Medicine's Whiz Kids?

As the federal government adds more bureaucratic dictates to a health care system that already ignores several basic economic principles, I am concerned it may end in a disaster that will define an era, much as the Vietnam War defined my youth. 

I began thinking along these lines while listening as a nurse, frustrated by what she calls medicine by computer, explained my recent Kafkaesque hospital experience in light of unhealthy changes she has seen develop in her workplace. I felt that once I stepped inside the hospital a preset script began to unfold one no had the power to stop. This experienced nurse explained why that feeling was valid. 

She talked of how hospital administrators have created checklists that are built into patient record keeping systems.  Since certain risk factors were present, a battery of tests were automatically called for, because something else might be wrong with the patient and they needed to discover exactly what those unknown factors were. Thus, even though a patient had quickly stabilized and all the proposed tests could be done with greater cost effectiveness to an outpatient, the protocols considered a release much too risky until every box on the computer screen could be checked off. 

As new data was input, new protocols were triggered that could result in another round of tests.  Any box that went unchecked were flagged for review, and staff who exercised judgment or discretion could place their jobs at risk. This nurse complains that she now spends much of her shift staring at a computer screen rather than caring for her patients. This is not why she became a nurse and she tells me the work environment is getting ever more formulaic and impersonal as the protocols grow in number. I liken it to taking a car in for service because it ran rough while fully loaded on a steep grade, then being forced to sit around while the engine and drive train are dismantled and rebuilt. Both driver and mechanic become frustrated by all the misplaced effort -- not to mention the prohibitive costs -- of having to test for and dismiss every cause in the book for a less-than-optimum performance.     

In recent years, several industries have met with disaster because of ill-conceived risk management theories.  Most of the time those theories dismissed real risks, but overreacted to hypothetical risks. The higher education bubble can be seen as an example of a segment of society overreacting to a perception their children would not find good jobs without an expensive degree.  I found the extremes to which medical bureaucrats would go in response to a risk factor to be astonishingly uncomfortable. 

While in the emergency room I had to go to the toilet.  The ER nurse showed me to a unisex facility near the examination rooms and wished me the best of luck.  I was puzzled until I opened the door to find a stainless commode, the seat of which was perhaps 12 inches off the floor.  Despite the surfeit of walking wounded present in such places, the Americans with Disabilities Act apparently does not apply to hospital emergency rooms.  Federal law mandates public facilities have ADA height toilets with hand rails to the side: There were no hand rails on this most extraordinarily low and shallow toilet bowl.  My knee joints are stiff from 60 years of hard use and I came to the ER complaining of severe dizziness.  It simply wasn't remotely possible that I could sit on this toilet, so I somehow disrobed and did a straddle/squat in the hope that I could avoid the embarrassment of soiling my clothes.

When I returned to the exam room I asked the reason for this unusual toilet.  It seems an ER patient committed suicide by drowning in the toilet.   Never mind that anyone determined enough to commit death by toilet bowl is probably determined enough to find another way to end it all while on hospital premises, the bureaucratic response was swift. They inflicted upon the daily dozens of infirm visitors to their ER a toilet only one of those 14 year old rubber maidens from the Chinese National Gymnastics Team could sit on without permanent joint damage.

This toilet has led to the ER staff wasting time walking to another part of the hospital when they have to use a restroom. I am told the staff also takes time to show their more ambulatory patients and family members the route to restrooms equipped with more conventional toilets. It seems only the least ambulatory ER patients are shown the toilet that is so ill suited to aching bones or reeling heads. 

Rest assured, however, the hospital will never again be threatened with a suit from the relatives of someone who drowned themselves in the ER toilet. Should a scam develop whereby persons in need of knee or hip surgery stage accidents in this rest room in order to coerce hospital administrators to pick up the tab, it would not come as a surprise.  In reducing the odds of a most unusual event recurring, the fact that a great number of people would be consigned to a hard-to-use toilet was either overlooked or intentionally disregarded.  
While this is an extreme example, the tendency of medical administrators to impose rigid and impersonal risk management protocols on what has traditionally worked best as an intimate relationship between patients and healers is all too real. Nor is it confined to the field of medicine.

When I searched for examples of systems that manifest a comparable disregard for human factors I was drawn to that of the late Robert Strange McNamara and his so called Whiz Kids. They sought to rationalize and even squelch the warrior culture of the Pentagon in the 1960s. 

The original Whiz Kids discounted traditional military values such as valor and esprit de corps while devising the theory of so called limited warfare in which every action was to have a controlled and predictable reaction.  A crucial word missing from their vocabulary was perhaps the oldest one in the military lexicon: victory. 

Of course, the enemy had not forgotten the word, nor did they behave as the theories predicted they would.  McNamara's Whiz Kids' theories drove mad the vital NCOs who keep the military running at the operational level. Escalation only made the problem worse, and created a vortex that a presidency into ruin and ignominy.

In the very same way, these new Medical Whiz Kids often frustrate the very practitioners most in tune with their patients' over all wellbeing. In designing their protocols the medical whiz kids don't seem to place much value on patient input or a physician's experience or discretion in diagnoses and treatment.  Nor do their protocols address such crucial patient satisfaction factors as advance explanation of procedures, sharing results in a comprehensive manner and basic trust.

A key word missing from the medical whiz kids' vocabulary is candor, particularly about the economics of their industry. (They can be quite candid about a patient's weight and lifestyle habits.) But ask about costly defensive medical practices or the inflation added to medical bills by the layers of administration required to make third party/government payer systems function and evasive euphemisms will abound. 

That much of what we pay for medical services goes to feed bureaucrats and lawyers who perform no patient care services seems as heretical to these people as the concept that a leadership in battle isn't learned in a college classroom was to McNamara's Whiz Kids. The crucial but unacknowledged issue in the Medical Whiz Kids' case management protocols is our current tort system, which the largess of plaintiff attorneys to the Democrats has been left untouched by recent so called reforms.  It is and will probably remain a huge driver of costs.  Had the energy expended in designing the risk management protocols been used to publicize the cost of spurious malpractice litigation, the economics of the healthcare system would be on a sounder basis.  Patient-doctor communications might also improve.   
The irony here is that many malpractice claims are driven more by a breakdown in communications between provider and patient than by the technical outcome of a medical procedure.  The formulaic medicine designed to ward off lawsuits raises communication blocks. Competent experts seldom need to run every test known to man before getting comfortable with a diagnosis.  When the system forces them too many tests they can become defensive answering patents' questions.  Patients sense any hedging.  That and being talked down to all increase a sense of dissatisfaction with the treatment.  Transparency and fully informed consent are perhaps a better way to reduce risk than advising a patient to chill until those final boxes on the protocol get checked off.  More transparency about what is medically necessary and what is more protection against a malpractice claim would also lead to more sustainable overall costs.     
In addition to the patient, physician and nurse or medical technicians, America's hospital and exam rooms already contain a team of medical administrators, a team of third party/government payers as well as lawyers for all involved, no matter where they are physically located.  Each player now demands a say in what gets done. Uncle Obama, Auntie Sebelius and the helpful folks at the IRS are about to join that crowd, and they promise yet more protocols, these new ones designed mostly to cover fat political agendas.

How much room will be left for the practice of the healing arts on a cost effective basis is seriously in doubt.  What is less in doubt is that people who have the empathy, concern and compassion necessary to be really good doctors and nurses will increasingly opt for less confining careers than the practice of medicine governed by protocols designed to keep the bureaucrats happy. 

An even scarier consequence is that no one likely to be found in those rooms has been seriously looking at the total cost engineered into the system.  McNamara's Whiz Kids were soon discredited, but a generation was lost in the form of capable commissioned officers and NCOs who opted for other careers (my academic advisor was one) and in terms of policy options that were not available to American political leaders because of the lack of trust in the US military to deliver. 

All systems that disregard human factors do eventually fail. Those that also disregard economics fail all the faster.  The question isn't how to save the medical system.  It is will we have a well-designed replacement on the drawing boards when the combination of an aging population, uncontrolled costs, greedy lawyers,power hungry politicians, unrealistic administrators and unhappy care givers reaches that point of no return?

As the federal government adds more bureaucratic dictates to a health care system that already ignores several basic economic principles, I am concerned it may end in a disaster that will define an era, much as the Vietnam War defined my youth. 

I began thinking along these lines while listening as a nurse, frustrated by what she calls medicine by computer, explained my recent Kafkaesque hospital experience in light of unhealthy changes she has seen develop in her workplace. I felt that once I stepped inside the hospital a preset script began to unfold one no had the power to stop. This experienced nurse explained why that feeling was valid. 

She talked of how hospital administrators have created checklists that are built into patient record keeping systems.  Since certain risk factors were present, a battery of tests were automatically called for, because something else might be wrong with the patient and they needed to discover exactly what those unknown factors were. Thus, even though a patient had quickly stabilized and all the proposed tests could be done with greater cost effectiveness to an outpatient, the protocols considered a release much too risky until every box on the computer screen could be checked off. 

As new data was input, new protocols were triggered that could result in another round of tests.  Any box that went unchecked were flagged for review, and staff who exercised judgment or discretion could place their jobs at risk. This nurse complains that she now spends much of her shift staring at a computer screen rather than caring for her patients. This is not why she became a nurse and she tells me the work environment is getting ever more formulaic and impersonal as the protocols grow in number. I liken it to taking a car in for service because it ran rough while fully loaded on a steep grade, then being forced to sit around while the engine and drive train are dismantled and rebuilt. Both driver and mechanic become frustrated by all the misplaced effort -- not to mention the prohibitive costs -- of having to test for and dismiss every cause in the book for a less-than-optimum performance.     

In recent years, several industries have met with disaster because of ill-conceived risk management theories.  Most of the time those theories dismissed real risks, but overreacted to hypothetical risks. The higher education bubble can be seen as an example of a segment of society overreacting to a perception their children would not find good jobs without an expensive degree.  I found the extremes to which medical bureaucrats would go in response to a risk factor to be astonishingly uncomfortable. 

While in the emergency room I had to go to the toilet.  The ER nurse showed me to a unisex facility near the examination rooms and wished me the best of luck.  I was puzzled until I opened the door to find a stainless commode, the seat of which was perhaps 12 inches off the floor.  Despite the surfeit of walking wounded present in such places, the Americans with Disabilities Act apparently does not apply to hospital emergency rooms.  Federal law mandates public facilities have ADA height toilets with hand rails to the side: There were no hand rails on this most extraordinarily low and shallow toilet bowl.  My knee joints are stiff from 60 years of hard use and I came to the ER complaining of severe dizziness.  It simply wasn't remotely possible that I could sit on this toilet, so I somehow disrobed and did a straddle/squat in the hope that I could avoid the embarrassment of soiling my clothes.

When I returned to the exam room I asked the reason for this unusual toilet.  It seems an ER patient committed suicide by drowning in the toilet.   Never mind that anyone determined enough to commit death by toilet bowl is probably determined enough to find another way to end it all while on hospital premises, the bureaucratic response was swift. They inflicted upon the daily dozens of infirm visitors to their ER a toilet only one of those 14 year old rubber maidens from the Chinese National Gymnastics Team could sit on without permanent joint damage.

This toilet has led to the ER staff wasting time walking to another part of the hospital when they have to use a restroom. I am told the staff also takes time to show their more ambulatory patients and family members the route to restrooms equipped with more conventional toilets. It seems only the least ambulatory ER patients are shown the toilet that is so ill suited to aching bones or reeling heads. 

Rest assured, however, the hospital will never again be threatened with a suit from the relatives of someone who drowned themselves in the ER toilet. Should a scam develop whereby persons in need of knee or hip surgery stage accidents in this rest room in order to coerce hospital administrators to pick up the tab, it would not come as a surprise.  In reducing the odds of a most unusual event recurring, the fact that a great number of people would be consigned to a hard-to-use toilet was either overlooked or intentionally disregarded.  
While this is an extreme example, the tendency of medical administrators to impose rigid and impersonal risk management protocols on what has traditionally worked best as an intimate relationship between patients and healers is all too real. Nor is it confined to the field of medicine.

When I searched for examples of systems that manifest a comparable disregard for human factors I was drawn to that of the late Robert Strange McNamara and his so called Whiz Kids. They sought to rationalize and even squelch the warrior culture of the Pentagon in the 1960s. 

The original Whiz Kids discounted traditional military values such as valor and esprit de corps while devising the theory of so called limited warfare in which every action was to have a controlled and predictable reaction.  A crucial word missing from their vocabulary was perhaps the oldest one in the military lexicon: victory. 

Of course, the enemy had not forgotten the word, nor did they behave as the theories predicted they would.  McNamara's Whiz Kids' theories drove mad the vital NCOs who keep the military running at the operational level. Escalation only made the problem worse, and created a vortex that a presidency into ruin and ignominy.

In the very same way, these new Medical Whiz Kids often frustrate the very practitioners most in tune with their patients' over all wellbeing. In designing their protocols the medical whiz kids don't seem to place much value on patient input or a physician's experience or discretion in diagnoses and treatment.  Nor do their protocols address such crucial patient satisfaction factors as advance explanation of procedures, sharing results in a comprehensive manner and basic trust.

A key word missing from the medical whiz kids' vocabulary is candor, particularly about the economics of their industry. (They can be quite candid about a patient's weight and lifestyle habits.) But ask about costly defensive medical practices or the inflation added to medical bills by the layers of administration required to make third party/government payer systems function and evasive euphemisms will abound. 

That much of what we pay for medical services goes to feed bureaucrats and lawyers who perform no patient care services seems as heretical to these people as the concept that a leadership in battle isn't learned in a college classroom was to McNamara's Whiz Kids. The crucial but unacknowledged issue in the Medical Whiz Kids' case management protocols is our current tort system, which the largess of plaintiff attorneys to the Democrats has been left untouched by recent so called reforms.  It is and will probably remain a huge driver of costs.  Had the energy expended in designing the risk management protocols been used to publicize the cost of spurious malpractice litigation, the economics of the healthcare system would be on a sounder basis.  Patient-doctor communications might also improve.   
The irony here is that many malpractice claims are driven more by a breakdown in communications between provider and patient than by the technical outcome of a medical procedure.  The formulaic medicine designed to ward off lawsuits raises communication blocks. Competent experts seldom need to run every test known to man before getting comfortable with a diagnosis.  When the system forces them too many tests they can become defensive answering patents' questions.  Patients sense any hedging.  That and being talked down to all increase a sense of dissatisfaction with the treatment.  Transparency and fully informed consent are perhaps a better way to reduce risk than advising a patient to chill until those final boxes on the protocol get checked off.  More transparency about what is medically necessary and what is more protection against a malpractice claim would also lead to more sustainable overall costs.     
In addition to the patient, physician and nurse or medical technicians, America's hospital and exam rooms already contain a team of medical administrators, a team of third party/government payers as well as lawyers for all involved, no matter where they are physically located.  Each player now demands a say in what gets done. Uncle Obama, Auntie Sebelius and the helpful folks at the IRS are about to join that crowd, and they promise yet more protocols, these new ones designed mostly to cover fat political agendas.

How much room will be left for the practice of the healing arts on a cost effective basis is seriously in doubt.  What is less in doubt is that people who have the empathy, concern and compassion necessary to be really good doctors and nurses will increasingly opt for less confining careers than the practice of medicine governed by protocols designed to keep the bureaucrats happy. 

An even scarier consequence is that no one likely to be found in those rooms has been seriously looking at the total cost engineered into the system.  McNamara's Whiz Kids were soon discredited, but a generation was lost in the form of capable commissioned officers and NCOs who opted for other careers (my academic advisor was one) and in terms of policy options that were not available to American political leaders because of the lack of trust in the US military to deliver. 

All systems that disregard human factors do eventually fail. Those that also disregard economics fail all the faster.  The question isn't how to save the medical system.  It is will we have a well-designed replacement on the drawing boards when the combination of an aging population, uncontrolled costs, greedy lawyers,power hungry politicians, unrealistic administrators and unhappy care givers reaches that point of no return?

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