An imbalance in the Ontario health care system

broken red cross

Our health care system is too brittle.

I think of design as an activity that seeks balance between efficiency and effectiveness. So understanding effectiveness and efficiency, and being able to recognize efficiency and effectiveness in systems, is a fundamental skill in design. In this post, I will describe a situation from my own life of hyper-efficiency in the Ontario health care system. The point is to demonstrate that the notion of balance is useful to explain why systems don’t always work properly.

I have Grave’s Disease, which is a kind of hyperthyroidism. While my condition is nicely controlled by a drug called methimazole, I check in with my endocrinologist every six months or so.

I’d had an appointment scheduled for last January, but a couple of weeks before the appointment, I was told by my endocrinologist’s excellent nurse-assistant that he was closing his practise immediately due to illness. She helped me out, though, by suggesting a new endocrinologist and offering to forward my file to the new specialist. I agreed.

Given that my old specialist was “out of business,” a fact the nurse-assistant noted to the new specialist’s staff, a referral wasn’t necessary.

But, apparently, it was. And no one told me from the new specialist’s office for a long time.

Eventually, I got a referral from my family doctor for the new specialist.

However, this confused the new specialist’s staff even more: why was the referral not from my old endocrinologist?

He’s dead, I’d say.

Oh. Right.

In the end, it took two months just to book the appointment to see the new specialist.

Now, I do not believe that any one person here is to blame. I think everyone involved did their jobs as well as they could.

Here’s the problem as I see it.

There is no specific protocol for passing clients from one doctor to another if the original doctor is unable to participate in the transfer. (I asked, and no one admitted to knowing of such a protocol.) This might not seem like a problem, but since there seems to be a protocol for everything else, the lack of protocol leaves staff in a lurch. How do they handle the situation without getting in trouble or causing trouble for the patient or the doctor? The notion of collaboration – of just getting on the phone and calling other people involved in the situation and talking it out – seems unknown to them. It isn’t their fault; it’s the fault of their training, and of the organizational system in which they work.

The system in which health care workers work is designed for high efficiency, and the efficiency is achieved by carefully describing how everything is done. If everyone knows what they have to do, and they all do it exactly when they need to, then everything gets done and with very little need for feedback.
But it is impossible to cover every eventuality with this kind of prescriptive approach. So when something does go even slightly sideways, the system simply cannot cope, and it fails.

You might be wondering why I’m making such a fuss over such a minor incident. After all, it’s not like I was on death’s door.

Answer: because the problem scales to major incidents too, and with a multiplier effect. Hyper-efficient systems are brittle. Witness the American financial system, exquisitely honed to be incredibly efficient, which fell apart like a house of cards.  The more efficient a system is, the less effective – the more brittle – it becomes. The hyper-efficient system becomes so specialized in doing only certain things exceedingly well, that it shatters like glass when the situation changes too much.

The medical system needs to move away from the prescriptive nature of protocols and toward a more descriptive approach. Descriptions can be made sufficiently abstract that they are flexible enough to account for greater variability than prescriptive approaches. Indeed, I would suggest that a pattern language might just be the way to go, to define a new way of practising the art and business of medicine these days.

A detailed description of pattern languages would be out of place here, but I will suggest one example. Chris Alexander, who invented design patterns, co-authored a book called A Pattern Language: Towns, Buildings, Construction. In it, Alexander and his colleagues describe 253 patterns that describe everything from siting a new town to how to arrange decorations in a room of a house. Each pattern is a description of a generalized method for solving a particular class of problem. Patterns can be hierarchically arranged, so that solving one pattern may invoke several other patterns as constituents.

I think that a pattern language should be created for medical practitioners, and that such a pattern language would provide the effectiveness that is obviously missing in the current, protocol-driven system.

Yes, some efficiency will have to be given up, and the politicians won’t like that, but I suspect that it will make the system much more effective – which will lead to better outcomes for patients and less administrivia for health care workers.

And that would be good for everyone. Even politicians.


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