Most of you have heard the quotation that “the true definition of insanity is to keep doing the same thing expecting the result to be different next time.” The other day I found a variant of the quote that had two extra sentences. “We, on the other hand, are sane. We watch people and keep expecting them to do something different next time.”
So why do people change? People change when the current state is intolerable. They will also change when the current state is unsatisfactory, but only if they can imagine a better future state and have some notion how to attain it.
My grandfather practiced in the time before insulin was isolated and retired as penicillin was being introduced. My uncle practiced as penicillin was being introduced and into the current era of truly effective medications for treating a number of important chronic diseases besides diabetes, and I have practiced in the era of organ transplants and dialysis. My grandfather’s ability to determine medical necessity was unlimited, largely because he had little or no effective therapy for most of the things he saw. (His particular specialty was tuberculosis.) He also never made very much money practicing medicine. My uncle (an internist) had a lot more effective therapy, but most of it was used on a short-term basis. He got paid better, but saw increasing regulation. I have spent my career caring for a group of patients who used to die, and have been well paid for doing so, but have also had to live in the most regulated area of medical practice, since dialysis has always been a laboratory for national health care. On the other hand, I suspect my grandfather and uncle would have loved the chance to help patients the way I have, and would make the trade-off without blinking an eye.
If your future state is one where we are able to improve the way we deliver care to our patients by reducing risk, avoiding unhelpful care, and keeping patients functional through most of their life, then you are in luck. Our tools for improving patient safety and quality, what I prefer to call improving the reliability of our care, our rudimentary, but have gotten better in the twenty or so years I have been working in the dialysis units to apply these notions. I once read a book where the author argued that the defining urge in Western Civilization was the urge to measure. He had five examples, the last of which was double entry bookkeeping, which started in Venice late in the 15th century as merchants there struggled to figure out if they were gaining or losing money while dealing with multiple local currencies. In medicine we are about 1510 rather than 2010, but the rate of acceleration is much higher. I can’t think of anything more interesting than being involved in the next revolution in patient care, which is likely to be every bit as important as insulin, penicillin, and dialysis. Will you join in the process of imagining ways to get to a better future?
Written 22 October 2010, revised 3 May 2014.
Failure is inevitable. Successful organizations expect failure even from highly reliable processes. A consideration of how to tolerate failure.
On Institutional Failure - Part 1
On Institutional Failure - Part 2
A central question for healthcare organizations as they face the future is what is our goal? While taking care of patients might seem the obvious answer, it is the one that is usually not considered.