Darwin's Cystoscope

What's wrong with this picture?

This is the printer ink cartridge aisle at my local office supply store. Or rather, it's just one brand's section of cartridges.

This...

...is the entire aisle. (Actually just one side of it!)

Do I need so many choices? Are these even choices? I spent several minutes hunting for the particular cartridge that suits my printer model. Finally, I had to ask for help. (I'm a guy. That hurt!)

I just want my printer to work. Having to pick through all these cartridges is a nuisance.

I'd be happier with this experience:

"Hi. I need an ink cartridge for my Nagamatsu BG154."

"Here you go."

"Um, are you sure? It looked like you just grabbed the first cartridge that was handy."

"I sure did. Nagamatsu only makes one type of cartridge."

Sometimes "choice" is just noise. Clutter. Fruitless variation. Muda.

Naturally, shopping for ink cartridges makes me think about inserting tubes up urethras.


Cystoscopy is a urologist's bread-and-butter procedure. By passing a small endoscope up someone's urethra, I can examine their bladder for tumors, stones, and infection. I'll usually do 20-25 examinations every week. Some days, my cystoscopy clinic seems like an assembly line.

And what's wrong with that?

I like the assembly line: I explain the procedure to my patient. The nurse positions him on the examining table. I prepare the cystoscope. I have a routine explanation (patter, spiel... whatever you want to call it) of how he can breathe and relax his muscles to make the procedure go as smoothly as possible. I pass the cystoscope into his bladder and look around, following a routine pattern.

I'm not interested in providing variety for my patients. If I change my routine, I'm more likely to miss an important step. I can accommodate change when necessary, but most of the time plain old vanilla cystoscopy is best. The nurses know my preferences for equipment, table set-up, and patient positioning. Routine makes it easier for them, too.

But cystoscopies are not all routine. There are nine urologists in our health region, and three separate cystoscopy suites (one per hospital site). As each urologist has his or her own technique for cystoscopy, and each site has its own procedures, there are 27 versions of this common examination in Saskatoon alone!

Here are some of the variations:

Among urologists

• Discussion of the procedure
• Reassurance of the patient
• Explanation of relaxation techniques
• Efficiency of equipment preparation
• Adherence to strict aseptic technique to reduce risk of infection.

Between hospital sites

• Methods of equipment sterilization and preparation
• Availability of private space for discussion after the procedure
• Antiseptic skin prep solutions
• Post-procedure instructions

How did these differences develop? It’s a process of evolution.

Biological evolution takes a single ancestral species and, through natural selection, produces 2 separate species. Even if there isn't separation into different species, the same process can produce widely disparate features, such as in dog breeds like the Great Dane and Chihuahua.

With dog breeding, humans decide the type of selection, but in natural evolution, geographic separation of organisms (by mountain ranges or large bodies of water) plays a major role. (If you guessed I've been reading Richard Dawkins's bestselling book about evolution, The Blind Watchmaker, you're right!)

The same process is at play in our cystoscopy units. Even if we had initially designed three identical cystoscopy units (same species), the fact that they are in three separate hospitals (geographic separation) with different personnel, physical layouts, and work practices (natural selection pressure) eventually leads to divergent practices (different species).

Is there anything wrong with these different practices? Is there any harm to our patients? Probably not. After all, these practices are scrutinized by the urologists and cystoscopy suite staff to make sure they meet standards of safe care. But there is a cost to the system.

Even if all three "cystoscopy cultures" are safe, one may be more efficient than the others. Perhaps one sterilizing solution is cheaper. One unit may put an unnecessary supply on the instrument table because it's "routine." Instrument preparation between cases may take three minutes longer in one hospital (at 25 cases a week for each urologist, that's a lot of wasted time). With a high-volume procedure like cystoscopy, standardization could save time, money, and effort.

Now, here's the part that would have Charles Darwin pulling out his hair. Evolution relies on the separation of organisms to let natural selection work differentially. Our cystoscopy units are separate geographically, but it's the same urologists that work at all three units! Our nine urologists travel between the three units like bees flying from one field of clover to another. Why wouldn't we cross-pollinate these different units and eliminate these practice variations? This completely violates my evolutionary model of cystoscopy practice.

We don't eliminate the variation because it's easier not to. Standardizing practice means change (for at least two of the three units). Change takes time and effort. Change is stressful. So, we give up a potential long-term gain (standardized, best practice) for short-term comfort (status quo).

We recently changed a practice in all three cystoscopy suites. It was a fairly simple change, involving using a new piece of plastic tubing for each patient, rather than reusing it. That process took about six months to complete. I was fortunate to have a surgical nurse leading the change because it took a lot of effort. I will think twice before tackling a bigger change.

Finally, practice variation puzzles patients/customers. When I see all the different types of ink cartridges available from the same printer manufacturer, I wonder what that company's engineers were thinking. It must be easier to manufacture one cartridge model that fits all printers. (Disclaimer: I'm totally ignorant of manufacturing processes. This is wild conjecture.)

Many of my patients, due to the nature of their bladder condition, have regular cystoscopies done, sometimes often as every three months. They may visit all three of the units. They're aware of practice variations and sometimes comment "Oh, that's not the way they do it at the other hospital."

Maybe they're also thinking, "Hmmm... same procedure, same surgeon, yet a different routine. What's wrong with this picture?"

P.S. If you want more "What's wrong with this picture?" fun, check out Plain Brown Wrapper.