Author: davidaron2

The Clinician Educator’s Advantage in Scholarship

Posted on by davidaron2

I was asked to give grand rounds at the Zucker School of Medicine by the chair of medicine who was an old friend of mine. This grand rounds was meant to celebrate faculty who had been promoted and my job was to encourage his clinical faculty to do research so that they might be more easily promoted. I knew this would not be easy, given the degree of pressure that clinical faculty are under to generate RVUs, i.e. $$ (an odd definition of “productivity” for a physician, but that is a topic for another day). I thought that I came up with an idea that might be helpful – scholarship in the overlaps – and I gave the talk. It was well received (which I interpreted as the audience found me to be entertaining), though whether it will have long term impact, who knows. As a cynic, I doubt it, but as a optimist, hope springs eternal. The following is a paper I wrote based on the talk. I showed it to a few people including the medicine chair and they suggested I try to get it published. This was followed by a series of rejections mostly without going out for review from the Journal of General Internal Medicine, the Annals of Internal Medicine, Academic Medicine, Journal of Evaluation and Clinical Practice and maybe one other which I have forgotton. So I decided to post it. If you think it would be helpful to your colleagues, please share the link. If you have suggestions or would like a pdf with better formatting, let me know (dca2@cwru.edu).


Clinician educators enable academic medicine (medical schools and academic medical centers) to achieve all three parts of its tripartite mission – teaching, research, and patient care. Clinician educators provide a significant amount of patient care and in so doing generate the clinical revenues that subsidize both teaching and research. Their clinical activity also enables the performance of clinical trials. They also provide significant teaching especially, but not exclusively in the clinical years. However, they are at a disadvantage when it comes to academic promotion, especially in a system that heavily weight grant funding and publications in so-called high impact peer reviewed journals. The idea of medical school promotion depending upon excellence in clinical care, teaching and research reflects the assumption going back to Osler and Flexner that clinicians who do research are the best teachers. This assumption underlies the idea of the “triple threat,” the individual “who would be surpassingly brilliant as an investigator, a dazzling clinician and a marvelous teacher.”[1] P. 92  However, such individuals are relatively uncommon.[2],[3] Embedding the medical school in a university also involved incorporation of the university’s ethos of placing the highest value on discovery, the creation of new knowledge. Moreover, the “hard” sciences are more highly valued than the “softer” social sciences. As Alvin Feinstein wrote: “…Prestige was least for studies of therapeutic interventions in patient care and rose as the research went to explication of organ-system pathophysiology, to physiology, and
eventually to molecular mechanisms of biology. Being inversely proportional to the structural size of the object under investigation, prestige increased as the investigated material became smaller, from intact organism, to organ, and
eventually to infracellular…”[4]   This further disadvantages the clinician educator because even when s/he conducts research, it is more likely to involve whole people. Moreover, academic medical centers and faculty must contend with the long-term trends of increasing competition for both clinical and research dollars which have resulted in faculty differentiation towards being either a clinician or a scientist, but not both.[5]   The lack of clinician educators’
participation in research has been a major impediment to academic advancement. Separate tracks and faculty development programs to facilitate clinician educators’ participation in activities considered to be scholarship have been established.[6] , Some medical schools have modified their criteria to specify what would be
considered scholarship, such as clinical case reports, literature reviews,
rigorous quality improvement projects, as well as medical education research.

The idea of scholarship itself was broadened in Ernest Boyer’s seminal work Scholarship Reconsidered: Priorities of the professoriate.[7]  He conceptualized four types of scholarship: those of discovery, integration, application, and teaching and learning. The scholarship of discovery involves the pursuit and creation of new knowledge. Such knowledge is validated by peer review and disseminated so that others can build upon it. It “comes closest to what is meant when academics speak of “research.” [10 p17] Integration makes connections across disciplines and gives meaning to isolated facts. [10 p18] The scholarship of application addresses effectiveness as opposed to efficacy, applying knowledge to real world issues. The scholarship of teaching and learning involves the aspects of pedagogy that make for teaching excellence combined with education research, although the latter can be subsumed into the scholarship of discovery. Finally, there is an overlap between the different kinds of scholarship.

Scholarship as opposed to scholarly, requires the creation of a work that is accessible, can be peer-reviewed, and can
contribute to a field whereby others can learn.[8] Thus, scholarship involves advancement of knowledge, dissemination, and impact, usually documented in peer reviewed publications.[9],[10],[11]   Criteria by which such work can be assessed have been established.   Such scholarship is not limited to randomized controlled trials published in so-called high impact journals. Much of the emphasis on clinical educators’ scholarship has been in the scholarship
of teaching and learning. This would seem natural for those committed to education. However, this emphasis is unnecessarily limiting. Even when Boyer’s model is not completely accepted or when the scholarship of discovery,
especially when narrowly defined is more valued far more highly, there are opportunities for discovery where clinician educators have potential advantages. These advantages occur where the categories of scholarship overlap,
specifically in the overlap between discovery and application and the overlap between discovery and integration. New knowledge creation which has the highest academic prestige can occur in these overlaps.[12] As clinicians, clinician educators are first and foremost committed to clinical excellence. In addition to diagnostic acumen and knowledge clinical excellence involves a scholarly approach to practice.[13]  As educators, clinician
educators, are expected to be scholarly: to maintain an inquiry of mind and approach questions systematically. This requires continuous learning, engaging in evidence-informed decision making and self-reflection.[14] Observation, one of the basic tools of a clinician, is an important part of inquiry. In a 1931 lecture to the Cambridge University Medical Society titled “The Physician as Scientist and Naturalist,” the physician John Ryle who would later initiate the academic
discipline of Social Medicine when he became the chair of a newly created department at the University of Oxford,[15] noted that the physician is first and foremost a student of nature, observing, recording, classifying, and analyzing. Going further, Ryle remarked that “the naturalistic temperament and the physicianly temperament are, as we should imagine, close relations, if not identical twins.”[16],[17] Another essential skill of a clinician is the ability to integrate data and information from different sources and of different types. This applies not only to routine patient care, but also in the identification of new or unusual manifestations of disease.[18] Case reports appear to be making a comeback for describing new or unusual manifestations of disease.[19] There are now peerreviewed journals published by prestigious societies/journals devoted to case reports, e.g., Annals of Internal Medicine: Clinical Cases and BMJ Case Reports. Case studies are low in the evidence-based medicine hierarchy for good reasons. They have serious limitations. For example, they are subject to various types of bias that threaten both internal and external validity, thereby limiting their rigor and seemingly providing no basis for extending findings to a broader population.[20] However, they are also undergoing new scrutiny and becoming more popular, also for good reasons.[21],[22],[23] First, learning from case studies has been accomplished in the fields of medicine and management, among others.[24],[25],[26] Second, they can serve different purposes including the generation of hypotheses, contributing to theory construction, and theory falsification. Case studies can provide a more holistic understanding by elucidating the nuances of context.  The premise of their being universal laws is suspect in context dependent situations since every context is unique to varying degrees.[27] Context is critical, playing a role in path dependence, sensitivity to initial
conditions, and other characteristics of complex systems.[28] The Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines were developed to provide a framework for reporting new knowledge about how to
improve healthcare and formalized a method for reporting the details of context. Application of a case study’s findings to another case or even classes of cases is possible. This has been referred to under several different names including naturalistic, heuristic, and inferential generalization.[29],[30]   Literature reviews which can be conducted by clinician educators, involve integration leading to new clinical insights.[31]  Integration of different disciplines can result in new insights.  The generative nature of multidisciplinary collaboration has been referred to at the multidisciplinary edge.[32] In addition analogies and metaphors may serve as a means to teach unfamiliar concepts as well as lead to clinical insights.[33],[34] The connection across disciplines is also an essential part of interdisciplinary practice, whether in a research project or in the scholarship of application or in teaching and inspiring students to pursue scholarly work.[35],[36],[37] Clinician educators have a unique advantage in the scholarship of application. As pointed out by Green: “if we want more evidence-based practice, we need more practice-based evidence”[38],[39] ‘Best practice’ in theory may not be “best” when it is situated in context.[40],[41],[42] The limitations of traditional research methods in promoting timely implementation of evidence-based practices have led to calls for further development of translational research and for embedding researchers in real-world settings, i.e., collaborating with practitioners who with their real-world expertise, understand the context.. [43],[44] Focusing faculty development on these areas of overlap will reinforce the clinician educator’s competitive advantage. Moreover, this is the type of research that we need.[45],[46] Taking advantage of the clinician educator’s scholarly advantage will necessitate overcoming barriers to their pursuit and the recognition of their scholarship; the usual suspects will have to be addressed, e.g., pressure to generate clinical income (to subsidize others), lack of “protected time”, lack of mentoring, and others.[47] ,[48] Recognition of that scholarship will require a change in attitude among those who have benefited from and jealously guard the system as currently constituted.[49] There are new initiatives and changes are occurring.[50],[51],[52]  However, in a system sorely in need of improvement, taking advantage of the intellectual efforts of clinician educators is an opportunity that should not be missed.  

[1] Greenberg RS. Donald Seldin: The Maestro of Medicine. University of Texas Press; 2020 Dec 31.

[2]Alpert JS, Coles R. Careers in academic medicine: triple threat or double fake. Archives of Internal Medicine. 1988 Sep 1;148(9):1906-7.

[3] Hebert RS, Elasy TA, Canter JA. The Oslerian triple-threat: an endangered species? A survey of department of medicine chairs. The American journal of medicine. 2000 Sep 1;109(4):346-9.[4] Feinstein AR. Basic biomedical science and the destruction of the pathophysiologic bridge from bench to bedside. The American journal of medicine. 1999 Nov 1;107(5):461-7.

[5]Bhardwaj A. What’s new in academic International medicine? The evolving terrain of American academic medicine. International Journal of Academic Medicine. 2019 May 1;5(2):85-92.[6] Coleman MM, Richard GV. Faculty career tracks at US medical schools. Academic Medicine. 2011 Aug 1;86(8):932-7.[7] Boyer EL. Scholarship reconsidered: Priorities of the professoriate. Princeton University Press, 3175 Princeton Pike, Lawrenceville, NJ 08648.; 1990 Dec 3.[8] Simpson D, Yarris LM, Carek PJ. Defining the scholarly and scholarship common program requirements. Journal of Graduate Medical Education. 2013 Dec 1;5(4):539-40.[9] https://www.umassmed.edu/ofa/academic/Evaluation/scholarship/   accessed 1-17-2024[10] Glassick CE. Boyer’s expanded definitions of scholarship, the standards for assessing scholarship, and the elusiveness of the scholarship of teaching. Academic Medicine. 2000 Sep 1;75(9):877-80.[11] Cleland JA, Jamieson S, Kusurkar RA, Ramani S, Wilkinson TJ, van Schalkwyk S. Redefining scholarship for health professions education: AMEE Guide No. 142. Medical Teacher. 2021 Jul 3;43(7):824-38.

[12]Wensing M, Wilson P. Making implementation science more efficient: capitalizing on opportunities beyond the field. Implementation Science. 2023 Sep 11;18(1):40.

[13] Christmas C, Kravet SJ, Durso SC, Wright SM. Clinical excellence in academia: perspectives from masterful academic clinicians. InMayo Clinic Proceedings 2008 Sep 1 (Vol. 83, No. 9, pp. 989-994). Elsevier.

[14]Zaccagnini M, Bussieres A, Mak S, Boruff J, West A, Thomas A. Scholarly practice in healthcare professions: findings from a scoping review. Advances in Health Sciences Education. 2023 Aug;28(3):973-96.[15] Porter D. Changing disciplines: John Ryle and the making of social medicine in Britain in the 1940s. History of science. 1992 Jun;30(2):137-64.[16] Editorial. The physician as a scientist and a naturalist. Lancet 1999; 354: 1485.[17] Schafer AI. History of the physician as scientist. The Vanishing Physician-Scientist. 2009:17-38.[18] https://www.acponline.org/clinical-information/journals-publications/annals-of-internal-medicine-clinical-cases[19] Packer CD, Berger GN, Mookherjee S. Writing case reports. Springer,; 2017.

[20]Perdices M, Tate RL, Rosenkoetter U. An algorithm to evaluate methodological rigor and risk of bias in single-case studies. Behavior Modification. 2023 Nov;47(6):1482-509.

[21] Flyvbjerg B. Five misunderstandings about case-study research. Qualitative inquiry. 2006 Apr;12(2):219-45.

[22] Mariotto FL, Zanni PP, Moraes GH. What is the use of a single-case study in management research?. Revista de
Administração de Empresas. 2014 Jul;54:358-69.[23] Sibbald SL, Paciocco S, Fournie M, Van Asseldonk R, Scurr T. Continuing to enhance the quality of case study methodology in health services research. InHealthcare management forum 2021 Sep (Vol. 34, No. 5, pp. 291-296). Sage CA: Los Angeles, CA: SAGE Publications.

[24]Thistlethwaite JE, Davies D, Ekeocha S, Kidd JM, MacDougall C, Matthews P, Purkis J, Clay D. The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23. Medical teacher. 2012 Jun 1;34(6):e421-44.
[25]Barnes LB, Christensen CR, Hansen AJ. Teaching and the case method: Text, cases, and readings. Harvard Business ress; 1994.

[26]Packer CD, Katz RB, Iacopetti CL, Krimmel JD, Singh MK. A Case suspended in time: the educational value of case reports. Academic Medicine. 2017 Feb ;92(2):152-6.[27]Numagami T. Perspective—the infeasibility of invariant laws in managementstudies: A reflective dialogue in defense of case studies. Organization science. 1998 Feb;9(1):1-5.[28] Anderson RA, Crabtree BF, Steele DJ, McDaniel Jr RR. Case study research: The view from complexity science.
Qualitative health research. 2005 May;15(5):669-85.[29]Stake RE, Trumbull DJ. Naturalistic generalizations. Review Journal of Philosophy and social science. 1982;7(1):1-2.[30] Lewis J, Ritchie J, Ormston R, Morrell G. Generalising from qualitative research. Qualitative research practice: A guide for social science students and researchers. 2003 Feb 19;2(347-362).[31] McGaghie WC. Varieties of integrative scholarship: why rules of evidence, criteria, and standards matter. Academic Medicine. 2015 Mar 1;90(3):294-302.[32] Varpio L, MacLeod A. Philosophy of science series: harnessing the multidisciplinary edge effect by exploring paradigms, ontologies, epistemologies, axiologies, and methodologies. Academic Medicine. 2020 May 1;95(5):686-9.[33] Pukk K, Aron DC. The DNA damage response and patient safety: engaging our molecular biology-oriented colleagues. Int J Qual Health Care. 2005 Aug;17(4):363-7. [34] Aron DC. Developing a complex systems perspective for medical education to facilitate the integration of basic science and clinical medicine. J Eval Clin Pract. 2017;23: 460–466.[35] Marks ES. Defining scholarship at the uniformed services university of the health sciences school of medicine: A study in cultures. Acad Med. 2000;75:935–939[36] Hofmeyer A, Newton M, Scott C. Valuing the scholarship of integration and the scholarship of application in the academy for health sciences scholars: recommended methods. Health Research Policy and Systems. 2007 Dec;5(1):1-8.

[37]Prideaux D, Alexander H, Bower A, Dacre J, Haist S, Jolly B, Norcini J, Roberts T, Rothman A, Rowe R, Tallett S. Clinical teaching: maintaining an educational role for doctors in the new health care environment. Medical education. 2000 Oct 5;34(10):820-6.

[38] Green LW, Ottoson JM. From efficacy to effectiveness to community and back:evidence-based practice versus practice-based evidence. In: Hiss R, Green L, Glasgow R, et al. (eds).From  Clinical Trials to Community:TheScience of Translating Diabetes and Obesity Research. Bethesda, MD: National Institutes ofHealth,2004:15–18.[39]Green LW. Making research relevant: if it is an evidence-based practice, where’s the practice-based evidence?. Family practice. 2008 Dec 1;25(suppl_1):i20-4.[40] Rhodes T, Lancaster K. Evidence-making interventions in health: A conceptual framing. Social Science & Medicine. 2019 Oct 1;238:112488.[41]Harrison M, Rhodes T, Lancaster K. Situating’ best practice’: Making healthcare familiar and good enough in the face of unknowns. SSM-Qualitative Research in Health. 2023 Dec 1;4:100343.[42] Aron, David, MD, MS. From Evidence-based Medicine to Evidence-based Management(and Policy)?. Med Care. 2015;53(6):477-479.

[43]Beidas RS, Dorsey S, Lewis CC, Lyon AR, Powell BJ, Purtle J, Saldana L, SheltonRC, Stirman SW, Lane-Fall MB. Promises and pitfalls in implementation science from the perspective of US-based researchers: learning from a pre-mortem. Implementation Science. 2022 Aug 13;17(1):55.

[44]Damschroder LJ, Knighton AJ, Griese E, Greene SM, Lozano P, Kilbourne AM, Buist DS, Crotty K, Elwy AR, Fleisher LA, Gonzales R. Recommendations for strengthening the role of embedded researchers to accelerate implementation in health systems: Findings from a state-of-the-art (SOTA) conference workgroup. InHealthcare 2021 Jun 1 (Vol. 8, p. 100455). Elsevier.[45] Greenhalgh T, Papoutsi C. Studying complexity in health services research: desperately seeking an overdue paradigm shift. BMC medicine. 2018 Dec;16:1-6.

[46]Murdoch J, Paparini S, Papoutsi C, Hannah J, Greenhalgh T, Shaw SE. Mobilising context as complex and dynamic in evaluations of complex health interventions. BMC Health Services Research. 2023;23:1.[47] Smesny AL, Williams JS, Brazeau GA, Weber RJ, Matthews HW, Das SK. Barriers to scholarship in dentistry,
medicine, nursing, and pharmacy practice faculty. American journal of pharmaceutical education. 2007 Oct 10;71(5).[48]Kools FR, Fox CM, Prakken BJ, vanRijen HV. One size does not fit all: an exploratory interview study on how
translational researchers navigate the current academic reward system.Frontiers in Medicine. 2023 May 5;10:1109297.[49]Albayrak‐Aydemir N, Gleibs IH. A social‐psychological examination of academic precarity as an organizational practice and subjective experience. British Journal of Social Psychology. 2023 Jan;62:95-110.[50] Schimanski LA, Alperin JP. The evaluation of scholarship in academic promotion and tenure processes: Past, present, and future. F1000Research. 2018;7.[51]Chang A, Karani R, Dhaliwal G. Mission Critical: Reimagining Promotion for Clinician-Educators. Journal of General Internal Medicine. 2023 Feb;38(3):789-92.[52]Staiger TO, Mills LM, Wong BM, Levinson W, Bremner WJ, Schleyer AM. Recognizingquality improvement and patient safety activities in academic promotion in departments of medicine: innovative language in promotion criteria. The American Journal of Medicine. 2016 May 1;129(5):540-6.







Complexity Theory: Developing a Complexity Lens – Part 1.

Posted on by davidaron2

David Aron, MD, MS  December 28, 2015.

Complexity is popular, made so by novels and films such as Jurassic Park and mass market non-fiction like Chaos: Making a New Science, and Complexity: The Emerging Science at the Edge of Order and Chaos, and many others. The field has been a rich source of metaphors, some more apt than others, and the terminology has been used to put a scientific veneer on evidence light (if not evidence free) opinions and unsophisticated analyses.  Nevertheless, there have been many efforts to advance the field, usually within traditional disciplines, but sometimes in a more transdisciplinary fashion.

The first problem comes with the definition. There are many definitions and descriptions of complex systems.  Melanie Mitchell’s definition has the virtue of brevity and clarity (at least superficially). She defines complex systems as “collections of elements, interacting nonlinearly, which produce emergent behavior.” The only problem with this definition is the use of the words: collections, elements, interacting, nonlinear, produce, and emergent behavior. How these terms are defined and characterized makes a great deal of difference. Nevertheless, although complexity theory/science is still relatively immature, there is still much of value to be learned. It has been argued by David Byrne that the “complexity frame of reference” was a more apt term. This approach was also endorsed by Boulton, Allen, and Bowman. Different scholars and practitioners have parsed complexity in different ways. Several have listed components, while others have divided complexity into broader categories that included several elements. Morin, a philosopher, divided the field into restricted complexity (a scientific and methodological approach) and generalized complexity (a philosophical and epistemological approach).  Manson, a geographer, divided the field into algorithmic, deterministic, and aggregate complexity. Geyer and Rahani, policy scientists divided complex systems into physical, biotic, and conscious.  Another approach would be to divide the field into academic versus experienced complexity (after Beautement and Broenner).

One of the issues is the separation between what might be termed academic complexity and what we experience as complexity.   In much of the academic literature complexity is approached primarily with mathematical models. This is a consequence of the hegemony of “science” and the particular view that rules in the groves of Academe.  These mathematical models are both interesting and informative. For example, the phenomenon of birds flocking or fish schooling can be described in three relatively simple mathematical equations. (see http://www.red3d.com/cwr/boids/ ), demonstrating that simple rules can result in complex behavior. (We err when we go on to conclude that complex behavior always results from simple rules or that we can impose simple rules on a complex system and have completely predictable results.) More recently, qualitative approached have been used, particularly in the context of the increasing popularity of “mixed methods.” A part of the stimulus to the use of qualitative methods is the desire to gain a richer picture of the experience of complexity.  We experience complexity in the world and often depend on intuition and sensemaking. For my course in the Doctorate in Management Program at the Weatherhead School of Management, on managing in complex systems I have felt the need to bridge academic and experiential complexity. Scholarly complexity may constitute that bridge.  I defined scholarly complexity as the conscious and systematic application of principles (regardless of their origin) that underlie complex systems to problems of practice in the real world – praxis. This frame of reference is a different way of looking at things and thus it involves a “complexity lens.”  In Part 2, I will describe the development of a complexity lens.

References:

  • Mitchell M (2009) Complexity: A Guided Tour. Oxford University Press, Oxford UK.
  • Byrne D, Callaghan G. (2014) Complexity Theory and the Social Sciences: The state of the art. Routledge, New York.
  • Boulton JG, Allen PM, Bowman (2015) Embracing Complexity: Strategic Perspectives for an Age of Turbulence. Oxford University Press, Oxford UK.
  • Beautement P. and Broenner C. (2011) Complexity Demystified, Triarchy Press. Axminster, UK.
  • Boisot, M. H., & McKelvey, B. (2010). Integrating modernist and postmodernist perspectives on organizations: A complexity science bridge. Academy of Management Review, 35(3), 415-433.
  • Geyer R., Cairney P. (20016) Handbook on Complexity and Public Policy. Edward Elgar Publishing, Cheltenham, UK.
  • Manson S. (2001) Simplifying complexity: a review of complexity theory. Geoforum 32:405-414.
  • Morin, E. (2007) Restricted Complexity, General Complexity, in: C. Gershenson, D. Aerts & B. Edmonds (eds) Worldviews, Science and Us, Philosophy and Complexity (London, World Scientific) pp. 5–29.
  • Richardson KA. (2008) Managing complex organizations: complexity thinking and the science and art of management. E:CO 10:13-26.

Nothing new under the sun

Posted on by davidaron2

David C. Aron, MD, MS, OC (optimistic cynic)

Nothing new under the sun.

What has been is what will be,
and what has been done is what will be done,
and there is nothing new under the sun.

Is there a thing of which it is said,
“See, this is new”?
It has been already
in the ages before us.

 

There is no remembrance of former things,
nor will there be any remembrance
of later things yet to be among those who come after.

Ecclesiastes  1:9-11 (Jewish Publication Society 1917)

The April 2010 issue of AHRQ Research Activities Newsletter led with the astonishing headline: “Patients admitted to the hospital on weekends wait for major procedures.” (http://archive.ahrq.gov/news/newsletters/research-activities/apr10/0410RA.pdf )  This finding was based on a report Characteristics of Weekday and Weekend Hospital Admissions that was based on data from 2007. (http://www.ncbi.nlm.nih.gov/books/NBK53602/pdf/Bookshelf_NBK53602.pdf)

 

There have been many critiques of health services research. Sometimes it has been called ‘academic,’ meaning not of practical relevance or of only theoretical interest. This particular article brings up another criticism that I have heard (and made) that health services researchers prove the obvious.  The authors of the report have used rigorous methods to support their conclusion and I suppose that should make us feel more comfortable in making the statement with scientific certainty.  However, one has the sense that this is something that could have been predicted more than 2000 years ago.

Genesis 2.1-3.  And the heaven and the earth were finished, and all the host of them. And on the seventh day God finished His work which He had made; and He rested on the seventh day from all His work which He had made. And God blessed the seventh day, and hallowed it; because that in it He rested from all His work which God in creating had made.

Exodus 20:7-10. Remember the sabbath day, to keep it holy. Six days shalt thou labour, and do all thy work; but the seventh day is a sabbath unto the LORD thy God, in it thou shalt not do any manner of work, thou, nor thy son, nor thy daughter, nor thy man-servant, nor thy maid-servant, nor thy cattle, nor thy stranger that is within thy gates; for in six days the LORD made heaven and earth, the sea, and all that in them is, and rested on the seventh day; wherefore the LORD blessed the sabbath day, and hallowed it.

Deuteronomy 5:11-14. Observe the sabbath day, to keep it holy, as the LORD thy God commanded thee. Six days shalt thou labour, and do all thy work; but the seventh day is a sabbath unto the LORD thy God, in it thou shalt not do any manner of work, thou, nor thy son, nor thy daughter, nor thy man-servant, nor thy maid-servant, nor thine ox, nor thine ass, nor any of thy cattle, nor thy stranger that is within thy gates; that thy man-servant and thy maid-servant may rest as well as thou. And thou shalt remember that thou wast a servant in the land of Egypt, and the LORD thy God brought thee out thence by a mighty hand and by an outstretched arm; therefore the LORD thy God commanded thee to keep the sabbath day.

The idea of a day of rest for the working class was an innovation and by no means the usual practice. The Jewish Sabbath was criticized by 1st Century Roman Seneca the Younger who was quoted by Augustine in City of God:  ‘Seneca, among the other superstitions of civil theology, also found fault with the sacred things of the Jews, and especially the Sabbaths, affirming that they act uselessly in keeping those seventh days, whereby they lose through idleness about the seventh part of their life, and also many things which demand immediate attention are damaged.( De Civitate Dei. 6:11) Nevertheless the concept caught on.

Since on the seventh day even God rested and no procedures were performed, is it surprising that delays have been introduced in the system?  I am not suggesting that the fact that the Sabbath appears in the Bible is scientific proof that this is the cause of waiting for procedures.  If anything, it is only correlation rather than proof of causality. Rather, it raises the issue of how much rigorous research is required.  Should we do an RCT to be sure of the causal relationship? Further, if waiting for procedures for patients admitted on weekends was not demonstrated, would you believe it? Is there a plausible counterfactual that would explain those results?  That is also not to say that there is nothing important to be learned here. Which procedures are delayed and whether that makes a difference in outcomes are legitimate research questions that have implications for hospital staffing.  Let us just not let ourselves be carried away with our brilliance. (For the record I am not aiming this at the authors of the study which included many more findings of considerable interest; rather, the idea that this was a headline struck me as funny.) This led me to ask the question, how much of the findings of health services and related management research, particularly in my area of implementation of evidence into practice, were at least foreshadowed in the Hebrew Scriptures.

There are several articles that provide so called lessons learned or prove the importance of one factor or another and these have been published in “high impact journals” (which means that other health services researchers cite them and not that they have high impact on actual practice – I am as guilty as the next in trying to publish in such journals). For example, some of the factors associated with implementation success include:

Leadership –  One need only read the Book of Exodus; and the ever popular importance placed on the leader’s vision.  See Proverbs 29:18

Spatial sufficiency (which probably means enough space)– which facilitates co-location of primary care and mental health clinics  Putting aside the laws of physics which don’t allow two things to occupy the same space simultaneously, one might recall that the Israelites are reminded that God led them out of Egypt. The Hebrew word for Egypt (מִצְרַיִם ) literally means the narrow places. Even then, spatial sufficiency was important.

I have no doubt that there are other examples. Health services researchers would be more useful if they looked at how to implement something in the face of poor leadership or how to accomplish things when space is a constraint. It is time for a change.

Bible translations and numbering from the JPS 1917 Edition

 

http://www.mechon-mamre.org/p/pt/pt0.htm

11/30/15

The Veterans Health Administration as a Wicked Problem

Posted on by davidaron2

David C. Aron, MD, MS

The Veterans Health Administration as a Wicked Problem — A commentary on Reforming the Veterans Health Administration — Beyond Palliation of Symptoms by Brett P. Giroir, M.D., and Gail R. Wilensky, Ph.D., N Engl J Med 2015; 373:1693-1695.

A recent article in the New England Journal of Medicine by the co-chairs of a blue ribbon panel summarizes the panel’s assessment of the Veterans Health Care System in light of recent scandals related to access to care, quality of care, and falsification of data. (http://www.nejm.org/doi/full/10.1056/NEJMp1511438) The title alone: “Reforming the Veterans Health Administration — Beyond Palliation of Symptoms” promises that recommendations will get to the “root causes” of VHA’s problems and identify real solutions. Unfortunately, the identification of problems is too shallow and doesn’t really get at their complexities and interdependencies. The report doesn’t adequately address the conflicting interests and political power of stakeholders nor does it deal with the issues of how and why the VA got to where it is now.  Thus, it is not at all surprising that the report notes that it includes numerous operational recommendations for the near term, few of which are unexpected. They are not only expected, they have been known for years. For example, the need for more exam rooms and increased staff-to-patient ratios to enhance physician productivity was noted in the Advanced Clinic Access initiative, a prior national VA effort to improve access beginning more than 15 years ago. (http://www.researchgate.net/profile/Mark_Meterko/publication/228478818_The_implementation_and_effectiveness_of_advanced_clinic_access/links/00b7d526555e853f00000000.pdf)

The key question is: if the problems were known, why have they not been addressed successfully?  First, as noted in the report, VHA is one of the largest health care systems in the US and size alone (9.1 million enrollees, 20,000 physicians, 1600 facilities, 288,000 employees) brings with it the challenges of minimizing undesired heterogeneity. In addition the various conflicting interests play out in a dynamic environment where how you got to where you are matters. This is path-dependence writ large.  All of these and other factors contribute to making the situation intractable and resistant to solution. In fact, the situation meets the criteria for constituting a “wicked problem.”

Rittell and Weber, two urban planners, described a class of problems that they called wicked. These wicked problems had a number of characteristics:

  1. There is no definitive formulation of a wicked problem
  2. Wicked problems have no stopping rule
  3. Solutions to wicked problems are not true-or-false, but good-or-bad
  4. There is no immediate and no ultimate test of a solution to a wicked problem
  5. Every solution to a wicked problem is a “one-shot operation”; because there is no opportunity to learn by trial-and-error, every attempt counts significantly
  6. Wicked problems do not have an enumerable (or an exhaustively describable) set of potential solutions, nor is there a well-described set of permissible operations that may be incorporated into the plan
  7. Every wicked problem is essentially unique
  8. Every wicked problem can be considered to be a symptom of another problem
  9. The existence of a discrepancy representing a wicked problem can be explained in numerous ways. The choice of explanation determines the nature of the problem’s resolution
  10. The planner has no right to be wrong

http://www.ask-force.org/web/Discourse/Rittel-Dilemmas-General-Theory-Planning-1973.pdf

These characteristics describe VHA in a nutshell and make clear why the panel’s recommendation: “First, the urgent need for strategic vision and dynamic decision making argues for a new VHA governance board that is representative, expert, empowered, and relatively insulated from direct political interactions” is not only laughable in the current hyperpolarized political environment, but likely to be nearly if not totally impossible.

How is the VA a wicked problem? For brevity’s sake, I will touch on only a few of the characteristics. First, VA has numerous stakeholders who perspectives differ and objectives conflict.  These include not only veterans and their families, but also their representatives in veteran service organizations, members of Congress, employees both unionized and non-unionized, professional and non-professional, the media, auditors, medical schools and other professional schools, and taxpayers, just to name a few.  For some members of Congress, VHA is a source of jobs for constituents; any attempt to realign facilities with need is resisted.  Similarly, unions are resistant to efforts that might result in staffing reductions. Physicians are recruited to VHA often come because they want to do research and teaching as part of their job. The current focus of attention leading to the blue ribbon panel is related to access to care.  However, although care for veterans is the primary mission, it is not the only one (the others being research, education, and backup for the Dept. of Defense). Time spent by physicians doing research (a major recruitment incentive) is time not seeing patients. Similarly, time spent lecturing in medical school or teaching in other venues (another recruitment incentive) is time not seeing patients. Moreover, physician trainees are less efficient than staff physicians, especially in ambulatory care, the focus of access. Physician trainees also have schedules that conflict with continuity of care. Meanwhile, medical schools want to preserve the inpatient setting for training students and residents while preserving high tech care, supporting research and teaching, and maintaining business relationships where VA facilities send and pay for patients to be seen in the affiliated hospitals. Auditors such as the Inspector General and GAO have an important role, but they also have to justify their role by finding problems. (See Michael Power. The Audit Society, 1997 and also Organized Uncertainty, 2007)  Media thrive on scandal and are even more dependent on it in the 24-hr news cycle.  The multiple stakeholders have the power (to varying degrees) to assert their values and interests. When these conflict, change is difficult. The problems are dynamic. Today it is access; tomorrow it may be something else and today’s solution may be tomorrow’s problem.  For example, as primary care in VHA expanded, the specialties required to support primary care were to a large extent ignored, perhaps because of the costs involved. Decreased access to specialists was predictable. This is not to say that there is no access problem. Rather, it means different things to different people. The patient’s personal physician? Any physician? A nurse? It remained rather murky.  Because success is generally determined in terms of objectives, when there is ambiguity in purpose, there will be a lack of clarity about criteria for success.Although various standards have been set, there is little if any evidence on which those standards are based. When the answer to question such as how quickly does someone need to be seen is “it depends,” then characterizing what the problem is can be difficult.  Moreover, “common sense” solutions may not be so simple in practice. Improving access such as after hours clinics requires changes in staffing way beyond the clinic. In addition to physicians, nurses, and clerks, there has to be additional capacity in supporting services such as radiology, laboratory, and pharmacy.  At the Phoenix VA Medical Center, ground zero for the access scandal, there was a shortage of primary care physicians and an inability to recruit them, a common problem nationwide. Common sense solutions may have unintended consequences.  The use of clinical reminders in the electronic health record to improve quality has not only led to check-box medicine, but has also been described as “death by a thousand clicks.”  This analysis just touches the surface, but the work necessary to have a better grasp of the issues should have been conducted in the Independent Review, but alas was not. In addition, some of the biases of the panel clearly show through. The consideration of the electronic health record is a case in point.

The panel made one statement: “electronic health record (EHR) has been stagnant for a decade, and clinicians are frustrated with the lack of integration and mobility and the feature deficits as compared with commercial systems.”  This is simply untrue. For example, in the  Medscape 2014 satisfaction her satisfaction survey (http://www.medscape.com/features/slideshow/public/ehr2014#7), the VA’s EHR called CPRS was the highest rated. The EHR with the highest market penetration is in the middle of the pack. That has been my experience talking to colleagues. Anyone who has had experience with two different systems prefers CPRS.  This is not to say that CPRS can’t be improved. It can and it should. Rather, the idea that the private sector must be better does not conform to the evidence. The panel also came down hard on VA because of the lack of interoperability of CPRS with the EHR used in the Dept. of Defense. This is fair comment. However, it is important to take note of a few things.  First, VA and DoD spent around $1 billion unsuccessfully trying to develop a joint EHR. DoD then chose a commercial package that promises interoperability – we shall see. ( Second, where is interoperability in the private sector. At an affiliated institution, the different modules in its EHR do not communicate with each other, much less any other institution’s system.   Parenthetically, in my own VA facility, we have access to the EHR in two non-VA health care facilities, albeit not our primary affiliate.  The problems with EHRs in the private sector have been well documented. http://hcrenewal.blogspot.com/

There seems to be an assumption that the private sector does things better. There are two health care systems in the US that are of comparable size – Community Health Systems (Brentwood, Tenn.) and HCA (Nashville, Tenn.).  (http://www.beckershospitalreview.com/lists/15-largest-for-profit-hospital-operators-2014.html) Do they have the degree of uniformity of quality demanded of the VA? Do they routinely share “best practices” and have similar operations?  Maybe they do, but we don’t know.  What we do know is that each of these systems has paid out millions of dollars in settlements over issues such as Medicare fraud, Medicaid fraud, Ethics in Patient Referrals Act (also known as the Stark law), the False Claims Act, and other federal and state laws and regulations. One could go on and on. It is not that I think that many of the recommendations are wrong. Quite the contrary, although because the problems are so intertwined, unintended and unanticipated consequences are likely, but though they call for systems thinking, a critically important issue for such a situation, the panel did not evidence much of it.

Additional references.

  1. Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs. http://www.va.gov/opa/choiceact/documents/assessments/Integrated_Report.pdf
  2. Rittel, W. J. and Webber, M.M. 1973. Dilemmas in a General Theory of Planning, Policy Sciences. 4 (2): 155-169.
  3. Australian Public Service 2007. Tackling Wicked Problems: A Public Policy Perspective. Canberra: APSC.
  4. Camillus, C. 2008. Strategy as a Wicked Problem. Harvard Business Review 86 (5): 99- 106.
  5. Conklin, 2006. Wicked Problems and Social Complexity, in Dialogue Mapping: Building Understanding of Wicked Problems. Chichester: John Wiley.
  6. Head, W. 2008. Wicked Problems in Public Policy. Public Policy, 3 (2): 101-118.