Tag Archives: evidence-based medicine

“Forgive and remember”

Forgive and remember

File this under “lessons about failure that the nonprofit sector can learn from medical sociology.”

Forgive and Remember: Managing Medical Failure, by Charles Bosk, is a classic of medical sociology, an analysis of how coping with failure is built into the training that surgeons receive in hospital rounds, mobidity and mortality conferences, and other settings.

Please note that I am not claiming that surgeons themselves have a lot to teach us about dealing with failure, because my experience is that while their sub-culture does have rituals and protocols that they enact privately, they still have a way to go in transparency and accountability to others.

This has been my experience in three instances of major surgery:

  1. Surgeon did not follow instructions given by the specialist physician managing my condition.  Acknowledgement: Partial.  Apology: No.
  2. Surgeon did not inform me that the tumor to be removed might be malignant and require addition surgery until I was under anesthesia. Acknowledgement: Yes, after I complained. Apology: Yes, after I complained.
  3. Surgeon did not respect my request regarding administration of anesthesia:  Acknowledgement: Yes, after I complained. Apology: No.

Not that I am bitter.

But let’s face it:  most of us are highly invested in showing the world that we are skillful, trustworthy, and deserving of whatever prestige is ascribed to us.  As a patient, I naturally blamed the surgeons, not only for their errors in judgement, but for the instances in which they failed to acknowledge or apologize for their mistakes.  As a fellow human being, I completely empathize with their reluctance.  I imagine that that reluctance is more acute among professionals who have to cut people open.  Their work is obscenely invasive but often lifesaving,  and therefore must maintain an impeccably trustworthy reputation.

That’s why Brent James is one of my heroes, along with surgeons and physicians like him who are putting it on the line for evidence-based practice.  There will be no accountability, transparency, or improvement in health care unless successes and failures are accurately documented.  Those results must then be carefully analyzed, made available to the public in appropriate ways, and used to improve their efforts.

As with medicine, so with other mission-based organizations.  We need to track outcomes, acknowledge failures, and then do better.  If it takes a pink feather boa and an amusing ritual for nonprofits to get there, I’m all for it, though I’m not expecting surgeons to adopt the feather boa.

As for the slogan, “forgive and remember,” I think of it as both a spiritual and a practical precept.  We not only need to forgive ourselves and others when we have failed – we also need to bear the lessons of failure in mind.  Both individuals and organizations not only need to keep learning, but to take appropriate action to protect those who are at risk.

I used to work in violence prevention, and for me, one of the most heart-rending aspects of it was the well-documented difficulty in stopping offenders from repeatedly battering their loved ones.  In some cases, they simply didn’t see their behavior as abusive, or their loved ones didn’t see any alternative to accepting abuse.

As I reflect on that today, it drives home very painfully the lesson that we cannot always change others, or even control a specific behavior of theirs.  The old cliche that they “have to really want to change” is true, and it’s also true that not everyone who wants to change can do so. This is the really difficult side of facing failure for nonprofit organizations – in some cases, there may be no alternative to severing ties with individuals or organizations, if the organization is going to face its failure and move on.  It’s going to take more than a pink feather boa, a “joyful funeral,” or a FailFaire to get past that.  When the well-being of vulnerable people is on the line, there are cases where forgiving and remembering is crucial, but it isn’t enough.


Bonus item:

Q:  How many psychotherapists does it take to change a lightbulb?

A:  Only one, but the light bulb really has to want to change.

“We count our successes in lives”

Brent James

Brent James is one of my new heroes.  He’s a physician, a researcher, and the chief quality officer of Intermountain Healthcare’s Institute for Health Care Delivery Research.

We had a very inspiring telephone conversation this afternoon, about whether the lessons learned from evidence-based medicine could be applied to nonprofits that are seeking to manage their outcomes.  We also swapped some stories and jokes about the ongoing struggle to document a causal relationship between what a health care organization (or a social service agency, or an arts group, or an environmental coalition, for that matter) does and what the organization’s stated aims are.  In fact, documenting that an organization is doing more good than harm, and less harm than doing nothing at all, continues to be a perplexing problem.  The truth may be less than obvious – in fact, it may be completely counter-intuitive.

In this phone conversation, we also waded into deep epistemological waters, reflecting on how we know we have succeeded, and also on the disturbing gap between efficacy and effectiveness.

It’s not merely a philosophical challenge, but a political one, to understand where the power lies to define success and to set the standards of proof.

I doubt that this is what William James (no relation to Brent, as far as I know) had in mind when he referred to success as “the bitch-goddess,” but there’s no doubt that defining, measuring, and reporting on one’s programmatic success is a bitch for any nonprofit professional with intellectual and professional integrity.  It’s both difficult and urgent.

What particularly struck me during my conversation with Brent was his remark about Intermountain Healthcare:

“We count our successes in lives.”

On the surface, that approach to counting successes seems simple and dramatic.  The lives of patients are on the line.  They either live or die, with the help of Intermountain Healthcare.  But it’s really a very intricate question, once we start asking whether Intermountain’s contribution is a positive one, enabling the patients to live the lives and die the deaths that are congruent with their wishes and values.

These questions are very poignant for me, and not just because I’m cancer patient myself, and not just because yesterday I attended the funeral of a revered colleague and friend who died very unexpectedly.  These questions hit me where I live professionally as well, because earlier this week, I met with the staff of a fantastic nonprofit that is striving to do programmatic outcomes measurement, and is faced with questions about how to define success in a way that can be empirically confirmed or disconfirmed.  Their mission states that they will help their clients excel in a specific industry and in their personal lives.  They have a coherent theory of change, and virtually all of their criteria of professional and personal success are quantifiable.  Their goals are bold but not vague. (This is a dream organization for anyone interested in outcomes management, not to mention that the staff members are smart and charming.)  However, it’s not entirely clear yet whether the goals that add up to success for each client are determined solely by the staff or by the client or some combination thereof.  I see it as a huge issue, not just on an operational level, but on a philosophical one; it’s the difference between self-determination and paternalism.  I applaud this organization’s staff for their willingness to explore the question.

When Brent talked about counting successes in terms of lives, I thought about this nonprofit organization, which defines its mission in terms of professional and personal success for its clients.  The staff members of that organization, like so many nonprofit professionals, are ultimately counting their successes in lives, though perhaps not as obviously as health care providers do.  Surgeons receive high pay and prestige for keeping cancer patients alive and well – for the most part, they fully deserve it.  But let’s also count the successes of the organization that helps a substantial number of people win jobs that offer a living wage and health insurance, along with other benefits such as G.E.D.s, citizenship, proficiency in English, home ownership, paid vacations, and college educations for the workers’ children. Nonprofit professionals who can deliver that are also my heroes, right up there with Brent James.  While we’re holding them to high standards of proof of success, I hope that we can find a way to offer them the high pay and prestige that we already grant to the medical profession.

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