The world of Policy and the Salzburg Statement

With his recent elevation to Taoiseach, something Leo Varadkar (who was supposed to work with me when I did a locum in Tallaght in May 2007… but he was occupied with some election or other) said in the late 1990s got a fair bit of coverage. This was to the effect that as a doctor you can help a few people, but as Minister for Health you can help millions. While at first glance this seems like a truism, it has for some reason got under my skin. There are various reasons for this, not all of which I will get into. Perhaps I am jealous of a road not travelled! (I am pretty confident I am not)

In a way it sums up a particular seduction – the seduction of the World of Policy. Get interested in any field – from the natural world to technology to medicine indeed – and sooner or later the siren song of policy will be heard. Wouldn’t it be great to Make A Difference not just on the piecemeal, day-to-day way, but on a grander scale? Increasingly I think not. Clearly someone needs to formulate policy and to think about things on a broad scale – but they should do so without illusions and with a certain humility. People have a habit of behaving in a way that the enlightened policy makers don’t foresee.  The circuit of conferences and “networking” can become an echo chamber of self congratulation. Doing good, perhaps, is best done on a smaller scale.

These thoughts are occasioned by reading about the Salzburg Statement. This is something I heartily approve of – a call for action to ensure all children enjoy the right to play in a nature rich space within ten minutes of their home.  The statement is made up of eight key actions:

Eight actions to transform cities for children

  1. Ensure children of all ages, backgrounds, income, and abilities have equitable access to nature and play regularly and in meaningful ways to promote good health and wellbeing.

  2. Embed nature in everyday places used by children, such as schools, backyards, parks, playgrounds and city streets, to make the city into a natural outdoor classroom.

  3. Involve children in designing and planning natural spaces for recreation, education, inspiration and health, to give them ownership and pride in their local communities, schools and parks

  4. Build curiosity, wonder, and care for nature in children (for example by greening school grounds and involving children with community gardens).

  5. Protect natural features across cityscapes and create an equitably distributed network of accessible green and nature-rich spaces that all generations can reach on foot.

  6. Connect cities with the broader ecosystems in which they are embedded, creating corridors for people, plants and animals to move safely across the city and into its surroundings.

  7. Establish more urban conservation areas to increase access to nature and connect cities to the broader protected area network.

  8. Work together through cross sectoral and multi-level partnerships to build an inclusive culture of health in cities.

 

There’s nothing there I would disagree with, though as with all these kind of interventions I would like more robust dissection of what, say, Item 3 would mean in practice.

I am always a little wary of dressing up worthy activity in the mantle of Health. What Resting a case for nature on the vagaries of purported health benefits can be a dangerous and debunkable game – especially with the media. This visual  handily shows how media can seize on single studies to generate headlines:statins.png

One can easily imagine a Katie Hopkins-ish journalist seizing on the inevitable ambiguities of research to “debunk” the claims for health benefits of nature.

I should state very clearly I have no reason to think that the Salzburg Statement is a wonderful initiative I look forward to hearing more of. But I am a little wary of the siren call of the World of Policy.

Leandro Herrero – “The best contribution that Neurosciences can make to Management and Leadership is to leave the room”

A while back I reviewed I Know What You’re Thinking: Brain Imaging and Mental Privacy in the Irish Journal of Psychological Medicine, and discussed a couple of studies which illustrate the dangers of what could best be called neuro-fetishism:

In 2010, Dartmouth University neuroscientist Craig Bennett and his colleagues subjected an experimental subject to functional magnetic resonance imaging. The subject was shown ‘a series of photographs with human individuals in social situations with a specified emotional valence, either socially inclusive or socially exclusive’. The subject was asked to determine which emotion the individual in the photographs were experiencing. The subject was found to have engaged in perspective-taking at p<0.001 level of significance. This is perhaps surprising, as the subject was a dead salmon.

In 2007, Colorado State University’s McCabe and Castel published research indicating that undergraduates, presented with brief articles summarising fictional neuroscience research (and which made claims unsupported by the fictional evidence presented) rated articles that were illustrated by brain imaging as more scientifically credible than those illustrated by bar graphs, a topographical map of brain activation, or no image at all. Taken with the Bennett paper, this illustrates one of the perils of neuroimaging research, especially when it enters the wider media; the social credibility is high, despite the methodological challenges.

I am becoming quite addicted to Leandro Herrero’s Daily Thoughts and here is another. One could not accuse Herrero of pulling his punches here:

I have talked a lot in the past about the Neurobabble Fallacy. I know this makes many people uncomfortable. I have friends and family in the Neuro-something business. There is neuro-marketing, neuro-leadership and neuro-lots-of-things. Some of that stuff is legitimate. For example, understanding how cognitive systems react to signals and applying this to advertising. If you want to call that neuro-marketing, so be it. But beyond those prosaic aims, there is a whole industry of neuro-anything that aggressively attempts to legitimize itself by bringing in pop-neurosciences to dinner every day.

In case anyone doubts his credentials:

Do I have any qualifications to have an opinion on these bridges too far? In my previous professional life I was a clinical psychiatrist with special interest in psychopharmacology. I used to teach that stuff in the University. I then did a few years in R&D in pharmaceuticals. I then left those territories to run our Organizational Architecture company, The Chalfont Project. I have some ideas about brains, and some about leadership and organizations. I insist, let both sides have a good cup of tea together, but when the cup of tea is done, go back to work to your separate offices.

It is ironic that otherwise hard-headed sceptics tend to be transfixed by anything “neuro-” – and Leandro Herrero’s trenchant words are just what the world of neurobabble needs. In these days of occasionally blind celebration of trans-, multi- and poly- disciplinary approaches, the “separate offices” one is bracingly counter-cultural…

What practice which seems perfectly fine to us now will seem weird/unethical/laughable in fifty years?

On my other blog I posted a quote from James Jeremiah Sullivan’s essay  on the polymath Constantine Samuel Rafinesque:

That’s what’s so terrifying but also heroic in Rafinesque, to know he could see that far, function at that outer-orbital a level intellectually, yet still wind up viciously hobbled by the safe-seeming assumptions of his day. We do well to draw a lesson of humility from this. It’s the human condition to be confused. No other animal ever had an erroneous thought about nature. Who knows what our version of the six-thousand year old earth is. It’s hiding somewhere in plain sight. In five hundred years there’ll be two or three things we believed and went on about at great length, with perfect assurance that will seen hilarious to them.

One could cite many many examples of “safe seeming assumptions” in every sphere – moral, scientific, social, cultural – which as time went by became unsafe and then positively harmful, laughable or just plain weird.

There is a self-congratulatory tendency to exaggerate and outright distort how wrong people were in the past. This is a form of epochalism, the belief that we live in a time unique in human history  True in a trivial sense, but blind to the patterns of human life and what could be called the human condition. One of the recurrent themes on Stephen Pentz’s poetry blog First Known When Lost is that the modern belief that We Are Somehow Unique is an illusion. Other people, at other times, have struggled with mortality, the passing time, what is a good life, and in times in their own way as complex and baffling as our own.

Anyhow, the point of this post is really to post a question, and a question that is in principle unanswerable. What will the practices in medicine in healthcare that, in fifty years, will seem either weird or unethical or simply bad, that we take for granted today? The nature of this question that these are not things that, by and large, are objected to today, but seem a normal part of practice. One could put forward many obvious answers about eHealth or about health insurance, but of course values change over time and assuming our values now will be the normative values of fifty years is a fool’s game.

Friendship and Work in Medicine and Healthcare

In 2001, Digby Anderson wrote a short book, Losing Friends, about what he described as the decline of friendship. This New York Times “At Lunch With” pieces ummarises his argument:

”All past civilizations have declined, and Western civilization is about due to go,” he said, gamely piling his plate with assorted meats and salads. ”The death of friendship is one symptom of that.”

He says he believes political extremism has rendered friends powerless to help one another. Liberals’ insistence on equal opportunity and impartiality, he said, has led to ”egalitarian bureaucracy,” a muddling of what had once been smooth-flowing business networks based on friendships. Years ago, he said, friends happily helped one another find jobs; today they shy away, lest they be accused of favoritism.

”Even though it makes sense to hire a friend, or even a friend’s friend, there’s this feeling that you have to give everyone an equal chance,” he said.

The blow from the right, he said, has been a constant emphasis on the family as the ”repository of all virtues” — and, thus, the only institution worthy of trust and time.

”The ancient Greeks had a better idea: they considered their friends to actually be their family,” Dr. Anderson said.

My recollection of the reasons he gives in the book why “it makes sense to hire a friend, or even a friend’s friend”, is because of the special knowledge which friendship gives us about someone’s true nature. A friend – a true friend – is also less likely to screw over their friend… or at least thats the theory. I wonder how strong the evidence is for the counter argument, that hiring friends is somehow bad?

I am not sure how much I buy of Digby Anderson’s overall argument about hiring friends etc, but there is definitely something in his reflections on the decline of friendship.

The official blurb is also interesting:

“One loyal friend is worth 10,000 relatives”, said Euripides. Aristotle thought friendship the best thing in the world. Saint Augustine was devastated by the death of a friend, “All that we had done together was now a grim ordeal without him”. For men as different as Dr Johnson, Coleridge and Cardinal Newman friendship was a great, moral love. For Cicero it was a foundation of social order. For Burke “good men [must] cultivate friendships”. To try to lead a good life on one’s own is arrogant and dangerous. In past ages business thrived on the trust of friends; armies won battles on the loyalty of men to their comrades and people were attracted to and schooled in medicine, law and academe by friendship. This friendship of the past was high friendship, a friendship of pleasure but also of shared moral life.

LOSING FRIENDS contrasts this high friendship with the “pathetic affairs” which pass for friendship today. Friendship is in trouble. An institution once as important as the family, has been “diluted to mere recreation…passing an odd evening together…sharing the odd confidence”. It is being outsted from business through fear of cronyism and squeezed between the demands of work and the increasingly jealous family. Fathers neglect their obligations to their friends at the club or pub to bath their children. Many of us will have no friends in illness, in need or at our funerals. Bewildered letters to agony aunts ask how to make friends. Schools are absurdly introducing classes on how to do so. Our society has no public recognition of friendship and cannot even discuss it articulately. When it does it sentimentalizes it. Modern society is wealthy, healthy and long lived. Aristotle would ask what the point of such a life is if lived without friends.

I have (or had) a copy of the book somewhere. I read it in around 2004. The message did resonate, and since I have seen how social pressures that tend to squeeze out friendship intensity.

Healthcare in general, and medicine in particular, is on one level a fertile ground for friendship. One ends up spending a lot of time with other people engaged in what is  a highly intense, demanding role. It is natural enough for some strong bonds to form, as over the hurried coffees and lunches some small talk is exchanged. There has also been a boozy culture around medicine in the past at least, and while one could make many observations on the role of alcohol as a form of self-medication, there was a social side to all this.

And yet the structure of medical training in particular is not conducive to longer term friendships. One spends three, or six, or at most twelve months in a post as a trainee  doctor. The intense friendships of one rotation are suddenly severed. With the best will in the world, and my sense is the unreal interactions of social media have exacerbated rather than ameliorated this, it is hard to keep up. And when one completes training, the camaraderie of the res room is something that is closed to you.

The factors that Dr Anderson discusses – the suspicion of anything that might hint of favouritism, the dulling bureaucratic managerial discourse of healthcare management, a sort of idolatory of the family now as much a left as right wing feature – are present in medicine too.

How does friendship relate to the issues of morale and a healthy work culture I have blogged about before? The importance of “psychological safety” in team interactions is emphasised in Google’s Project Aristotle as key to successful team interactions. Fostering a sense that teams can communicate openly, without fear of recrimination or embarrassment, sounds to me very much like fostering friendship. Of course, perhaps this is falling into some kind of trap where friendship can be subservient to the interests of an organisation, and indeed denigrating friendship as something that needs to be justified in pragmatic, utilitarian terms.

Morale, adaptive reserve and innovation

I have another blog post on the CCIO website – the contents of which may remind readers here of this and this and also this – so here is the Greatest Hits version:

 

Morale, adaptive reserve and innovation

HSEQCMLogo
On the ARCH (Applied Research in Connected Health) website, research lead Dr Maria Quinlan recently wrote a post called Happy Organisations and Happy Workers – a key factor in implementing digital health.

In the opening paragraph, Dr Quinlan invokes Anna Karenina:

 

To paraphrase Tolstoy, “all happy organisations are alike; each unhappy organisation is unhappy in its own way.” The ability for healthcare organisations to innovate is a fundamental requirement for adopting and sustainably scaling digital health solutions.  If an organisation is unhappy, for example if it is failing to communicate openly and honestly, if staff feel overworked and that their opinion isn’t valued, it stands to reason that it will have trouble innovating and handling major complex transitions.

The whole post is a fascinating read, with implications for team functioning beyond the implementation of digital health and indeed beyond healthcare itself. Dr Quinlan cites research on what makes a happy worker;

What these factors combine to achieve is happy, engaged workers – and happy workers are more effective, compassionate, and less likely to suffer burnout. Clear objectives, praise, a sense that your voice matters – these can seem like fluffy ‘soft’ concepts and yet they are found over and over to be central to providing the right context within which new digital health innovations can flourish. Classic ‘high involvement’ management techniques – for example empowering team members to make decisions and not punishing them for every misstep are found to be key.  As Don Berwick of the Institute of Healthcare Improvement (IHI) says, people who feel joy in work are “not scared of data”, rather “joy is a resource for excellence” 

stressed-nurse

Dr Quinlan goes on to describe the high rates of burnout and emotional exhaustion among healthcare workers. Unfortunately this is a phenomenon that has been consistent in survey after survey. Not only does poor morale compromise the introduction of innovation, it also causes direct human suffering and compromises what an organisation is trying to achieve.

The concept of “adaptive reserve” is an important one, especially in the context of reforms and innovations being introduced into already pressured environments:

Adaptive reserve is an internal capability for change which includes being agile; capable of continuous learning; and being adept at self-assessment, reflection and improvisation. The Adaptive Reserve questionnaire asks staff to rate their organisation according to a variety of statements which include statements such as; ‘we regularly take time to consider ways to improve how we do things’ and ‘this organisation is a place of joy and hope’.

There is sometimes an urge to reform or innovate our way out of the situation healthcare finds itself in, and yet the concept of Adaptive Reserve suggests that this is inverting how reform and innovation work; there needs to be not just systematic space and infrastructure for it to happen, but psychological space among staff.

A related blog post on the ARCH website by Dr Marcella McGovern on the blame culturethat exists within many organisations, and particularly in the Irish health care context is worth reading. Dr McGovern uses Melvin Dubnick’s framework of “prejudicial blame culture” to describe how systems focused on blame stifle initiative and responsibility.

download2Google recently completed Project Aristotle, a study of what makes a successful team. Far and away the most important factor is “psychological safety” – “Can we take risks on this team without feeling insecure or embarrassed?”  Focusing on technological fixes in the absence of a sense of psychological safety is a recipe for innovations to fail and for morale to decrease further. Can technology, in and of itself, foster psychological safety? My inclination is to say no, that psychological safety is much more about interpersonal relationships within a team and a system. What technology may be able to do – in a positive sense – is help facilitate team communication.

Of course, this also has to be carefully thought through. Evgeny Morozov’s “To Solve Everything, Click Here”  is a fascinating and at times rather frustrating book which takes a searching look at technology in the modern world. Morozov is against both the excessive hype of technological utopians and the excessive gloom of technological pessimists. He strongly decries what he calls “solutionism”:

“solutionism.” … has come to refer to an unhealthy preoccupation with sexy, monumental and narrow-minded solutions – the kind of stuff that wows audiences at TED Conferences – to problems that are extremely complex, fluid and contentious. These are the kind of problems that, on careful examination, do not have to be defined in the singular and all-encompassing ways that “solutionists” have defined them; what’s contentious then, is not their proposed solution but their very definition of the problem itself. Design theorist Michael Dobbins has it right: solutionism presumes rather than investigates the problems that it is trying to solve, reaching “for the answer before the questions have been fully asked.” How problems are composed matters every bit as much as how problems are resolved.

The problems of healthcare are truly “extremely complex, fluid and contentious” and any honest attempt to solve them must engage with this complexity.  Can judicious innovation help foster psychological safety within a team, and thereby not only create happiness among health workers but also help them achieve the organisational goals they are engaged in meeting?

 

Unintended consquences and league tables

I have just finished Simon Westaby’s memoir Fragile Lives: A Heart Surgeon’s Stories of Life and Death on the Operating Table . This is for a review which will follow in due course. The main focus of the book is on the stories of the patients and the surgeries themselves, some passages have a (literal) heart-stopping intensity.

One recurrent theme, towards the end of the book especially, is the deleterious effect of blame culture and league tables on surgical practice. Prof Westaby, it turns out, wrote a recent paper on surgeon’s perception of this:

National Survey of UK Consultant Surgeons’ Opinions on Surgeon-Specific Mortality Data in Cardiothoracic Surgery

Abstract

Background—In the United Kingdom, cardiothoracic surgeons have led the outcome reporting revolution seen over the last 20 years. The objective of this survey was to assess cardiothoracic surgeons’ opinions on the topic, with the aim of guiding future debate and policy making for all subspecialties.

Methods and Results—A questionnaire was developed using interviews with experts in the field. In January 2015, the survey was sent out to all consultant cardiothoracic surgeons in the United Kingdom (n=361). Logistic regression, bivariate correlation, and the χ2 test were used to assess whether there was a relationship between answers and demographic variables. Free-text responses were analyzed using the grounded theory approach. The response rate was 73% (n=264). The majority of respondents (58.1% oppose, 34.1% favor, and 7.8% neither) oppose the public release of surgeon-specific mortality data and associate it with several adverse consequences. These include risk-averse behavior, gaming of data, and misinterpretation of data by the public. Despite this, the majority overwhelmingly supports publication of team-based measures of outcome. The free-text responses suggest that this is because most believe that quality of care is multifactorial and not represented by an individual’s mortality rate.

Conclusions—There is evident opposition to surgeon-specific mortality data among UK cardiothoracic surgeons who associate this with several unintended consequences. Policy makers should refine their strategy behind publication of surgeon-specific mortality data and possibly consider shift toward team-based results for which there will be the required support. Stakeholder feedback and inclusive strategy should be completed before introducing major initiatives to avoid unforeseen consequences and disagreements

This was reported in the Daily Telegraph as follows:

Patients are dying because heart surgeons are too worried about their mortality ratings to operate on critically ill people, a major study has found.

One surgeon claimed he had a watched a three-year-old child die waiting for a valve replacement because a doctor was “too chicken” to operate because of the potential risk to his reputation.

Another warned that surgeons had “become experts in running away from difficult cases”.

 Patients have been able to see league tables showing how well doctors perform on an NHS website since 2014, while information about individual heart surgeons has been available for a decade.

But nine in 10 heart surgeons claim that publishing individual data has led to blame culture where the sickest patients are denied treatment for fear it will lead to an investigation if they die in theatre.

Research carried out by doctors including Stephen Westaby, of the John Radcliffe Hospital in Oxford, and Professor Lord Darzi, chair of surgery at Imperial College and a government adviser, found nearly 60 per cent of surgeons said they were opposed to the current system.

Some 87 per cent of the 264 heart surgeons who replied to a survey said that publication of surgeon specific mortality data had caused a “risk averse” culture in the NHS.

Report author Dr Westaby said: “We have been trying to establish what has been happening among colleagues for some time now. It’s so damning you can hardly believe [it].

“Doctors won’t see a patient if they think it will be a risk to their reputation.

“And it’s often the guys that are doing the sickest patients who end up with the worst scores, because their patients are more likely to die.”

One wrote: “Decisions have become about protecting me, not about what is best for the patient. This is a terrible form of medicine to practice. There is no dignity at the end of life, with surgeons delaying inevitable adverse outcomes in the hope of a miracle or transferring patients to other units so that they don’t count in the figures.”

Another said: “When previously surgeons would have been willing to give it a go on a patient who was certain to die, as there as nothing to lose, now they will be concerned that there is quite a lot to lose.”

“Blame Culture” in the Irish Healthcare System – another ARCH blog post

Another excellent blog post on the ARCH website, this time by Dr Marcella McGovern, on the blame culture of the Irish health system. The trigger for this article was the recent controversy on “hidden waiting lists.” This led to a rather predictable response from the current Minister for Health:

The Minister for Health, Simon Harris, responded to this programme by saying that he “intends to shine a light” on management in the Irish Health Service Executive (HSE) and that if management does not “measure up”, they will be removed from their roles.

 

Tough talk, but as Dr McGovern writes:

 it fails to acknowledge the Government’s responsibility for that problem. Governance, performance oversight and holding the HSE to account for the implementation of national health policy are key functions that the Minister for Health and his Department are responsible for performing on an ongoing basis; not in response to a crisis. The question put to Ministers for Health in a crisis therefore, should be where in your Department’s oversight of the HSE did you fail to detect this problem and what steps are you taking to correct the problem and ensure that it doesn’t happen again?

 

Of course, this is hardly new:

Paul Cullen highlighted in an analysis piece in the Irish Times (Irish Times, 11th February 2017) that Minister Harris’ predecessor, Leo Varadkar, similarly promised that “heads will roll” over hospital overcrowding. Yet, this winter again saw overcrowded Accident & Emergency Departments resulting in planned inpatient and outpatient appointments being postponed.  The back-log of these postponed appointments are now contributing to the current crisis over long waiting lists, illustrating that unjustifiably “blaming the bureaucrats” (Dubnick, 1996) has knock on effects.

 

Dr McGovern uses the work of Dubnick on “prejudical blame culture” as a framework for her piece:

Three major conditions (for defining prejudical blame culture):
1. It makes no requirement that the blamed person or collection of persons have assumed responsibility for the condition they are blamed for; rather, it targets an ill-defined but inclusive group that everyone knows to exist (e.g. bureaucrats);

2. It doesn’t require any role for the blamed in contributing to the cause of the blameworthy or harmful condition. It is assumed that the vaguely defined ‘they’ are highly influential in shaping the world;

3. [It] eliminates the need for any degree of specificity regarding what the harmful condition entails. It could be the decline of the economy, or the loss of national prestige, or the general malaise of society. (Dubnick, 1996: 22).

Dr McGovern’s work, in the ARCH context, is on the effect on system readiness for innovation. Of course, blame culture has a much wider impact, paralysing innovations beyond the technological sphere:

From a Connected Health perspective, there is a danger that a blame culture demonstrated at the highest levels of the Irish health system will have a trickle-down effect, compromising system readiness for innovation. If the Department of Health blame the HSE for poor management and the HSE blame the Department of Health for inadequate resources, and if clinicians blame managers for excessive bureaucracy and managers blame clinicians for resisting change; organisational trust may be lost in the battles between “us” and “them” (Firth-Cozen, 2004). Within such environments, potentially transformative leaders and early adopters behave cautiously and become reluctant to take “ownership” of innovations (Heitmueller et al. 2016), which by their nature carry the risk of failure and unintended consequences (Ash et al. 2004).