Day 1 of Road to Right Care #Lown2015 Recap

What a great day!

Hundreds of mainly American (I am one of 4 Canadians here) doctors, patients, nurses, health administrators, and other health providers gathered today for the first of three days on the Road to Right Care Conference, put on by the Lown Institute.

Being in a room with so many like-minded individuals is invigorating but also offers hope that together, we can actually do something radical.

Main Themes:

  1. Patients and their families and advocates must be at the centre of this movement; young health care providers are the future of this and must be engaged early in their training
  2. Health care is not about consuming, being sick; most of what we do in medicine has no impact on health; health care should be about being well, and about people not diseases:
    “A good physician treats the disease, the great physician treats the patient who has the disease.”  - DR. WILLIAM OSLER

  3. Social determinants of health, especially poverty must be addressed for greatest impact:
     "I can cure homelessness. You just house them and it's cured. Completely curable problem." - DR. MITCHELL KATZ

  4. Our system must be radically transformed; we have many ideas but they boil down to the fact that HIGER QUALITY CARE leads to LOWER COST

  5. Barriers to improvement: financial conflicts of interest, profit-based systems, not listening to what patients really want (eg. independence)

  6. Things that will help us achieve RightCare: team work, communication, destroying the imbalance of power, narratives

Knowing this is what was waiting for us outside, it could have been pretty hard to sit indoors all day... (Harbour of San Diego, view from the Convention Centre steps after my walk last night)

Knowing this is what was waiting for us outside, it could have been pretty hard to sit indoors all day... (Harbour of San Diego, view from the Convention Centre steps after my walk last night)

Luckily it was highly engaging and much hope was offered (Bright Spots in #RightCare, highlighting innovative successes)

Luckily it was highly engaging and much hope was offered (Bright Spots in #RightCare, highlighting innovative successes)

My actions as a result of today:

What was missing?

  1. Emphasis on relationships between patient and caregiver. The ONLY big mention about meaningful relationships was by a Reverend B. Stanfield during his reflection at the end; the data tell us that strong relationship = better care, and less costly care
  2. Focus on patient safety. Americans talk A LOT about cost! Cost is important, but were this conference anywhere else in the world, the main focus would be on reducing harms done to patients by too much or too little medicine.
  3. Acknowledgement of this as a world-wide cultural issue. There was a lot of discussion about insurance companies, ways of paying physicians, etc. as if these financial structure problems all explain the issue; some people seemed to believe that changing the way doctors are paid – abandoning fee-for service payments – would fix everything. But, there is no system of remuneration that incentivizes good care. "Wrong care" is a problem around the world, even in socially progressive and fully public health systems. 

I can't wait to see what is in store for us tomorrow!

Transforming the Canadian Healthcare System with Integrative Thinking

I had the incredible privilege of participating in the inaugural class of a partnership between the Canadian Medical Association (CMA), the Provincial and Territorial Medical Associations (PTMAs), and the Rotman School of Management (University of Toronto).

Forty physician leaders from across the country are spending a week together, learning about Integrative Thinking and its application to Transforming the Canadian Health Care System.

My experience:

- 1 week in a room with 40 flabbergastingly amazing physician leaders from across the country
- Values: we all want to achieve the same things for patients, have similar values, and all have different ways to do it; some have tried and failed, some have succeeded, others are not sure where to start
- Focus: on how to radically transform health care in Canada using Integrative Thinking
- Experts: Rotman School of Management geniuses, the earnest and persuasive Brian Golden & the engaging and hilarious Jennifer Riel, as well as conflict superstar Janice Stein (who I remember watching on TVO as a teenager). Also "Outside Voices" representing PTMA leadership/government, with a call to action from a peer leader.
- Background: the history of the technique of Integrated Thinking is nebulous, but in interviews, Roger Martin identified it as the common strategy used by many successful leaders use to work through impossible or "wicked" problems. It may be rooted in elements of Hegelian dialectic and is highlighted in F. Scott Fitzgerald's writing:

The test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function. One should, for example, be able to see things as hopeless and yet be determined to make them otherwise.
— F. Scott Fitzgerald

- Technique: cracking the unsolvable problem by changing the rules, addressing assumptions, and employing the tension between two opposing models to create a third, better answer. And there are many of these better answers, never just one.

The Rotman School of Management defines integrative thinking as:

"the ability to constructively face the tensions of opposing models, and instead of choosing one at the expense of the other, generating a creative resolution of the tension in the form of a new model that contains elements of the individual models, but is superior to each . . .

Integrative thinkers build models rather than choose between them . . .  they creatively resolve tensions without making costly trade-offs, turning challenges into opportunities."

- Variations:

  1. weaving best elements of conflicting solutions together to make a better hybrid (HIDDEN GEM)
  2.  stretching or bending one model in a way that it can produce the best aspects of the opposing model (DOUBLE DOWN)
  3. re-framing the problem, taking smaller elements of it or changing the underlying problem (DECOMPOSITION)

- Examples: Double down integration

Wal-Mart Stores Inc. is an example, when the company thought it had to choose between protecting the environment or protecting the bottom line. Under attack from sustainability critics, the retailer doubled down, using its strong influence on its supply chain to push suppliers into greater sustainability without raising its overall costs.

Read more in this handy summary, "Melding two thoughts to find the best approach," in the Globe and Mail; the original article is "Integrative Thinking in Three Ways." I could not find a free version but if you have a subscription you can read it in the Harvard Business Review.


- Our Example: Our group had to design an acute care system that could get the best of patient empowerment and physician accountability. We designed an emergency room flow that had various points at which self-directed patients could enter or exit the system, with an advocate or medical expert able to guide them at each step along the way.

We could have easily suggested Shared Decision Making where providers and patients work together to make decisions at every step (Variation 1), a totally patient-responsible system that somehow managed to uphold and employ physician guidance & expertise (Variation 2), or suggested that patient-directed care would be in some settings and paternalistic (provider-dictated) care would apply in others (eg. in an emergency, where the patient cannot be consulted) (Variation 3, kind of).
Frankly our rough solution seemed to involve elements of each approach. As a group member said, "we gave the patient a paddle instead of sending them down the creek (of acute care) without one."

Other considerations in the process:
- reconsider 'opponents' in negotiation as partners in creative problem solving; you probably share common goals (eg. both government and physicians want good quality healthcare for patients); working with those in mind will help create a win for everyone
- slow down, take a step back, and think about the needs you are addressing and challenge all assumptions before jumping to a solution
- know the people that you are representing and frequently share with them and seek their input
- create an institutional culture where conflicting ideas are embraced and used to make the projects and product better; encourage this with techniques like a rotating Devil's Advocate, focusing on common goals and values, and not forgetting about the psychology of political intelligence (which we learned through watching 12 Angry Men)

How does this relate to Less is More?

I assure you, it relates entirely! Furthermore, learning about Integrative thinking has allowed me to take a step back and look at the underlying needs, tensions, and to work through to some solutions. Plus, I need to round up some opposing viewpoints, because people who challenge the idea are my new best friends (for creating change)!

Stay tuned for the next post.