Sunday, November 7, 2010

5 Rules for Medical Students to "Tweak" the system

Many fellow medical students are eager to improve "the system." However, an overeager attitude offers both promise and peril— promise that budding physicians are inspired to improve the inner workings of their chosen field, peril in that our naiveté may simply clutter the very complexities we seek to improve.

How do we strike a balance between getting involved and getting in the way?

I found guidance in law professors Raustiala’s and Sprigman’s post on the New York Times Freakonomics blog: "Tweakers and Pioneers in the World of Innovation":

Some innovators create radically new ideas.  These people — the Thomas Edisons of the world — are the kind that we most commonly associate with innovation.  Let’s call them “Pioneers.”

But the Pioneers aren’t alone.  There are many innovators who improve ideas by refining what others have done.  We call these “Tweakers.”  Tweakers don’t get as much attention as Pioneers.

Pioneers provide big insights….  But Tweakers diversify and improve upon what the Pioneers create — often with great success.  And, importantly, by pushing foundational … innovations to their limits, Tweakers open up the next round of basic innovations.  So both Pioneers and Tweakers are essential to sustained innovative change.

Perhaps this balance can be achieved with a focus on tweaking rather than pioneering. The sheer magnitude of pioneering changes in medicine require vast stores of knowledge and experience, as well as trust and authority to test and ultimately implement these changes. But, ensconced in the workflow of clinical life, yet removed from the obligations of time and patient care, the medical student is perhaps uniquely suited as a Tweaker, “essential to sustained innovative change.”

How? I'm compelled to adapt Dr. Atul Gawande's Five Rules for medical practice from his 2005 Harvard Med commencement address:

Rule #1 Ask an unscripted question.
  Be openly curious about barriers to better care. Ask your seniors about tools they appreciate and implementations they don't.

Rule #2 Don't whine.
  Be careful to characterize your efforts as contributing rather than complaining. Our role is to honor the Herculean efforts and tragic realities of our forebears; we should actively preempt misinterpretation.

Rule #3 Count Something.
  In Dr. Gawande's words: "... a doctor should be a scientist in his or her world. In the simplest terms, this means that we should count something." Pillars in the field can sway with opinion; medical students need data.

Rule #4 Write Something.
  If you want someone else’s consideration of your tweak, you owe it to them to clarify and distribute your ideas.

Rule #5 Change.
 Best to let Dr. Gawande have the last word here:

There will come a time when … it seems safest to do what everyone else is doing—to be just another white- coated cog in the machine.
Don’t let yourself be. Find something new to try, something to change. Count how often it succeeds and how often it doesn’t. Write about it. Ask a patient or a colleague what they think about it. See if you can keep the conversation going.


Chris said...

Nice post -- I have a frame with those 5 rules hanging on the wall next to my desk as a reminder. Working on consistently accomplishing #3, glad to see you're on #4-5.

I think the notion of tweaking is key -- it's actionable, without being too esoteric and/or overwhelming. I think using data/outcomes can be a jumping off point to begin to find places to tweak, the key being experimenting with what works at your given practice location (FP, outpatient specialty clinic, etc) rather than just theorizing. Unfortunately, collecting data requires work/time/money, but hopefully the ease of doing so will be improved with EMR and some of the PHRs that you've shown.

Control charts are an intriguing way that this can be accomplished by detecting special cause (new variable present in the system) and/or common cause variation (general variation), and then using the data as feedback to see if changes are beneficial (does common cause variation improve resulting in some special cause variation). This could be used by diabetic patients in following glucose levels, small practices for amount of time spent with patients/other "harder" outcomes, etc etc. I haven't used any of this out in rotations, but I learned a lot about it and used some of it doing my MPH. Dartmouth medical school/ Dartmouth-Hitchcock Medical Center implements a lot of this. Don Berwick (formerly of institute of healthcare improvement (IHI), now CMS Director) used a lot of these principles in conjunction with Paul Batalden (DMS/DHMC) for his work at IHI.

astupple said...

So, if you happened to be sold on Family Medicine, and you were me, how strongly would you look at the Dartmouth program?

Can I get my hands on one of your control charts?

Have you seen fitbit?

Thanks for the comments!