Friday, January 15, 2016

Too quick to judge, Jerry.

Jerry Groopman is such an admirable person and has so much good to say that when he is off track, it hurts to see it.  In a recent article in the New England Journal of Medicine, he and Pamela Hartzband conflate two issues.  One the one hand, there are their legitimate complaints about the depersonalization and attacks on professional judgment that derive from so much that is wrong with the health care system today.  On the other hand, there is a complete misrepresentation of the tenets and application of Lean (or Toyota Production System) in clinical settings.

I'll not go through all the details.  Mark Graban does that in excellent fashion here.

No, what hurts more is the fact that our clinical staff at BIDMC, where the authors reside, were overwhelmingly engaged in the the philosophy and practice of Lean--at least during the time I was there.  What's more, they enjoyed it and found that it made their lives better.  Indeed, Mark Zeidel, our Chief of Medicine, regularly offered many positive thoughts on these matters in his missives to his staff, called Kaizen Corner.

The same is true in many other hospitals and physician practices.  I've told many of these stories in my companion blog, "This is Not 'Not Running a Hospital." Gene Lindsey has done the same on his blog posts.

In his marvelous book, How Doctors Think, Jerry explains the occurrence of diagnostic anchoring among physicians, noting the power of confirmation bias--the tendency to see and believe evidence that supports your view and ignore facts that don't. I fear that this NEJM article is infected by this cognitive error.


Mark Graban said...

Thanks for linking to my post and adding your thoughts, Paul.

I remember the one time I was invited in, back in 2009 or 2010, to talk about Lean to a group of residents that were being taught about Lean and process improvement by BIDMC and medical faculty. I remember positivity about using Lean mindsets and principles to ENGAGE people in improvement... not telling others what and how to standardize.

"Standardization" is merely one concept in the entire Lean methodology and approach.

Paul Levy said...

Indeed, and "standard work" does not mean unthinking, inflexible protocols. It is part of a dynamic process of engagement and improvement. Indeed, I dare say Lean is very similar to the scientific method Jerry would use in his own experiments.

Mark Graban said...


Even Toyota leaders, decades ago, emphasized the idea that standardized work should be written by the people who do the work.

Isam Osman said...

Paul Levy said...

Superb example, Isam. Congratulations to your team in Ipswich.

Stefani said...

In my experience, unless there is persistent and visible support from the C-suite, Lean becomes the latest flavor of the month.

Paul Levy said...

So true. It is not a "program."

Tomás J. Aragón said...

The pillars of lean are "respect for people" and "continuous improvement." It is not "Taylorism." I was shocked and disappointed to read the Dr Groopman's commentary in the NEJM. He completely misrepresents lean health care.

Thanks for bringing this to our attention.

Mark Graban said...

It might also be useful to look at Toyota's explanation of the Toyota Production System:

Which includes:

"People are the Most Valuable Resource: Deeply respect, engage and develop people.
Continuous Improvement: Engage everyone each and every day."

"Leaders inspire and develop people to surface and solve problems to improve performance."

That's not classic Taylorism. Far from it.

Mark Graban said...

The comment I left for NEJM:

The authors unfortunately confuse Taylorism with Toyotaism, or “Lean.”

They also confound the issue by raising valid concerns about excessive or inappropriate measurement and EHR systems making live more difficult. Neither of those problems are driven by Lean principles or methods. In fact, a Lean thinker would stand arm in arm with the authors to decry waste in all forms, including bad quality measures and lousy computer systems. Lean is about serving the patient, creating a less frustrating workplace, and making things easier while ensuring quality and safety.

I’d also join the authors in decrying Taylorism. But, again, Lean is not the same thing.

Taylorism is a century-old model where engineers and managers designed the work, and workers just shut up and did the work.

The Toyota model builds upon what was taught by W. Edwards Deming, where employees at all levels are respected and are treated as partners in quality improvement and process improvement. Patients are not widgets, facts are facts. Lean is helpful and transferrable as a philosophy, and improvement methodology, and a management system. It’s about people leading people and improving the way work is done.

Vamsi Aribindi said...

Dr. Groupman may misrepresent the Lean philosophy to some degree, but it can not be denied that his overall point stands. And for that matter, many a consultant has misrepresented Lean into meaning that doctors should simply see more patients in less time because thats how it is at the hospital down the road! A focus on statistics and grading doctors based upon them always risks resulting in failing at what the statistics don't measure. This is fine when you are building a car, because the stats can measure everything. Not so much with healthcare where we often still have no real idea what we are measuring. I give you a paper out of Northwestern which reveals that the vaunted New York grading system for cardiac surgery mortality actually increased deaths and costs- in ways that simply weren't reflected in the statistics of the time.

In fact, the same errors show up in both teaching, where an over emphasis on test scores has destroyed teachers' engagement and inculcation of actual thinking abilty, and police work, where trying to grade officers based on how many arrests they made and how much crime dropped predictably led to mass arrests of dubious public value and rape victims disbelieved to keep the stats looking good.

Yes, the Lean philosophy and methods may not be directly responsible, but the messages of those pushing for more efficiency in Healthcare and the so called tripple aim are at least at partial fault.

Vamsi Aribindi

Carole said...

Who is truly worthy of our trust? Who and what should we people "patients" believe in and on?
"Lean" philosophy and methods seem completely honorable, a step forward in the right and positive direction, at least.
Knowing and learning more about it definitely gives those who have lost hope and faith in our medical system, for a variety of reasons- Hope and Faith again!
Frightening reality is- while Leaders are agreeing to disagree, on just about EVERYTHING!!! very little or zero progress is ever made.

Davis Liu, MD said...

Big fan of Dr. Groopman since reading How Doctors Think in 2008 and recommend it as a must read for all 1st year medical students I mentor. However, even that book, like this NEJM piece had confirmation bias. In this NEJM he notes that it was Taylorism that inspired the Toyota Production System. If he means Taylorism = scientific management and "one of the first attempts to systematically treat management and process improvement as a scientific problem" that is a good thing. From his article, it sounds like TPS / Lean wasn't implemented or understood as well as it should have been. -

Similarly in terms of his book, Dr. Groopman suggests that the pressures of managed care and inadequate time are the cause of many cognitive errors that doctors make which result is misdiagnosis, unnecessary or inappropriate testing and referrals. Yet, he never actually proved this in the book. He never showed that doctors were more likely to make the correct diagnoses in an era with fewer time constraints. In fact, he laments that doctors in training, where he teaches at Harvard, don't know how to think and then realized that he hadn't be trained how to think either over thirty years earlier (and hence the reason for his investigation and this book).

He claims that quality of medical care shouldn't be simply defined as whether or not a patient with diabetes has his blood sugar checked routinely, but Dr. Groopman also doesn't acknowledge that the major reason the United States ranks last in the world in keeping people healthy it is because the quality of care delivered never was measured as carefully as it is today. Research shows that 80,000 Americans die prematurely (twice the number of breast cancer deaths) simply because the right preventive care wasn't delivered. Had the nation adopted those health insurance plans, hospitals, and doctors, who performed at the top 10 percent of providing this care, these individuals would be alive today. How do they do so well? It is because of implementation of systems that promote excellence. This means systems and processes like the Toyota Production System (TPS).

We all know if you don't measure something and then re-evaluate it, how do you know if you are doing better? If anything, Dr. Groopman seems to suggest from his book and partially in this NEJM piece that medical care would be better if doctors didn't have to prove that they performed these metrics to the level of what the evidence shows to be effective even though other industries like financial services, manufacturing, and the airline industry do so rigorously to maintain their high levels of reliability, consistency, and safety. Better thinking doctors alone aren't going to improve healthcare quality in the United States. Dr. Groopman's subtle suggestions that they might are simply his error in thinking and his inability to remain open-minded and see that the world he trained in is far different than the world his trainees are about to enter.

Ironically when done well and implemented correctly, TPS can give doctors time and space to think!

Paul Levy said...

"When done well and implemented correctly, TPS can give doctors time and space to think!"

So true!