Friday, May 29, 2009

Tight Spot

A couple of summers ago, my family visited Scenic Caves near Collingwood, Ontario. As we hiked through the caves, we came to a cleft in the rock called “Fat Man’s Misery”. It’s a narrow gap in the rock that only slim people can squeeze through. The alternative route is to backtrack and take a slightly longer path.

My younger sons – then aged 8 and 10 – were amused at the thought of someone getting stuck in this crevasse. They thought it would be easy to pass through, and before I could stop them, they both did so. That left me with a problem.

A turn in the middle of the crevasse made it impossible for me to see the other end. I could see the passage narrowing as it turned. It looked like I would fit through the visible part, but I had no way of knowing whether it narrowed even further around the corner. Also, the passage was irregular and I would only be able to fit through facing one way. If there were any other rocky protrusions around the corner, I might get stuck in an awkward position.

As I tried to plan a way through, my boys called to me from the other side. What’s taking you so long? They wanted to continue hiking through the caves. I started to get anxious. I didn’t know if there was any dangerous terrain on the other side of Fat Man’s Misery. I called for the boys to stay put, but worried that they would want to start exploring on their own. I could backtrack and take the longer path around, but I didn’t know how long it would take, and for how long the boys would be on their own.

Eventually, I gathered enough courage to work my way into the crack in the rock. As I rounded the corner, the passage narrowed and took an awkward angle. I found myself wedged in between two outcroppings. I ended up being trapped for hours before rescuers could free me. You probably saw the story on the national news.

Just kidding – I got through easily. On the other side, my boys chided me for taking so long. I glanced back at the opening and mentally kicked myself for being such a chicken. In retrospect, it was so simple to get through.

My last post reported results from our recent physicians’ meeting about reducing our internal demand/patient recalls. I mentioned some of the technical changes we’re going to try. But, the real impact of that meeting came when someone dropped this bomb:

You’re saying we’re bad doctors!

We’d been discussing the variation in patient recall rates among our urologists. I think it’s clear that much of the follow-up care we provide could be safely and effectively carried out by primary care providers. We may not know exactly what the optimal recall rate is, but I believe it is significantly lower than our current clinic average.

We’ve been tracking recall rates over the last year, and encouraging docs to consider whether their patients could be appropriately followed by their family physicians. The clinic average recall rate has dropped slightly, but not significantly. This initiative hasn’t been as successful as pooling referrals, or our hematuria referral information sheet. Why not?

I think it’s because this is the first significant effort that has required our urologists to profoundly change behaviour.

Pooling referrals, in order to distribute new consultations evenly, was a technique we had already been using. Making it our default condition didn’t require any effort from our docs. Asking referring doctors to arrange appropriate testing before specialist consultation (through the hematuria referral information sheet) didn’t require any effort on our part. Even our work to reduce the backlog involved more of the same behaviour, i.e., work harder to see more patients, not a change in behaviour.

But now, we’re asking docs to change the way they practice medicine. That goes to the heart of a doctor’s self-image. His operating system, if you will. And that’s pretty threatening. I think that’s what led to the “bad doctors” revelation.

Don’t be ridiculous was my first reaction on hearing the comment. How could anyone so badly misinterpret what I meant? Every system can be improved upon, and any improvement, by definition, requires change? But that doesn’t mean the current system is “bad”. Isn’t that obvious?

However, as the clouds of my indignation began to settle, I saw that the problem wasn’t that he had misinterpreted my meaning. The problem was a massive failure of communication on my part.

I hadn’t realized that this change was “Fat Man’s Misery” all over again.

Change leaders (champions/early adopters/evangelists) relish new challenges, and sometimes forget that not everyone shares their enthusiasm. They embrace the concept of failing 99 times in order to succeed once. Others (the majority!) are more conservative. When my sons charged through Fat Man’s Misery, they had no idea that I would be hesitant to follow. While I thought them reckless, it was just business as usual for them. I wanted to assess the risk of following them, knowing that there was a real risk of failure/getting stuck.

One size doesn’t fit all. Just because 2 little boys could squeeze through the gap in the rock didn’t mean that I could. While some of the enthusiasts in our clinic were embracing the idea of returning patient recall to family physicians, not everyone tolerates the same rate of change.

My boys didn’t understand what was holding me up. Didn’t I want to join them for the rest of the hike? On the contrary, I was highly motivated to join them. I was worried they might get injured or lost if they continued hiking without me. But my anxiety over their well-being was balanced by concern for my own safety. In the same vein, I sometimes wonder why others don’t leap at the chance to change our systems. Are they lacking motivation? Maybe not.

Eventually, I made it through Fat Man’s Folly, but it took a leap of faith to do so. It was a complete unknown to me. Change leaders often ask others to make similar leaps of faith. The leaders may have already made the leap, and it always looks easier when you’ve already passed through the gap. In retrospect, I realized that I was never in danger of getting stuck in the crevasse. But, the threat had been very real to me, up until the moment I actually made it through.

When proposing changes to our recall practices, I had utterly failed to appreciate how threatening these changes may seem. I hadn’t realized that some of my partners read my proposal as a message that they were delivering poor quality care, and that they needed to shape up. And, now, I can understand why they would reach that conclusion. After all, if someone wants you to change your behaviour, no matter how much they sugarcoat it, it means that they think the status quo is unacceptable. That smells a lot like “bad.”

In retrospect, I was fortunate that someone expressed their misgivings. The alternative would be for me to blithely carry on while silent resistance sabotaged the project. I should have asked more questions and invited more comment, rather than pushing the changes that – to me – seemed so simple and obvious.


  1. Originally posted by Bridget (Alberta Health Services) 05/29/09 1:10 PM

    Thank you, Kishore, for being so honest in your blog about the challenges you are facing in making change. For all of us in health care, the pressure to constantly improve and change is intense, and you are correct, in that there are times we don't really appreciate what we are asking of people when we say we need to change. Please keep the blog going, as I get so many insights from your experiences that I hope I am using to effectively change my area of influence. Cheers!

  2. Originally posted by Vince Salamon 05/29/09 3:55 PM

    I've followed your blog and some of the commentary from the readers (or followers) for quite some time now. I have always been very pleased with the insights and humor you share. I have just now read back through the commentary, particularly Stephen Lewis' remarks along the way. I make special efforts to read Mr. Lewis' comments as he is also very insightful in his articulation of the quality challenges faced within healthcare. If I can accurately describe what I read, I saw Mr. Lewis suggesting consideration for a review not only of Lean/streamlining/efficiency aspects of providing healthcare service but, for an even more complete/thorough quality improvement effort which would encompass safety and (cost/clinical) effectiveness also. If I am correct in this assessment, and Mr. Lewis is gently "pushing" you in this direction; I think that you should consider "pulling" in the same way. All aspects of quality in healthcare require massive overhaul but, managing the learnings required to make these improvements must be consumed in suitably small enough increments or stages by those who are willing and able to take them on. There's more to improvement than efficiency. The methods and relationships are the means. Today's was a lesson well-learned and received. Thank-you.