systemwise

San Francisco: Let's do a Red Cross blood drive

Sun, 04 Nov 2012 11:39:30 -0800

Ever since Hurricane Sandy hit, I’ve been sitting here unable to tear myself away from the news about friends and loved ones, about places I’ve lived and used to go as a little girl. I’m feeling far away and helpless.

Giving money is hugely important, and if you haven’t done so yet, please do. There are many ways to donate money, both for people and for animals. But giving blood is also critical, and the Red Cross has stated that the hurricane has affected blood and platelet supply.

There’s a mass of us in a very walkable area. We could easily have a Red Cross blood drive. In order to do so, the Red Cross recommends at least 300 participants. With all of us at the many companies from Embarcadero to Civic Center, from Market St. to South Park, we can find a location for the bloodmobile (I’m sure there’s another name for it but I kind of hope not).

Companies can work internally to recruit teams. I’ve talked to my fellow Mules, and I’d love to see a Twitter team and a Wired team and a Square team, because for all the whatever of we’re the center of tech now no way we are or omg gross Silicon Valley vs. Silicon Alley and ugh South Park and Brooklyn vs. Berkeley and tech journalist throwdown of the week and guys, I have no idea anymore, because there will always be time for that once the people we know and love are no longer going through such miserable, (literally) dark times.

Please let me know if you and/or your company would participate in this FOR REAL. I want to gauge interest so I can contact the Red Cross with a real plan and have it get carried out. We’ll have to schedule 300 appointments and really organize this.

Some people think we deserve what we get for living in earthquake zones or hurricane paths or whatever, but at the end of the day, I feel like we’re all in this together. Please let me know.

The Thread That Binds

Fri, 02 Nov 2012 23:15:00 -0700

A few years ago, when Tumblr was going through some of its earlier growing pains (as opposed to just its regular pains), I was a very dedicated Flickr user, relying on it both as a way to share my photography and as a home to a beloved community. There was a period when Tumblr users were taking photographs from everyone they could, removing all attribution and sometimes even the embedded data, and then posting the photos in an endless stream on their Tumblrs. It was essentially a mass aggregation of visual content, a constant scraping of Flickr, blogs, and portfolios to take images and post them without permission or attribution. A lot of photographers became incensed, and an endless series of arguments with the Tumblr users and Tumblr itself ensued.

The core of these arguments were nothing new—copyright laws have existed practically since the dawn printing press, and I imagine arguments about copyright have therefore existed almost as long. Photography is a trickier subject when it comes to copyright, in that we’ve thought a lot about copyrighting words but much less about images, not only because photography is a much more recent invention but also because of perceptions around photography as an art form and as a mode of representation. The digital age has ushered even bigger complications, with the benefit of an increased audience and the downside of a loss of control over the work you produce and release. So there were a lot of concerns, opinions, and feelings expressed about ownership, and rights, and copyright vs. creative commons vs. fair use. There was a lot of “no one likes it when writers get plagiarized, so why don’t people raise the same stink with photography?” And there was a lot of anger from people who felt they had their Flickr accounts raided, only to see their images appear on countless Tumblr pages with thousands of reblogs and not a single bit of attribution or a link back. Frequently even the embedded data was gone, meaning the only way to find the original owner was to image search—easier now, but still not ideal.

Whatever we ultimately conclude about copyright and ownership, it’s this last part I want to think about. The link back. I thought a lot about the thread that connects the creator of the image to the image, and the story that may or may not go with it. I’m a firm believer that once you’ve created something and released it into the world, you no longer have a claim to it. You cannot control how people react to it, what they see in it, how they reflect on it or project onto it. You’ve let it go and you have to let it go. But that thread that ties you, the creator, to whatever it is you’ve created is still valuable. It may be valuable for someone who wants to know who created the image to find more like it, and to buy them (money!). It may be valuable because someone resonates deeply with the story being told in the image and needs to learn more—if the thread is snipped, that’s a missed opportunity. And in the case of Hurricane Sandy and the spread of false photographs and information, the thread is a way to learn the provenance and story of the image before damage is done. Sure, it’s easier than ever to research images and figure out where they’ve come from, but how far and fast did those images spread before anyone did so? How many people saw them and asked friends, neighbors, strangers if they’d seen the crazy photos of the storm cloud over the Statue of Liberty or the seal that escaped the zoo? The internet works to correct itself and to find the truth in these images, but do we think about how quickly ideas, perceptions, even history can be affected by the spread of false photographs and misinformation? The faster information and disinformation spread and the more imagery is available, the more valuable these threads may be in connecting us to the best version of the truth available.

Not Either/Or: Doctors and Algorithms

Fri, 20 Jan 2012 16:17:00 -0800

Almost ten years ago, I wrote a thesis for a Master’s degree at Georgetown. It was about the artistic representation of the machine in human form. I was curious about the human drive to create cyborgs and robots and machines that look and behave like us, and what it means for us to also have the fear that seems to crop up in so many movies and books: The fear that the cyborgs and robots and machines that look like us are going to turn around and destroy us. I looked at a couple of texts, and I considered the Prometheus myth and, of course, Frankenstein’s monster. Naturally, I called the thesis “Doomsday or Desire: Do Androids Dream of Robotic Lovers?” (Download it here.)

It never occurred to me that a decade later I’d be considering a very similar question, albeit in a completely different industry and from a different angle (and without all the critical theory).

The other day, there was a big media flurry about a pretty cool and exciting announcement. You may have heard about it: The Qualcomm Tricorder X Prize. It’s a competition with a $10 million prize for the first group to design a Star Trek Tricorder: A device that can monitor a set of health metrics and diagnose 15 diseases. It’s pretty cool, right? Absolutely. Talk about potential!

But something was nagging at me. So I got to thinking. I got to thinking about a self-scanner and diagnoser. I got to thinking about the rise of self-tracking apps and health technology in general. I especially got to thinking after I read Vinod Khosla’s piece on TechCrunch, with the unfortunately polarizing title Do We Need Doctors or Algorithms? (NB: He addresses some of my concerns at the very end.)

Here’s what’s been bugging me: There’s a particular strain of thought, or maybe even of person, that says, “I have a set of constructs that solve these particular problems. Hey, you know what? I bet I can use them over here to solve this totally different problem!” Now, I’m not talking about using a theory from one sphere to help understand something in a totally different sphere. I’m talking about the applied version of my favorite aphorism: Running around looking for nails while wielding a really big hammer.

There are a lot of amazing ideas and possible solutions to big problems coming out of the health tech sphere right now. But there’s also what I see as a lot of this hammer/nail-ness too, this “I’ve figured out how to reengineer this over here, so I’m pretty sure I can reengineer this as well” - even though the bigger problems behind and connected to “this” haven’t really been explored. I see “my best guess” and “I’m going to assume here” more than I see “patients want to self-diagnose these types of ailments, but they want specific types of physician support in these medical cases.”

Let me explain. As I mentioned, I think the idea of a self-scanner could be great. Empowering patients is really important. But once a patient is empowered, what then? How do we work with physicians and nurse practitioners to give up some of the control they may (or may not) want to have over their professional knowledge? How do we get them to work with patients and use this technology in a mutually beneficial way? How do we educate patients so they can use this technology to have better healthcare experiences and make healthier choices? How do we go rebuild the system to train and create better doctors, period, so labor isn’t being duplicated and patients can get the best out of doctors and doctors can focus on necessary clinical tasks and the personal aspects of patient care?

Just creating the technology isn’t enough. Like I’ve said before, sometimes we look at technology as this silver bullet. Ah ha! This - this one - this is what will fix this problem. We’ll get rid of crummy doctors, right? But isn’t that treating the ecosystem of healthcare the way many of us treat our own bodies? Rather than engage in some preventative care and understand the root cause of some our problems, we allow it to get bashed around and then hope technology will save it. Technology can help it, most surely, but we have to fix the whole system. Including the human parts of it.

More than that though, if we see doctors as replaceable by algorithms, what does that mean? Yes, I know, part of being a doctor already is using an algorithm, so why not just let a computer do it since computers are more powerful. I’m not arguing against that. What I’m saying is: If we take much of the diagnosing and clinical decision-making away from doctors, and then the surgical duties, what’s left? Yes, there’s personal connection. But so far no one’s offered a solution for making sure that personal connection is good, for helping both clinicians and patients be better at making and sustaining it. We’re focused on building the technology but we need to also dig into in medical schools to make sure we’re creating a system that can support these technologies in positive ways. I’ve seen some people argue it’s just an expensive placebo. I disagree, because medicine isn’t just a quantifiable science. With the best doctors, it’s also an art, based on observation, an ability to synthesize knowledge and experience, an understanding of people as well as science and medicine.

Think about what would happen if we took away diagnosing entirely from clinicians. Think about what would be left - for clinicians to be the janitors of health? If we gave the creative part of your job to a computer - because it’ll be entirely possible to do that in almost any field - what would be left for you? What would your value be?

So let’s not make it an either or. Let’s build powerful algorithms and more powerful doctors and more powerful patients. Let’s create a better system.

January 10th: Speaking at BayCHI

Tue, 03 Jan 2012 16:01:22 -0800

A quick bit of news, for those of you in and around the Bay Area: I’m speaking next Tuesday on my research at BayCHI, held at PARC in Palo Alto. Please join me! Go here for more information.

Here are the details on my talk:

On or Off the Record? Organizational Culture and The Physician Experience Implementing Electronic Health Records
Leah Reich, XpcXpts

Electronic Health Records (EHRs) are not everywhere yet, but by 2014 they will be, given the mandate in the American Recovery and Reinvestment Act of 2009. There are many things we don’t know about EHRs, but one thing we know for sure: Like other big technological disruptions, implementing them is enormously stressful. Given the looming deadline, relatively little research has been done into the experience of clinicians in implementing health IT and EHR. If conflict or a problem arises, where and why? How do people then navigate their way through it?

I’ll answer these questions by presenting research I conducted during eighteen-month longitudinal ethnography in a networked group of ambulatory care clinics during the transition from a paper record system to an EHR. It’s a compelling case study of the clinician experience during the transition to EHR, with its empirical examination of the contexts, routines, and conflicts. I’ll discuss the critical role organizational culture plays in the way people learn about technology, identify issues, and manage problems. This can help clinicians, administrators, and designers anticipate stress, conflict, and the consequences of both.

Hope to see some of you there. Please say hi!

I'm really on-board with Cary about the ego thing. I worked in medical sales and training for almost 8 years, focusing mainly on MDs and DCs (Chiropractors). The MDs were typically bright, decent guys, but their egos sometimes made it difficult to teach them anything, or even to get them to just LISTEN to what I was trying to say - even when I knew WAY more than they did on the subject at hand. That kind of arrogance is dangerous when the topic is life or death.

Tue, 27 Dec 2011 11:50:00 -0800

Again, I agree: There’s a problem with arrogance. I don’t deny it. And I don’t deny that there’s a big problem with that arrogance, the way it’s displayed, and the effect it has.

Here’s the thing though. The reason I write the way I do and the perspective I present is that I would like to have a constructive dialog. Yes, there can be an ego problem. We can express our frustration and anger. Nurses/NPs have a lot of it. But I know, from experience particularly while conducting my research, that physicians do as well. And it turns out that not only do many of them not have egos and arrogance, but their frustration is justified too.

Not only that, but here’s where I’m coming from: Expressing our frustration is useful, yes. But ranting about it (which you aren’t doing at all, but some do) and expressing personal experiences will only get us so far. Engaging in dialog about it is very important. I’m trying to get to the heart of why these problems are there so we can see if we can fix them.

Nurses have an entirely different approach and philosophy from doctors. Our tasks overlap, but the approach is so different on some issues it's like choosing between a surgeon and a chiropractor. The biggest problem the nurses I know have with doctors is close minded arrogance, not knowledge problems. Just ego. I could go on at great length about this, having worked in hospital, clinic, and home health environments.

Fri, 23 Dec 2011 12:26:00 -0800

Thanks so much for responding. This is so helpful. And I wish you would go on about it at more length, it’s an important dialog.

My research included a number of nurse practitioners and physician assistants but only one nurse, an advice nurse. I had some great conversations and interviews with the NPs and PAs about their roles, and I absolutely agree: Based on what I learned in this experience, the approach and philosophy is different. This is why I think there can be a real symbiosis between NP and physician, or doctor and nurse, or any configuration. I saw it happen. I’d like to talk more about it, so maybe you and I can talk about it here together.

You hit on two really important points: close-minded arrogance and ego. I have given a lot of thought about them, and they are worth a larger discussion. They relate to two points I made in my previous posts. The close-minded arrogance relates to the idea of professional knowledge and credentialing. Whose knowledge is it? Who is “the doctor” and who is not? I think we even see it between specialties of doctors. I’ve seen specialists dismiss generalists in very arrogant ways, and vice versa.

The ego issue is connected to the idea of the whole system, and how we begin fixing it at the top. I try and separate out “healthy ego” - the confidence and ability to trust in one’s self and decisions, something I think is important in any professional practice, particularly one in which a person has to make life and death decisions - from “unhealthy ego,” the kind you’re talking about here.

Not everyone who wants to become a doctor does. I think Ian Welsh’s point about schools sometimes not admitting people who care too much is true, as well as about medical schools grinding down the care out of people. So the selection bias on ego may be skewed slightly. Medical school, internships, and residency are all about plucking the best and the brightest and dropping them back to the bottom of the totem pole and pushing them to climb back up, repeatedly. What does that to to your ego? It either breaks it or builds it up substantially. Plus, what is taught in medical school and beyond is the antithesis of teamwork. Sure, making a mistake in medicine is about someone’s life, but in medical school it also means you’re an asshole. It’s an opportunity for public humiliation. So the ego becomes a protective mechanism, and this is on top of an already fairly strong ego.

This isn’t to defend doctors, because I really do believe there are a lot of naturally egotistical jerks in the profession. I also happen to believe there are a lot of egotistical jerks in every profession. But it’s also a huge problem within the training process, the credentialing mechanism. There has been a fairly recent movement to focus on and teach teamwork in medical schools, because that’s how it should be. Few patients, over the course of their lives, see only one provider forever, and no provider works in a vacuum. Doctors, nurse practitioners and nurses, physician assistants, medical assistants, support staff, and the patient - team effort.

Doctors, Nurses, and the Credential Crisis: Redefining Value

Tue, 20 Dec 2011 09:30:37 -0800

As you may have noticed these past few weeks, I’ve been thinking a great deal about anti-doctor sentiment. Whether it’s at a party or at lunch, on Twitter or in comments on news articles or on blog posts, there’s this anger at doctors. Doctors do their jobs poorly, doctors are trained “wrong” from the get-go, doctors should simply be replaced by nurses because nurses do the same thing and they do it for less money, doctors have the American Medical Association (AMA) which is a monopoly and is at the root of so many of our problems in healthcare, and so on. As you may have also noticed, I’m pro-doctor. I think there’s a lot of misplaced anger and a lot of misunderstanding about how the system works. Even so, I decided it was time to pick at some of these knots. If we’re going to rebuild the healthcare system - and we should - we have to address this issue. And it’s bigger than people realize, in that it’s a larger and more fundamental issue than the doctor or doctors at whom they’re angry.

So where do we begin? Which knot do we start with? Well, when I conducted my research on electronic health records (EHRs), I considered the issue of professional practice and identity. What does it mean to people to be a doctor? What sorts of knowledge and practices are encompassed in “clinical” work? What do you do all day? These questions are important to me because I think they tie into some of the fundamental issues with the healthcare system. They’re tied in to problems with arguments being lobbed at the education system more broadly, and with something we’ve been discussing for a few weeks, these ideas of symbolic and social exclusion.

As you might expect, when I asked doctors these questions during in-depth interviews, they found them interesting - but sometimes tough to answer. Many respondents paused and became very thoughtful. We talked about how it was one of the more abstract topics in the interview - along with “what does the patient’s chart represent to you?” Even so, I received a lot of wonderful responses to the question, “What does it mean to you to be a doctor?” Caring for patients was a theme. Multiple clinicians also gave me responses like “making a contribution to society” and “doing something that’s valuable.” This theme of value is one worth examining. What is this value doctors experience? What is the value doctors can, or should, provide?

I’m not talking about monetary value, or how physicians should increase profits. I’m talking about a more fundamental value that doctors can provide as not only individuals but as the profession of “doctors.” This would help us understand why and how - perhaps if - doctors and nurses play different roles and offer different types of value that should - but sadly, often do not - complement each other. For those who are working on problems like EHR, this idea of value, along with these larger contested issues of professional identity and practice, can provide insight into why clinicians balk at doing work they consider to be “clerical” in nature. Where does that fall compared to the knowledge that is “theirs”? What’s the value in it? What’s the value compared to the value they think they can provide?

People argue that the bulk of the work doctors do should be given to nurses: they do it already, they often do it better, and they do it for less money. The problem here lies in understanding the value intrinsic to different roles and how they work together. Nurses have long been undervalued, which is not news. But how does it help to devalue doctors, rather than to understand the value both provide and can more effectively provide together? If you simply train both types of professionals, won’t that push each group to just become ever more protective of the boundaries that define “their” professional, expert knowledge - see Andrew Abbott’s The System of Professions: An Essay on the Division of Expert Labor for more on this. If you keep changing the names of the credentials and expanding the available credentialing options, won’t that just create rival classes of professionals rather than a collective, healthy ecosystem in which different types of skill, knowledge, and intellect are needed and used?

Here’s where it starts to get complicated: Could the intrinsic value be the same? Are doctors and nurse practitioners offering inherently different values? Or is it more appropriate to say that the value is much the same but the training is different, so we focus on the curriculum and the credentials, which allow us to argue that one is more socially and financially valuable than the other?

We tend to think of value in these social and financial senses. We assume being a doctor offers social and cultural capital, and we assume one becomes a doctor in part because of the social and cultural capital one already has - the ability to access and afford education, to find internships and residencies, to establish practices. We also assume that doctors make a lot of money. On the whole, this is not untrue: physicians make a good living, and many types of physicians are well-paid. But if you average out an internist’s salary on hours worked, given the amount of paperwork PCPs have - unpaid labor - and standard time off (if taken), you may find the salary comes closer to that of a high school teacher (on an anecdotal basis, and as most of you know, my mother is an internist and we did this with her salary). Further, not all doctors make what you think they make: Some types of surgeons make in an hour or two what can take some types of primary care physicians a few days, if not a week to bring in. (For the record, there are some types of specialized advance registered practice nurses (ARPNs) - also known as nurse practitioners (NPs) - who make more than some primary care physicians. And also for the record, nurses and NPs do have prescriptive authority (the ability to prescribe medicine), but the laws on their autonomy differ state by state.)

Again I return to this idea of value. Why is a surgeon more highly valued than a primary care practitioner? Why is a physician more highly valued than a nurse? What do we value?

We have come to value the credential. Credentialing theory’s roots are Weberian in nature, and if you remember your Weber, this means that our ever-expanding system of diplomas serves our ever-expanding bureaucracy. For those who are calling now for the end of higher education, or to find a better way to train our next generation than “useless degrees,” you’ve been beaten to the punch by the seminal work by Randall Collins called Credential Society: A Historical Sociology of Education and Stratification. You’ve also been scooped by a somewhat less pessimistic text by David Labaree called How to Succeed in School Without Really Learning,

Setting aside the historical reasons within the industry that many specialties, especially the surgical specialties, make more money than primary care physicians - and thus are more “valued,” I argue we value as a society value surgery/specialization over primary care. We like to think we’re being taken care of by certified, highly trained people. We like action. Not hard work, although many of these surgeons work very hard. We think action is great, and we like this idea of a highly “skilled” professional who can perform tasks.

We don’t like being treated like parts, but we don’t want to do the work of seeing ourselves as a whole person. We also like the idea of being invincible until we’re not, and then having someone who can come in and save the day.

You know what we like less? Ideas. Intellect.

Before surgeons write to me to yell because you think I’m saying that being a specialist or a surgeon doesn’t require ideas or thinking or intellect, hang on: I’m not. But I do think that primary care is different. It requires a different type of thinking, rather than action. One internist, in an in-depth interview, told me her advisor asked her why she was going into primary care because she was “so brilliant.” He practically begged her not to. Primary care isn’t highly “specialized” in the same way that urology or podiatry is, and that makes us devalue it: In our evermore bureaucratic society, who likes a general practitioner? We like specialization. In a more bureaucratic society, specialization makes you smarter, better, more valuable. Primary care requires - or it should, ideally - knowing a pretty good amount about basically everything, and how those everythings are intertwined not only with each other but with the social and emotional stressors in your life, the different medical issues you’ll be having, and more. It’s a lot more talk-y and think-y, a lot less do-y. In which case, we stick it at the bottom of the value pyramid. We forget that primary is in the name.

The problem, I think, is that the value has been lost from the very start, at the top of the system. Because we are focused on the credential and the title, knowledge becomes codified into “doctor” and “nurse” knowledge and is jealously guarded. I do not agree that medical school should be abolished, nor that we should forget higher education - quite the opposite. I think school, before on-the-job training like internships and residency, is needed to help teach all of us how to think. To teach us that in every situation there’s more than a what, there’s a why and a how of what to do, and we must understand the process, to make decisions about each individual, or group, or set of situations. In other words, rather than see school as a place to learn a “skill,” we can use school as the place to share that most dangerous of things: ideas. We can teach people to think critically, particularly in a medical situation. Diagnosing is only partly scientific. It is also a human, intellectual process. This is part of the anger being directed at the medical profession: “I went to the doctor and she didn’t figure out what was wrong with me for so long.” “This problem became a huge, serious issue because no one bothered to THINK.”

Perhaps it is in the focus on the wrong value system that we forget about the value they want to and can offer: not only the ability to care, but the ability to provide this necessary critical thought. How do we teach that? Abolishing the system or dismantling it entirely is not the answer. Simply adding more complexity to the credentialing system weighs the system further and takes away from this value focus. Can nurses do the job of doctors? We haven’t defined what anyone’s value is, so how do we know? Giving better access to people who are capable and who may not otherwise be able to become a part of the system because of institutional barriers (education, finances) is important. We need to restructure the system to value the right things: not only patient care, saving lives, preventing disease, but also this type of critical thinking, this type of care. Whatever we call our caregivers - doctors, nurse practitioners, clinicians, - we need them not only to care, we need them to be able to provide the right value.

Building a We out of a "To Me" Nation

Fri, 16 Dec 2011 14:45:56 -0800

Last week I wrote on the idea of connection. How has the way in which we connect to one another, not only as people in society but as patients and physicians, changed? And how has it affected the patient/physician relationship?

I received two fantastic comments from Ian Welsh that I didn’t want to respond to in the comments because it’s worth bringing the discussion out into the open, and because he pointed out something I’d planned on discussing this week (prescient!): the structure of the work done by physicians and the systems we design in which we do those work - both the larger systems and the smaller, including EHRs.

But Welsh points out a few other things that I want to respond to first, beginning this week with this:

I will also say that as a group, Americans (and Westerners in general,but Americans are leading this charge, as with many others) we have become a nasty, self-centered people. The constant fear we live in, of losing everything, which most people cannot acknowledge but which they feel, has eroded social trust. Likewise so many people make their living doing, well, bad things. If you work in the health insurance industry, your job is to extract from the health care system money which in a system which was working properly, would be used to care for patients, for example.

This is an interesting point. It’s a difficult one for me to discuss because I’m pulled in two directions. The sociologist and researcher in me wants to say “have we? That’s (you know what’s coming) an empirical question. And one very much worth asking, if it hasn’t already been asked.” The writer in me wants to say yes, we have. The writer in me then sends the researcher off to do a quick search and right off the bat, a study or two by psychologists on increasing levels of narcissism. Of course, psychology looks more at the individual level and we’re talking at the group level - which is more sociological - but both these look at trends across groups, and I’m still looking. Let me know if you have any studies. But I feel more comfortable saying this now:

Yes. We’ve become increasingly self-centered. We are fearful.

One of the things we seem more and more afraid of is not being an individual. Of not being special. Of not having a special place somewhere, anywhere, everywhere. I jokingly refer to this as special snowflake syndrome, but it can of course be very ugly: If I think you are more special than I am, it scares me. I don’t like that about you. I don’t trust you. I will tear you down in order to build myself up. We’re all familiar how the internet feeds this, with its windows into the Very Happy Experiences and Perfect Lives of Others.

Some time ago, I began to observe this around me, in my life and in others, particularly with women. It bothered me, so I took pains to see if, on a small and personal level, I could correct it. Sometimes I’ve been successful: I’m better at telling women I admire them, or learning from people who are better at doing things or being a certain way than I am. Sometimes I’ve not been successful, and yes, it’s a nasty experience for everyone involved. But when it works, it is amazing the trust it engenders in others: It goes back to the connection I discussed last week, but it also touches on this idea of fear. What do you lose if you stop being afraid that you’re not so special? Or that your specialness doesn’t rest on being a perfect individual catered to by the universe at every single moment? You lose a lot of bad stuff, actually.

On a less personal - and less self-helpish (sorry) - level, I think this is partly how we begin to rebuild systems Welsh talks about in the rest of his comment. Systems that no longer exist, in which people who go out of their way to help others are not outliers, are not punished for caring in systems that reward mediocrity. We simultaneously need to be willing to be people whose first instinct is to care for others and accept that the universe is not putting us first at all times, and perhaps not ever. We have to stop being “TO ME” Nation.

When you walk into the doctor’s office, for example, and you get pissed off that the doctor has only 15 minutes to see you and is 45 minutes late, what do you do? I’m not talking about a particularly rude doctor or one who doesn’t give you the right information. I’m talking about very specifics. Do you spend part of that allotted 15 minutes complaining about the wait and then demand the doctor spend longer than your scheduled time discussing other problems, because you are important? Tiny insight into how the system works: Doctors have to see a specific number of patients every day in order to cover costs, such as malpractice insurance. They are reimbursed for particular types of visits in particular ways by insurance companies, and they can get around that but it depends on the doctor and whether they get around it in the patient’s favor or in their own favor. They don’t see you for 15 minutes because they just decided to be “efficient.” Sometimes they’re running 45 minutes late because the office is poorly run, sometimes because of another patient’s emergency, sometimes because other patients were late and then each of them wanted or needed the doctor to spend more time in the exam, or sometimes they themselves have a hard time staying focused.. Having observed physicians, it’s a rare one who can quickly and skillfully extract him or herself from a patient visit without making the patient feel slighted or like they got less than.

My point here is that it’s more than the connection I discussed last week. And yes, like I’ve brought up, being a patient in today’s healthcare system can be awful. I know. And there are plenty of self-centered, “to me” doctors. I’m not letting them off the hook. But we’ve build a system that sets us up for these failures, and we keep pushing it along. In these everyday healthcare settings, the “to me” moment arises, and we let it shine through. I’ve done it. We all have. We don’t think about it. Rather than say “hey, what a crap system,” we look at the individuals. We think “I’m paying for this, whether through a deductible or a co-pay or my ridiculous insurance premiums or what. I’m the patient. I’m the consumer. Me. Focus on me and my needs. Plus, I don’t want to wait. Plus, I just had to take off the afternoon from work and now you’ve inconvenienced me.”

Welsh jokingly (or not-so-jokingly) said, in reference to my last post, that “Be excellent to each other is a fine prescription, but it starts at the top, when we design the systems which run our society.” But I’m not joking when I say we can look at it as a 60/40 divide. Caring for yourself is necessary. As someone who has been a caretaker: Yes, you have to take care of yourself and be aware of your needs. You have to put your mask on first if the pressure drops in the cabin so you can help those who can’t help themselves. But put in 60, take 40. Take the focus off “me” for a minute. We are a society. Not a group of individuals.

Although here’s where I disagree - or if not disagree, then ask for a minor refinement. We can start at the bottom too, because we’re going to have to be the ones to design those systems. We have to want it. If we stay on the path we’re on, behaving the way we do, then who’s going to design it for us? Why would they? We stand up to fight for them and then focus on the fight through our individual lenses. If we are going to write this new social contract, if we are going to build these new systems that allow doctors to once again spend more than 15 minutes with you and to help you focus on preventative care, systems that are better than health insurance, which pulls money out rather than pours it back in, and systems that enable doctors like the one Welsh mentions in his comment, who sacrifices for his patients (and there are more of those than you think), rather than system designed to keep him from doing exactly that, then we - WE - have to be a we. Not just “to me.”

Patients and Physicians: Frayed Edges

Tue, 13 Dec 2011 13:11:49 -0800

Lately I’ve been thinking a lot about the doctor/patient relationship.

When I conducted my research, I wasn’t able to observe the physicians interacting with their patients due to privacy issues and the approval I was granted by my university’s review board, but I observed the physicians as they conducted a lot of clinical work and spoke to them at length about patient care. I’ve also talked to a lot of people on an anecdotal, non-research basis about doctors, about their own experiences in and out of medical offices and hospitals, and about being patients or caring for patients.

Something’s pretty fundamentally frayed, isn’t it? Maybe even broken.

Somewhere along the line, the relationship we used to build between ourselves and our doctors, or if you’re a patient, between yourself and your patients, is gone. There are so many reasons for it - the healthcare landscape has changed dramatically. The cottage industry of physicians as it once existed is now a realm of private practice vs. bureaucratic medicine. Social and cultural capital has changed: doctors no longer hold the rarified social positions they once did. Even the hold physicians once had on the knowledge that defines their profession is changing. These are big, often scary changes that can seriously affect professional and even personal identities. They’re worth discussing.

But you know what’s also changed? Us.

Yesterday I was talking with a friend, who proposed that the disintegration of the patient/physician relationship was part of the decline of the larger social contract. How do we connect with others? How much do we connect, on an emotional or an intellectual level? Or are we becoming ever more concerned with self-reliance, individualism, and exceptionalism?

Before you jump up and yell about the amazing friends you’ve been able to meet because of the internet, or the deep connections you’ve forged thanks to technology that you otherwise might not have been able to - hang on. That’s not what I’m talking about. Yes, there are a lot of good people in this world. I’m talking about a larger issue, similar to what I discussed the past two weeks: the drawing of boundaries, and then being unable to move beyond them.

Over the past few years, I’ve had the unique experience of being able to both observe doctors and be a patient caretaker and advocate in an intense/intensive medical situation. I’m very sympathetic to physicians, because I think being a doctor is a lot harder than people often realize. People are furious at physicians, but there are so many good ones, so very many more than people realize, who struggle to focus on patients and on quality patient care, in a system that is not designed to focus on either of those things. I’m also incredibly sympathetic to patients, because being a patient in the modern healthcare system is akin to being dropped in another country with no map, no dictionary, and little to no money. Also, you’re naked.

So many people are furious at doctors. They’re angry at the way they’ve been treated by physicians, and rightly so. I myself have had some awful encounters with some awful doctors. But sometimes we forget that every profession has its share of idiots and jerks. That sometimes it’s the office you’re mad at, or the system, and you’re taking it out on your doctor who honestly has little to no control over what you’re upset about. That some doctors start out as jerks and others are ground down by medical school, or by the institutions they work for, or by something else altogether. That your doctor can only see you for 15 minutes at a time, but that’s because of a larger systemic dictate based on compensation by the providers and insurance companies and do you have any idea how expensive malpractice insurance is? That nurse practitioners and nurses are indeed wonderful but just like doctors they too can be jerks sometimes, because no one, and no profession is perfect.

That we as patients can be terrible on occasion too.

That maybe we all need to find a way to reconnect with each other.

Healthcare, like so much in our society, is a fragile ecosystem. We’ve tromped all over it, ripped out delicate relationships, layered on bureaucracy, turned it into a business - and we expect it to thrive. It can’t, not like that. Physicians should be compensated for their work. Patients should always be treated with care, in an industry designed not to confuse and bankrupt but to promote wellness and prevent illness.

We also need to encourage patients and physicians - hell, all of us, in every day life - to reconnect. To be willing to see each other as human beings, not just as “provider” and “problem list.” Your mother-of-two OB/GYN may be on her feet from 7:00 am to 7:00 pm with barely enough time to go to the bathroom, seeing 30 patients, participating in at least one surgery, filling out charts, returning patient calls, talking to insurance companies, and consoling at least one recipient of very bad news. Your patient may have dealt with a frustrated underpaid receptionist and then waited an extra 45 minutes in your waiting room immediately following a bus ride and a tense discussion with her boss regarding taking the afternoon off work for a doctor’s visit despite not having any PTO, and after the appointment she’s going home to make dinner for a husband, three kids, and a sick parent who is going through a divorce.

Technology can help us, but so can seeing beyond our own boundaries.

Symbolic Exclusion in a Diverse Democracy: A Response

Fri, 09 Dec 2011 10:23:48 -0800

Last week, Reihan Salam responded to my piece on symbolic exclusion. He discussed how symbolic exclusion can be possibly used to understand where disagreements in diverse democracies are so hard to resolve.

Salam makes particular note of the idea that social exclusion is not a linear hierarchy but rather a set multiple of parallel hierarchies. I agree: social exclusion is no longer the straightforward class-oriented, cultural and social capital-based experience it once was, whether here United States or in other more overtly class-driven societies. Certainly, a set of divisions based on cultural and social capital remain. However, there are now different types of social exclusion hierarchies, and more importantly there are individuals and even groups with the agency to transcend boundaries.

Culture is no longer simply divided high or low. As Herbert Gans tells us, there are now five “taste cultures.” However, as much as we would like, in our more modern, more populist era, for anyone and everyone to be able to traverse cultural boundaries and consume at will, they can’t and don’t. People with PhDs have different access to culture and thus to cultural consumption than those who have never been to college. I’m not talking on an individual or an anecdotal basis - this is across groups, on the aggregate, as a whole. It’s tempting to think “I, Leah, have a PhD and like terrible trashy TV shows” or “Steve Jobs was a college dropout and knew more about history and culture than people with seven times the education” - or any number of examples in which someone came from a particular background that would belie their sophistication or lack thereof. Whether these are individual cases or even outliers is, as I love to say, an empirical question. The point is that while the “cultural elite” or the “social elite” may not look the same as the did or even be as immovable, object-wise, as they once were, they still exists and they still have effects on access to other resources.

But what of the argument regarding disagreements in a diverse democracy? Salam writes:

This helps explain why many disagreements in a diverse democracy end in an impasse. Disagreements flow from heterogeneity in tastes and preferences, e.g., basic disagreements regarding the meaning and implications of fairness. Recently, for example, I had an exchange with several friends on Twitter (which comes up a lot) over whether or not Harvard graduates who take lucrative jobs in the financial services industry should be the objects of moral condemnation. To me, the idea seems absurd, as it is premised on the notion that our lives aren’t our own, or that the relevant constellation of social and moral obligations isn’t family-centric but rather state-centric or polity-centric or, more ambitiously still, humanity-centric. My own view is that evaluating my choices as an individual in terms of what is best for “humanity” soon collapses into absurdity, as the range of human societies and value systems is irreducibly diverse and complex, e.g., urban individuals living in the metropolitan West will presumably value different practices and ways of life than hunter-gatherers. State-centric utilitarian moral architectures strike me as flawed because they overgeneralize from an American or French experience of stateness, in which the writ of the state is relatively complete. In other societies, as we’ve discussed, the writ of the state is incomplete; rather, the state is a vehicle for one or several ethnic or tribal mafias that compete with others in a constant series of negotiated settlements. This, and not paradigmatic Weberian stateness, is actually the historical norm, and it’s not obvious that it will be inevitably swept away through technological progress or the march to modernity.

Rather than position ourselves as operating only as independent operators or only as agents of the institution of the family, I argue that people are influenced by a wide range of institutions in any given society. In fact, I suggest this can be how we view the concept of “stateness” in the discussion of both social and symbolic exclusion. This provides a more nuanced perspective than two views of “stateness” that Salam offers: whether a “paradigmatic Weberian stateness” or an either/or existence of Western state completeness/non-Western tribal-based mafioso.

When I consider social institutions, I’m referring to a very core sociological concept that relates to what Salam discusses here: “a complex, integrated set of social norms organized around the preservation of a basic societal value.” Included in types of social institutions are family and marriage, education, religion, art and culture, military, medicine, and so forth. These exist in any state, regardless of how “complete” that state may or may not be.

When I work with institutions, I work with what Hallett and Ventresca call “inhabited institutionalism.” Institutions are not these monoliths or macro “logics” that inform us, the little institutional dupes/dopes, and tell us what to do and how to do it. Instead, there is a greater pattern of action and interaction between institutions and individuals. Take “the family,” for example. The institution of the family is not a towering monolith but is very much inhabited by the people who interact not only with each other but with the institution and its meanings. These interactions in turn affect how we come to understand and define “the family.” This is an iterative process, meaning it repeats itself in a cycle. The institution affects us, we affect it, and onward.

I argue then that we can view the state in terms of the institutions we value in the society within whatever our boundaries are at that time. This is one reason Bourdieu’s arguments are so powerful: French society is bound not simply by a utilitarian idea of “stateness” but broader institutions valued within “French” society and how those institutions are valued and interpreted. We can say the same with how we function here in America. What do we value? How do we value it? Why?

Certainly the range of individual choices in this society and across all societies is vast, so vast as to be “absurd.” But there are patterns of choices and behaviors, there are things that influence us and that we influence. To say we are family-centric versus other-centric is to miss the bigger picture. We can have individual preferences as well as be influenced by these institutions, to influence them and to function in society as both self-oriented and unselfish members.

Remember how I said I wanted to talk about organizational...

Fri, 02 Dec 2011 08:05:00 -0800

Remember how I said I wanted to talk about organizational culture? The other day on Twitter, I overheard (overread? eavesread?) this snippet of conversation between Jason Kottke, Anil Dash, and Mike Monteiro. When I read these three comments together, I immediately thought “What about taste? What about symbolic exclusion?” Right now you’re thinking “um, what does this have to do with EHR?” Let me pull the focus way back for a second, and then we’ll focus down again.

These three comments got me thinking about something that has been an integral, central focus for me, no matter where I’ve been in my career: Culture. Culture is one of those things that often seems like the most hand-wavy, indefinable, airy-fairy - forgive me - Berkeley-esque concepts around. I mean, what is culture, right? It turns out culture is definable, although like so many things, there are many ways in which we can define it.

One of my favorite definitions comes from a scholar named Ann Swidler both in “Culture in Action: Symbols and Strategies” and in her later book Talk of Love. What I love about Swidler’s definition is she thinks of culture as a tool kit. This tool kit is essentially a set of resources, like symbols, rituals, and traditions. We’re influenced by these resources and we draw on them - selecting from our repertoire of knowledge, of symbols, of experiences - to create what Swidler calls “strategies of action.” We depend on our cultural settings in order to define not only ourselves but also to develop perceptions of and to figure out how to behave in and adapt to a wide variety of contexts and circumstances.

Now, there’s no way I could sum up Bourdieu’s Distinction here in a sentence or two - it’s long, it’s dense, and, y’know, a seminal work of great sociological importance, plus it’s in storage, along with nearly all my books - but I got to thinking about it. I also got to thinking two long-time favorites: another book (also in storage) Herbert Gans’ Popular Culture and High Culture: An Analysis and Evaluation of Taste and Bethany Bryson’s paper “‘Anything But Heavy Metal’: Symbolic Exclusion and Musical Dislikes”. Because when we ask the question ”why are people jerks about not liking sports?” we’re kind of asking “why do people draw a symbolic boundary around themselves and a particular set of cultural tastes, and then proclaim dislike about the cultural tastes outside those boundaries - or the cultural tastes of people who are not like them?”

That second question doesn’t sound as good, I know. And maybe you’d ask a different question. But that’s what the question sounds like to me, and I hear pieces of Distinction: We have what’s called “taste,” which provides us with a ”sense of one’s place,” or a social orientation. For Bourdieu, this has to do with class, social position, and the properties of those social positions - what people buy, listen to, watch, consume, more. These tastes and preferences are ”cognitive structures…are internalized, ‘embodied’ social structures” that become natural to people. What does that mean? Your taste is something that orients you and it’s also something that becomes a “natural” part of you. That means different tastes are - you got it - unnatural, so we reject them. Bourdieu says the result is a “disgust provoked by horror or visceral intolerance (‘feeling sick’) of the tastes of others.”

Bryson’s proposition then rings in my ears: ”Individuals use cultural taste to reinforce symbolic boundaries between themselves and categories of people they dislike.”

Bryson brings up one of Bourdieu’s most famous concepts, and one a lot of people may be familiar with: cultural capital. She presents cultural capital as “cultural knowledge that can be translated into real economic gains, for example, by allowing access to elite social networks and clubs.” Of course, this cultural capital is knowledge based on consumption of culture, and in order to consume that culture, a person must have access to it. If access is restricted, because of social status, then only certain types of people can gain that type of cultural capital, gain access to elite social networks and clubs, and so on.

So Bryson points out there are two interrelated levels of cultural exclusion. There’s social exclusion, which is based in part on this cultural and social capital (and on capital itself), and there’s symbolic exclusion. Not everyone has access to social exclusion, but we all have access in different ways to different types of symbolic exclusion. Symbolic exclusion is all about taste, like Bourdieu talks about. When we proclaim taste or distaste, when we symbolically include or exclude, we reinforce our own taste and our own self-definitions. When I state that sports are stupid, or that this aspect of pop culture is a waste of time, I’m drawing a boundary. I’m including myself and others like me, and I’m excluding you. If I can’t shut up about it, it’s because I’m expressing my disgust. I really want to reinforce that symbolic boundary.

Now, there are many perspectives on culture - not everyone agrees with Swidler, and there’s been much scholarly work that has challenged aspects of Bourdieu. In addition, the cultural landscape of the United States has shifted in ways such that - as Gans and Bryson, among others, point out - there is less cultural inequality and inaccessibility so we need to differentiate between being excluded from culture and simply not liking something. If anyone who reads this wants to offer more recent works and/or counterarguments - I’ll be delighted. But for those who have an interest in this, these are fantastic places to begin. In particular, I use Swidler in my dissertation research, so keep that in mind in future weeks as we return to the connection between electronic health records, technology, and culture.

Eat the Change You Want to See in the World

Wed, 23 Nov 2011 11:19:39 -0800

I’ll get back to EHR, ethnography, and culture next week. This feels a little more important.

Last night I watched an episode of Chopped that made me cry. Four lunch ladies - who should rightly be called School Chefs - competed against one another. I wasn’t the only one who cried, either. Guest judge and White House chef Sam Kass was totally crying, as were judges Amanda Freitag and Marc Murphy.

The first thing you should know is that the producers managed to find the four nicest ladies in the entire country. They decided to compete, but to compete nicely. They were totally supportive and kind, and while they competed their hearts out, you could very obviously see two things:

1. They were honored - and I mean HONORED - to be on the show, to be recognized for what they do, to cook for the judges, to be treated so well, to be able to show that lunch ladies are more than just lunch ladies.

2. They care about the kids in their schools in ways I cannot begin to describe.

I don’t want to tell you the outcome or too many details because I want you to go track down that episode and watch it, sniffling into a tissue the whole time at the incredible decency and kindness of these people who work so hard for so little money and even less respect to FEED CHILDREN. In fact, I think this episode should be required viewing for all of us, whether we have children or not. Particularly those of us who love food. Because I’ll tell you this: It made me think a lot about what it is I love about food, and realize I was missing out on one of the biggest parts I love.

When I watched it, I couldn’t help but think the following:

What’s wrong with this country? 1 out of 5 (Marc Murphy says 1 in 4) children doesn’t have enough food?

What’s wrong with this country that we don’t stop and think about this whole crazy food movement and how we’re so delighted by this restaurant or that, and this new wild ingredient or the other, while School Chefs like these women are cooking on bare bones budgets, trying to make the best with what they have, trying to change the face not only of the “lunch lady” but also of the school lunch itself?

What’s wrong with this country that we’re yelling about how broken our healthcare system is but very few of us - how many, really - are talking about fixing the whole system. And that means starting at the beginning: If we work to ensure kids have enough to eat and enough of the right stuff to eat, if we help kids develop healthy eating habits, perhaps we can encourage wellness and even preventative care at a much earlier age. Yes, healthy eating and good habits need to happen at home too, but why not work to help every kid have the chance to eat well and be healthy when they’re growing and learning and need it most? Parents are supposed to raise children, but think how much you learned in school. Not in the classroom but from your environment, from your friends and enemies and peers, from your teachers and counselors and even lunch ladies, from the people who took an interest in you and from those who were cruel or who flat out ignored you.

I know, it’s the day before Thanksgiving. It’s my favorite holiday, and the reason for that is it’s always been about two of my favorite F-words: food and family. Yes, it’s also our national stuff yourself to the max day, but the point of it is sort of to stuff yourself with a lot of love and then lie around and feel thankful about the bounty in your life. And there I was, last night, thinking about kids who don’t have anywhere near enough. Not just on Thanksgiving, but every day. Honestly, the whole fetishization of food has been bothering me for a while, but last night it felt pretty selfish. Food is best when it’s full of love. Man, food is love. Here we are, full up and those kids don’t have enough.

I don’t have children. Whether I ever will is up in the air. I’m saying this as someone who has gotten to know the healthcare system pretty well. You don’t need me to tell you it’s got some problems. I’m convinced systemic change - cultural change - is the way to fix the problem. Not just insurance, not just electronic health records, not just the relationship between doctors and patients, although all these are important. I mean the way we view health and wellness. The way we relate to our bodies and our own well-being. The kinds of foods we eat, when we eat them, how often, in what quantities. Habits are tough to form, but they’re tougher to break. There’s no way to convince kids that pizza and ice cream and all that good stuff isn’t great. But there is a way to help kids eat well, even if they may not have the resources to do so when they’re not at school.

If you notice when you search “childhood hunger,” ConAgra pops up a lot. Where are the rest of us? Those of us who like to declare we eat organic this and local that? I know small organizations are out there, but if we’re so righteous about our own diets, let’s not be selfish. Let’s work to support, enable, create, finance networks that can bring food to kids at a price that allows smaller farmers and producers to participate and not just huge organizations that the rest of us sniff our noses at.

This is a part of the healthcare system we can fix. Those ladies - dammit, those School Chefs - inspired the hell out of me. Here are some places you can learn more about how to help. And you have more information or more resources, please let me know. I’m interested too in local volunteering opportunities. I’d like to spend Christmas with the Little Brothers Friends of the Elderly but I’d also like to get involved in volunteering with food programs for schools here in the Bay.

First watch that episode. Go get inspired. It’s been a tough go for a lot of people, but I’m feeling a little extra thankful this year.

Feeding America: Childhood Hunger Facts

Campaign to End Childhood Hunger

Share Our Strength: No Kid Hungry

Ethnographic Research: What is it? How do you begin? And why?

Wed, 05 Oct 2011 16:18:00 -0700

About a month and a half ago, I went to a workshop just outside of Santa Barbara. The workshop was for ATLAS.ti, the software I use to code data from the qualitative research I conduct. It was a great workshop, and I highly recommend it - in fact, if I could take it again, I would. That’s how good it was.

But one of my absolute favorite moments had nothing to do with the software. Nick Woolf, the instructor, was discussing the difference between quantitative and qualitative research. I’m someone who has done quantitative work, from working on statistical analysis in SPSS to doing social network analysis in R but became decidedly more captivated by qualitative research, and ethnography in particular. So my ears perked up. How would he define them? Would he “take sides”?

Nope. He presented the two in a completely fantastic, straightforward manner that delighted me. Quantitative research, particularly statistics, uses what are called univocal concepts or factual codes. These are unambiguous and exact, pre-defined and pre-established. We know the concepts we’re researching, but we want to measure them. Qualitative research, on the other hand, is about trying to form those concepts. We’re not trying to measure them because they don’t yet exist. We want to learn about ideas, to form these definitions that are much more ambiguous, at least when we begin.

Ethnography or ethnographic is a type of qualitative research - there are many! - in which we want to understand the ways in which people form those concepts. The point is, in a general sense, to understand human behavior in its natural setting, like where people live or where they go to school. But it’s more than that. Ethnography is about getting the “insider” view of a culture or a cultural phenomena.

You can probably see how this is interesting from an academic standpoint but it’s also useful for businesses. Think of it this way. Imagine you’re a big clothing company. You want to know who buys your clothing, how often they make purchases, what they buy, and who they’re with when they buy it. You could definitely do some quantitative research on that. But what if you wanted to approach if from a qualitative perspective, or even do an ethnography of shopping - or an ethnography of how people respond to brands like yours? You might be able to access behaviors, attitudes, perceptions and other phenomena that would be tough to tease out from quantitative data: Why different types of people make different types of shopping decisions; how emotional experiences influence shopping experiences in positive and negative ways; and how their shopping experiences will differ when a friend joins and when a sister joins, or vice versa.

In order to do that the researcher (or researchers) must provide a detailed and in-depth description of the experience using a number of methods, which includes data collection through participant observation, in-depth interviews, surveys, and institutional data. We often do something that’s called “triangulation of data,” which is exactly what it sounds like: It allows you to confirm what your data tells you by providing more than two points for verification.

So what was I interested in, back in 2007, when I started my dissertation research? A few things. I was interested in how people experience significant organizational change. I was particularly interested in the ways in which they navigate such a change, especially when the organizational change revolves around the introduction of a new technology. How do people learn about the new technology? How do they deal with conflict and problems? How do they resolve issues and make sense of the changes? Focusing on electronic health records and the healthcare industry - which is itself experiencing some fairly monumental changes - meant I could look at how individuals experienced cultural and professional changes too.

I was introduced to an organization in Northern California that had recently formed - another major organizational change - and would be implementing an EHR system within the next year to year and a half. At the time, the two-year-old organization was a network of smaller medical groups, most of which had previously been private practices or newly-formed groups of clinicians who had worked in solo practices or in other small groups. The organization had the same structure it has today: two “halves,” a for-profit medical group and a not-for-profit foundation that provided management services and support. I can’t reveal the location of my research, so I created pseudonyms. In my research, I call the medical group is “Transitions Medical Group” (TMG) and the foundation “Concerned Physicians Foundation” (CPF). As a whole, the organization is affiliated with a larger regional medical group called “Jumbo Medical.”

When I began my research, there were 18 medical offices. I chose six to focus on - three OB/GYN offices, two primary care offices, and one neurology office - although I would eventually conduct some observations and/or collect surveys at 15 of the sites. In total over a period of 18 months, I conducted nearly 400 hours of participant observation and a total of 49 interviews (34 clinician, 10 support staff, 5 administrator/executive). I also collected institutional data and conducted two surveys, both before and after the implementation. I conducted my research using a modified grounded theory approach. This means that I did not go in with a hypothesis that I wanted to try and support. Instead, I started with the data and let it hopefully lead me toward an explanation of the phenomena at hand. As I collected data, I coded it (using ATLAS.ti), and as I coded the data I grouped the codes into concepts and then categories.

What categories did I find? Collectives, battlegrounds, and silos - oh my! Organizational culture is more important than you realize.

My Research: How Did I Get There?

Wed, 21 Sep 2011 14:12:45 -0700

Today I planned to give you an overview of my research project but it occurred to me: before I get there, I should tell you how I got there. One of the first questions people ask when I tell them about my dissertation is how I became interested in electronic health records. Unlike many people who have studied health IT or work with informatics, I didn’t come through healthcare.

I’ve always had an interest in how technology informs, shapes and changes social interactions (and by extension, culture). My first professional experience — writing an advice column for teen-aged boys with a passion for videogaming — was actually an excellent test bed for these interests. My column existed as part of media entity that was oriented around entertainment and would seem to have no interest in social good. But because I was passionate about my work, serious about helping my readers, and willing to embrace the technology available both as a writer and as someone nurturing a community, I truly believe my successes reflected the best potential of technology: positively impacting individual lives while also hopefully informing and entertaining wider audiences.

I addressed questions of love, sexual health, emotional growth — and the potentially contraceptive effects of Mountain Dew — with honesty, respect and fact, all of which were and sadly still can be in short supply for your average teen male.

After my tenure as an advice columnist, I moved back into academic work. I pursued a Master’s degree at Georgetown where I became interested in some of the more theoretical underpinnings of cultural representations of technology. I also continued to explore the ways in which technology impacts people and culture itself, specifically in organizational and business contexts, both nationally and internationally.

At UC Irvine, I followed these threads by studying three main areas of interest: organizations, social networks, and culture. In 2007 I began work on my dissertation research. By that time, I was trained in qualitative research methods and knew I wanted to conduct an ethnography. My combined and ongoing interest in organizational change, technology, social networks, and culture pointed to the healthcare field and specifically to EHR.

But why clinicians? Why focus on physicians and other healthcare providers? Healthcare is a complicated industry with — as everyone knows — an ever-growing number of problems. Even if every solution we can come up with is oriented around patient care, the clinician should somehow be involved in those solutions in a positive, collaborative way. All I could think of was that, ultimately, happier physicians able to do their jobs more effectively might lead to better patient care. It’s simple and perhaps to some, too simple, but why not see if we could solve some problems at the physician level to see if there would be a ripple effect?

As the mandate for EHR grows, the contested landscape of healthcare will not likely calm, and there is a palpable lack of knowledge about how massive technological shifts will affect everyone along the chain of wellness. The outcome of this research is not a unified solution for how or why EHR is useful (or not), or the best way to design or implement it. Rather, it’s another milestone in a long term interest in observing and questioning how people make use of technology. I believe there are answers in those questions that can shape both the technology and ways people use it so that we can realize the best hopes of a technology-infused culture: health, happiness and security for everyone who engages. Even those lonely teen boys, looking for an answer.

So, in order to begin looking for these answers, I set out in late 2007/early 2008 to examine a networked group of ambulatory care clinics that, as a recently formed and unified organization, was poised to transition from an entirely paper record system to an electronic system. In my next post, I’ll tell you more about how I conducted my research.

It's official!

Tue, 20 Sep 2011 13:26:29 -0700

Three weeks ago, I finished my dissertation for good and submitted it, revised and formatted, to the UC Irvine library. Two days later, on September 1, 2011, I handed over my signed paperwork to the graduate office completing the requirements for the conferral of my degree.

As the newly-minted Dr. Reich who has a little more time on her hands now that she’s not working on revisions and meeting that crazy end-of-summer deadline, I thought it high time I got back to this space to write about what I found in my research as well as topics related to my project and qualitative research more generally. I’ll start tomorrow with a summary/overview of my research, including some of the findings and will branch out from there. Please let me know if you have questions or anything you’d like to discuss. I’m looking forward to it!

I should have posted this here! I’ll be writing about this...

Tue, 17 May 2011 12:40:15 -0700

I should have posted this here! I’ll be writing about this sort of stuff too.

Or maybe I should just consolidate and have one site. We’ll see!

ohheygreat:

thedocumentarian:

Voguing: The Message, by Jack Walworth, David Bronstein & Dorothy Low, 1989

Another good film on the gay ballrooms and drag scene of eighties NY. Predates Paris is Burning by a couple of years.

I can’t wait to watch this.

In all of the years I’ve been a graduate student, one of my absolute favorite parts has been the class I created and taught on the sociology of popular culture. It was a summer course and I taught it twice, two summers in a row. It was the first course I taught as a solo instructor, an undergraduate seminar, and I was full of enthusiasm. I got to create the syllabus! I got to prove my mettle! But more than that I loved the material, maybe more than any material I’ve loved except organization theory and critical theory the first time I came across it.

One of texts we read was Dick Hebdige’s Subculture: The Meaning of Style, which he wrote in 1979 and which is rather famous. If you haven’t read it, you should, as it’s also rather fabulous and fascinating. Certainly there are criticisms of it, but those criticisms are also fascinating, so get to reading.

Anyway, one of the points Hebdige makes in the book is that a subculture is not simply a group whose culture is different from the larger culture that surrounds them. A subculture is a group whose culture that exists in opposition to the majority culture. The subculture’s culture is deviant, a subversion of the normal culture.

Definitions are always, of course, up for debate, but I felt it was important to show how the word “subculture” has come to be used almost interchangeably with “lifestyle.” This takes power away from a concept that can show how groups in which the sub(versive) culture is threatening enough to really and truly scare mainstream culture into either squashing it or absorbing it.

I showed my class documentaries and movies about subcultures to give them an idea about how this occurred and what the results were. Yes, I showed scenes from The Filth and The Fury to give the students an idea of how scary punk had been to a conservative public that had never seen such a youth uprising before. I showed parts of Dogtown and Z-Boys, to show how a small, insane skateboard subculture had really maddened the larger mainstream culture of skateboarding and took it over, only to be itself mainstreamed.

And then I showed important parts of Paris Is Burning. I showed black and Latino drag queens having their drag queen ball, clothed and nude, at 3:00 am. I showed them looking at mainstream white culture that excluded them and subverting it by inhabiting it as black and Latino gay men in the ’80s, and then I showed the prices they paid: having a white star take over their style and make it hers or being erased by violence. For students whose closest encounter with “subculture” was often Hot Topic or being told not to skateboard at the mall, it was a huge eye opener into what a subculture could be.

If you’ve never seen Paris Is Burning, I cannot recommend it enough.

Digitizing workflows

Wed, 11 May 2011 17:26:56 -0700

Digitizing workflows:

And we are back!

Sorry for the long delay, especially when things were so new around here. I made an executive decision to get the draft of my dissertation FINISHED - which I did - so my writing efforts were tied up temporarily. But there’s so much to talk about, so let’s get back to it, shall we?

chrisereneta:

leahreich:

It’s 2011. Why isn’t every single doctor in this country on electronic health records?

Because, Leah points out, the transition to EHRs will require a bit more rigorous thinking than “Technology GOOD, paper BAD.”

Right? And that’s the thing that gets to me: What a pervasive attitude and how totally - stay with me, folks - wrong.

Of course, there are aspects of the paper system that are terrible, obsolete, unwieldy, frustrating, unnecessary, even unsafe. Small aspects and big aspects. But to dismiss the entire system as BAD and to hold up the new technology as GOOD, as Chris points out, misses some really important points.

Such as:

Is everything about it bad? Are there good things about it you might be missing, things that are important to its users? What about things that are so familiar and ingrained in their routines that they rely on them in ways you might not have imagined? And will disrupting those routines without understanding why they’re important and why the old system facilitates them cause more problems than you realize?
Is everything about the new technology good? Are there things about it that might be problematic in ways you haven’t thought about, because you’re excited about it for one set of outcomes and someone else might use it for a related but different set out of outcomes? Or even - do you define your goals the same way?

Here’s what I mean. One of the ideas I discussed in my dissertation is that people pattern their daily routines and practices based on the way they interpret the broader institutional logics that surround them. By “institution,” I mean the organizations and the industries that provide the backdrop for my study - so the healthcare and the health IT industries. The big health organization my research sites were a part of is also included.

Two of the big “logics” about EHR in both healthcare and health IT are that EHR improves efficiency and patient care. This makes sense, right? Those are great reasons to implement a new technology, to go through the pain of such an enormous cultural and organizational change, if it will make your work more efficient and ultimately improve the reason you do your job.

But what if a doctor interprets a logic in one way and an administrator interprets it in another? Take efficiency. What if a doctor wants to be able to refill prescriptions as quickly as she did before, and an administrator wants to be able to get information to billing faster than ever? What if a doctor wants to be able to enter data in the way that makes sense for quick charting the way he defines quick charting and an administrator wants to be able to have data entered in a way that streamlines charting for everyone, even if there were 50 doctors charting in 50 different ways prior to the implementation?

Either you’re going to have to come to a compromise or someone’s going to win out. In the situation we’re describing here, chances are whoever’s in charge of the implementation will win out, and I have some idea of how that’s going to work out down the line.

Oh, as for the good/bad dichotomy, let’s not forget one other important thing: The human factor. Hey, the paper system is a technology, it’s just an outdated one. One problem with the system has always been the human factor. People make mistakes. People misfile. People lose things. People forget.

The thing with new technology, particularly computerized technology, is that we see NEW! COMPUTER! and we think oh hey look, silver bullet! As if it’s the instant solution. But the EHR will still be run by humans, right? Who will have to learn and who will still make mistakes, no matter how much better the new technology may in fact be.

The new technology is an improvement. It can be even substantially better, leaps and bounds. But the good/bad is a mistake, and it sets you - us! - up for failure.

Even at the very basic level, it’s shocking to see how little people seem to know about the workflows clinicians perform now, with the charting systems they already have. Or even what a workflow is.

What I like? Is when a management team maps out a workflow on a wall-sized chart after interviewing a few individuals on the team, and expects that by simply showing the other members of the team the chart that everyone will jettison their own individual work habits and communication channels and behave as the chart expects them to.

I watched this happen except for the part of getting shown the chart in some cases. Some people didn’t get shown workflows before implementation. Oh wait, technically they did - the DAY they implemented.

Also? When the management team spends three-plus years developing a content management system built to service the workflow that only the chart believes exists. With the aid of technology teams and UX consultants, who by referring to the chart as their functional spec never get the opportunity to realize that the core functionality/metaphor of the software might be wrong.

Because for the small group of team members whose work is redirected through the system first, meetings begin to sound an awful lot like yelling.

I love when Chris writes about this stuff. Chris, please write more. This is so true. This is what I saw and it’s avoidable. Or at least it should be.

So over the past week, while I’ve been working on edits to my dissertation and prepping for a...

Mon, 21 Mar 2011 12:09:55 -0700

So over the past week, while I’ve been working on edits to my dissertation and prepping for a job interview on the other coast, I’ve been thinking a lot about the great responses you guys gave to my first post here. Before I go off in another direction, I want to reply to some of them.

healthpolitics:

Health care is a complex system. And American health care is a distinct beast from British or French or Canadian health care. We must approach it with some humility, and study the way pieces fit with each other and operate in their environments before we start changing things. There’s a reason the ACA works the way it does — stepwise efforts and pilot programs are a much more sane approach than massive delivery overhaul. The same goes for EHR.

Here’s one of the most important things to remember too: It’s not just that it’s a complex system in the way it’s used in each location. It’s also the second most decentralized industry in the country, second only to the floral industry. For much of healthcare’s history, it’s been a cottage industry. The introduction of major government oversight, in the forms of Medicare and Medicaid, and the emergence of HMOs that paved the way for the corporatization and bureaucratization of medicine have done a lot to change the landscape. But much of medicine is still practiced in those small private practices. It’s that kind of a complex system.

EHR also presents some unique difficulties. The main one is a hold-up problem. I have written about this before. Insurers and patients benefit, as Leah points out, and the situation for doctors is a bit messier. I happen to believe that they benefit in the long-run from increased efficiency and a lighter workflow burden (administrative tasks consume massive amounts of physicians’ time and are among the chief things they complain about when discussing low job satisfaction) but are punished in the short-run because the onus of learning the new system and adapting workflow is placed solely on them, and they are much, much too busy to put up with it. I am sympathetic to their resistance. It is a clear case for a subsidy program, although this has already been tried with limited success, perhaps because physicians don’t really want extra money to spend extra time learning a new system; they value that extra time far too much.

This is such a great point: “the onus of learning the new system and adapting workflow is placed solely on them, and they are much, much too busy to put up with it.” Also, let’s not forget that physicians are a valuable resource when it comes down to it. You don’t want to keep waiting all those hours to see your doctor, right? Then we shouldn’t have systems that keep physicians doing administrative tasks and keep them away from clinical tasks.

Here’s the way I look at it. Imagine this scenario:

Someone comes to you and says, “You need to change the way you do your job. We’re pretty sure it’s a good idea to do this change, and we think it will benefit someone - maybe you, but actually maybe some other groups - but we can’t absolutely guarantee it.”

You say, “Well, ok. I can see the way I do my job could stand for some improvement, but the routines I have set up? I’m quick. Maybe it’s old-fashioned, but I feel I can do my work efficiently and effectively.”

The person says, “That’s nice. But times are changing. We need to change those parts. It’ll take about two years for you to feel proficient again. You’ll probably see benefit in these other areas! But just maybe not in the efficiency areas. You might not ever be that quick again.”

How would you feel? I will hazard a guess. You’d probably feel, I dunno, not okay. Screw changing times! What is this? A punishment?

This is obviously an extreme - and extremely negative - example of how EHR implementation can be presented. But I’m not making it up. There are physicians who have been through it and still feel this way.

Of course, there are really positive examples of EHR implementation, of physicians who absolutely LOVE IT. Who feel 100 times more efficient after than before. I’ve interviewed those people. There are entire systems that are renowned for their fully successful implementations and their almost impossibly happy clinicians.

At the same time, there are also people who feel they’ve gotten lost in a maze of clerical duties, in tasks that take them away from patient care. They feel they can’t enter data in a way that properly reflects their patient visits. They feel overloaded with tasks they never had to perform before, tasks they see as administrative, tasks they feel leave them little time to perform clinical duties. They feel that what made them quick can never be regained, and they don’t feel the benefit has been worth it, because of system design or because the benefit is neither to them or to the patients but to administration. So why change? Why go through the pain and misery when the system they have serves them well enough? These are important questions to answer.

The doctors who love it are male, female, younger, older, white, black, Asian, and work in primary care, OB/GYN, neurology, rheumatology. The same goes for those who don’t love it. It’s not just about the technology or the money, as healthpolitics points out, although both of those are important factors. Time is an incredibly precious resource. Other important issues are how people interpret patient care, and concerns regarding professional identity, division of labor, and authority.

One big problem I think needs to be addressed - and that I plan to write on separately - is how distanced we as patients have become from physicians. As angry as we are at insurers, there’s a lot of blame and finger pointing at doctors. This isn’t to say there aren’t doctors who don’t deserve every ounce of the anger we send their way, or that the healthcare industry hasn’t made its share of missteps. Rather that after spending 18 months in ambulatory care practices, I discovered a newfound respect for just how hard many physicians work and how much they care. Transitioning to EHR is a difficult endeavor in an already tough job. I’d like to find a solution that is as much pro-patient as it is supportive of the physicians who will bear the brunt of the change. To me, that’s the only way we will be successful. Supported, happier, more effective doctors will be better equipped to take care of their patients. Whether they do so in managed care, large medical networks, or small, pay-for-service practices - doesn’t that sound like a healthier system than the beleaguered, finger-pointing, vitriolic one we have now?

One thing that isn’t mentioned in Leah’s post is hospitals. I think facilities actually lose when EHR is implemented because in the status quo they routinely replicate scans and procedures done at other facilities at significant profit. Streamlining the system means less procedures, hence the benefit to patients and insurers, but the big losers here are hospitals, which already operate at fairly low profit margins.

As I mentioned, I spent my research time in ambulatory care, so I have yet to gain expertise in EHRs in hospitals. I hope to in the future, but until then I leave this area to someone who has more knowledge. While related and connected, they are different beasts. So please, keep this info coming - I find it fascinating.

I look forward to hearing much more from this blog.

Thanks! Please, keep responding. This is such a critical dialog.

E-H-R, where are you?

Wed, 16 Mar 2011 11:09:00 -0700

It’s 2011. Why isn’t every single doctor in this country on electronic health records?

You’ve probably wondered that at some point. When you’ve gone to the doctor and wondered why, as she flips through a manila folder, she doesn’t just get a computer system. Or why her information can’t easily be sent to another doctor and no one knows what anyone else is doing and it is so, so frustrating.

Or maybe you’ve read articles in the news or even posts here on tumblr, questioning and arguing and demanding the healthcare system get off its duff and get digitized. Some of the people who’ve written about it are policy people, some are in health care, some are doctors themselves. Many argue vehemently about how much we need EHR and how ridiculous it is that we don’t yet have it.

Last year, Generic asked me what I thought of this Ezra Klein column in The Washington Post. In it, Klein writes:

In part, you’re dealing with the fractured incentives in the system: It’s good for patients and good for insurers if doctor’s offices spend money setting up computer systems, but it’s not necessarily going to make doctors any money, and the doctors themselves are frequently older and don’t want to learn a new system. That’s one reason why systems where the insurer and the provider are the same — think Veteran’s Affairs or Kaiser Permanente — tend to be ahead of the curve on electronic medical records.

It’s true. EHR systems are prohibitively expensive. Purchasing the software, installing it, training all the users, taking a huge hit in income due to a massive decrease in efficiency as you learn the new system. Let’s not forget transferring data over if you don’t have a legacy system. It’s not just the making money—it’s making money back. Now, under ARRA, there’s money to help smaller practices without deep pockets install these systems.

It’s also true that EHR is good for patients and good for insurers. We like things that are good for patients, and we should. We should support those. But keep that “good for insurers” part in mind. And note: There’s no “it’s good for doctors.” Can something that’s possibly not good for doctors ultimately be good for patients?

But when Klein says that doctors are older and don’t want to learn a new system - when you read something like this, stop for a minute and think. Me, I ask this question: Are you making an assumption? Are you stereotyping doctors? Is that reallythe reason they don’t want to change? Or “part” of the reason? Maybe it is, but it would help us to know if that’s real data, or just an opinion. I’m not being a pedantic annoying academic - I’m thinking about this in terms of a real, applied, fixable problem. What if the issue isn’t that doctors are old and don’t like learning a new system? What if it’s something else, and something we can’t just dismiss outright but a problem we can try and solve?

Hey, we might be able to do something with that.

As for Kaiser Permanente - it’s not just the fact that it’s provider and insurer all in one. It’s also the fact that KP is totally vertically integrated. Everything occurs within the KP system. How much easier is that problem to solve, systems design-wise and organizationally speaking, than a multi-site network scattered across urban/suburban locations where patients use external labs, scanning facilities, and pharmacies? And even with vertical integration and centralized medical centers, I don’t think KP would say their road to electronic records has been “easy.”

Klein also notes that it’s ridiculous the medical system isn’t digitized, while banking is. Here’s where it gets really interesting, especially if you like to think about how systems and organizations work.

Take the banking system. Set aside for a moment the fact that the banking system started on the road to computerization ago. I’m not in any way an expert on banking. In fact, I welcome anyone to explain the banking system to me, as well as most anything on financial institutions. But even as relatively not-knowledgeable as I am, I know this: The banking industry is fairly transaction-oriented, right? Transactions that move data from one spot to another, tracking and monitoring it, and sometimes moving it back. That’s something you can build a computer system around.

Think about it. What does Ezra Klein mention? He specifically mentions only that you want to go in and make a transaction. He doesn’t say that when you walk in to the bank, the teller tracks your entrance, makes a note that she spoke with you, looks up your name, logs the result, and so on. There’s basically one action she performs.

A medical record - that big fat manila chart - is a totally different beast. Do you have any idea how it gets created? How it gets maintained? How things are sorted and filed? Then, say, if a patient needs a prescription refill, or a referral, or some kind of insurance form, or help with something regarding the nursing home, or a Medicare form, or a letter sent to an employer. Who does what? How do different people in an office communicate? What are the tasks? What are the resources? Hell, does anyone even know what a workflow actually is?

I’m not being flip, I’m being deadly serious.So much of the conversation about EHR and why the healthcare industry doesn’t have its act together rests on issues of “the technology” or “do you know how much money they cost” or “doctors are so resistant.” These are all massively important. But does anyone know why they’re important? Why they happen? How they relate? Not really. Only sort of.

Even at the very basic level, it’s shocking to see how little people seem to know about the workflows clinicians perform now, with the charting systems they already have. Or even what a workflow is.

Transitioning an office to an electronic medical record system is a fairly monumental task. There are different definitions for success. Me? I do not define success as “We got the technology installed and people are using it. For the most part.” I’m still working on my definition of success but I know it involves things like: implementing system that addresses pre-existing problems, tries to solve them without replicating them or worsening them, and, if it does make some tasks more difficult, provides support where necessary.

So here’s a challenge for all you UX people out there: If you really care about UX as much as I know you do, dedicate some time to working on the user experience for something that really, really matters: the electronic health record. So many people bitch about healthcare and the state its in, but it’s not really a sexy fun industry. If doctors don’t have EHRs they can use that won’t drive them crazy - I’m talking Windows 3.0 based stuff here, folks - how do you think they’re going to implement a system that will replace this “insane paper system” that you find so ridiculous?

You want a better system? Then help me create one. I’m being serious. I’m not just talking about the computer program itself. I’m talking about the larger system. The organization in which an EHR is embedded. The healthcare system in which the medical organization is embedded. The society in which the healthcare system is embedded.

Systems. Organizations. Society.

Call to arms. Let’s do this thing.