Thursday, October 10, 2013

Administrators, Clinicians, and Professionalism

From “Not Running a Hospital” ( by Paul Levy, today:
“We still find hospital administrators more interested in market dynamics, mergers, and the like than improving the quality and safety of care.  We still find doctors untrained in the use of the scientific method to achieve clinical processes.  We still see medical schools and residency training programs as woefully deficient in such matters.”
And from an article in Kaiser Health News today:
A recent study by researchers at the Yale School of Medicine found that only a third of 400 elderly patients were discharged with a follow-up doctor's appointment and 25 percent were handed instructions written in impenetrable medical jargon.

Right.  When I read about this, I am outraged.  It gets to the core of professionalism.
I learned this in internship.  On rounds at UCSF, I said to my attending pediatrician that the lab was very slow and unresponsive, and that as a result the patient would just have to suffer.  I was being passive aggressive, and I knew, provocative.
He turned to me with heat  He said, "You will not do this!  You will go down to the lab and get those results personally!"  (The attending was Henry Shinefield, a wonderful man and clinician, with whom I developed a very warm relationship.)
Structurally, he was wrong.  I would be enabling the lab's poor service.  A system correction was needed, and all the clinicians should have gone to administration and demand they get the damn lab fixed.
But his doctor's solution was also correct.  The patient, the individual patient, comes first, and the doctor's job is to get it fixed for the patient, right now.
In fact, to be successful, both views are needed, the clinician's impatience to fix the individual situation, and the the administrator's view to fix the system for everyone once and for all.  
In our 10-office practice, I taught our managers, "Patience is not a virtue!  Insist that things go right, right away.  If you don't get a fix on something, call me directly.  That will be my job."  I taught them not to have an "off my plate" mentality.  It's not off your plate if the problem is simply on some else's plate now -- it's only off your plate when the problem is fixed.
How successful was I at Bayside in teaching organizational professionalism?  I truly don’t know.  I think I changed some of the managers’ attitudes, maybe.  I know they admired my point of view, but how much could they adopt it themselves?  Some did.

How successful was I with the clinicians?  I’m pretty sure they were professionally responsible to their patients, one by one.  How much were they responsible for seeing that a system got changed?  Some, but not so much.  This depends a lot on leadership.  I had quarterly meetings in each office with an agenda that featured systemic problems in the office from both the clinician’s and my own (leadership's) point of view.  After each meeting I made sure to effect improvements within a week, demonstrating to the clinicians that it was a responsible system.  But since I sold the practice I understand that the meetings have been sporadic at best and the Medical Director does not attend.  Leadership is key.

It is hard to overstate the importance of responsibility and persistence as ingredients of success.  As an executive, one thinks: who takes the job seriously?  Professionals take it seriously; that’s what is meant by being a professional.  Economics mixes us up by distinguishing an amateur and a professional by accepting money or not.  But the deeper meaning is the degree of responsibility accepted.  A true professional is someone who figures a problem is off his plate only when a problem is solved systemically.

It is so easy to talk about an "uncoordinated system," but within that system are real people, who are taking responsibility or not.  A system will hold the individuals accountable, but a real top-quality professional will hold not only him or herself accountable, but will hold the system accountable as well.  
As in the above hospital example with poor follow-up and undecipherable patient instructions, where are the professional members of the system headed to the offices of the administrator and the chief physician saying, how can you let this happen?  Where is your leadership in fixing this?  Do we only see individuals doing their jobs with their patients, heading down to the lab to get the results that should have been there at morning rounds, enabling a poor system?  Do we see ER docs readmitting patients, knowing they didn't have follow up appointments, knowing their instructions were indecipherable, and not insisting the leadership improve this performance?  I don't think so.  They might being a professional in the narrow sense, but it’s not enough.  
On the other hand, the profession called attention to the problem some 14 years ago (the Institute of Medicine report on safety), professionals conceived of this study and someone gave a grant for it, and a journal published it.  In my view it's too much time and the cumbersomeness reveals a lack of true interior professionalism -- if everyone were professional in the system the research results would have been different -- but at least we're on the right road.  It's just bumpy and meandering while people die and money is wasted, is all.

Budd Shenkin

Sunday, October 6, 2013


It is JFK season, but even apart from that, I’ve been reassessing him and the era in the last few years, reading accounts of general history of the era, Eisenhower histories, the Stephen King book, and most importantly the 2007 David Talbot book “Brothers.”  My life-long friend Bob Levin has also been immersing himself, principally in the civil rights literature, I think – Taylor Branch, and a book we both read about the Freedom Riders, which was great.

So here is Bob’s current take on the Kennedy Administration:

Those I know who believe most strongly that a vast conspiracy lay behind the assassination of President Kennedy place great emphasis on his commencement address at American university in June of 1963.  They believe these remarks revealed him to be committed to achieving global peace through agreements with Nikita Khruschev and certainly prefigured his intent to end our involvement in Vietnam and, hence, made the CIA, the military, and others decide to murder him.  Never a great believer in conspiracy theories myself, and not a greater admirer of JFK, I decided to see what went on between the time of this speech and his assassination five months later.  For my admittedly non-exhaustive research I turned to the Stanley Karnow book, my only Vietnam reference on hand, and my conclusion is i don't think Kennedy knew what the fuck he was doing with Vietnam.

Shortly after the speech he sent 3000 troops to Thailand because of unrest in Laos.  In early September, he told Walter Cronkite withdrawing from Vietnam would be a mistake.  He tried to get the New York Times to pull out David Halberstam because his reports were hurting the war effort.  He went back and forth about whether to support the coup against Diem, worrying mainly if it would work, not if it was the moral thing to do, eventually leaving it to his ambassador Henry Cabot Lodge to do as he felt best.  
The only support I found for the existence of an anti-war attitude in Kennedy was Larry O'Donnell's recollection of JFK's telling him he would pull out troops once he was re-elected, but couldn't do it before without being tarred as soft on Communism.  But O'Donnell was a Kennedy loyalist likely to paint him in the best light, which, in 1970, when he recounted this conversation, would have been to make him a peacenik.  And even if O'Donnell's memory and account were accurate, it still doesn't mean Kennedy would have acted in line with this sentiment.
So I see the Am U speech as just political talk.  I think Kennedy was a pol, playing things for maximum advantage, not out of principle.  (Certainly that's how he acted in the South on civil rights.)  Maybe that was enough to get people in the CIA pissed off enough to want to kill him but he was not the figure this other crowd is trying to make him out to be.

I believe Kennedy was essentially an unprincipled politician, telling audiences what he thought they wanted to hear, always seeking to manage events to his and his party's political advantage.  Certainly, that was how his administration conducted itself with respect to the civil rights movement then raging in the south.  And civil rights, remember, was more of an issue than Vietnam was in 1963.  Freedom Summer was about to launch, whereas hardly anyone knew where Vietnam was, and there was no anti-war movement to even speak of.

Then again, as my friend Richard Weber points out, it isn't necessary to burnish JFK's reputation in order to find motivation for the CIA, for instance, to take him out.  He had already pissed them off by firing Allen Dulles and not giving them carte blanche in Southeast Asia.

I myself have a different view:

I went around for years thinking that I liked Kennedy, his panache, the change from the 50's, but I knew the charges that he was essentially a cold warrior, not so progressive on many things.

Then I read the book by Talbot, who polishes everything to a high sheen, and my images of him reunited: he was indeed great, or at least was getting there!  He was fighting the militarists who predominated, but was severely limited in what he could do.  The Talbot book essentially says that he learned quickly, and was in ascent to the gods of right-thinking.  He takes Bobby's ascent in righteousness in the subsequent years as a surrogate for where JFK was going.

That is a speculative view, but an attractive one to reunite my psyche.  And it can't be disproved by his knowledge of political necessity; you can only do what you can do.  I think I'll stick with it.
Budd Shenkin