Tuesday, 14 October 2014

Power words to avoid in healthcare

On words such as 'intelligence', 'insight' and 'discretion' used as tools in demonstrating power.........................

A colleague had an email from a clinical director asking to ‘acknowledge that CT Cologram is a scarce resource to be used intelligently’.

When we got talking about this we wondered how one was supposed to respond, react or put this into action. What did that mean? Does it mean that they as a department they were using the resource like a bunch of idiots? Is this saying that they were a part of a group of people with not such a high intelligence? They were talking about doctors most of whom had at least two degrees and many years of training and experience - generally thought of as abundant proof of intelligence.

You can see this has raised my hackles. What is really interesting is this comes from a hospital which had one of the highest utilisation of CT scans in the country. If they were abusing CT facilities already, why would a cologram (colonography) be an exception? 

The issue is not the CT use intelligent or otherwise. The issue is the lack of understanding of how clinical management works and the use of operational management language. It is the lack of analysis and lack of definition behind these statements that are the problem. Of course no manager who imagines he/she is worth his/her salt will ever agree that this type of communication is grossly deficient. In fact the managers will insist that ‘intelligent use of resources’ is essential. And they can prove it. They will prove it by letting others use the resource and then using their higher hierarchical authority by making a post-event, ad hoc individual judgement on others who used the resource intelligently. You can see how it massages the ego of individual managers and riles up everyone else.

There are many other terms which lack analysis or definition yet used very liberally by everyone. Insight is one. Discretion is another.

Many doctors in trouble are accused of lack of insight. A GMC related official described insight as breathtaking arrogance in the face of overwhelming evidence.....  So, it is safe to assume that when evidence is presented to a doctor that he/she is no good and yet the doctor maintains that he/she was good would probably classed as lack of insight. At this point, it may look acceptable.
The point is, the use of ‘lack of insight’ as a reason and sanctions that follow often comes from a people with higher authority and directed against people with lower authority. In medical practice there is none or very little evidence for many things we do. In such a situation evidence becomes the view of a group of people in power who are then not inclined to look at the evidence presented by the weaker party. Insight becomes a power game. 

Let us look at discretion. Let us say that your boss in clinical medicine says that all patients are not the same and you must use your discretion according to the given situation. You are likely to think that your boss has given you a lot of freedom. What you are actually being set up for is another power game where your boss retains the right to question your discretion, pitch your discretion with others discretion and to override your discretion. Now you might think that is why you have bosses. But what actually happens is a clear recipe for failure and conflict. 

There are better ways of dealing with these. At a simple level as a starting point is to stop using such words which have the potential to confuse and cause harm; words such as discretion, insight and intelligence in day to day operational activity. I am not saying these words or their implications are not important, of course they are; I am questioning if they should be used in day to day operational management especially in healthcare. 

Instead clear definitions agreed as a group, in the form of specific and detailed protocols with further second and third order protocols defined when the first one does not fit might be a better way in operational management in healthcare. There will be a situation when these definitions will not work in which case a variation made after very quick group consultation which is then analysed later may be needed.

The main issues are that you will not like this since you might feel your autonomy is being reduced; your boss won’t like it since he/she may feel that his/her power is being reduced. Finally the chances are you, your colleagues and your boss will not agree on most things at an operational level; well you see this is not your fault as clinicians are taught only how to make individual decisions implemented according to a power based hierarchical scale. 

Clinicians have never been taught on how agreements are reached and never experienced the power of agreements between them.
There are clear ways to achieve this. That is when you will find Success in Healthcare.


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PS: If you would like to get away from the conventional use of terms such as discretion, insight, intelligence and move to a different approach; if you would like to know what agreement actually means and would like help to achieve it – you are welcome to get in touch with me mr.hemadri at gmail dot com

1 comment:

REFIT said...

Does it not all arise from lack of respect of another's clinical ability and autonomy? When this is lacking, all tools lead to bullying and denigration - sometimes directly, sometimes indirectly, mostly without malice and occasionally with.