Virtues of doing nothing

In article titled 'Buffet succeeds at nothing' http://www.fool.com/portfolios/rulemaker/2002/rulemaker021030.htm  Buffet fan and investor Mohnish Pabrai writes about the need to avoid reacting to every little flicker of the ticker, enjoy long periods of relative quiet and inactivity. Sitting on their butts as they put it. Apparently it is beneficial, well of course it is, it made them very rich.

I love it when Pabrai says 'Eventually the nerds got fidgety....'. High intelligence and high skills can sometimes be an high intensity problem - people want to use their intelligence and skills often. They want to prove it often to themselves - a need to pamper our egos. They want to show off to lesser mortals around them - the feeling of superiority gives us a true 'high'.  This leads to the cleverer ones doing things when the better option would be to actually do nothing.

Masterly inactivity is well known to doctors especially who are obstetricians. Anaesthetists achieve excellent safety in the administration of general anaesthesia and we know very well that for most general anaesthetics there are brief periods of intense activity followed by long periods of studious and judicious inactivity. However for many other doctors there is the desire to do something. That sometimes actually achieves good results for patients. However, this urge to do something also results in unnecessary investigations, overdiagnosis, un-indicated procedures, too many follow up appointments, wasted education programmes, mere activity replacing achievement, medicalising normality, therapeutics for the false positives, narrower sub-specialisations,.............. Do I need to go on?

In quality improvement theory, to intervene when not indicated is actually called tampering, which is inevitably a waste of time and could be seriously harmful. The term inactivity is actually used with caution here, it does not mean completely switching off and going to bed, it means that we need to observe the effects of action. Once an action is initiated, it takes time to see its effects, it takes time to gather data, it takes time to analyse the data, it takes time for trends to develop, it takes even more time to understand trends and it takes a lot longer to decide on how to respond to the trend analysis. The frame of time of course varies depending on the activity; seconds, minutes, hours, days, weeks, months, years, etc

Most of us have no respect for this line of thought and would react to individual events rather than proper trends. Anyone who has studied some decent management would have learned that the cost of indecision is higher than the cost of a decision. This is taken as a call for action, often hasty, often unindicated. The decision not to act before it was necessary is a wise decision, this is often mistaken by fools as indecision. I would say the cost of unindicated action is higher than the cost of indecision. 

The importance of doing nothing is especially acute in clinical medicine and healthcare. We have in Clinical Wrongology already touched briefly on the lack of evidence for most of the activity we do in clinical care, the high rate of errors in clinical care delivery processes, our inability to agree with our colleagues and our lack of acceptance of these issues. Logic demands that under these conditions we should often do nothing, since doing something is more likely to be wrong. To act hastily under these conditions and to react to every point rather than proper trends is indeed a recipe for disaster and adds to the wrongness in healthcare.

Whenever there is a choice between action and inaction the cleverer ones chose action. We all know for every action there is an equal and opposite reaction. That reaction may neutralise the effect of the action or worse cause harm. To do or not to do, becomes a very relevant question for clinicians. To do something when doing nothing would be better requires a higher level of maturity and judgement apart from better operational evidence. 

Do be very discerning in understanding this blog, I am not saying we should not act when the situation demands it. I am asking you to think if we act even when the situation does not demand it, if we do, then I am arguing that there may be virtue in doing nothing.

 

©M HEMADRI 

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Abilene Paradox: Watch out, it could hurt you

Abilene paradox - the importance of managing agreements and agreeable colleagues

Last month I wrote about the Bad Apple theory and argued for a slightly softer approach in understanding and dealing with clinical 'bad apples' in healthcare. In a subjective sense, bad apples (irrespective of whether they are actually right or wrong) are persons who tend to disagree with their group and use negative behaviors to show their disagreement.

The Abilene paradox is some what the opposite phenomenon. This is when we do not voice our concerns, do not speak up, do not disagree. In fact in this paradox we actively do something that we do not fully believe in or want to do, because we felt that is what our boss, our group, our organisation wanted. We agree with our colleagues and peers to please them, we think our agreement will make them happy, will vindicate their opinion. If you are the leader, manager or proposer of ideas you come up with ideas, projects, activities, etc with the intention to please your team; your team in return go with your idea not because they think it is a good idea or want to agree with you, they simply run with your idea as they do not want to displease you or dampen your enthusiasm.. They might agree due to fear of authority, lack of knowledge, loyalty, the desire to play the part of a cooperative team member or perhaps even with the hope of getting something from you in return in the future. Obviously these are all the wrong reasons to play along with an idea if it was bad in the first place.

Watch out. This is something which has the potential to take you well away from your mission and plunge you into problems despite everyone's support and agreement; well actually because of everyone's support and agreement. Some might consider this a version of what we know as 'group think'; perhaps. In my view, group think is when all members of the group are convinced that it is a good idea, whereas the Abiline paradox is when group members may not believe it is a good idea but push the idea along forward and ahead simply because they think it will please other members of the group. This is something you want to avoid at all costs.

The fairly old but very interesting article called the Abilene paradox can be found at http://www.rmastudies.org.nz/documents/AbileneParadoxJerryHarvey.pdf .

In summary, the author John Harvey says
‘’Organizations frequently take actions in contradiction to what they really want to do and therefore defeat the very purposes they are trying to achieve.’’

‘’.......a major corollary of the paradox, ... is that the inability to manage agreement is a major source of organization dysfunction.’’

This is the opposite of what many of us often assume that managing conflict is the usual big problem that frustrates us.

He suggests

‘’through the process of active confrontation with reality, we may take respite from pushing our rocks on their endless journeys’’

Abilene paradox is very relevant to healthcare. Just think, at your department level in MDT (multi disciplinary team) meetings and at national/international levels the unanimous decisions, at the consensus groups. Could the paradox be in play or could group think be in play? May be yes, may be no. But has the question been asked and answered if these phenomena could be affecting our decision making? I think we do not consciously explore this; we simply assume sometimes rightly, sometimes wrongly, that such ill effects did not afflict our decision making. In highly technical industries, in highly scientific industries and in highly evidence based industries adverse effects of the Abilene paradox will be negated pre-event by knowledge and post-event by data. In healthcare with its relatively poor evidence levels which results either in large variations in clinical practice or practice without improvement, the problems with group think and managing agreements are undoubtedly huge with its negative impact on patients.

Abilene paradox may turn out to be the bigger problem in recognition and management of healthcare's complexities.

You see the bad apples are easy since they are visible, audible and apparent. They make you uncomfortable or annoyed. You will be able to identify them and deal with them as early as you wish. Since we are all trained on how to deal with 'difficult colleagues' we at least imagine we can deal with people who disagree with us. Abilene paradox does not make you uncomfortable or annoyed till it might be really late. Since the intention of the group, who fall prey to the paradox is to cooperate and please, it will be really difficult to identify early and when identified we will be reluctant to deal with persons who have cooperated with us with good intentions. We have no knowledge or training on how to deal with easy colleagues who might pleasantly mislead. In organisations and teams peoples role is to cooperate appropriately and that can only happen when people support their team by critically questioning and vigorously analysing the issues. Only after a robust process should people offer their cooperation or agreement. 'Yes (wo)men' are probably more harmful to teams than bad apples in the longer run.

In old Jewish writings it is said that in a case subject to capital punishment if a guilty verdict was unanimous then the accused would walk free. This was generally thought to prevent group think, I feel their wisdom probably included concepts of the difficulty of managing agreements as in the Abilene paradox. It is said that good effective leaders surround themselves with a good team. Of course that is very important, but good leaders should make sure that the Abilene paradox does not frustrate them. Good leaders should demand that their team provide a genuine expression of opposing or divergent views so that higher quality decisions are made which would enable longer term success.

©M HEMADRI 

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