Albert Wohlstetter usually stop at.

He was young, energetic, and very smart – think Tom Clancy's Jack Ryan, think the young Alex Baldwin, think the Hunt for Red October, but think the Pacific. The Chief of CINCPAC, Admiral Harry D. Felt, wanted to know what was going on under his command, really know, not just get reports. One of the things we learned in public policy school, I think it was from our favorite book, Inside Bureaucracy by Anthony Downsv – I think that was where it was, but maybe not – was about information, conformation to orders, and chain of command. Think about a chief giving an order to his or her subordinate. How much of that order is understood and accepted? Never 100%. Maybe 80% would be an average? Then the subordinate orders his or her own subordinate. As you go down the chain, you expect less understanding, more shading, so at the second level it's maybe 70%. By the time you get to the fourth level down, what's going on? 80% times 70% times 70 % equals about 40%. This means that if an order requires just three levels down, less than half of the order is understood and enacted.

It's a general issue, not just military. Remember the Hubble telescope disaster? They spent $1.5 billion to put a great telescope up in space and it wouldn't focus. Why? Despite the most quality control surveillance possible, the very best people working to maximum capacity at the respected Perkin-Elmer company, way down the production chain of command, the skilled workers found that there was a small flaw, and instead of reporting it up the chain of command, they fixed it on the spot the way they were used to fixing things, by putting in a small shim. It worked at their level, but when it integrated at the necessary higher level, it didn't. People do things the way they are used to doing things, and it is impossible to coordinate complexity in large organizations with 100% fidelity. It just can't be done.

So the savvy Admiral Felt was being very competent when he sent the young RAND analyst Ellsberg out to the field, to forward bases in Okinawa, in Korea, and in Japan where nuclear weapons were – and are - attached to planes close to China and ever-ready to achieve airborne alert status. He was right to be suspicious that on-the-spot commanders, especially those trained in the American way, to be able to improvise, to take responsibility on themselves, that diffusion of responsibility that had worked so well when it was local commanders who invented a way over the hedgerows in the Normandy invasion – he was right to think that his information in command headquarters in Hawaii would be incomplete.

And incomplete it was. Ellsberg found, for one thing, that they rehearsed their roles constantly, and no matter the time of day or night, planes were ready for takeoff with their nuclear loads within ten minutes. Amazing – ten minutes. But, being very smart, Ellsberg went to the next steps. The battle plans called for them to take off and rendezvous with other squadrons from other bases at a forward point in the air, and await radio signals there which would order them forward if there were to be a real honest to goodness attack. If they were ordered back – or, if there were no communication at all at that time – they were to return to base. Ellsberg asked, “Is this ever practiced?”

Answer – no. It was impractical. The bombs were not really well enough secured to trust them if there were to be takeoffs time and time again. It would be very expensive to constantly rendezvous. So it was only the initial part that was practiced. What were the implications of that? Ellsberg reasoned that part of practicing was to get used to routine, so that mistakes would be minimized – see Thinking Fast and Slow by Danny So if there would ever be an event that led to the squadrons actually taking off, it would be very unusual, everyone would be extremely edgy, and many would reason that this time it was the real thing.

So what would happen if they took off and made their rendezvous as ordered, and then, no signal came to them? First, how likely would that be? Ellsberg asked the Korean base commander how often communications were out. It turned out that communications were regularly out part of every single day! Weather conditions, other problems, they said. If what had triggered the alert in the first place was some kind of accidental explosion somewhere, it would also be likely that this would interrupt communications. So it would be quite possible that at the rendezvous there would be no signal forthcoming; they would be on their own, never having practiced this part before, and having to remember under stressful conditions that they were supposed to return to base. And believing that if they got no signal it could well be that a capitation event had occurred in Washington and/or Hawaii.

Ellsberg's account of this possibility, of airplanes circling at the rendezvous and getting no communication, in interviewing the forward base commander in Korea, pp. 55-56:

I asked, “How do you think that would work?”

The major said “If they didn't get any Execute message? Oh, I think they'd come back.” Pause. “Most of them.”

The last three words didn't register with me right away because before they were out of his mouth my head was exploding. I kept my face blank but a voice within me was screaming, “Think? You think they'd come back?”

This was their commander, I thought, the one who gave them their orders, the man in charge of their training and discipline. As I reeled internally from that response, the next words, “most of them,” got through to me.

He added, “Of course, if one of them were to break out of that circle, I think the rest would follow. He paused again, and then he added reflexively, “And they might as well. If one goes, they might as well all go. I tell them not to do it, though.”

Then there was the question of the nuclear football that is carried by an aide to the President. We all think, we are told repeatedly, that the President has the power, and only he has the power, to order a nuclear strike. But was that, and is that today, really true? It's not really logical, after all. What if there is a decapitation strike? Would all of the US retaliatory forces not be launched then, because the President and his entourage had been destroyed? It is much more logical to think that others had the command ability as well. In his Jack Ryan role, Ellsberg asked Admiral Felt about it and was put off. There were rumors all over CINCPAC that there was a letter sent from the President authorizing CINCPAC Commander to order a nuclear strike on his own. There were rumors that others had that command possibility as well. Ellsberg couldn't find evidence of the letter, until years later. But then he found that yes, there was a letter. The idea we have of unitary command over nuclear strikes is false.

Then there is the issue of different points of view. This gets down to bureaucratic politics of a sort. The chief concern of the civilian sector of the nuclear project was that there be no accidents and no mistaken attacks because of mistakes in thinking that we were being attacked. That was the civilian focus. The military focus, however, had a different priority. The military's priority was that if there were an attack, that a nuclear counterattack was assured. To them, the possibility of an accidental attack from our side was less worrisome. So, anyone who has worked in a bureaucracy knows where this leads. The civilians wanted to make sure that bombs were only dropped with full authorization. So each plane had a specific code that it would need to match with the order coming in – as we are used to getting into our accounts on the internet, as we need the code texted to our phones. But the military's priorities being what they were, they knew that codes get lost, you can't find your code sheet, etc. So they made every single code the same, 0001, or something like that. You don't need to be an organizational theorist, you just need to have worked in a bureaucracy to know that this would happen, as it did. It took a close looker like Ellsberg to discover this. In short, our control over bureaucracies is limited.

These competing priorities would also be reflected in the organization of the war plans. Ellsberg discovered that the specific war plans were a closely guarded military secret, and not only from the enemy. The civilian masters of DOD, and the President himself, were not privy to these plans! In the estimation of the military, there was no need for them to know! As in, “The Navy will run the blockade, Mr. President.” In fact, the plans were so closely guarded that it was forbidden for anyone to mention the name of the plans!! That way, there would be no troublesome requests to see the plans.

The war plan as developed by the military – think Curtis LeMay, if you want to think of the mindset of where this came from – could not be too intricate. Large organizations are ponderous by their nature; they cannot be otherwise. So many logistics, so many details, so many people. So, when it came to war plans, Ellsberg discovered that there was only one. If we were attacked, we would retaliate by taking out the Soviet Union and China. What if China were not involved in the attack? Well, too bad, said the military, we can't do more than one plan, and 300 million Chinese would just have to pay the price. What would set the war plan in motion? Conflict between the US and USSR. What would constitute “conflict?” Undefined. Forces fighting somewhere in the world? Maybe. Depends who was judging, maybe.

This is just the way organizations and people work. A few weeks ago Hawaii experienced the incoming missile alert fiasco, a half-century after the time Ellsberg describes. What led to it? A worker who had had difficulty previously differentiating practice from the real thing, and had been counseled (or not) and had been kept on. When the call came in from the U.S. Pacific Command secure line to the Hawaii Emergency Management Agency, the worker who received the call didn't put the initial part on speaker phone, the part that said “exercise, exercise, exercise.” He did put it on for the part that said, mistakenly, “This is not a drill.” The AP relates: “the agency had a vague checklist for missile alerts, allowing workers to interpret the steps they should follow differently. Managers didn't require a second person to sign off on alerts before they were sent, and the agency lacked any preparation on how to correct a false warning.” And the Governor forgot his Twitter password. There is no excuse for our believing that people and large organizations will be any different in the future, be it making infant formula in France ( rolling recall with infants dying, corporation delaying and denying) or trying to control life-destroying armaments.

I was born three weeks before Pearl Harbor; I'm exactly ten years younger than Ellsberg. His father, a superb structural engineer, was a complete patriot. He was in charge of building the Ford Willow Run plant and the Dodge Chicago plant that produced B-24's and B-29's which was what I pretended to be as a four or five year old jumping off our porch on Osage Avenue in Philadelphia, arms extended laterally, as the war came to an end. Ellsberg's family history led to his becoming a Marine and taking his plunge into defense policy at the highest level. My own family history led me to medicine. While he was pursuing defense policy I was wondering why I kept studying when Kennedy has just been on TV about Cuba, and when our pompous professor of physical chemistry who had been and Eisenhower adviser, George Kistiakowsky, declared that Kennedy had made a basic error in leaving Khrushchev no way to save face. I looked askance at the Ban The Bomb marchers, maybe because they were so “sensible,” with no real plans on countering evil aggression. Were they willing to have standing armies, etc.? There is evil out there, do you remember Hitler? I took more seriously the clock on the cover of the Bulletin of the Atomic Scientists, but did what most people did, marched against the Vietnam War, chanted “Fuck you, Agnew,” but otherwise stuck to my knitting. That is, I chose denial.

Now we are faced with more and more nuclear problems, not fewer. What started as Eisenhower's less expensive alternative to keeping vast armies in place in Europe to guard against the Soviets – Brinksmanship enabled our 50's economic expansion – and then morphed into American domination by ultimate nuclear threat and our military all over the world “training” – now looks worse than ever. We can imagine an ignoramus such as we see in the White House now saying, “Why do we have these weapons if we can't use them?” We can see him saying, “Why don't we at least use the little ones?” Indeed, the Pentagon is currently reconsidering the use of tactical nuclear weapons.vii

LeMay had wanted to use them earlier – wipe out the Commies, he said. He and others were real militarists. Wiping out huge swaths of people was fine with him. WWII was a great opportunity to experiment – would wiping out a city with firebombs demoralize a country and take them out of the fight or make them more steadfast? Hey – a chance to experiment! Luckily for them, the Japanese militarists kept the war going long enough for them to see what Little Boy and Fat Boy would do. Seriously. I read elsewhere that LeMay told McNamara at one point, “If we lose this war, we'll be hung as war criminals.” And McNamara nodded assent. How different are the Iranian Revolutionary Guards? I'm on our side and I'm against those terrible Iranian militarists, but among people who think that way, there is a lot of commonality. In Japan, after all, it was Tojo and the militarists who were in charge. They had to be told by the Emperor to stop fighting; many of them wanted to go on. There are militarists everywhere, and it's not hard to see the connection between arguments for gun control and arguments for nuke control.

To our eyes, the militarists are clearly nuts. As Ellsberg says, during the Berlin Crisis, when nukes were contemplated against the Soviets, he wondered, after all is said and done and we use nukes on each other and we look back, will we think, was Berlin worth it? As Ellsberg says, what was once an issue of the destruction of civilization as we know it, since the discovery in the 1980's of Nuclear Winter, the stakes have been raised even higher. We are talking about an extinction that would dwarf the other five in our past. We are facing the possibility of extinguishing most of all the life forms we know. We are talking about starting from scratch.

What we know about human nature is frightening. What we know about organizations and how they work and don't work, is frightening. What we know about modern history is frightening. And we haven't even mentioned WWI and wiping out a generation, of the disillusionment with the wonders of technology born of machine guns and attacks over the top.viii

Putin interfering with our elections? China constructing bases in the South China Sea? North Korea threatening what, a defense of its awful government? Let's remember Ellsberg's question, would Berlin have been worth it?

The wise men cold warriors, McNamara, Schultz, Kissinger, Nunn, – all those who were the most aggressive – what they say is, we have to get rid of these weapons. Look at what can happen. These organizations that have control of nuclear weapons are only poorly controllable.

The intimate history of the top leaders of the United States as told by Ellsberg is that they would never have used the nukes. Kennedy wouldn't have, McNamara wouldn't have, others wouldn't have. Eisenhower wouldn't have, no matter what. To them, it was the biggest bluff in the world. The survival of the world is a large task to leave to a small and ever-changing leadership group. Like, for instance, now.

Finally, here is what is the most amazing thing to think: Dr Strangelove, Or How I Learned To Stop Worrying And Love The Bomb, was not a work of fiction. It was fictionalized and exaggerated, but the essence was amazingly true. From “Bodily Essence” Buck Turgidson, to Dr. Strangelove and his dream of bunker survivors with the most beautiful women, to forward commander Major “King” Kong, to a system with no recall the bombers capacity, to the Doomsday Machine itself – in it's essence, it is all essentially true!! It is. Stanley Kubrick and Terry Southern got some of their information from Herman Kahn, with whom Ellsberg worked as a junior colleague, but they must have had lots of other inputs, because what they wrote was essentially true, (Tom Lehrer's song was also true, I guess), just made funny with the gallows humor that we were familiar with as medical students when we saw our patients sicken and die.

Denial is a pleasant state. We live in denial most of the time. I deny that I will die, despite the fact that most of my tomorrows are in the past. We leave to others the custodianship of the world, despite the fact that we know that they and the organizations that they sit at the head of, are not sufficiently responsible to trust them with the future of the world.

There's a lot more in Ellsberg's book. It will make you think and tremble. It will make you long to Ban the Bomb. Hey, a universal service obligation isn't a bad idea, anyway.

Budd Shenkin

3/3/2018 -- After posting this piece, I became aware of a New Yorker article by Eric Schlosser that makes many of the same points I make, including the essential truth behind Dr. Strangelove.


Thursday, February 8, 2018

Modern Medicine -- Essential To Me, And Probably You, Too

Tomorrow morning I will be at Alta Bates Hospital here in Berkeley, and my friend and colleague Joel Piser will be operating on my prostate, which has grown too big for my britches in an excess of manliness, I guess. It should be a minor laser procedure, and here's hoping that that's all it is.

It has led me to reflect, once again, on the proclamation of the public health community that the major advances in health have not been personal medical services, but advances in hygiene, cleanliness, food safety, immunizations, and other mass programs. While I'm sure that is true as far as it goes, it should not lead to a derogation of the importance of medicine. Without them, I wouldn't be here, and neither would millions of others who overpopulate our world.  In the near term, facing this newly available prostate surgery, I reflect that without it, I would sooner or later be in the situation faced by Peter the Great, who died after 13 days of not being able to pee, in great distress as we can imagine, as especially I can imagine.

Indeed, my medical adventure started early.  When I was born, I had tight tendons in my right foot and bony abnormalities that must have resulted from malposition in the womb as my foot was forming. The tendons were released by an orthopedist – I believe by Richard Kaplan, whose wife later became my father's companion when my mother died at age 72. Without that surgery I would have been crippled with a permanent limp. In primitive times I would not have survived.

At the age of 14 I broke my right tibia and fibula sliding into home plate in a misguided attempt to steal home – I still remember my friend John Raezer, my third base coach, saying, “You can do it, Budd! Steal home!” Out by a mile as Jimmy Laird blocked the plate with ball in glove. Off to the hospital to have my leg set and casted by my father's colleague Dr. Kim. Again, were we in primitive times (pre-baseball), perhaps death.

Same thing at age 40 when I fell off a skateboard and was taken to Merritt Hospital where friend Mal Barer put a pin in to stabilize that right fibula.  Not so much danger when Mal operated twice on my right knee to trim the meniscus, nor years later when my left knee had similar surgery, but still, seemed helpful to my walking without pain.

In 2009 I had my right hip resurfaced; otherwise I would have been crippled; now, I'm pretty good. 

In 2011 I was going blind from a pituitary macroadenoma, fixed by miraculous surgery that is now routine. Death would have been certain without he surgery.

In 2016 my melanoma was removed, which I appreciated, and again were it untended, it would have killed me.  Still could, though I doubt it.

I currently take two blood pressure medicines daily. Without these I would have been long gone from hypertension complications. These medicines were unavailable 50 years ago.

I currently take a statin for hypercholesterolemia and hypertriglyceridemia. I would probably have had a fatal heart attack or stroke without these.

I take thyroid replacement and androgen replacement medicines because of the destruction wrought by the pituitary tumor. I would be severely impaired by lack of thyroid hormone, and I guess the absence of testosterone wouldn't be good for me either.

In sum, the point I'm making is this: complain that personal medical care is overemphasized, complain that it is far too costly, complain that public health is underfunded and underappreciated, complain all you want. But personally, I wouldn't be here without it, and neither would many of you reading this.

How we pay for it is optional and could be a lot better. How luxuriously we are treated is likewise optional. But as for me, give me personal medical care or give me death.

Budd Shenkin

Monday, January 29, 2018

Quality in Medicine and Missile Detection

Hawaii under attack! Incoming missiles! People ran here and there. Representative Tulsi Gabbard, always a bastion of sober consideration, gathered her family in the bathroom. On Maui, Peter Shenkin slept, thinking it wasn't worth getting up for. His partner in gym ownership, Logan, out golfing when his party was flagged back to the clubhouse, objected. “It's probably an error,” quoth Logan, “and if it's not and we're going to be incinerated, at least let's see if we can get a few more holes in.” Golfers are rarely dissuaded from their chosen path.

In the end, of course, it was an error, the origin of which was depicted this way: one employee going off duty was presented on the computer screen with the choice of two buttons, one saying no attack and one saying yes attack. He chose the wrong one and the debacle unfolded. Understandable calls for his head have been unavailing – Pete says that in Hawaii, everyone is someone else's cousin and can be called a “good guy” – and according to the Honolulu Star-Advertiser, he has not been cooperating with the investigation. We'll see what happens.

Aside from the insight this event affords to the quality of Hawaiian governmental organization – one of the states where implementation of an Obamacare insurance exchange collapsed ignominiously to the surprise of few – it reminds me of my experience in running a pediatric practice. All practices are faced with the problem of how to maintain and improve quality. How can we do what we are supposed to do, what we want to do, what we need to do? How can we make sure all our prevention is done completely and correctly, how can we make sure our patients receive excellent customer service, how can we be sure we diagnose correctly, follow up correctly, remember everything we need to remember? It's a challenge not altogether different from the one that faced Hawaiian Civil Defense, at which they failed so miserably.

When you come down to it, there are two basic ways to deliver high quality and reliability. One we can call Professional Enhancement (PE). PE aims to improve the knowledge, skill, and motivation of the employee or the clinician. The other one we can call Systematic Reengineering (SR), where the focus is not on the individual but rather on the system. PE aims to put things into the brain of the individual. SR aims to put things into Standard Operating Procedures, which are outside the individual brain, but exist instead on routines, on paper, or in a computer.

In medicine, clinicians tend to think in terms of PE. We are all used to this, because this is what we were exposed to in all our years of schooling and clinical training. Remember this, there will be a test! Don't forget to put this in your differential diagnosis! Did you check to make sure the referral was completed? They are all over us, and we come to think we should be all over ourselves as we move into practice. That is our SOP – remember! It's not bad training per se, but it's incomplete.

Students of organizations take another tack. While they are aware of the requirements of knowledge, intelligence, and mindfulness of individuals in organizations, they tend to think not primarily in terms of PE, but rather in terms of SR. (Or sometimes not so aware, as this from W. Edwards Deming: “Ranking (of personnel) is a farce. Apparent performance is mostly attributable to the system that the individual works in, not to the individual himself.”i) SR comes from the context of QI in industry, where establishing regular procedures decreases variability, with the mantra “do-it-once-do-it-right.” The SR approach finds recurrent stereotypic situations within medicine’s endless complexity that can be choreographed for standard execution with low variation, and hence higher quality. SR introduces changes in how the system operates by introducing such elements as care plans, flow sheets, forms, and reminders, all of which could now theoretically be made so much easier with Electronic Medical Records. (In practice, of course, EMRs being the oft-reviled cumbersome obstacles that are best avoided, not so much – but I'm sure that's temporary. Pretty sure.) The goal of SR is for the clinical team to operate ensconced in a system where the easiest thing to do is also the right thing to do.

Those familiar with the work of Danny Kahneman will recognize the similarity of the distinction of PE and SR to his difference of thinking fast and thinking slow.ii If you do something routinely, it becomes a reflex and you don't have to think very hard about it, you just do it automatically and it's the right thing to do. As a matter of fact, thinking about it can lead to a problem which in sports is called, somewhat inelegantly, “the yips.”iii Having a behavior embedded in a system within an organization is the equivalent of thinking habitually, and therefore fast. When you have to cogitate about what the right thing is to do, when you have to search your memory bank, when there is nothing in the system to guide you and no button to push or menu to bring up, that's the equivalent of thinking slow, and is prone to error.

The key to management and organizational analysis is to realize that both approaches are applicable depending on the situation. For many situations – perhaps for all situations where one can think of a good system – SR is best. Clearly, for instance, narcotics control is better handled by a computerized check-in-check-out system than by education on the harms of addiction. In our own practice we approached the complex question of asthma, where I was bedeviled by clinicians opining “well, what I like to do is....” Instead of the extreme PE approach leading to everyone's taking his or own special path, we tried to have standard approaches, where one check mark led to a bevy of actions that were SOP for standard asthmatics. One check mark led to doing the right thing at the right time every time – at least for those who accepted the system. Docs are a tough crowd.

Some say that SR is inevitably superioriv, but it seems to me that this would be true primarily for stereotypic situations – immunizations, for instance. PE needs to be the primary approach of choice for human relations, complex diagnoses, unique situations, and judgments as members of adaptive organizations. Empathy is better achieved by education and reinforcement than by signs on the wall saying “We Care.” As clinicians we understand very well the non-SR behaviors of being reflective, seeking the hidden meaning behind patient visits, and continually trying to detect disease early from small clues.v Clinicians remember when a stray piece of medical knowledge led to a clever diagnosis, or when even in the midst of a busy schedule they were patient with a patient and then made an important diagnosis. We recall the meaning we bring to some patients’ lives, and vice-versa. This is the core of traditional medical quality. Silicon Valley has a lot to add to medicine – a lot! – but the day is far off when these qualities will be replaced.

To be practical, if you are involved in managing an organization, when faced with a quality issue, the first question to ask is often, can we put this into a systematic routine? If so, that's the way to go, with the usual problems of implementation, including operator acceptance and understanding. Sometimes, however, as with empathy, the solution will not be SR, but rather PE. And likewise, if you look hard enough, I think that very often the solutions will be a mixture. If your problem is friendly reception at the front desk, part of the solution will be education and practice on how to be friendly, and some of the solution will be rewriting the job description and finding good ways of measurement and feedback. Most times, it seems that an artful mix is required.

Which brings us back to the missile attack. What if this error had been made in a hospital? My friend Paul Levy, former CEO of Beth Israel Deaconess Hospital in Boston, is fond of recounting his intelligent approach to error. If a nurse makes a dosing error, for instance, and he or she is called in to recount the circumstances in the process of seeking the root cause of the error, he likes to ask: “Did you intend to do what you did?” It would be unusual for the answer to be “Yes.” His inference, then, is that most often one should seek the error in the system that led the nurse to give the wrong dose. It can be something as simple as two vials of different strengths that look virtually the same sitting side by side in the refrigerator, leaving it to the nurse to make a difficult distinction as to which is which. Fair enough – systems problem. Amazon, King of Systems, fixes this by storing similar looking items at a distance from one another. I often differ with Paul, however, in leaving it at that and exonerating the perpetrator. Yes, it is expected that people will make mistakes, but it is also fair to ask how often that particular person has made mistakes, whether sloppiness in endemic to that person, whether mis-assignments are habitually made by that supervisor, etc. To me, it's always a mix.

So if the non-cooperating nuclear missile attack declarer was confused by similar looking buttons sitting side by side – basically, an attractive nuisance – that's a systems problem. If there is no second check necessary in sending out the attack notice, that's a systems problem. If there is no way to expeditiously correct an error in something less than the 38 minutes it took in Hawaii while Tulsi Gabbard was cowering in her bathroom, when the governor knew within 2 minutes that it was an error but couldn't tweet out a correction because he forgot his Twitter password, that's a systems problem (not to mention a Governor problem.)vi Instead of calling for the head of the careless employee, it's the head of the system designer that should be called for. Differing with Paul, I'm always looking for incompetence, and in this case the probability that the job was awarded to someone with a connection, this being Hawaii.

Or, if the employee, despite his inevitably being somebody's protected cousin, if he continues to be uncooperative, it's entirely possible that he could suffer not from the original act, but because of obstruction of justice. Yes, it's a system, but in the end, systems are manned by people, and everyone has to take responsibility.

It will be interesting to see what happens, especially as the one-term Governor is being challenged. It will be interesting to see if anyone is implicated, and if anyone suffers anything, and if an “A team” is brought in to fix the system, à la Obamacare, and if people then wonder why there wasn't an A Team in the first instance.

But in the end it was only the public who suffered. And poor Tulsi in the bathroom. No heads will likely roll, cousins will keep their jobs, and another contract will be let to a putative A Team, headed by someone else's cousin. Hawaii....

Budd Shenkin

iDeming WE, The New Economics for Industry, Government, and Education. 1994, MIT Press, Cambridge, Massachusetts.
ivShojania KG, and Grimshaw JM. Evidence-Based Quality Improvement: The State of the Science. Health Affairs 2005; 24:138-150.
vMiller WL, McDaniel RR, Jr., Crabtree BF, et al., Practice Jazz: Understanding Variation in Family Practices Using Complexity Science. J of Family Practice 2001; 50: 872-878.