Presidential Address to ASMS Conference
National Presidential Address
8 November 2001
A Caring Culture:
We Are What We Repeatedly Do
Change is inevitable. Many of us feel that there is something fundamentally wrong with the health care system in which we work— it often has the wrong priorities, the wrong processes for selecting our leaders and the wrong incentives for driving our culture. We are not able to draw on our collective creativity to direct change toward relationships we recognise to be right for our profession and our society.
What’s going to happen doctor? Since time immemorial we have been asked to predict the future, but sometimes we fail and fail miserably. Some people, including other doctors, tell us we must change our culture and give up clinical freedom in the interest of more uniform, hence more financially predictable, behaviour even if it fails to meet the needs of our individual patients. Many doctors perceive a diminished role in their relationships with patients, decision-makers and society. Although we have repeatedly alerted our government to the resource deficit the past 15 years’ policies have created, we also need a better system. What we smell is the rotting corpse of the top down managerialist hierarchy of a failed market model. Our professional relationships with each other are the first place we need to allow clinical democracy to blossom so that our collective wisdom can speak with a unified voice. Our calling needs us to be moved to action.
I propose that we see healthcare in the context of a complex adaptive system of professional people rather than the abstract reductionist view of managerialism. Today I intend to look at the roots of our concerns and explore opportunities to influence our future by drawing on our creativity. I warn you at the outset that it demands hard work, open minds and commitment, but these are not characteristics lacking in our profession. It is time we had a say in the culture of our health system and our greater culture. My definition of culture is the way things are done around here.
A lesson from history: clash of cultures
In his book, Guns, Germs and Steel: The Fate of Human Societies, Jared Diamond recounts the encounter between the Spanish conquistador Francisco Pizarro and the Inca emperor, Atahuallpa at Cajamarca in 1532. It was a meeting of extremely uneven forces. Pizarro, with a ragtag band of 168 soldiers in unfamiliar territory, ignorant of local inhabitants and thousands of kilometres from reinforcements defeated Atahuallpa in the midst of his empire of millions of subjects and immediately surrounded by 80,000 experienced troops. In spite of the odds, Pizarro captured Atahuallpa within a few minutes of seeing him, killed his guard of noblemen and held him prisoner for 8 months while extracting history’s greatest ransom in return for the emperor’s promised release. However, after collecting enough Inca gold to fill a room 22x17x8 feet, about 10% of the world’s existing gold today, he executed Atahuallpa and established his brothers as governors.
The rest, as they say, is history.
Diamond ascribes the conquest’s incredible success to Pizarro’s technological advantage of horses, guns, and steel arms against sticks and stones. He also tells of other Indians who facilitated the ambush for their own reasons, but subsequently were subjugated themselves.
Diamond does not mention another unassailable advantage. They believed they had a God-given right to subjugate the “heathen” a right to command and control this foreign culture. The only value they wanted from the encounter was gold, which had religious and aesthetic value to the Inca. The people were of no more value to them than slaves to economic and religious purposes.
The Spaniards had no honour for the culture of those they slaughtered. They demeaned and then destroyed their leadership, routed their established social order, stole their very purpose and replaced it with a regime of fear and wanton destruction. Was this progress, the ‘right’ way for things to go in the world of the Inca, or for that matter, the Spanish? Today’s actions become tomorrow’s history.
Another clash of cultures: managers and clinicians
I see parallels between this history lesson and aspects of our relationship with many decision- makers. I must be careful not to extend too far this analogy of a culture clash between a god-king’s feudal empire and agents of a technologically advanced colonial power motivated by self-righteous greed, to that of clinicians’ relationship with managers and bureaucrats put there by a democratic governments. Doctors have a culture because we have a way things are done around here. All cultures change due to influences within and without. Does it need to change in the way that some claim it must? Perhaps it does, or perhaps we need to re-examine the value systems working within the greater culture of our nation and our world. Rigid command and control rarely manages relationships well and there has always been a tension between it and professional creativity.
I am not the first to note the clash between professional and managerialist cultures. Joseph Raelin’s book, Clash of Cultures: Managers Managing Professionals outlines the source of conflict. He contrasts the commitment of managers within a command-and-control corporate culture and the socialised culture of professionals. Professional socialisation arises from disciplines and culture begun with extended education and reinforced in peer group relationships. Managers are socialised, on the other hand, with shorter education time that stresses interdisciplinary and practical problem solving. The corporate culture sees their role as articulating organisational goals, often based on abstract modelling processes, and devising control procedures to meet them.
Conflict arises when goals fail to align. Every organisation must serve both production and protection roles. Service contracts usually concentrate on price and volume- the managers measure of productivity, without due care to the quality of the product, which directly reflects our protection role. When we voice our concerns about this, we are accused of shroud waving. However, the Health and Disability Commissioner’s considered reviews and the Gisborne Cervical Enquiry show this is a central issue. A significant reason that Dr Bottrill’s lab did not maintain the accepted review standard was that RHA contract managers dropped the standard to attract “new players into the market.”
Andrew Hornblow called New Zealand health reforms of the 1990’s a “clash of cultures” in a BMJ article in 1997. His first line says volumes, “To reshape a health system without due regard for cultural imperatives is to risk failure, as it has proved to be the case with New Zealand’s health reforms of 1993.” He referred to the 1997 coalition government’s intention to remove the commercial, competitive basis of the reforms. They failed miserably and the present Government still faces a gargantuan task that makes salvaging Air New Zealand’s errant commercial behaviour look like child’s play. That salvage was simply about money, this is about values— changing and integrating fundamentally different cultures.
This may appear negative and fail to recognise pockets of successful melding of the two cultures, but the important thing is to recognise that in fact the vocabulary, the processes and behaviour of our recent past are managerial, not clinical. They are identical words and incentives to a US managed care organisation. Their purpose is to command and control the cost of the care we provide. This is still the context in which we live. Some doctors have adapted to the environment, but in adapting, they risk adopting the underlying values of another culture. If we are to change and improve our future context and culture, we need to look at the forces already at work in our environment.
Twin Chimeras: Contractualism and Consumerism
Two of those forces still at work, and perhaps still in ascendancy, which determine our everyday context, are the twin chimeras of contractualism and consumerism.
Contractualism was introduced in 1987 to New Zealand’s public sector based on Treasury’s assumption that “provider capture” meant that, without the strict dictates of binding contracts, we could not be trusted to provide the care and succour that we have professed to do. Hence, we live in a corporate Tower of Babel, dominated by unintelligible jargon and funder/provider role-play using rigid corporate devices to maintain them. Contractualism still rules our lives.
Contractualism’s priorities distract our attention from our task, which is to balance production and protection. They institutionalise mistrust and construct Chinese walls between funder and provider limbs of DHBs. When we criticise this, we are accused of being negative, anti-progressive, patch protecting or “difficult to herd as cats,” but who sees the impact on people better than we do?
Too few seem to be learning a new language or exploring a modern approach to delivering and monitoring an efficient public health system driven by values that have to do with improved lives for people. Our performance in trying to help people is still measured in dollars and cents, not professional or common sense. Unfortunately, a chosen few doctors have been caught up in the thrill of the funding target chase and simplistic models of care without necessarily considering their outcome. For many, lack of control and confused goals erode confidence in the system and in ourselves and we burn out.
It also creates disturbing trends. The profession must choose between a piecework model and reaffirmation of our professional relationships. As we speak, agencies and hospitals create positions for young doctors as $75/ hour shift workers. What of learning and mentoring relationships with senior clinicians? What of teamwork, mutual respect or devotion to duty? We are here because we share fundamental values that should persist. If we are here only to maximise self-interest, we deserve what the market delivers us.
How can we help make New Zealand’s health system attractive to junior colleagues and how are we going to organise our work to create a learning, nurturing culture based on values as well as skills and knowledge? The marketplace for us should be a marketplace of ideas where our values and willingness-to-invest time and knowledge are recognised as commodities of inestimable worth to our society- now and in the future.
Consumerism is constantly thrown up to us as a dominant force in our relationship with patients. A key tenet of the commercial model is that the consumer is always right and must be satisfied or go elsewhere. I challenged the BMJ Editor, Richard Smith, about this at a Health Ministry meeting. He proposed that the informed patient, armed with Internet-derived information would know more than his doctor about his ailments. Patients so empowered would “threaten their doctors.” While I welcomed access to information for all, I pointed out that information in some ways is the least important commodity needed from a doctor. People come to doctors for compassion, wisdom and objectivity.
Far more important than downloading meta-analyses or protocols from the web is the doctor’s ability to recognise a patient’s uremic breath, to allow for his foibles or to know that a woman has been abused by the way she doesn’t answer questions. In short, no machine can replace judgement tempered by humanity, empathy and well meaning. Unfortunately, we now face situations where humans are found wanting for lack of machine-like reproducibility rather than professional reliability.
While doctors must guard against doing harm to their patients, so too must those who take it upon themselves to judge others. This is at the core when some doctors demand we give up clinical freedom— just act according to their opinion, not our own judgment. Suppression of variability is a far less likely means to achieve healing than a professional attitude.
In some ways the term consumer has become a pejorative one, as in the consumer of resources — resources that should have gone to someone more deserving, perhaps. Dr Paparangi Reid has asked me why so many of the medical records that she explains to Maori patients use terms that are quite judgmental and dismissive of the person that they describe— “This obese, diabetic, hypertensive non-compliant 63 year old Maori man is readmitted for the 4th time in three months with….” I can’t say why we are so judgmental of each other, patients and doctors, but I observe that it has become a part of our culture to our detriment. Where is our objectivity, our willingness to see others’ lives in their context?
We are what we repeatedly do
Aristotle’s concept, “We are what we repeatedly do,” is deceptively simple. Another translation would be “Our conduct determines our character.” It also influences the perception that others have of us. This is one of the central tenets of being a professional that’s why we swear an oath to uphold the profession and protect its character.
If what we are is generic labour providing generic services at an agreed price, then that is what we are, but why does our character come into it? Because we are trusted and we need processes that reinforce, not diminish that trust.
Are we repeatedly trustworthy? I have had several debates around this question lately.
A lawyer friend and I had a friendly discussion about the value of the proposed (and legislated) ACC providers’ levy. He believed the levy would give health professionals greater incentive to think about being safe. My argument, backed by impeccable economic jargon, was that even if our professional dictum to “First, do no harm” were insufficient incentive, the incidence of this tax would not fall in the right place to change incentives. That is, GPs would simply pass the levy charge on to patients and salaried health workers on to their employer. Hence the patient/taxpayer bears the cost of the levy with no real change in incentives.
We also debated the value of ACC medical misadventure claims (determined to result from “bad luck”) to the Medical Council as a proposed reflection of doctor’s competence. I suggested that it be seen as an experiment and have explicit policies about what action might arise from such abstracted and imprecise data.
I asked a visiting quality consultant what we should do to re-establish trust in NZ patient-doctor relationships. He thought we should find something to fix, like waiting lists, and fix it. After hearing the history of that rationing process in New Zealand, he expressed concern that he had heard nothing about consumers’ needs, only about doctors. I rephrased my question. I said, “How, in a country where a professional is being put on trial by a Parliamentary select committee, can we change from a blame culture and re-establish a trusting relationship between patient and doctor?” At that point he said he thought I was living in the past. In reply, I quoted Santayana and citied evidence that trust had therapeutic effect and helps patients more than doctors.
Perhaps I missed something. I think he meant doctors are supposed to become more trusting and open in their professional lives so that we all can learn from mistakes and that’s fine. But are they to do this in a society that pillories a professional without natural justice? We can never cast aspersions on suffering people, even when they claim that we caused it. We are bound by a code that requires us to turn the other cheek.
Where a segment of society makes itself more vulnerable for the good of that society, society has a duty to implement fair and just processes to protect it.
To be professional is to profess values, to be devoted to those values, in our case, to prevent and relieve suffering, and to negotiate with society. Where is the negotiation taking place? Is it in a select committee meeting in Northland rehearing complaints of women against a doctor who tried to relieve suffering? Does a media feeding frenzy that selectively ignores the context and factual information of events represent the forum? Were the escalating charges, since partially reversed, within the Medical Practitioners Disciplinary Tribunal’s proceedings society’s expression of open justice and fair play? On Monday the Health Ministry reported that two external examiners had found his practice met the accepted standard in over 500 cases. Where is the balance?
The reason that professionals must review other professional’s behaviour is because they are the only people who have an inkling of the complex context in which innocent mistakes or blatant violations can occur. It is embarrassing that the two doctors on the select committee actually went along with the sham for party political reasons.
I made the ASMS submission to that same select committee about the foreign doctor’s qualifications amendment. To highlight the much-maligned Medical Council’s difficult task of measuring competence, I presented a copy of an 1839 certificate from the Dublin Lying-in Hospital and Dispensary. It said, “He has this day been carefully examined by us and he appears to possess a competent knowledge (my emphasis) of this branch of his profession.”
Focus on professional competence is cogent in socio-technological fields like aviation as well as medicine. However, pilots and doctors face the same challenge- time and repeatedly doing what we do. A pilot is only as competent as his next take-off and landing. Hopefully, the pilot learned something on the last approach that will add to skills and knowledge for the next time. This is why we value experience.
More to the point, the core element of professional knowledge is that we know things can go wrong and we strive to be prepared and respond flexibly to those threats. We are less worried about being accountable, explaining what happened, than we are about being responsible, not letting it happen in the first place or recovering when it does. Of course, we take individual approaches to this according to the processes our experience and study suggest are trustworthy.
I think it is the concatenation of our individual pursuit of preparedness and flexibility that promises opportunities for a more creative and sustainable approach to the challenges we face. This comes from superseding simplistic command and control managerialist culture, celebrating, not denying, our clinical freedom and accepting the natural tensions from cultural differences. This, I submit, is forward looking by learning from the past.
Somebody down at the Minister’s office understands this approach because it is at the core of the recent discussion document, Quality Improvement Strategy for Public Hospitals to which ASMS, represented by David Galler and Ian Powell made a significant contribution. The document is written “with the intent of establishing a quality improvement strategy for public hospitals that is primarily developed and implemented by clinicians in a democratic framework collaborating with patient advocates, and with the support of management. The strategy would be focused primarily at the clinical team level and would complement the new standards regime that will be introduced next year after the passing of the Health and Disability (Safety) Bill.”
Complex Adaptive Systems- the past and the future
If we are what we repeatedly do, then we should repeatedly do what we value and hold dear. Perhaps we need to see our world through more natural, less judgmental, reductionist eyes and having seen the world that way, we might behave in more human and logical— at least from our viewpoint— ways as our culture evolves and matures.
My son showed me a January 2001 Scientific American article, “Complexity’s Business Model- Part physics, part poetry— the fledgling un-discipline finds commercial opportunity.” Healthcare organisations, like the immune system, are complex adaptive systems better understood as the interdependencies of multiple self-adjusting and interacting individual parts rather than the hierarchical boxes and lines of corporate models. Unpredictability and the paradox of variation (variation can be both good, in terms of safety because we stay alert and bad, in terms of not being able to predict the cost, for instance) are constants and many things remain unknowable. Although the authors accept concepts I would challenge, such as consumerism instead of autonomy, I recommend the BMJ series on Complexity science to you as a well-articulated balance to command and control.
Clinical democracy’s collective wisdom is a complex adaptive approach more likely to harness the creativity in all professional groups than ill-fated corporate governance’s attempt to know the unknowable and control the uncontrollable— the very limited view of mechanistic organisations and the humans in them. Yes, doctors need to take on leadership and management roles, we always have, but it should not be a one-way trip where we leave professional relationships and values behind.
Top down clinical governance models however; give me little confidence because many of those doctors involved are selected for compliance with management’s priorities, not clinicians’. We must first negotiate among ourselves before we can adequately negotiate with society. We need to democratically elect leaders of units, services and medical staff representatives. In a country that functions under democratic process, who but control freaks and empire-builders could be threatened by that? And think of the strength consensus gives our argument.
While some claim that credentialing will somehow guarantee competence, I have my doubts. Competence (our knowledge, skills and attitudes) is at best an apparent property of performance, not a concrete one. Complexity theory would suggest that we focus on capability (our ability to adapt to change, generate knowledge and improve our outcomes) enhanced through feedback, challenge of unfamiliar contexts and learning in ways that are optimal for our learning style and approach. This directly influences how we help junior colleagues teach themselves.
To get our eye back on the ball, we must see beyond the simplistic scope and inherent inefficiency of foreign contractualism and liberate professional attitudes and wisdom, respond to minimum specifications and maximum attention to the process of care, delegate responsibility based on widely held respect and select leaders by democratic means.
Our relationship with our patients has always been more than simplistic consumerism. Patients and doctors need to understand the complexity of what we do is far more than the customer/seller abstraction. We need to refocus on the ethical principles of autonomy, beneficence, non-maleficence and justice. We also need to respect the rights and duties inherent on both sides of our very human relationships. None of us can see the future perfectly, but with better understanding we can learn new ways to make it better.
The challenge is for government to unleash the dynamic of professionalism within a democratic, responsible and accountable process with district health boards that is inclusive of clinical leaders working within a mandate of their peers. The discussion document referred to earlier, Quality Improvement Strategy for Public Hospitals, recognises the link between such a process incorporating clinical democracy and the achievement of safety and quality improvement. The government should further engage with the ASMS and NZNO at the very least in order to provide operational and practical teeth to the intent and spirit of that document.
We cannot make these changes alone. We need society; through our elected representatives, to provide not only adequate resources, but also an environment in which our self-learning, self-teaching, caring culture can flourish. The first step is for New Zealand itself to become a just culture, a culture less concerned about controlling and judging other people than about enhancing human performance in an effective system where our creative capability can be nurtured and respected for the treasure that it is. All we want to do is help.
Leadership inspired by complexity theory recognises
that change occurs naturally within the system and that
individuals engage in this effort for a variety of reasons.
Good practice will spread more quickly within the health
system if leaders acknowledge and respect the patterns
reflected in the past efforts of others to innovate. The
leaders role is to create systems that disseminate rich
information about better practices, allowing others to adapt
those practices in ways that are most meaningful to them.
— Paul Plsek & Tim Wilson, Complexity science series, BMJ 2001
It is a great advantage for a system of philosophy to be substantially true.
— Dr. George Santayana (The Unknowable)