In Innovation Projects, Mayo Physicians See Their Roles Anew

A series of remarkable, documentary-style video interviews, present five Mayo physicians describing the very individual but very similar personal journeys of physicians deeply trained in the science of medicine, who now are striving to master medicine as an art.

Created by the Yale School of Management as part of an online, multimedia case study of the Mayo Clinic Center for Innovation (CFI), the nation’s largest health care innovation center, the videos describes how the three-year-old center was launched, how it operates, and how its goals mesh with Mayo Clinic’s historical mission to innovate in medicine.

Mayo’s CEO, Dr. John Noseworthy, is interviewed on video, as are Dr. Nicholas LaRusso and Dr. Michael Brennan, two Mayo physicians who co-founded the Center for Innovation. Two prominent innovation consultants, Tim Brown of IDEO and Larry Keeley of Doblin, who have both advised Mayo on how to apply innovation disciplines to health care delivery, are also interviewed.

The multimedia case study also includes video interviews with CFI designers Lorna Ross and Maggie Breslin; project manager Dan O’Neil; Mayo historian Matthew Dacy; outpatient lab manager Naomi Woychick; Mayo internist Dr. John Paat; administrative director Barb Spurrier; Mayo hospitalist Dr. David Rosenman; Mayo gastroenterologist Gianrico Farrugia; Mayo dermatology nurse Donna Beyer; and Mayo patient Kathie Philo; and others.

In-Depth Views

At the core of the Yale case study is a series of video interviews with five physicians who each participated deeply in different Center for Innovation projects, since its founding in 2008. While the projects sometimes led to significant changes in the physicians’ practices, the interviews are in many ways most notable for the personal reflections of physicians who were challenged to rethink their relationships to patients, families and their own colleagues – even to rethink their definitions of health and healing.

Dr. Victor Montori, an endocrinologist specializing in diabetes treatment, describes a personal turning point during which he shifted perspective away from the data collected about a particular patient’s disease, towards empathetically understanding the patient’s life, of which the disease, diabetes, was just one part.

“Say you are a patient who has been struggling with a condition for a few years,” Dr. Montori said. “When you come in to the visit, the doctor doesn’t ask how your efforts have been going. He does not acknowledge that you have been partially successful in a few of these. Instead he only holds you accountable to the results of your blood test, and then tells you that your sugar control has not been good.

Education Cards

“Immediately, you feel labeled as a bad patient,” Dr. Montori says. “You feel you are at the principal’s office and are being scolded! Now, what if we were to rethink that visit and think about the patient as a complex individual, living in a complex setting, and we try to provide support and expert advice along the way?

“My personal journey was from being an evidence-based medicine person, trying to get science to inform practice, to becoming a person interested in how health care service can be sensitive to the needs of the patient.”

Armed with this new perspective, Dr. Montori developed a series of diabetes education cards. The cards, showing the risks and benefits of taking the medicine over a period of time, structure a patient-physician conversation in which – surprise! – the physician acknowledges uncertainty about whether a particular patient will enjoy the benefits, or suffer the risks, of taking a medication.

Rather than undermining trust, Dr. Montori said, the physician acknowledging uncertainty actually reinforced the patient-physician relationship.

Dr. Dana Thompson, a pediatric ear, nose and throat surgeon, asked the Center for Innovation to help her department address a complex of issues concerning overwork, work flow, and lingering personnel issues.

Minnesota Nice

“With the changes in health care, new regulations, documentation and insurance and all these things, the burden to deliver care in a high-rate fashion just exponentially stressed our group,” Dr. Thompson said. “That’s how we started to partner with the Center for Innovation, to look at new ways of how might we redistribute the work load? How might we meet the needs of our patients and yet improve our job satisfaction, and not stress our entire team out?”

The project was carried out through a series of intensive, candid discussions, guided by CFI staff embedded in Dr. Thompson’s unit, in which all employees were allowed to fully voice their concerns, no matter how sensitive they were, and not matter how long it took to air them. It took a while to get going.

“We have a culture here of Minnesota Nice,” Dr. Thompson said. At first “it was really difficult to get people to speak out. People were good at saying, ‘This is what I like about the practice.’ We had to break that ice, that culture, to get people to talk about what the touch points were. Once we started working through that, people really opened up and got excited about the process. We said ‘We’re going to make this work better, move the process forward.’ That’s been really good.” The upshot has been increased numbers of patients seen, as well as increased satisfaction about the work roles of the unit’s staff, Dr. Thompson said. A distinctive feature of the Center for Innovation’s method is the application of “design thinking” – a creativity discipline widely used in the manufacturing and retail service industries – to drive innovation in health care delivery. At the CFI, designers trained at the nation’s top design schools and consultancies partner with health care providers on projects, guiding the process of practice or product redesign through observation, brainstorming and prototyping phases.

Creative Terms

For Dr. Clark Otley, a dermatologist, and Dr. Terri Vrtiska, the radiologist, working with the CFI’s artistically-minded designers offered not only a refreshing, but a critically useful change in perspective from medicine’s scientific mindset.

“Designers talk in very creative terms,” Dr. Otley said. “They are not so bound by tradition. The Mayo Clinic has so many amazing elements to it that I deeply respect, but there’s a time and a place to challenge everything. And they were challenging to us. They challenged each of us to step out of our preconceptions of how things had to be. They were awesome at breaking old concepts, facilitating open discussion, bringing new ideas and a can-do attitude to the process.”

The dermatology innovation project focused on helping a community-based Mayo dermatology practice boost its daily patient load to more than 50 patients a day, while hopefully also increasing job satisfaction among the providers.

Partnering with the CFI’s designers and project managers, the dermatology staff brainstormed their practice from top to bottom. In many cases, they saw opportunities for staff who previously had little interaction with patients, to take on tasks that previously only physicians had done. Work roles were redefined and, after some experimentation, the practice was seeing 65 patients a day.

Magical Moments

Importantly, “job satisfaction increased,” Dr. Otley said. “Initially, it was viewed as a threat and more work. But suddenly it became, ‘This is kind of cool, I get to interact more with patients, I feel like I’m part of a team and I’m an important part of this medical institution.”

Dr. Terri Vrtiska, a Mayo radiologist who heads a CFI project to fund new medical innovations by Mayo Clinic employees, said working with the CFI’s designers introduced new perspectives that reinvigorated her medical practice.

“As a physician, you are used to being in control,” Dr. Vrtiska said. “I didn’t have the designer’s skill set, so you had to let this opportunity grow behind your own limited knowledge base. But that became the most exciting part of it.

“Every time I came up and worked with our designers, I felt refreshed and rejuvenated. It was like being cold and coming to a fire. So I would come and get my flame built and then I could go back into my regular work day.”

Dr. Montori also described a certain kind of letting go of control as a way, paradoxically, to more artfully handle the human equation in medicine.

“We have to make sure all the education we get doesn’t get in the way of being human,” he said. “At the end of the day it’s that magic that happens, that dance that happens between the patient and clinicians. The job of the innovation program is to create as many of those magical moments as we can.”

By Doug McGill

The Medical Icons of Vernon Smith, M.D.

A sample of computer icons created by Vernon Smith, M.D., Mayo Clinic. These icons are used in the “YES Board”, a communication device created with assistance and funding from the Mayo Clinic Center for Innovation.

A hospital emergency room is just about the last place one would expect to find a very particular, highly sophisticated, ancient form of art hanging on the walls – much less hanging every 15 feet or so, much less being watched constantly by everyone.

But look closer: affixed just a few inches above eye-level throughout the St. Marys emergency rooms are 21-inch, black-framed computer screens. Each screen is filled with parallel rows of rectangular boxes glowing red, green, yellow, white and blue.

The screens are an electronic patient tracking system created by Dr. Vernon Smith, a St. Marys emergency physician with a passion for combining computers and medicine. 

Designed with financial help from the CoDE awards program of Mayo Clinic’s Center for Innovation, the “YES Patient Locator Boards” offer a real-time, at-a-glance overview of emergency department patients including what rooms they are in, their vital signs, whether they are trending towards dangerous status, and a great deal more.

Now look closer still: each of the several dozen brightly-colored rectangles on a YES screen represents a patient’s room, and each box contains a vertical row of tiny works of art, each one only about ¼ inch high. These tiny images connect the walls of St. Marys to prehistoric cave walls displaying hand-drawn artistic images of human hands, fish, spears and bison, and the great halls, too, of the Louvre, the Prado and the Metropolitan museums — all great catalogs of images of human and natural life.

So what are these miniature objets d’art?

Computer icons — modern, digital kin to all works of art that throughout history have merged aesthetics with information, sensory delight with practical guidance, artistic form with actionable function.

Computer icons are more inspired, certainly, by comic books than by Caravaggio, but nevertheless constitute a deep and indelible part of 21^st century visual culture.

On today’s ubiquitous computer screens – such as the one you are doubtless reading this article on — we are talking about icons of tumbling hour glasses, ticking clocks, speech bubbles, calendar pages, camera lenses, butterflies, clipboards, compasses, diskettes, notepads, checklists, paperclips, bowties, wine glasses, umbrellas, globes spinning around and crumpled wads of paper flying into the trash.

On the wall-mounted computer canvases at St. Marys, Dr. Smith paints his world using icons such as valentine-style hearts, sets of lungs, C-clamps, ZZZZ’s, “Closed for Cleaning” sandwich boards, discussion bubbles, spinning biohazard symbols, mortars and pestles, nurses’ caps, pulsing airborne droplets and flashing geometric shapes. 

“My goal is to make the symbols obvious to the untrained eye,” Dr. Smith says. “I want the information imparted by the icons to change what you were going to do. I try to limit the use of words as it requires a separate subprocessor from your mind to make the interpretation, whereas a picture requires only recognition.”

Initially designed for the Emergency Department, the YES patient tracking system is now used as well in St. Marys units. Dr. David Klocke, a Mayo hospital medicine specialist, is collaborating with Dr. Smith to install the system in many more. 

A half-dozen or fewer icons per patient gives practically all the at-a-glance information an emergency caregiver needs to know about that patient’s medical status.

An icon depicting a tiny set of lungs indicates a patient on a ventilator. A rotating biohazard symbol indicates a patient susceptible to whole-body inflammation, or “sepsis.” A heart placed inside a C-clamp indicates a patient being treated with a “pressor,” i.e. a drug to keep blood pressure from crashing. Meanwhile, a flashing heart indicates a patient with critically abnormal vital signs and thus in need of quick attention; and a series of ZZZZ’s floating skyward says that patient is on sedation.

To make his YES Board icons, Dr. Smith uses a combination of pen and paper, digital camera and graphic design software. Sometimes he borrows clip art form public domain collections on the web. Other times, starting with a photograph, he’ll use Photoshop to create a more stylized, simplified shape.

To indicate a hospital room that is closed for cleaning, the YES icon shows the bright yellow sandwich board placed in rooms that are getting swept and mopped. To make the icon, Dr. Smith took a photograph of an actual sandwich board, stylized it, typed in the “Closed for Cleaning” text and – as a final artistic flourish – drew a teeny-tiny mop.

His most complex creation is the icon that indicates “patient is on a ventilator” — a pair of tiny lungs with a set of tiny mechanical gears superimposed. He used two photos, one of lungs and one of gears, then used photoshop to stylize and superimpose them.

Like any artist, Dr. Smith struggles to find just the right image. Sometimes, a solution eludes him for months or longer. Showing in icon form which specific doctors, nurses and other staffers are on duty at any given moment is proving to be such a challenge.   

“I would like to show staffing as a picture, but I can’t find a way to do it,” Dr. Smith says. “I also want to show the waiting room as a meter, but the gauge would change too rapidly, so I have to resort to using a number. And I’m still looking for the right model for an icon to show how many ambulances are on their way to the ED.”

Whether the YES Boards offer “too much information,” overloading instead of simplifying life for its users, is something Dr. Smith keeps his eye on.

But he’s seen no evidence for it yet. “I get two or three requests a week to add more information,” he says, with no complaints of TMI so far. “Think about air traffic control displays, or stock market tickers, or the cockpit of a 747. We are nowhere near that yet.”

The biggest challenge created by the icon-based YES system is patient privacy, a sacrosanct value at Mayo Clinic. Some privacy protections are built in, such as restricting access to personal data on more publicly-accessible screens. But at some point it is recognized that most people would decide to trade off some degree of privacy, for example, to avert a permanently debilitating condition or to save a life.

“It’s a tough balancing act,” Dr. Smith says. “On the one hand, you want to make the data as easy as possible to get for those who need it. But on the other hand, make it impossible for those who don’t. The trick lies in determining who needs to know what.”

It seems a trick well worth mastering since, when it comes to Dr. Smith’s gallery of medical icons, art doesn’t only imitate life. It can also save it.

By Doug McGill

Devola Funk’s Health Care Reminder: “You feel healthier when you’re dressed.”

"Conversation" side of the Jack and Jill room

“Exam” side of the Jack-and-Jill room

A Mayo Clinic patient, Devola Funk, said something to me the other day that stopped me in my tracks and got me thinking.

“When I’m dressed I feel healthier than I do in a paper gown,” Ms. Funk said. I was absolutely stunned to hear how she had so firmly, confidently and clearly equated the state of being clothed with the state of being healthy.

The shock must have shown on my face because Ms. Funk paused a moment, smiled gently, and then rephrased her gem.

“How can I talk about my health while sitting in a paper gown?” she said and repeated: “When I get dressed, I feel healthier.”

She had just been seen by Dr. John Paat, an internist at Mayo’s Center for Innovation (CFI), in a new two-room consultation suite designed by the CFI  in collaboration with General Internal Medicine, called “Jack and Jill Rooms.” In the Jack and Jill Rooms, patients spend most of their time discussing their health while fully clothed, sitting with the doctor at a round table in an office designed to feel something like a living room.

There is no examination table present and only one medical instrument, a blood pressure monitor. The exam table is located in an adjoining room where the patients don their gowns, submit to the necessary pokes and prods, and then quickly redress to join the doctor at the round table, where they continue their conversation as equals.

The remarkable thing is that according to Ms. Funk, this arrangement, with the dressed and undressed portion of the visit happening in two separate rooms, not only felt more comfortable and dignified to her than the one-room version.

It actually made her feel healthier, because she feels healthier when she is dressed.

We’ve heard for years about how cool it will be, in our glorious technological future, to wear clothing that monitors our blood pressure and plays tinkling musical reminders to take our pills.

A tot’s pajamas with sewn-in sensors will alert us if baby is growing short of breath in the crib. Electrodes hidden in Grandpa’s socks will analyze his gait and warn if he’s at risk for a fall.

Now, believe me, I love the promise of telemedicine. I love the idea that smart clothing as a “telemedicine platform” will keep me in better touch with my doctor and others taking care of me.

But I love even more Ms. Funk’s reminder that simply by wearing comfortable clothing, I can feel healthier.

That kind of health plan doesn’t put me in closer touch with my doctor, necessarily. But it puts me a lot more in touch with myself.

Suddenly, I’m a one-man dispensary every morning, treating myself with socks, pants, shirts, shoes, a hat and a coat.

When you put on your clothes as if taking medicine, you can literally feel the warm rush of health as you put on each new soft, protective layer. There is no side effect but contentment.

And if I feel healthier, who’s to say I’m not?

Thanks to Ms. Funk, for the past several days I’ve gone around feeling incredibly healthy. Suddenly, it seems like a miracle that every morning I am able to put on layers of clothing that embrace me, warm me and protect me.

I have never before seen my clothing as medicine.

But now I’m seeing it that way all day, and I feel great.

My sense of gratitude that this miracle repeats itself every morning, and then lasts all day, has further enveloped me like a warm, protective cocoon surrounding my body and spirit.

It’s made me rethink my attitude towards health care innovation.

On the one hand, I know firsthand the benefits of technological innovation in the treatment of disease. It has extended and improved my own life, and the lives of many of my friends and family, countless times over the years. As it has for most of us.

At the same time, magical innovation happened in the Jack and Jill Rooms that wasn’t technological at all.

It was human. It applied ancient wisdom. It was simple.

It was Devola Funk’s Health Care Reminder: You feel healthier when you’re dressed.

Some doctors and designers listened, and some health and happiness occurred.

By Doug McGill

Fact Checking: Part 2

Okay. Here we go.

I started by searching “third leading cause of death in america.” One of the first websites that returned was The Healthy Skeptic. It references an article called “Is US Health Really the Best in the World?” authored by Barbara Starfield MD MPH and published in the July 23, 2000 issue of JAMA. Turns out that most of the references to healthcare being the third leading cause of death in the US trace back to this article.

In the article Starfield highlights the following numbers (bulleted below) which are estimates of “the combined effects of errors and adverse effects that occur because of iatrogenic* damage not associated with recognizable error.” My interpretation of that sentence is that these numbers detail both deaths which have been specifically attributed to and documented as errors (doing the wrong thing) and deaths in which an outcome perceived as avoidable resulted from a medical intervention.

• 12000 deaths/year from unnecessary surgery

• 7000 deaths/year from medication errors in hospitals

• 20000 deaths/year from other errors in hospitals

• 80000 deaths/year from nosocomial infections in hospitals

• 106000 deaths/year from nonerror, adverse effects of medications

So the most interesting part there is the deaths perceived as avoidable. One assumes that an error has clearly defined criteria (although we might be surprised) but how does “could have been avoided” get defined and how is data collected? One of the great things about medical journal articles is that they reference each other. So one of the first things we’re going to do is see what we can understand about where these numbers come from.

The statistic of 12,000 unnecessary deaths per year comes from an article titled “Unnecessary Surgery” written by Lucien L Leape and published in the Annual Review Public Health in 1992, issue 13. In the first part of the article he defines an unnecessary surgery.  I’m going to include the full paragraph because it mentions a specific example and I think the example is helpful to understanding how usefulness in this context is often tied to research evidence.

In contrast, Webster’s definition of unnecessary, “useless,” is easy to use, as it can be based entirely on objective data. No operation is necessary if it is ineffective, i.e. if it does not accomplish its objective for a given clinical situation.(1) For example, if the objectives of coronary artery bypass graft (CABG) surgery are to relieve pain and prolong life, CABG is ineffective­ and, therefore, unnecessary-for an asymptomatic patient with coronary artery disease that causes blockage of only one of the three coronary arteries, because studies have shown that CABG does not increase longevity in patients with single vessel disease. An unnecessary operation, then, is one that is ineffective or useless. An operation is also unnecessary if it confers no clear advantage over a less risky alternative. In both instances, the operation does not represent a net benefit to the patient. The patient will not be better off. This is the definition we will use.

(1) Rarely is an operation totally ineffective. Internal mammary ligation for the treatment of angina pectoris and glomectomy for asthma are examples. These operations were ultimately discredited by randomized trials. More commonly, an operation is effective for its initial use, but as experience is gained, the indications are broadened to conditions for which it is useless.

Leape goes on to say that unnecessary is also defined at a moment in time. A surgery that right now is thought to be necessary because there are no other options or because enough data hasn’t been collected might come to be seen as unnecessary in the future. Of course we can’t classify interventions by future information that can’t be known, but it is an important nod to the dynamic nature of medical knowledge.

Having defined unnecessary surgery, Leape turns his attention to the question of data collection which gets to the issue of assumption. When someone dies, we have no established system for pausing to reflecting on all the moments that lead up to this one and collectively deciding if there was a moment when a different decision might have lead to a different outcome. There isn’t time for that. If the moment was a true error – the wrong medication or the wrong amount of medication or the wrong surgery – it will likely get noticed and recorded. But all the other decision moments, the choice to recommend a surgery instead of another less invasive intervention or the use of one medication over another that caused an adverse effect that wasn’t predicted, those often pass with little reflection and are not recorded in a consistent manner across the country. So researchers do their best by looking at all the data we do have and speculating about relationships between that data to build an argument, in this case, about unnecessary surgeries.

For the next post, I’ll go into the evidence Leape presents to build a case for capturing data about unnecessary surgery. Stay tuned…

*Iatrogenic means “of or relating to illness caused by medical examination or treatment.”

Fact Checking

The most retweeted statistic from Transform 2010 (watch the videos!) was this one. “Receiving healthcare is the third leading cause of death in America.” The statistic was part of a presentation by Jill Morin and Jim Rasche from Kahler Slater Experience Design. I was a little skeptical that this could be true, or at least I questioned how receiving healthcare was defined, so I thought I’d take a cue from Esther Dyson, another speaker at the conference, and do some fact checking. It turned out to be a pretty fascinating trip down the research rabbit hole. So I thought we’d do a fun experiment. You are invited to come down the rabbit hole with me.

Over the next few days, I’m going to walk through the article most commonly associated with this claim and show some of the trail of research that led to the summary statement “receiving healthcare is the third leading cause of death in the US.” It is a powerful, educational lesson about data, definitions and narrative in medical research. What ended up as a startling, pithy, shareable critique actually began as many thoughtful attempts to shed some light on a disturbing and little understood reality of our healthcare system. It seems to me that some important concepts were lost in that evolution.

Join me here tomorrow and we’ll work together to figure out what we are really saying when we say receiving healthcare is the third leading cause of death in the US. And maybe if we are lucky, it will inspire us to do something about it.

 

“… for the rest of your life or cured.”

A Buddhist Model for Health Care Reform
By Mettanando Bhikkhu BSc, MD, BA, MA (Oxford), ThM, PhD
http://www.mat.or.th/journal/index.php?command=preview&selvol=90&selno=10&selids=1861

This was another article given to me from my physician consultant while working on a project around remote asthma care management. Again, what a refreshing read about education, health and spirituality. This triad represents quality of life in accordance to the Buddhists and has been the base for reshaping heath care in Thailand.

The responsibility of a community’s spiritual and physical welling is reflected in this story from the Book of Monastic Discipline of the Theravada. The background to this excerpt is Lord Buddha’s response to caring for a sick monk who has “not been good to any of his brethren.”

“Monks, you have no mother or father to take
care of you. If you do not take care of each other, who
will take care of you? Monks, who want to care for me,
should care for the ill(10). If you are ill and you have a
preceptor, your preceptor should take care of you for
the rest of your life or cured. If not a mentor should
take care of his students for the rest of your life or
cured. If not a fellow student should take care of his
masters for the rest of their lives or cured. If not an
inner student should take care of you for the rest of
your life or cured. If not, students of the same preceptor
should care of you for rest of your life or cured. If
not, students of the same mentor should take care of
you for rest of your life or cured. Without any preceptor,
mentor, fellow student, inner student, apprentice of
the same preceptor or mentor, the Community should
take care of you, otherwise, this will befall every member
of the Sangha for their misconduct. (Vin. I, 302) (11).

In the section about “Emerging Essential Elements For Communitarian Health Care System,” the author sites efforts in made in Thailand that activate community involvement, particularly in volunteer medical and nursing students.

This reminds me of one of my favorite talks from our Transform conference last month from Rebecca Onie and Sonia Sarkar. They presented on their work with Project Health. What a smart and simple solution in caring patients with basic resources.
http://centerforinnovation.mayo.edu/transform/

A Little Bit of Theory and Love

[This is a bit ironic that I’m writing about the love just after Fran’s post about the ROI of Love. Something’s in the air, I suppose.]

I’m currently wrapping up the design research on a project around remote asthma care management and one of my physician consultants sent me this article. What a refreshing read. Brings me back to the heart of my (art leaning) practice.

Yawar writes about how science has in some ways lost sight of the individual. He opens ups the article with asking, “Is medicine better served by science or by art?” However, then posits that art, too, has lost sight of the human experience. With references to the scientific mind of Francis Bacon and artists like Marcel Duchamp, Yawar suggests we rethink our practices to allow for a willingness to connect, share and learn from the narratives of our lives.

But the central problem remain unresolved, “How do we develop medicine that encompasses and attends to the human story?”

The Art of Medicine: Medicine and the Human Story
By Athar Yawar

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60218-8/fulltext

What is the ROI on love”

Susannah Fox has crafted a wonderful post on the thread of “Love”, that ran through Transform2010. A beautiful image, and I see it now, thanks to her words. Enjoy, and ponder the return on YOUR investments as you read What is the ROI on Love.

The Artist, the Scientist and the Doctor in Each of Us

Oddly enough, amidst many flashier session topics advertised at the recent symposium, “Transform 2010: Thinking Differently About Health Care,” it was a modest three-word heading that most firmly caught my eye.

“Making Good Decisions,” the title read.

It sounded pretty ordinary at first. But come to think of it, what could be a more accurate description of the single most essential skill we need to guide ourselves safely across the bleak borderland dividing sickness from health?

What is every healing encounter in essence but a delicate dance of moral decision-making between the patient and all those who gather around to help?

To paraphrase the punch-line of the myth about the universe being made of turtles standing upon turtles, one could as well say that the practice of health care is morally complex and difficult decision-making, all the way down.

Having said that – and this is no knock on the most adventurous, open-minded and joyously humanistic health care confab in the world — where was the moral philosopher in Transform 2010’s speaker lineup?

More specifically, where was the speaker to represent the new breed of scientists who in recent years have revolutionized the study of moral decision-making? These neuroscientists, social psychologists and evolutionary biologists have discovered nothing less than an entirely new perspective on who we really are as human beings – what really motivates us and why we act in the zigzagged, maddening, miraculous ways we do. They are rapidly spinning off new metaphors that may one day transform humanity as thoroughly as the heliocentric solar system or Einstein’s E=MC2.

These researchers – such as Antonio Damasio, Michael Gazzaniga, Jonathan Haidt and Elizabeth Phelps – have created what was mostly dismissed as wishful thinking barely a decade ago: a new science of morality.

Their scientific findings are generating enormous excitement not only in the academic ivory tower, but also about possible practical applications in politics, ethics and the law.

As yet, to my knowledge, no thinker or writer in health care has begun to systematically absorb, explore and apply the new science of morality to medical healing. For my money, though, the unique history and mindset of Mayo Clinic – perhaps through its pioneering Center for Innovation – suits it perfectly to the task. I hope they take it up.

So what new view of humanity do the new moral scientists give us?

Here’s one way to summarize their findings: most of the time, human beings are unconscious. A far larger proportion of all of the decisions that we make in our lives – about 99%, the scientists say – are made by our unconscious minds and are based on automatic conditioning, than are made as the result of conscious thinking and principled will. We do have a precious chance to use analysis, reason and willpower to guide our actions, but it’s a tiny, fleeting one –1 percent or less of all decisions made.

Here’s another summary: at peak levels of skillfulness we navigate our lives more like artists than scientists. Especially when facing our biggest decisions we draw mainly upon the intuitive wisdom we have gained through our arduous human wanderings, and our hardwired moral conditioning, to guide our next steps.

Consider these stories of how unconscious decision-making shapes our lives, in much the same way that deep ocean currents create the surface weather in which we live: 

• People named “Dennis” are more likely to become dentists, and people named “ Lawrence ” are more likely to become lawyers.
• Exposure to words related to the elderly make people walk more slowly; words related to rudeness make them act rudely; words related to politeness make them act politely.
• Children who can resist the urge to eat a marshmallow that is placed in front of them, because later they will be given two marshmallows, later get into better colleges than children who are unable to resist the urge to eat a single marshmallow and thus delay gratification.
•  Ancient brain organs that regulate the emotions, especially the amygdala and the posterior cingulate cortex, make snap judgments about people within seconds of meeting them, and those judgments that rarely change thereafter.

The journalist David Brooks has offered a compelling description of how the new science of morality may influence public policy. In it we may read a suggestion of its potentially transformative impact on health care and health care policy as well:

“We try to do the things we do in the policy world. We try to increase high school graduation rates. We try to develop human capital. We try to close the achievement gap. But these policies often produce disappointing results. To me it’s because they are based on a shallow view of human nature and what levers you really need to pull to make some change. My hope is that the new cognitive revolution will give us a new humanism, a new view of who we are.”

In practical terms, who or what could bring the new science of morality fully into the health care world?

My ideal candidate is design thinking, a creativity discipline that helps many manufacturing and service companies stay fresh, innovative, collaborative and constantly open to changing conditions in the world. 

Several health-focused innovation centers, such as Mayo Clinic’s Center for Innovation, are embedded inside host institutions. The designers who staff these centers have access to the inside workings of their host’s clinics and hospitals. Like anthropologists or journalists – sometimes they are actual anthropologists who have changed careers – the designers sit in on physician-patient consultations and visit surgical theaters, admitting offices and patient waiting rooms for weeks at a time, carefully noting the interactions they see. Through these sessions they build the archive of experience from which, later, using their artistic intuition, they create their new designs.

What is immensely hopeful is that the new science of morality offers a foundational, empirical, legitimizing rationale for health care designers to ply their trade.

Instead of being seen merely as artists whose skills are primarily aesthetic, or even simply decorative, the new science of morality connects design principles directly to the life and death matter of human healing.  The affinity of aesthetics and morality, once celebrated mainly by poets, artists and philosophers, is now a proven scientific fact.

Viewed through the lens of this new perspective on human nature, designers should and must be regarded as full and active collaborators in the health care process.

These two potential collaborators – designers and the new science of morality — are already very close to each other in temperament and view.

 Listen to Lorna Ross, the creative lead and manager of Mayo Clinic’s Center for Innovation, describe the sensibility and working methods of her trade:

“As designers we are trained to be fascinated by the human condition and to examine that heightened sensitivity to witnessing, particularly, the extremes. Everything we observe is a story and we are trained to see, to observe and to document what we see. Working in the area of health care we have a heightened sensitivity and level of empathy to the user. We quickly capture and synthesize what we see, and we store it as part of a catalog that we have around the human condition in general, and health care in particular.” 

The delicate duet of patient and physician proceeds like a song with its own harmony, melody and rhythm. The two voices entwine and the resulting melody, harmony or disharmony translates into comfort or discomfort, health or illness, life or death. 

This is the great lesson of the new moral science for anyone – doctor, patient, family member or health care designer – who is engaged in the mysterious, deeply human process of whispering our sick souls and bodies back to health.

The master of health is the artist inside each of us.

This post was written by Doug McGill.

Thinking About Life, Death and Design at Transform 2010

More than anything, the recent two-day symposium at Mayo Clinic – “Transform 2010—Thinking Differently about Health Care” – got me reflecting about how we make moral decisions as human beings.

This question was to me the sparkling golden thread running through the symposium’s 42 brilliant presentations offered by clinicians, surgeons, nurses, computer programmers, human rights activists, inventors, social workers and many others who brought their mighty passion for healing to bear on a single stubborn problem – the conundrum of human suffering.

Some speakers showed electronic devices they’d invented to increase health and decrease disease – pill bottles that play music reminding their owners to open them, or desks that double as treadmills to give office workers exercise. Others of a technical bent had written software programs to synthesize tons of health data into useful, attractive screen displays.

Other speakers looked more to the soft side of the human equation, seeing solutions to suffering in practices that bring human kindness, humor and wisdom to bear directly on disease. A nurse has started a clinic where patients weigh themselves, take their own blood pressure, and record their own medical histories. A clown-doctor in baggy pants told how he cries and laughs with his patients in the face of sickness and death.

Morality is how we make the big decisions in life – how we live in ways that decrease the harm we do to ourselves and to others; and how we regulate our thoughts, our speech and our actions to maximize happiness and health.

How many types of solutions to these problems were on display!

At Mayo Clinic’s Center for Innovation and other innovation centers in the U.S., “design-thinking,” a creativity discipline used by many successful companies, is one of the guiding intellectual frameworks. As used by creative designers, it powerfully taps creativity in institutions that might otherwise tend towards repetitive operational dullness. Design thinking’s focus on teamwork and collaboration also generates a powerful counterforce to the silo-thinking that can stifle creativity in large organizations.

As I watched the symposium’s presentations – designers very proudly and rightfully displaying their buildings, spaces, products and services that without the slightest doubt improved what they replaced – I thought also of the overall failure, so far, of any person or system to bring American health care back to earth in terms of cost, size, and indeed, simple humanity.

It made me wonder if perhaps design thinking itself – writ broadly, even beyond the few “design thinking” gurus to encompass most overarching design theories — could use a partner, a comrade in arms, a complementary theoretical framework to enhance its own effectiveness. Especially, when the art of design is practiced to create not functional, aesthetic or consumer items, but in the very special, life-and-death case of health care design.

Because for all of its strengths, design thinking simply isn’t grounded in any systematic understanding of moral decision-making – i.e., in a scientifically-validated theory of how humans reach moral decisions. And yet, moral decision-making is the very quintessence of good medical practice.

Lorna Ross, the creative lead of Mayo’s Center for Innovation, winked broadly at the wider practical and ethical issues of this question in her conversation with Tuesday morning panel moderator Lew McCreary:

“Design in health care is so incredibly human,” Ross said. “Health care is so personal and it’s not very generalizable. Being able to represent that at a granular level is important. We always try to bring the conversation down to the individual.”

But if health care solutions to highly personal, localized problems are not easily scalable – i.e., subject to merchandising beyond their original markets – how are they ever going to succeed in a market economy?

Economics aside, if the solutions to health care problems as they arise in specific contexts and cultures are hard to translate to other cultures and locales, what hope is there for global good health to eventually arise?

This may be exactly where a disruptive, revolutionary, “new way of thinking about health care” must be firmly and consistently applied. Because if highly local solutions are usually the best ones in health care, and yet are not easily scalable, it would be absolute folly to keep trying to make them so.

So instead of focusing on final products, how about looking at the very process that produced them as the scaleable thing? If the process and not the product was then reproduced on a mass scale, local populations everywhere could adopt them and start producing their own localized best solutions.

And what would that scalable process look like? To me, it would look a lot like design thinking with its creativity-spurring, teamwork-encouraging practices. Yet it would complement that powerful method with principles grounded in practical, skilful moral thinking – again, the one critical area, although it is the essence of medical practice, design thinking largely lacks.

These complementary moral principles to design thinking would in turn need to be grounded not in religion, the traditional foundation of moral thought, because that would automatically limit their global reach and effectiveness. And, create much unnecessary clamor, friction and heat.

Rather, these would have to be moral principles firmly grounded in findings reached by the universal, objective methods of science.

I have a candidate to offer, which I’ll do in a later post.

This post was written by Doug McGill.