The Tyranny of Infallibility

Why is it so hard for we physicians to acknowledge that we’re human, prone to mistakes, misstatements, lapses in judgment, fatigue, or failure? I’ve had a most amazing week criss-crossing the country, doing presentations and having discussions with very interesting people.

One of those people was Jeff Skiles, co-pilot of USAir Flight 1549 that landed on the Hudson River in January 2009. I guess we say “on” instead of “in” because it didn’t sink - for awhile, at least. In the year and a half since I’ve known Jeff, he’s developed a very effective presentation on the impact of moving from autonomy to teamwork in commercial air transport. It’s that teamwork which contributed to the miraculous result for the passengers and crew.

A key point of Jeff’s comments is acknowledging fallibility, and dealing with it by building a team of people who learn how to communicate without “taking it personal” when they’re questioned by a team member. He said authority used to be based on fear or intimidation by the senior pilot. It’s now role-based authority.

When Capt. Sullenberger declared, “my aircraft” after the A320 hit the geese (Jeff was flying the plane), it was clear that the captain was taking responsibility for bringing the aircraft down. Jeff would go through the checklist to start the engines, if possible. Once it was clear that a crisis was occurring, the cabin crew began their respective autonomous actions to secure the cabin.

Jeff says his training in aviation comes in handy in his other roles as general contractor, husband and father. Now that’s a powerful testament to the effectiveness of these concepts!

I joined other ACPE faculty for some on-site teaching last week, and the topic of human error was discussed as a key component of the engineering science of reliability. I don’t know about you, but my instinct from years of being a physician is to believe that “human error” doesn’t apply to me – I’m a physician and not supposed to be fallible like other humans. That’s crazy!

Once we start talking about human error and the physician’s role, whether in full time clinical practice, or in system leadership, typical comments turn to our inability to admit we make mistakes because of the legal system. Are we using the legitimate but separate issue of the tort system to avoid discussion of our own human foibles, and appropriate methods of building safer care? Maybe we could find humor in our foibles, and have some fun with the topic instead of avoiding a necessary discussion!

Like many of you, and like some of the physicians with whom I teach, on certain occasions I’ve deliberately ignored the advice of a malpractice attorney to not admit I made a mistake in diagnosis or treatment. Knowing the truth of what happened and my role in it, withholding that truth from any human being isn’t right, and it eats away at me.

Most studies of physicians conclude that we do not like to be controlled or directed by others. If we don’t like the control that the tort system and lawyers have over us, then why do we exhibit learned helplessness by agreeing with them that we must not admit our fallibility?

Frankly, it’s liberating to discard the illusion that I should be immune from human error and weakness. That holds true for both clinical care, and in leadership or management roles. It’s self-imposed tyranny to think otherwise. Best yet, I believe that the key to improving safety, reliability – and changing the tort system – is in throwing off the chains of infallibility and perfection that we expect of ourselves, and adopting many of the concepts that helped other industries become much safer.

Notes from the San Antonio Annual Meeting

ACPE's Annual Meeting, held in San Antonio, ended this past week. The participants had an energy, enthusiasm and passion to improve health care that was noticeable to me and the ACPE staff. Here are some comments and observations from the meeting, in no particular pattern, that might be helpful in your daily activities. These thoughts might also help you put the current uncertainty of health care in perspective.

• Kevin Fickenscher, long-time ACPE member and editor of Dell's Washington Report, noting in his Vanguard presentation that in 2009, the federal government collected $1.3 trillion in taxes; expenses for Medicaid, Medicare, Social Security and service on the national debt totaled $1.2 trillion. We borrowed the rest.


• David Nash, dean of Jefferson University School of Population Health, who has an uncanny knack for sound bites, shared his new four word summary of Accountable Care Organizations: "No outcome, no income."


• Grace Terrell, CEO of Cornerstone Health Care in High Point, N.C., and Sue Freeman, CMO at Temple University in Philadelphia, both commented on facilitator Francine Gaillor's thought-provoking statement that "leadership is a stage." Everything a leader does is under a spotlight. Your words, actions, body language and moods are constantly on display. How does your performance come across to your audience?


• Chal Nunn, CMO of CentraHealth in Lynchburg, VA, commenting in a break-out session on quality and safety: "A 99-1 vote is considered a tie by the medical staff."


• One of the participants in the same break-out session commenting on the challenges in getting agreement by the medical staff, got a big laugh when he mentioned, "the 'silverback male' on the medical staff can derail the best laid plans."


• John Kenagy -- surgeon, author, advisor and keynote speaker -- outlined his concept of Adaptive Design, which allows front-line workers to rapidly and energetically spot and solve problems on their own. No layers of bureaucracy and hierarchy needed! Several attendees commented on how useful the A3 Problem-Solving Report will be in developing operational plans to resolve problem areas in their workplaces.


• Tom Royer, physician CEO emeritus of Christus Health System, gave a moving address to the new CPEs and Fellows at the Induction ceremony. Relating several poignant moments in his leadership career, he asked all of us to ponder why we're put on the earth, and to appreciate the opportunities we have to help others.

Now we're changing our focus to the Summer Institute in Boston, July 15-19. In addition to our Integrated Health Systems course, which covers everything from strategic considerations to physician engagement to financial integration, we're launching a new course on entrepreneurial thinking. This new course was developed in response to one of our ACPE Board Task Force's recommendations. It will be taught by the director of the Entrepreneur Program at the University of Southern California's School of Business.

Bostonians say the snow has melted and that summer is a great season to visit their historic city. If you haven't ridden the water taxi there, I can highly recommend the experience as a cool summer mode of transportation.

The Bus or the Rope?

How many times have you heard leaders talk about “getting the right people on the bus”?

I find that analogy in health care to be difficult. It just doesn’t resonate with my experiences or my sense of how we should be thinking of our work on behalf of patients. First, let me outline why the “bus” and its occupants makes me uncomfortable. Then I’ll outline a model that makes more sense to me.

Ask a group of physicians or executives where they’ll be sitting on that bus if they’re the leader. The immediate and most common response is, “In the driver’s seat, of course! I know where I want to go and how to get there. I want people on the bus who support my direction.”

A few want to sit in the back and monitor what’s happening as the bus barrels down the freeway. Some are comfortable with rotating drivers.

Are riders on your bus comfortable pointing out problematic strategic, operational, or patient safety-related decisions? What do you do if your riders disagree with you? Usual responses: “They’re asked to get off the bus” or “They’re thrown under the bus!”

Ask about where the patient rides on the bus. That question gets some very interesting responses: “Somewhere behind the driver”; “In the driver’s seat”; “In the baggage compartment.” That last response gets a lot of laughter, and heads nodding in agreement.

Now imagine a different image. Imagine you, your team of health care professionals, and a patient are on a rope, climbing a mountain in the Rockies, Andes, or Himalayas. You are all linked together on that rope, all with the same goal. In health care, it might be evidence-based medical care, highly reliable and safe care with optimal outcomes, or patient centered care. It’s risky work. There might be many ways to get to your collective goals, but it will require input from everyone.

It might also require vigorous disagreement from time to time about the safest and best way to proceed. If you’re the leader of the team, and know how you want to achieve your goal and how fast you want to get there, are you comfortable with agreement, or perceived agreement? No one speaks up. Do you assume everyone agrees? Do you want to encourage disagreement before starting up that dangerous part of the journey?

As you proceed up that mountain, you’re about to step in a crevasse. We’re all prone to mistakes as human beings. How do you want the team member behind you on that rope to respond? I want to hear, “STOP – that’s not safe!” Or feel the sudden tightening of the rope as an ice axe is plunged into the snow. We’re all in this together – each one of us concerned about one another’s personal and professional safety – regardless of our status in the hierarchy of the team. What happens to one of us is likely to happen to everyone else on that rope.

Finally, imagine a situation where the patient is the only person on the rope who isn’t ready, or in shape, for the push to the top. Not strong enough. Circumstances don’t seem auspicious or comfortable. Do we have the courage, compassion, and situational awareness to listen? Do we decide to wait until another day or moment, or do we drag the patient up to the top because the health care team believes it’s the right thing to do?

Put me on a rope with people who aren’t shy about voicing their concerns for patients, and for safety. People who can be counted on to do what’s right, for the right reasons. I don’t mind if those people are a little rough around the edges. If everyone realizes that the most important individual on that team is the patient, we’ve got a great team! Come to think of it, maybe that patient is the true leader of the team.

Physicians and Disruptive Innovation

Last week, ACPE Vice President of Career Services Barbara Linney hosted a webinar on career options that broke previous attendance records. This one was notable for the number of physicians looking outside the hospital sector for new roles. Consulting, insurance, pharma, or entrepreneurial ventures were mentioned as preferred destinations.

I’ve been racking up frequent flyer miles the past few months doing on site training on clinical leadership and moving from autonomy to teamwork in a health care system undergoing stress and change. If energy, enthusiasm, and engagement of the audience is an indicator of most physicians’ state of mind, it appears that many are thinking about what they can do beyond individual patient care to provide remedies for a broken system, and to get more satisfaction from their professional careers.

The topic of disruptive innovation generates the most animated discussion. They’ve been giving thought – when they can steal a few moments from their roles as production workers in the fee for service system – to what they would change, and the technologies or business models that would help them do just that.

Just as we talk of the ACO concept as moving from “volume to value” for consumers and purchasers, clinicians are thinking how they can provide value beyond their role as patient care “volume producers”. Henry Ford’s comment about the people wanting “a faster horse” before his disruptive innovation of the Model T resonates with physicians. Most don’t believe they can be a “faster horse” in their practice situations. They cite patient safety and quality as their first concerns. Our pledge as physicians to “first, do no harm” is jeopardized.

John Agwunobi, a long time ACPE member and Senior Vice President at WalMart, made some very insightful comments last week on a conference call with us here in Tampa. John is using his background as a MD, MBA and MPH to change the status quo through his role at WalMart. The joint announcement by WalMart and First Lady Michele Obama last week about reducing salt, sugar, and fat content of foods sold at WalMart as one step to improve the health of our population is just one example of that.

John (and I) encourage you to think of being a physician as just the start of your lifelong journey of learning, improving health, and making a difference in people’s lives. Your clinical experience is a foundation for adding new competencies that will give you new opportunities to improve health and health care. Imagine what you might be doing if you didn’t view being a physician as your only identity, or the only valid destination for your learning and education!

Would you learn how to incorporate engineering principles of reliability and safety into patient care? How about learning how to lead people from different professional backgrounds? Does disruptive innovation appeal to you? Starting a new business, or improving the business we’re in? Studying behavioral economics to find ways to change our population’s unhealthy lifestyles and habits?

Like you, I’m proud of my path to becoming a physician, and honored to be recognized as such. Paradoxically, recognizing that there are many other people and professionals – besides physicians - who make important contributions in our society and work just as hard, helped me put my “physicianhood” in proper perspective. It was the foundation to build on – not the ultimate destination in my life.

My Day at a Free Clinic: The Truth Behind the Rhetoric

I just got back from a most remarkable experience: volunteering at a free clinic in Charlotte, NC.

Like many of you, each day I read my Daily Digest to be aware of the health care news of the day. The political rhetoric about the work ethic of the unemployed has been awfully harsh lately. Opinions about health policy and the tug of war between the two political parties that appear on the editorial pages of our nation’s newspapers seem very disconnected from the reality on the streets and country roads of the United States.

I had the opportunity to hear the stories of hard-working and proud Americans who have lost their jobs, and with the jobs, their health insurance. It’s these stories that make the policy issues come alive, and drive home the absolute necessity for clinicians to help create a system that is worthy and respectful of the character of these Americans.

Mary, 60, is a well-educated woman whose COBRA coverage expired two months ago. She lost her job as a loan evaluation specialist at a bank 20 months ago. She paid the full cost of coverage for her health insurance under COBRA because she knew the consequences if she developed a serious illness, and couldn’t pay for the costs of care.

With hypertension and thyroid disease, she’s familiar with generic drugs that keep her costs down. She’s not sure what she’ll do to cover the years until Medicare coverage becomes available, because she’s caring for her 87-year-old mother, and helping her son who moved back home when he lost his job. She’s also back in school re-training as a health care billing specialist, because even “dumbing down” her resume to not appear overqualified for many jobs hasn’t helped her land any interviews. She takes care of herself, and relies on her faith that she will make it through her difficult situation.

Susan, 45, is a wife and mother of two elementary school children who stayed behind in New York to continue working at her job when her husband got a new job in North Carolina. Though living apart as a family was difficult, as an accountant she knew it was necessary to get through the recession. She was the first to lose her job. A few months after moving to NC, her husband’s job disappeared. Neither has been successful in finding new work. She told me her children have health care coverage, and that her kids have been very supportive of her as a good mom, even though times are tough for the family.

Those were just two of the nearly 1,200 people who showed up for the free clinic. Not only was I privileged to be part of their lives for a few minutes, but it was an opportunity to work as a team with nurses, other physicians, and volunteers to help others in this season of hope and goodwill. The young physician (six months out of internal medicine residency) working in the cubicle next to me was my lifeline to high quality, current medical thinking. She thought my years of experience were equally as important. We made a good team yesterday. Thank you, Nicole.

Finally, on behalf of other ACPE members who served as volunteers yesterday, we thank Ed Weisbart, one of your ACPE colleagues who is a leader for the National Association of Free Clinics, for letting us know of this opportunity. Included with Ed in making this happen is our own Charisse Jimenez, who helped us get the word out.

Interested in volunteering or making a donation? Visit the National Association of Free Clinics to learn more. In addition to practicing physicians of all specialties, residents and medical students are welcomed to volunteer. The NAFC also needs mid-level practitioners, nurses and everyone else who can help, clinically or nonclinically.