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James L. Holly, M.D. |
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| James L. Holly,M.D. |
| February 13, 2003 |
| Your Life Your Health - The Examiner |
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(Editor's note: This is the second in a three- part series which summaries Dr. Holly's address on Medical Informatics to the Massachusetts Medical Society. On February 11th, Dr. Holly was in San Diego, Cal, where Southeast Texas Medical Associates, LLP was presented with the Microsoft Healthcare User's Group Clinic of the Year Award.)
Learning Disabilities Which Impede Electronic Patient Management
We -- you, me, all of us -- whether -- vendor, payer, provider, patient -- must actively and willingly participate in this "learning organization" which has no walls. Yet, the development of a "learning organization" is resisted, Dr. Senge suggests, by seven learning disabilities. These disabilities, which encumber our organization and team mobility, are applicable to medicine as well as to other enterprises. These learning disabilities and their application to health care informatics are:
1. I AM MY POSITION --
Dr. Senge comments: "When people in organizations focus only on their position, they have little sense of responsibility for the results produced when all positions interact. Moreover, when results are disappointing, it can be very difficult to know why. All you can do is assume that 'someone screwed up.'"
This disability principally addresses vendors. When all a vendor does is focus on his/her product and its functionalities, the vendor may accomplish something which has virtually no value, if it is not dynamically related to other members of the "medical information technology learning organization." Progressively, vendors are going to hear from end users, "You have a good product, if it worked with our other systems, but it doesn't. This means that while you have a great idea, we will not benefit from it."
Here is the counterintuitive decision vendors are going to have to make if they are going to contribute to solutions in healthcare informatics rather than simply continue to aggravate the problem. Vendors must create products which can either interact with other proprietary products or they create products with an architecture which is easily adaptable to interaction with the products of their competitors.
2. THE ENEMY IS OUT THERE --
Senge says, "There is in each of us a propensity to find someone or something outside ourselves to blame when things go wrong."
This disability addresses providers and very often patients. The idea that someone is responsible for my difficulties is a common ploy with which to avoid responsibility for being a change agent yourself. Charging someone else with negligence or mistakes is an unproductive substitute for being willing to change. The reality in health care is that, like Pogo, "We have met the enemy and he are us!"
The only hindrance to our success with medical informatics is our willingness to provide ourselves with an excuse for not succeeding. When a physician recently told me that he gets discouraged when things don't work in a week or so, I told him that I was going to give him a list of 100 excuses. In the future, he would not have to tell me why he didn't succeed, he could simply send me a note saying, "I was not able to succeed because of 16, 44 and 73." Anyone who wants an excuse can find one, but successful people refuse to accept an excuse, particularly for themselves.
3. THE ILLUSION OF TAKING CHARGE --
Senge argues that "All too often, 'proactiveness' is reactiveness in disguise. If we simply become more aggressive fighting the 'enemy out there,' we are reacting -- regardless of what we call it. True proactiveness comes from seeing how we contribute to our own problems. It is a product of our way of thinking, not our emotional state."
Often we think action is good and inaction is bad, but we fail to recognize that disorganized activity, while fatiguing and sometimes fulfilling, rarely produces a positive result.
Remember the recent coal-mining accident; the success was won, not by furious action, but by careful planning and correct assumptions, however improbable that they were. Here's where vendors and providers often collaborate in ineffectiveness.
It is our nature by design that we try, but we must try with both insight and correct analysis. We must not tilt at windmills, yet we must continue to build wind turbines.
4. THE FIXATION ON EVENTS --
Senge explains:
"The primary threats to our survival, both of our organizations and of our societies, come not from sudden events but from slow gradual processes; the arms race, environmental decay, the erosion of a society's public education system"
This learning disability addresses the possibility and even the probability that our "vision" may be obscured by our experience and by the subtle changes taking place in our world. In healthcare, this learning disability warns us not to devise solutions which are tied so closely to current phenomenon that they cannot adapt to changing realities. If we don't, then we will design solutions which will not only be outdated by the time they are available, but they will be solutions which will encumber our ability effectively to respond to the new realities of which we will suddenly become aware.
Vendor, provider, payer, participant, almost always forget that the issue is the process, not "a" or "my" or "your" product! Focusing exclusively on "my product" makes us guilty of the first three "learning disabilities" as we illustrate in our behavior the fourth.
5. THE PARABLE OF THE BOILED FROG --
Senge illustrates:
"Learning to see slow, gradual processes requires slowing down our frenetic pace and paying attention to the subtle as well as the dramatic."
As long as the frog swims around in the slowly heating water, he can't focus on what is really bothering him -- the rising temperature -- and what he needs to do about it -- get out of the water.
How often have we seen those who are constantly busy but equally ineffective? They vigorously work but rarely solve the problem they are intent on addressing. I have known people who were very busy about their task, but who never did their job. They were "busy as bees" but without the bees purposed efforts and design.
This applies to all participants in the healthcare industry. Very often, we are so fatigued from our frenetic swimming about that we don't take the time to do that which initially doesn't make sense, but which ultimately leads us to the solution we desired in the first place.
Repeatedly, Senge addresses "counterintuitive" behavior -- doing that which initially does not seem to make sense, but which ultimately accomplishes your goal. Senge gives an illustration
On a winter canoeing trip, his party faced a waterfall. Porting around the fall, they noticed a man going over the water fall. The canoe capsized and the man furiously tried to swim away from the water fall. The freezing water overcame him. His body then sank below the water and was pushed by the current to the side of the river. The man's dead body ended up exactly where he was trying to go, but too late to save his life.
Success in this instance, involved doing that which was counterintuitive, holding your breath, going under water, and allowing the current to carry you to safety. Business solutions and particularly medical informatics solutions are often like this.
6. THE DELUSION OF LEARNING FROM EXPERIENCE --
Senge cautions:
"When our actions have consequences beyond our learning horizon (a breadth of vision in time and space within which we assess our effectiveness), it becomes impossible to learn from direct experience."
Linear thinking will lead us to solve the problems of which our own experience has made us aware, without our realizing that the ultimate solution is just beyond our experience. This is why we all need one another, because all of us have different experiences and all of us have drawn different conclusions. It is only by consulting with our competitors that we will not create solutions which perpetuate the problems we are trying to eliminate.
This disability is a culmination of the deficiencies created by a "fixation on events" and by being like a "frog in boiling water." If learning is more than "taking in information" and if learning is the managing of "creative tension" to create a future of our choosing, then we will need to move beyond a posteriori knowledge -- experienced-based learning -- to an apriori comprehension -- an intuitive apprehension both of reality and of creativity -- of the future and of its demands.
7. THE MYTH OF THE MANAGEMENT TEAM --
Senge declares:
"All too often, teams in business tend to spend their time fighting for turf, avoiding anything that will make them look bad personally, and pretending that everyone is behind the teams collective strategy -- maintaining the appearance of a cohesive team."
The deception employed here is the illusion of competence. It is never popular to say, "I don't know," but sometimes it is the most creative approach to solving a problem. The admission that you don't know, or that the "management team" does not know, often makes the team aware of possibilities which otherwise would be excluded.
This is the foundation of the last three characteristics of "personal mastery" which Senge addresses in The Fifth Discipline. People who have a high degree of personal mastery:
- Never ARRIVE!
- Are acutely aware of their ignorance, their incompetence, and their growth areas.
- Are deeply self-confident! (p. 142)
How can you be "deeply self-confident" and yet be "acutely aware of your ignorance and incompetence?" It is that very contradiction which is the foundation of a learning organization. If we are going to move forward in medical informatics, we will have to be part of such a team. We will have to confidently, but with a degree of incompetence, move forward to create a future of our own design.
If the health care industry is going to design its own future by solving "the" problems, it means that we must develop a collaborative, learning team which avoids these disabilities.
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