Translator: Jim Taylor Reviewer: Denise RQ
A while back, I was driving to work one day,
and my son Adam asked me a question,
"Mommy, what do you do for a living? What's your job?
I quickly answered, "Adam, I'm an ear, nose, and throat doctor.
I operate near people's brains."
I peeked into the rear-view mirror. He looked confused.
I quickly added, "I help patients to get more healthy."
He broke out into a big smile.
Later that day, I went to clinic, I started seeing patients
and I forgot about this conversation.
At the end of a busy day, when I was an hour behind,
I looked at the clock, it was 4:30,
and I waked in with my last patient, Charlie.
As soon as I walked in, I asked Charlie, "Hi sir, how are you doing?"
Charlie bristled.
"Do not call me sir.
You are the seventh doctor that I'm seeing.
I've had oodles of tests, multiple blood work,
nobody knows what's wrong with me,
and I tell you, there is something that's going on."
Puzzled, I examined Charlie
I looked inside his sinuses, and I tried to figure out what was happening
But nothing! I couldn't find anything.
So, I did what all of us sinus surgeons do when we don't know the answer:
I ordered a CAT scan.
Then I looked at Charlie and said,
"While I'm excited to figure out this journey with you
and figure out what's happening,
I have to go.
I'll call you tomorrow with the results of this CAT scan."
And off I went,
to the hospital to see patients and then back to pick up Adam.
When I got Adam, he asked, "Did you help patients today?"
I smiled and thought of Charlie.
"Yes, I did."
So the next day I went to clinic, and I immediately open Charlie's CAT scan
and try to look through the images to find out what was wrong.
Negative. Nothing on the results.
Nothing on the sinus scan.
Essentially, I was still curious. Puzzled, I scrolled the images myself.
I looked through the brain images and the neck images.
And suddenly, I noted with growing horror that Charlie had a mass
that was growing in his brain and eroding through the bone.
I called him in, and I let him and his wife see the scan.
His wife started slowly weeping. But Charlie looked relieved.
"Thank you, doc, for believing in me."
And long story short, Charlie went on to get treatment
and still is doing well today, cherishing his beautiful family.
But this is not a story about me as a doctor or Charlie as a patient.
This is a story about the 1,000 Charlies in the world
who are unable to get a health care diagnosis.
Why is that?
Why is it that we have so many talented physicians
dedicated to helping patients
who are unable to help the Charlies of the world?
We all have heard of medical errors.
Ninety-eight thousands people per year are dying from preventable errors.
But let me ask you guys a question.
How many of you have gone in to see the doctor,
and the doctor doesn't know what's wrong with you?
And how many of you have a family member
who you know has felt scared because they don't know the answer?
So I'm here to [tell] you today
that we can't solve the health care system
because maybe we haven't been asking the right questions.
Einstein once said, "We can't solve problems
by using the same level of thinking that created them."
I'm here to tell you today
that we need to adopt a systems thinking mindset
in order to approach our health care crisis.
And in order to do that, I pose three questions for you today.
Systems thinking is not a new philosophy,
it has reframed conversations in several industries,
but the reason it's important
is it helps us understand how things are related -
events, people, and places - even if they don't seem connected.
What it also does is it looks for leverage points,
small actions that have really big impact.
So I'm going to ask you three questions
that I think will help us to find some of that impact.
The first is how do we talk to our doctor as our friend.
The second is why is it that competition is so bad in health care?
And the third is why do we fear failure and what we can learn from it?
So let's go to the first question.
In order to answer the first question, I want you all to think about this number.
As a patient, when you walk in to see your doctor, there is a 15% chance
that they're either going to miss your diagnosis
or have the wrong diagnosis by the end of the visit.
That's going to increase your chance of getting sicker or dying
twice as likely.
So where do we go from here?
I think the systems thinking asks us
to structure the conversation completely differently,
to take a step back and really ask, "Why is this happening?"
Perhaps because when Charlie went to the doctor,
he stated his problem, then he received some tests,
got a medication that didn't help him, and was sent home.
And the pattern repeated itself.
We're trying to engineer a relationship
between the doctor and the patient
that is efficient but not meaningful.
Perhaps what we need to do is change the nature of the conversation
and ask physicians to [mean] that you are able to have the time
to step back and listen to Charlie's story.
In order to do that,
we have to ask ourselves the following question:
shouldn't seeing your doctor not be something that's rushed?
In fact, I believe that seeing your doctor
should be like getting together with a friend for a cup of coffee.
But I know some of you are still thinking about this 15%.
What if we don't know the answer as the doctor?
What if we can't find out what's wrong with you?
Where do we go from here?
This is where the health care system and its competitive nature
does not help us.
So from the moment we get into medical school,
it's a deep culture of competition.
We have to get the best grades to get into the specialties we want,
be the best surgeon with the fewer complications,
and work in the best hospitals.
And I found that despite my training as a surgeon, despite doing research,
despite teaching at Harvard Medical School,
all these enabled me to do
is to continue to focus on the body parts that I operated on
and not really have a holistic view.
The bigger problem with that
was that I was so focused on proving individual performance -
for which we as doctors are measured, rewarded,
and now publicly displayed -
that I didn't have the time to really collaborate with other doctors
when patients were trying to get a diagnosis.
So this brings us to the third question:
what if we don't know the answer?
What can we learn from failure?
I have to be able to, as a doctor, get permission from you, the patient
to be able to look you in the eyes
and tell Charlie, "I don't know what's wrong with you.
But I'm going to help you get that answer."
We as a doctors have a lot of anxiety when you come to see us.
When we don't know what's wrong with you, the stakes are high;
maybe life and death.
In that way, when patients come in
and expect that we are able to tell you what's wrong,
it really stresses us out to not be able to do that.
And so we reach, we reach for more tests
in order to quickly come up with a diagnosis.
But what we really need to be able to do
is go on this journey together, to partner with out patients in our quest.
Because for Charlie, a systems thinking approach says
that if he and I accept that there is a possibility of failure,
that I wasn't able to see this incidental finding on the scan,
and that all of the doctors that were looking for answers in him
were very good doctors,
but we were asking them specific questions about a specific body part.
What Charlie really needs
is a better patient experience through this journey.
And in order to do that, he needs to give me permission as a doctor
to say, "I don't know what's wrong with you,
But we can get there together."
So that brings us to the systems thinking approach
which is downright confusing when you look at it.
But if you think about it,
what we talked about here today is reframing the conversation,
making the doctor our friend,
thinking about failure and what we can learn from it,
and perhaps changing the paradigm
so that is OK with ourselves, our colleagues, and our patients
to not always know everything.
Perhaps Charlie's manifesto or call to action today
is really for you as patients to be able to demand to tell your story,
and for us as physicians to be able to go on this diagnostic journey with you,
and more importantly,
to be able to look you in the eye and tell you when we don't know.
Are we ready to accept this?
My journey to systems thinking started with Adam's innocent question.
But that very same day, I met Charlie, and my journey continued.
Getting to a diagnosis is not the 100-meter sprint that we've created.
It should be a relay race
like a well-orchestrated race with several runners
in order for us to win.
And more importantly,
I didn't come here today to tell you how to fix the health care system.
I'm simply here to ask you
if you even think that we are asking the right questions.
Thank you.
(Applause)