IT systems in large enterprises often cause as much anguish among the users whose lives these very systems were created to simplify in the first place. In this piece from the New Yorker, Atul Gawande a surgeon and better known as a best-selling author applies this situation particularly to the world of doctors where the advent of healthcare systems haven’t really helped them be significantly more effective nor productive enough to have a better work-life balance but instead diverted much of their working hours away from facing patients to facing computer screens logging information. He points out that at the same time, there is no denying the fact that systems can help doctors improve the diagnosis by for example providing better access to case histories, etc. Dr Gawande concludes by saying much like everywhere else, it is a matter of a fine balance between systems and human interaction that makes service delivery most effective. As we build out our systems to make Marcellus a scalable organisation, this comes as a timely reminder.
“A 2016 study found that physicians spent about two hours doing computer work for every hour spent face to face with a patient—whatever the brand
of medical software. In the examination room, physicians devoted half of their patient time facing the screen to do electronic tasks. And these tasks were spilling over after hours. The University of Wisconsin found that the average workday for its family physicians had grown to eleven and a half hours. The result has been epidemic levels of burnout among clinicians. Forty per cent screen positive for depression, and seven per cent report suicidal thinking—almost double the rate of the general working population.
Something’s gone terribly wrong. Doctors are among the most technology-avid people in society; computerization has simpli?ed tasks in many industries. Yet somehow we’ve reached a point where people in the medical profession actively, viscerally, volubly hate their computers.
…Before, Sadoughi almost never had to bring tasks home to ?nish. Now she routinely spends an hour or more on the computer after her children have gone to bed. She gave me an example. Each patient has a “problem list” with his or her active medical issues, such as difficult-to-control diabetes, early signs of dementia, a chronic heart-valve problem. The list is intended to tell clinicians at a glance what they have to consider when seeing a patient. Sadoughi used to keep the list carefully updated—deleting problems that were no longer relevant, adding details about ones that were. But now everyone across the organization can modify the list, and, she said, “it has become utterly useless.” Three people will list the same diagnosis three different ways. Or an orthopedist will list the same generic symptom for every patient (“pain in leg”), which is sufficient for billing purposes but not useful to colleagues who need to know the speci?c diagnosis (e.g., “osteoarthritis in the right knee”). Or someone will add “anemia” to the problem list but not have the expertise to record the relevant details; Sadoughi needs to know that it’s “anemia due to iron de?ciency, last colonoscopy 2017.” The problem lists have become a hoarder’s stash.
“They’re long, they’re de?cient, they’re redundant,” she said. “Now I come to look at a patient, I pull up the problem list, and it means nothing. I have to go read through their past notes, especially if I’m doing urgent care,” where she’s usually meeting someone for the ?rst time. And piecing together what’s important about the patient’s history is at times actually harder than when she had to leaf through a sheaf of paper records. Doctors’ handwritten notes were brief and to the point. With computers, however, the shortcut is to paste in whole blocks of information—an entire two-page imaging report, say—rather than selecting the relevant details. The next doctor must hunt through several pages to ?nd what really matters. Multiply that by twenty-some patients a day, and you can see Sadoughi’s problem.
…The I.B.M. software engineer Frederick Brooks, in his classic 1975 book, “The Mythical Man-Month,” called this ?nal state the Tar Pit. There is, he said, a predictable progression from a cool program (built, say, by a few nerds for a few of their nerd friends) to a bigger, less cool program product (to deliver the same function to more people, with different computer systems and different levels of ability) to an even bigger, very uncool program system (for even more people, with many different needs in many kinds of work).
As a program adapts and serves more people and more functions, it naturally requires tighter regulation. Software systems govern how we interact as groups, and that makes them unavoidably bureaucratic in nature. There will always be those who want to maintain the system and those who want to push the system’s boundaries. Conservatives and liberals emerge.
The Tar Pit has trapped a great many of us: clinicians, scientists, police, salespeople —all of us hunched over our screens, spending more time dealing with constraints on how we do our jobs and less time simply doing them. And the only choice we seem to have is to adapt to this reality or become crushed by it.
….Medicine is a complex adaptive system: it is made up of many interconnected, multilayered parts, and it is meant to evolve with time and changing conditions. Software is not. It is complex, but it does not adapt. That is the heart of the problem for its users, us humans. Adaptation requires two things: mutation and selection. Mutation produces variety and deviation; selection kills off the least functional mutations. Our old, craft-based, pre-computer system of professional practice—in medicine and in other fields—was all mutation and no selection. There was plenty of room for individuals to do things differently from the norm; everyone could be an innovator. But there was no real mechanism for weeding out bad ideas or practices.
Computerization, by contrast, is all selection and no mutation. Leaders install a monolith, and the smallest changes require a committee decision, plus weeks of testing and debugging to make sure that fixing the daylight-saving-time problem, say, doesn’t wreck some other, distant part of the system.
Why can’t our work systems be like our smartphones—?exible, easy, customizable? The answer is that the two systems have different purposes. Consumer technology is all about letting me be me. Technology for complex enterprises is about helping groups do what the members cannot easily do by themselves—work in coördination. Our individual activities have to mesh with everyone else’s. What we want and don’t have, however, is a system that accommodates both mutation and selection.
Many fear that the advance of technology will replace us all with robots. Yet in ?elds like health care the more imminent prospect is that it will make us all behave like robots. And the people we serve need something more than either robots or robot-like people can provide. They need human enterprises that can adapt to change.”
Note: the above material is neither investment research, nor financial advice. Marcellus does not seek payment for or business from this email in any shape or form. Marcellus Investment Managers is regulated by the Securities and Exchange Board of India as a provider of Portfolio Management Services and as an Investment Advisor.
Copyright © 2018 Marcellus Investment Managers Pvt Ltd, All rights reserved.
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Note: the above material is neither investment research, nor financial advice. Marcellus does not seek payment for or business from this publication in any shape or form. Marcellus Investment Managers is regulated by the Securities and Exchange Board of India as a provider of Portfolio Management Services. Marcellus Investment Managers is also regulated in the United States as an Investment Advisor.
Copyright © 2022 Marcellus Investment Managers Pvt Ltd, All rights reserved.
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