Blogging A Book: Sharing the Secret of Lean & Six Sigma In Healthcare (Introduction)





Editor/Author’s note:  Hello All.  As we described earlier on the blog, we’ll be releasing pieces of the e-book we’re writting:  Sharing The Secret of Lean & Six Sigma In Healthcare.  Here’s our rough copy introduction–feedback always welcome.





Introduction–Why Bother With The Hunt For Effective Quality Improvement?


By:  DM Kashmer, MD MBA FACS

Lean Six Sigma Master Black Belt (MBB)



Healthcare Is In A Bad Place


If you work in or around healthcare you know there are many challenges that we are facing as a group.  After all, we have heard the story of quality challenges in healthcare for the last decade or more.  We have heard the fact, over and over again, that the United States spends more than 14% of its Gross Domestic Product on healthcare each year.  For this amount of expenditure, our quality endpoints are poor at best according to many classic measures.  What has this translated into?  Many of us feel that we are currently in age of cost containment.  What I mean by this is there is a strong focus, now, on decreasing the cost of healthcare to the exclusion of much else.  Some assert that the cry of “quality!” really is being used as a stick to control costs.  You may or may not agree and of course that’s ok–and either way, reading on is worth your time.



Many Classic Quality Improvement Tools That Could Help Are Unknown Or Shunned


Unfortunately, many of the classic tools for quality improvement are either shunned or unknown in healthcare…and that’s why this book exists.  In this book, we explore many of the classic quality tools and describe how they can be deployed effectively in healthcare.  Why do we do this?  This book is written for one simple reason:  improving quality can decrease the amount of costs we endure for poor quality–and when I say “costs”, by the way, I don’t just mean financial costs.  After all, since most service industries operate at one defect in every one thousand opportunities at making a defect (yes I’m talking to you here healthcare) the issues associated with our current performance are many and go far beyond simple finance.  At the end of the day, the Cost of Poor Quality (COPQ) includes things like re-operation, wrong site surgery, and many other problems that go beyond financial considerations.


And remember healthcare friends:  just because you don’t know about Lean and Six Sigma (yet) doesn’t mean they don’t work.  In fact, they are very effective and (just like healthcare) they take some expertise and training.  You’ll be even more surprised to hear that much of both Lean and Six Sigma is really just utilizing tools that you’ve heard of such as histograms, multiple regressions, and other classic statistical implements you’ve learned about in healthcare training–it’s just that these are put together and arranged in certain ways to help a group own its process and implement positive change that is measurable and rigorous.


Quality Improvement Teaches Us Many Issues Aren’t Just People Issues


It’s clear that, if we are able to improve quality, waste in terms of financial waste and other waste is substantially reduced.  Currently, often, we hear the refrain of physician-work-harder or (“doc work harder”).  Don’t get me wrong–I’m no stranger to work and in fact I don’t mind it.  Work is what got me through medical school, residency, and to this point in my life.  However, “doc work harder” is not a valid solution for quality improvement.  It turns out, after all, that many quality issues that healthcare deems “personally assignable” are actually much more multi-factorial.  If we want a real way to improve quality that works, let’s try something different than the blame game we see too often in healthcare.  It divides us as physicians and practitioners.  So let’s listen to the data from the quality improvement world and actually use the tools.



Externally Imposed Endpoints Would Likely Be Satisfied With An Increased Internal Focus On Quality


Also, as a physician, I often feel that my time with patients and attention to detail is limited owing to system issues.  One of the reasons why is that in hospitals, the revenue side is most sensitive to patient volume.  That is, proformas in hospitals are most sensitive to patient volume.  See more patients, treat more patients, and go go go.  As a result, my ability to care for individual patients and spend time is limited.  It is easy to see the impact of volume on the hospital’s bottom line.  However, it’s not so easy to see the impact of the COPQ and this is part of why a quality focus is often brought to healthcare from without (eg the government and things like “never” events or SCIP measures) rather than from within.  If we followed the tools in this book and the philosophy of Lean and Six Sigma, SCIP measures and similar endpoints would be met or exceeded as a consequence.  More on that later.


I view quality improvement as one type of investment that allows me to spend more time with patients and treat more patients effectively and compassionately.



The Sibling of Quality Improvement Is Innovation


As I depart the soapbox and we turn toward the tools and tips, let me share that perhaps the brother or sister to quality improvement is innovation.  It’s one thing to refine a system with quality tools and yet it is quite another to build one with quality in mind in the first place.  That is, if we can innovate the business models with which we deliver care, we can perhaps break out of the “volume crunch” that we are currently experiencing in Healthcare and Surgery.



Better To Work In A System That Sets Us Up For Success


Disclaimer here before we go to the tools:  I love to work and operate.  I add that in because, in healthcare and surgical culture, a quality focus or mentioning quality is often taken as a synonym or code-word associated with someone who doesn’t like work.  Let me share with you all that, in fact, a high-quality, high-performing system enables more work to get done with less re-work.  That’s the aim here:  it would be better to be able to deliver higher quality care in a system that’s built to set us up for success.



Use The Tools–Don’t Reinvent The Wheel


Please enjoy this series of quality control tools, and their rationales, applied to healthcare.  Consider using them–don’t re-invent the wheel in the hunt for tools that already exist and work.  These are written up as vignettes with a focus on either a philosophy or tool of the process and its uses.  There is also a focus on innovation, with these tools offered to demonstrate how to take an innovative process and refine it.  After all, if we can innovate business models and evolve streams of revenue that are not sensitive to patient volume, well, we may be able to effectively deliver care and break out of the difficult cycle in which healthcare currently finds itself.  It would be great to be less focused on patient volume and more focused on quality care, innovative means of delivery, and new ideas to decrease the pressure to see more and more patients so we can be able to spend more time delivering higher quality care.


–David 5/16/14

Coming Soon: Sharing The Secret of Lean & Six Sigma In Healthcare


Hi Everyone,


For the last few years, our team has focused on the idea that many of the tools we’re looking for in healthcare already exist.  What I mean is, we’ve seen quality initiatives from different professional groups and institutions that often rebuild the wheel–that wheel is called Lean and Six Sigma.


One of the most interesting parts, to us, is that healthcare professionals like our colleagues may feel that the Lean and Six Sigma methodologies don’t apply to healthcare; after all, they were “invented” for manufacturing right?  Well, interestingly, many of the Lean and Six Sigma tools weren’t “invented” at all.  Many of the tools are routine tools from statistics that are strung together with an approach that fosters team building, culture change, and meaningful, actionable data.


I’m not saying that Lean or Six Sigma is the only way to do quality improvement.  Yet, what we do want to share is the fact that many of the tools for which we are looking or those that we are building already exist in the Lean and Six Sigma toolbox.


So, to share the “secret” of the tools and how they work in healthcare, we’re blogging our e-book.  Coming soon to the blog (this week) is the beginning of our e-book on Sharing The Secret Of Lean & Six Sigma In Healthcare.  Yes, we’re building out the book as we progress through blog entries.


As always, we invite your feedback on everything from style to content…and even title.


See you soon on the blog,



Coming Soon: Single Minute Exchange of Dyes For Trauma & Acute Care Surgery


Hello All,


This week on the blog we’ve already heard from our colleague, The Generation Y Surgeon, with some thoughts on how trainees in Surgery are (or rather are NOT) selected and trained based on technical talents.


Later this week, we’ll review an interesting tool that can improve things like signouts and other patient turnovers.


This fits with our team’s contention that many of the tools for which we look (or de novo create) in healthcare have already been built, named, and validated.  Often, we as healthcare practitioners just don’t have training in these tools, and here at the blog we look to provide that exposure as a toolset that can be used to improve and innovate systems.


See you soon and look forward to your feedback on the blog.



Do You Know A Butterfingers?


Editor’s note:  The Generation Y Surgeon has been on a tear recently!  Perhaps this is in response to you all reading along.  Please insert our standard comment, here, that although not everyone at the blog agrees with GenY, the viewpoint is an appreciated and important one.  Enjoy the read…we always do!  –David




By:  The Generation Y Surgeon (@GenYSurgeon)


I just finished the Fundamentals of Laparoscopic Surgery testing.  I passed but then again the technical stuff has always been easy for me.  I have good hands–always have.  Learning new skills is easy for me and I’m thankful because that’s not the case for everyone…


Watching My Friend Operate Reminds Me Of What’s Out There


As I watched one of my incredibly brilliant friends stumble through the skills test I wondered why we don’t test technical abilities until the end of our training.  I mean, this guy will be a wonderful doctor.  He’s exceptionally brainy, safe and has an uncanny ability to charm his patients.  He’ll never be a showstopper but he will be a great doctor.  The technical aspects are only part of what makes a great surgeon great.  The decision-making, after all, is what keeps patients alive and healthy.  Yet I wonder, why don’t we select for the technically gifted and train those students to think like surgeons?


No One Gets Fired For Having Bad Hands

We all learn to tie knots in medical school.  Some of us learn to suture.  Most learn to place a foley and a few even get to try their luck at central lines.  For the most part, however, medical education in the USA is focused on knowledge.  No one really grades you on technical prowess until you’re already committed to a surgical field and only then do the Butterfingers start to show themselves.  And, guess what, even then the Butterfingers don’t go away.  Have you ever heard of someone getting fired as a resident for having bad hands?  And it’s not like residencies are firing people who have bad hands yet are using other stated reasons–at least I haven’t seen that.


The Butterfingers Are Out There

You may or may not have worked with Dr. Butterfingers and you may or may not be one yourself.  But they’re out there.  They struggle with technical tasks, and the sad part is that after residency they no longer have coaches available to help build their skill set.  Surgeons are solitary creatures.  Sure we come together for conference and meetings, but we rarely operate together.  It’s nearly impossible to compare yourself to your peers, so if you’re a butterfingers then you’ll likely struggle for the rest of your career without even knowing it.


I’m not sure how to fix this other than to start selecting residents with an aptitude for cutting, sewing and handling tissues.  Yes, this may prevent some would-be surgeons from getting certain residencies, but hey, this is a competitive field!  May the most gifted win!  Talent after all is important, especially when it’s your loved one under the knife.


A Shout Out For Simulation Technology

I do think that modern gaming and simulation technologies deserve a shout out at this point.  We now have the ability to teach and test students/residents outside the operating room in lower-stakes environments (dry lab, pig lab then the OR).  It will be interesting to see how far we can go with gaming and simulation technologies.  How early can we start testing for technical skill? Medical school? Residency interviews?  And will earlier training or selection of the technically gifted change patient outcomes?


I’m interested in any thoughts you all may have. Once again, thanks for reading!


Money Isn’t Dirty–It’s Necessary


Editor’s Note:  Here’s another entry from The Generation Y Surgeon.  The team at the blog has been amazed by the response to our young surgical colleague’s entries, and we appreciate you reading.  Remember, the team, and GenY, is interested in your feedback about these and other entries.  Although GenY is often controversial, we appreciate this unique, uncensored voice of this finishing resident trainee and, as always, think it’s important to hear opinions like this whether or not we agree with some of the more controversial ideas.  As always, pass along your feedback and enjoy this entry from our colleague.

By:  The Generation Y Surgeon (@GenYSurgeon)

A Difficult Conversation Reminds Me of How Un-glamourous Residency Is

I had to have a difficult conversation with a difficult patient in a difficult situation last week.  (Haven’t we all done that a lot?) She and I were as different as could be – different race, an age gap, contrasting upbringings and our financial futures were headed in opposite directions.  What we had in common was healthcare, and as jaded as a chief surgical resident can be, I was sympathetic to her situation.  I still care.  

As a surgeon, I present patients (and families) with life changing news on a regular basis.  Death, impending death, mutilating procedures, dwindling hope–frequently in the wee hours of the morning and under strained, emotional circumstances.  The drama of Surgery is not lost on me and I try hard to remain sympathetic to how terrifying surgeons and procedures can be.  I don’t expect patients to react well when I share bad news, however I don’t deserve to be attacked on a personal level.  

This particular patient responded to our conversation with a rage that was directed at me.  It was personal and it was completely unnecessary.  “You doctors…with all of your money…you don’t understand…[profanities]…get your racist ass out of my room…who do you think you are driving here in a fancy car and talking to me like that…”  It went on and on. 

I’m a resident.  There’s nothing fancy or glamorous about it.  I struggle to live.  My personal life and my finances are constantly at odds.  If you’re reading this chances are you have either completed residency, are looking to start a residency or are currently in my same shoes.  (Well, hopefully not these exact same shoes because I mean these things are disgusting.) I complain about it but I know that my life will change soon and my years of hard work will be rewarded.  In the meantime I remain grateful to be a part of this because my training is a privilege.  Medical school, residency, fellowship….all competitive and I was one of the few who earned the right to be a part of this nobel profession.  

Things Surgeons Like and Patients Expect To See

As this woman continued to yell and scream and judge me harshly as a result of my “successes” I thought about how I’ve struggled with presenting myself.  As a resident and future attending there is a certain standard of living that people expect.  We are educated and proud, hardworking people who want to live near others with similar interests.  We want to look nice and wear nice clothing, drive nice cars and go home to comfortable houses.  We like steaks and wines and fancy banquets and meetings in fabulous destinations.  We train hard to help people and, yes, to make money…and money is fun to spend.  I think it’s fair to say that most physicians expect a comfortable income because the hours and training can be brutal.  This has nothing to do with the care we give to our patients.  If anything, a comfortable life makes it easier to give better care because our struggles are focused on others instead of our own lives.  I wouldn’t want a surgeon who is going hungry for income making the decision about whether to operate on my family member.

I also think it’s fair to say that patients expect the same for their caregivers.  Show a patient two doctors, one with corduroys and a 1990 Toyota (my car) and then another in a slick suit and a BMW…who do you think they’d choose to operate on them?  This lady wasn’t the first patient who has tried to use my (future) successes to make me feel bad.  But this was the first time I was really angry about it.  I don’t feel bad about my success and I don’t feel bad about my (future) salaries.  

The Stigma of Money In Healthcare

Residents struggle with presenting themselves as successful physicians and looking the part and we have to do it with minimal funds.  The money comes later and it’s all part of the process.  It’s uncomfortable because our wants and our needs don’t always jive with our ideals and our altruistic roots.  It’s uncomfortable to talk about money as well, especially when it’s associated with so much stigma in healthcare.  It’s uncomfortable yet handling money is part of being a professional and doctors notoriously do a poor job of it.  

Let’s acknowledge this and start talking more about money.  I mean, shouldn’t it be part of my training to teach me about how reimbursement works?  Does any other profession just throw their finished trainees out there with no idea about how the money side works?  Let’s make sure residents learn more about this dimension of healthcare so we can be better about it.  Savings, insurance policies, wealth management and planning for retirement should be a part of our training.  Money isn’t dirty, it’s necessary.

Failure To Teach About Money Gets Us Managed By Others

Failing to stare the economic realities of practice in the face may be responsible for allowing administrators to manage us rather than us managing our own profession.  We lost out a long time ago to MBAs and other administrators when we abdicated responsibility for providing financially responsible care while maintaining high quality.  Thanks to all you dinosaurs out there who screwed this one up for me too.  After all, since we don’t teach the next generation (me!) about how money works–well, believe me someone will be there to manage the situation for us.

Thanks again, dinosaurs.  Guess my generation needs to work on this one too.


Call For New Authors



Hello All,


You may have noticed a recent update that explained how we are bringing on new writers to the blog.  Well, here’s your chance!


We have several new voices coming on board (you may have already met @GenYSurgeon) and more will follow soon.


If you’d like to add your voice to ours, we’re interested in talking with you.


Our team is particularly interested in once to twice weekly posts on these subjects:


(1) healthcare business model innovation

(2) personal stories of systems issues in healthcare

(3) statistical process control, Lean / Six Sigma, and other data-driven process improvement initiatives.

(4) “Big Data” and its applications in healthcare


The blog now has hundreds of unique readers each day, and we appreciate all our readers out there very much.


We now have the opportunity to add your voice (anonymously if you’d like) to the already excellent team at the blog.


Let us know if you’re interested in adding this forum to help spread your unique voice.  Don’t worry if you’re new to all this–we’ll help edit and format your work for posting.


Contact me at because our 5 open spots are filling soon.


Fresh Voices Welcome,




What Can We Learn From The Top 5 Not So Innovative (Anymore) Business Models

In this entry, we explore some well-known entities with their business models formatted according to the business model canvas technique that we described earlier here.  What can we learn from these now well-known (not as innovative anymore) models?


By:  David Kashmer, MD MBA (@DavidKashmer)

The Top 5 Not So Innovative (Anymore) Business Models–But They’re Really Useful!

One of the key features of the blog is that we focus on innovative business models as they relate to Surgery and healthcare.  In this entry we highlight business models that have been done before in an effort to look for certain lessons learned, commonalities, and ideas we can use to further our own business experiments.  We hope you enjoy this collection of not-so-innovative business models so that you can find and utilize those ideas.  Note, by the way, this is not to say that these business models were not innovative when they were first seen.  That is, many of these different examples were (or still are) functioning as highly innovative business models.  Here, we mean that these business models have been done or are now becoming more tried and true.  That is, these are not so innovative because they are ideas we can formalize, represent, and maybe even reproduce or appropriate as desired.  So, here are our Top 5 business models (some are well-known entities) represented as business model canvases with our commentary.  Here we’ll focus mostly on the value proposition and revenue streams.


1.  LinkedIn



LinkedIn’s canvas points us directly to a clear value proposition:  manage professional identity and build a professional network.  See how the value propositions are clear and can be fit on those little post-it notes?  Notice how there aren’t 30 value propositions, but rather there are only four short maxims?  This is one of the first commonalities we’ll highlight for you across these entities:  they are clear with respect to what value they add.  They know what they are about and it’s NOT 30 different things.


Is LinkedIn’s value proposition unique compared to other social networks?  Well, we don’t see a lot of CEO’s pop up on Facebook–at least not labeled as CEO.  It seems to do something different and unique that we would find valuable.  So, ok, this one passes our Michael Porter test.


(By the way, when we evaluate models, we check them to see if they incorporate a unique and clear value proposition.  We call it the Michael Porter test.  No, Porter is not the only one to think startups and other entities need a unique, clear proposition.  We just call our test that because we like Porter’s take on competition and his work reminds us of the value of a premium positioning in terms of creating startup success.)


Notice, next, that LinkedIn has several revenue streams.  Although basic service may be free, it offers premium upgrade subscriptions (so called “freemium” model)–yet this is not the only way it obtains revenue.  It allows for hiring solutions and marketing too.  LinkedIn has a diversified revenue stream that centers around people’s professional lives.

Now let’s look at Apple.


2.  Apple



Apple’s value proposition is perhaps even more clear than LinkedIn’s and customers “feel” it.  How many times have you heard Apple users say that they use Apple products because they “just work” or “don’t crash” or are so much more stable than other companies’ products?  Apple’s value proposition is obviously clear.  When it comes to revenue streams, notice that Apple has multiple streams including hardware and software.  Notice anything else?  Ahhh…there’s a rental / subscription fee component that’s another example of evergreening.


“Evergreening” is a term used to describe a revenue stream or similar entity that, like some plants, constantly gives green leaves.  In other words, a subscription model (think iCloud here or Mobile Me or whichever Apple calls it now) allows for a revenue stream that’s self-renewing as customers must act to opt out–which they don’t always do–and so the subscription marches on as Apple collects revenue and delivers value.  LinkedIn’s model showed evergreening too.


Next, let’s look at a model that’s quite distinct from Apple and LinkedIn.

3.  Google



Hmmm…do you agree that the value propositions shown are really Google’s?  Where are we in there?  Doesn’t Google deliver value to us?  It gives us all that free email!  Wait a minute…something is up here…


Oh we at the blog don’t mean something bad is going on…we’re just pointing out that we are NOT Google’s true customer.  Google delivers us free email but in reality what it is really doing is showing us ads and delivering positioned content.  That’s one major value proposition Google puts out there.


Now, for some of the businesses with which we work, Google provides cloud infrastructure (mail, calendar, online storage, etc.) for a price.  There’s another value proposition.


It also will run ads for us or a business if we pay.  So, then, Google’s value proposition focuses around effectively marketing to us and targeting ads to us.  Its value propositions focus on us as advertising targets.  Not saying that’s bad–just saying it is what it is.


Revenue streams?  Yes, Google has streams that are very focused on ad revenue.  Moves like Google Glass and the Nexus phone may be bids to diversify the revenue stream by entering the hardware market.


Last, note there is evergreening here.  If your business signs up for Google Apps, well, there we have it.  Google’s model has a subscriber base of businesses to which they provide cloud infrastructure.



4.  Skype



You’re probably getting good at this by now:  Skype’s proposition may not be too different from similar offerings, but it is (again) clear.  In terms of revenue, here we have a freemium model for accounts, again, that evergreen as users sign up for premium versions.  There’s also a hardware piece to the revenue stream that my colleagues and I didn’t even know existed.



5.  Retail Clinic


This one is for all you out there who are saying:  “Well that’s great…here we have another technique from business world that really doesn’t apply to healthcare.  After all, I’ve never seen this before and have never seen this applied to healthcare.” Well, my skeptical friend, here’s an example of a retail clinic startup diagramed as a business model canvas:




This canvas changes some of the typical terminology we use, yet all the concepts are there.  The Benefits section represents the Value Propositions, and what do we see?  This entity wants to be the close-to-home, transparent pricing, short waiting time, affordable clinic.  Perhaps, some would argue, it wants to be everything to everyone or too much to too many people.  We notice, however, that diagnostic and therapeutic accuracy don’t seem to be part of the value propositions.


Keeping us close to home but misdiagnosing us wouldn’t be too valuable to us…but maybe we just think that way because we’re surgeons.  In any event, this clinic is clear about what it wants to be.


This doesn’t seem to be particularly unique, however, among clinics.  How will this be different than the Urgent Care we drive past every day?  That’s probably an important question for this entity to answer.


Also, the revenue streams aren’t too diversified.  Here we have the typical:  “We’ll charge the third party payers” and “We’ll accept cash too!”


Now, armed with inside knowledge of the other models, can you think of any innovative twists on this clinic’s model?  What if users had a monthly “subscription” and most were fairly healthy so they weren’t in clinic every day?  It would evergreen.  Maybe you could do something freemium.


More importantly, what about non-patient based revenue streams?  A conference on Urgent Care clinics that had attendees?  Consulting for other clinics?  Something…anything…to not have the clinic be a one or two-trick pony that is totally reliant on the third party payers.


As you can see, visualizing each of these business models as a business canvas is a powerful way to have a quick view on the key value propositions and structures that drive the business.  It leads us to obvious questions about that last Retail Clinic business model.  This reinforces just how useful the business model canvas is to get a snapshot of how businesses will function, how business runs, and what it does.  Remember, as you change portions of your business, pivot, or otherwise adapt to a changing environment it is important to note that the business model canvas serves as a visual representation of your business and can be a quick summary from meeting to meeting.


We recommend updating your business model canvas at your meetings with your startup team.  As you can see, there are multiple business models from which we can select.  You can take pieces that work well together and plug them into your experiment if need be.


Many of these models are highly successful for different reasons.  Some commonalities include a unique value proposition that is well-delineated and a diversified number of revenue streams.  A focus on evergreening is always nice to have.


In short, whatever you do it really helps to be positioned differently than your competitors in a way that adds value.  This is just one portion of the business model canvas and yet it is an important piece of your business.  Although here we focused on two portions of the canvas, you can see from examples like Apple that a unique value proposition is key and so is the manner in which that value gets to customers.


Additionally, we know the discreet jobs a firm must perform in industry. We have discussed representation of these as Porter’s Value Stream earlier:  these include bringing inputs into the system, adapting these with operations and procedures, and getting them out of the entity with outbound logistics.  Opportunities for advantages also exist at the interaction of one discreet portion of the value stream with the next.


Just as important, if not moreso, is what the business is busy about and what value, as mentioned, is added…and that’s the piece for which the canvases are great.  We can’t say enough about visualizing some of these now classic business models as business model canvases and we hope that you have really enjoyed reviewing these in this useful format.  Remember, as always, we encourage you to take those pieces that are functional for you and leave the rest.


FYI:  As we were doing the research for this entry, we started to create the business model canvases for each of these businesses ourselves.  Then, my colleague realized someone else probably had done it already.  It was then that we found

Very useful!  It highlights the importance of the business model canvas, explains the system, and even runs through interpretations of the canvases as we have above.  Yes, our interpretations are different (and we are looking for commonalities we can apply to our next experiment) but this blog is new to our team and falls right in line with techniques we’ve learned.  We didn’t take the idea for this entry from–yet we’re are obviously close kin with regard to how we were trained with the technique.

Take a moment and visit that useful blog when you have time.

Disclosure:  David is an Apple stock holder, and Apple is one of the companies described in this entry.  David was a fan of Apple’s long before his investment and this entry explores Apple’s business model while it does NOT describe anything about investing in the company.  David says he owns Apple stock for the same reason he writes about it favorably (he really likes the company) rather than writing about it favorably because he is an investor in the company.

Thoughts, comments, or questions about applications of this type of technique to healthcare?  Let us know!

Don’t Use The Patient As A Weapon (!)


By:  The Generation Y Surgeon (@GenYSurgeon)


In my last blog entry I described one of the maladaptive behaviors physicians have learned to defend themselves: using literature as a weapon.  Today, as part of my as-a-weapon series I’d like to talk about a more controversial weapon…using the PATIENTS as a weapon.

Before I get started I need to explain that I don’t think these behaviors make us bad people.  These pathological behaviors are the result of an environment that breeds frustration and systems that leave us high and dry.  We are largely unsupported and therefore we do what we can to defend ourselves, our interests and our patients.  As a profession we need to acknowledge our deficiencies so that we can begin to fix them.  Like David said in his post “A Sandbox Hospital to Test Our Systems,” the problem is NOT the physician, it’s the system and circumstance that surrounds them. 

Now for the weapon, the patients.  Whether it was directed towards the insurance company, a boss, or a colleague, we are ALL guilty of using the patients as a weapon.  Here are just a few scenarios:

  • An administrator moves your office to a building that’s a quarter mile farther from where you park.  Moving is inconvenient and your daily commute just got even longer.  Your response?  “But my patients won’t know where I am!  What if the patients get lost?!” or “What if I can’t respond easily to emergencies?”
  • On your way out the door you get a call from a clinic patient who is 45 minutes late.  Your partner (already home) says “Can you see her?  The patient really needs some help.”
  • On the podium at M&M you defend a completely retarded decision with “well the patient wanted…” 
  • In the middle of the night the nurse calls with questions about minutia.  You gruffly answer her questions and she responds defensively with “I’m only trying to do what’s best for the patient!”

In none of these situations is the first thought REALLY about the patient.*  It’s about preserving convenience, defending your personal time, covering your ass or trying to get some sleep!  Why do we do this?  Well, in my opinion, it’s related to why we chose to go into medicine in the first place.  You expect me to say that it was to “save lives,” to “help the less fortunate” or to simply “give back to my community.”  But I’m not going to say that because the altruism is only part of the story.  It’s a given that we want to help patient, that’s at the heart of Medicine, yet we also went into medicine because we are dorks and we like Science; we are proud and we enjoy power and prestige; and Medicine is a good living which allows us to provide for ourselves and our families in a way that many other workers cannot.  Besides that, Surgery is just plain cool and being a surgeon is, frankly, badass.  

When we enter Medicine however, we don’t accurately anticipate our daily grind.  Be it an uncooperative insurance company, an administrator who creates hoop after hoop for us to jump through, or another provider who is just as frustrated, tired and grumpy as you….none of it is fun or productive.  In fact, it makes your life unnecessarily difficult and that’s a problem when you already work as hard as surgeons do.  The patient-as-a-weapon tool is a response to unnecessary stresses and unproductive interactions.  It’s the quickest way to guilt other healthcare providers into doing what you need them to do.  It’s a nuclear option that we throw into the ring far too frequently.  

So next time you catch yourself (or someone else) using the patients as a weapon to get things done, challenge yourself and just say it like it is.  Don’t use the guilt and social capital to help you succeed–use facts.  Put all that extra emotional energy into designing a system that eliminates the need to use patients-as-a-weapon and makes it easier to do what doctors are meant to do – provide the best possible care for their patients.  You’ll enjoy your life much more.

This is why innovating how we deliver care is so important:  we need to innovate our way out of this mess that makes us use patients as a weapon against each other and others.  Maybe our lives could be better if we did.  When the system is so dysfunctional that we turn to things like that, well, Steve Jobs said (on returning to Apple) that it wasn’t about cutting costs and it was about finding a way out by innovating the future.  That’s where we are now and issues like these show we need to make changes.  It’s not easy, but if we want things to improve it’s time for us to show up and rebuild a legitimate system.

Feel free to say hi on Twitter (@genYsurgeon) and we can talk about some of the times you’ve seen this weapon deployed. 

* The attending surgeon / administrator level maneuver is to use a patient’s case to attack a colleague or another physician.  How many times have you seen a minor issue, a non-issue, or a manufactured issue be used to try and push a surgeon out of their job?  These always make me sad and really just aren’t ok.  It sure would be nice to have clear job descriptions that we honor instead of the patient-as-a-weapon maneuver used to let someone go!


Coming Soon: Don’t Use The Patient As A Weapon


This week on the blog, the GenYSurgeon continues with Part 2 of a 3 part series on common issues in surgical culture.  Here, the millenial GenY cautions us against avoiding crucial conversations by, instead, using the patient as a weapon.

Also this week, we’ll explore some not-so-innovative business models you can use for your startup experiment, and contrast these against models you can develop with a business model canvas.

Visit us throughout the week to check for these and other useful entries.

Remember, you can follow the Generation Y Surgeon with @GenYSurgeon on Twitter.  See you this week on the blog!