Guns Move In to First Place.

April 21, 2022

Recent studies in Pediatrics and the New England Journal of Medicine show that thanks to a sharp decline in deaths from motor vehicle crashes, and an increase in gun deaths (especially suicide), in 2019 guns became the leading cause of death for all US youth age 0-19.  More than childhood cancer, drowning or poisoning – combined.  This has generated some media attention, which I have mixed feelings about; after all firearm injury has been the leading cause of death for Black youth since 2001.  Also, while I’d love to think this might jolt policy-makers into action, it is unlikely, despite the inevitable hand wringing, that we will see any of the common sense measures to reduce this epidemic such as those proposed by the study authors, the same types of regulatory measures that have dramatically improved motor vehicle safety while still allowing free access to automobiles.  Perhaps it’s time to follow the advice of singer-songwriter Cheryl Wheeler.

Why Black History Month Matters

February 28, 2022

In 1721, Boston was facing an outbreak of smallpox.  Onesimus, a Black man originally most likely from what is now Ghana, then kidnapped and enslaved, told his enslaver of a practice common in parts of Asia and Africa for centuries, of inoculating an individual with matter from a healing smallpox lesion to prevent them from getting the disease, a practice known as variolation.  A physician was convinced to try it, and it helped mitigate the outbreak.  This was 75 years before the much more widely known English physician Edward Jenner developed the technique of preventing smallpox by inoculation with matter from a cowpox lesion (also known as vaccinia, hence the name vaccination).

Many people see Black History Month – established in 1976 and observed in February – as a chance to learn about people like Onesimus and his achievement.  I certainly appreciate learning about and celebrating the many ways that Black women and men, both individually and collectively, have enriched and contributed to the history of this nation. But its significance is far greater than that.  It is a time to reflect on why, for example, I have known about Edward Jenner since middle school but only learned about Onesimus this month. It’s a time to reflect on why we need a Black History Month.

I recently finished Caste: The Origins of Our Discontents, a 2020 book by Isabel Wilkerson. (This is where I heard the story of Onesimus.)  She provides a compelling framework for understanding the answer to that question, and for understanding much about the persistence of systemic racism in the US.  In short, she draws on the work of numerous scholars to show that America is a caste society, one where the defining characteristic determining caste is race.  For centuries, Blacks were kept in the lowest caste by legal means: at first slavery, then a host of discriminatory laws collectively referred to as Jim Crow, economic and physical segregation, and acts of sanctioned violence. These were reinforced by many social conventions designed to buttress Blacks’ inferior status.  This included denigrating the intelligence or attractiveness of Black people through humor and popular culture, and enforced deference and subservience on the part of Black people toward Whites.

Since the 1950s and 60s, when the legal means of suppressing Black people have largely evaporated, it is left to these social conventions – the many insults, overt and subtle, we now refer to as microaggressions – to prop up the caste system.  I have to admit that I have wondered why microaggressions have been such a focus of antiracist action.  After all, it’s not as bad as segregated facilities and poll taxes, right? Understanding the outsized role microaggressions play in maintaining White supremacy in an era where the laws are (at least technically) race-neutral, helped me appreciate the importance of confronting them.

The fact that Edward Jenner is widely known while Onesimus is generally ignored is one of those microaggressions. Highlighting the historical achievements of White people while downplaying those of Black women and men is a way to reinforce the heinous myth of White superiority and Black inferiority.  Admittedly, Jenner’s technique was far safer and represented an improvement.  But why did the supposedly inferior races in Asia and Africa have a method for preventing smallpox for hundreds of years before the Europeans figured it out?  Better to distort the historical record than to raise an uncomfortable question like that.  Black History Month is a step toward correcting the record.


January 26, 2022

Dear Dr. Watson:

As Dean of the medical school, you have a responsibility to train the next generation of health care providers.  I believe the time has come for some significant changes in our curriculum.

First, we should prohibit physicians from asking questions about illness and health.  We are taught, “first, do no harm.”  But talking about their symptoms might make some people uncomfortable.  They might feel guilty about the fact that they still smoke, or experience mental anguish when confronted with the need to reduce their salt intake.

Similarly, we should not be prescribing treatments that have any side effects, even if it is a minor discomfort.  It is not right to make someone uncomfortable solely because they have an illness.

You could argue that if we don’t ask questions about health or provide treatments, patients would not get healthy.  But honestly, I think we are making too big a deal about health.   These days, it seems everyone is trying to make everything about health. You can’t turn on the TV or the radio, or look at social media, without someone raising the issue of health. Health might have been an issue a long time ago, but now that we have antibiotics, illness isn’t a problem anymore.  People need to just get over it.

Now that we have finally stopped making people uncomfortable by talking and teaching about race, thanks to legislators in Tennessee, Texas, Wisconsin, and other places, it’s time to stop making people uncomfortable about their health status.

MLK’s Legacy Misappropriated

January 17, 2022

Today is a day set aside to remember the Rev. Dr. Martin Luther King, Jr., and to reflect on his legacy.  It’s also important to call out when that legacy is being misrepresented, as has been happening by those who want to limit the teaching and discussion of the subject of race in schools.

Over the past couple of years, and particularly following George Floyd’s murder in 2020, the notion of systemic and institutional racism became a topic of national conversation.  Recently there has been a backlash, as school boards and state legislatures have passed a number of bills intended to restrict what is taught about race and how.  Tennessee House Bill SB 0623, for example, prohibits teaching that could lead a student to “feel discomfort, guilt, anguish or another form of psychological distress solely because of the individual’s race or sex.”  In Texas, House Bill 3979 forbids teaching that “slavery and racism are anything other than deviations from, betrayals of, or failures to live up to, the authentic founding principles of the United States.”  It also specifically bans requiring assigning the 1619 Project, based on a series of articles in The New York Times Magazine, as a resource.

How American history and the topic of race are taught is a legitimate and important area of discussion.  But what is disturbing is that proponents of these laws are citing none other than Dr. King to support their stance.  Here is a representative quote: “Martin Luther King once said that he had a dream that his grandkids would be judged not by the color of their skin but by the content of their character. But what you have going on … they’re trying to make everything about skin color.”  And another: “Critical race theory goes against everything Martin Luther King has ever told us, don’t judge us by the color of our skin, and now they’re embracing it.”

As is true of most things in life, context is everything. Yes, Dr. King spoke hopefully and eloquently of a day when color will not be relevant.  But he had no illusions that such was the case today.  Consider the opening of that same speech:

“Five score years ago a great American in whose symbolic shadow we stand today signed the Emancipation Proclamation. This momentous decree was a great beacon light of hope to millions of Negro slaves who had been seared in the flames of withering injustice. It came as a joyous daybreak to end the long night of their captivity. But 100 years later the Negro still is not free. One hundred years later the life of the Negro is still badly crippled by the manacles of segregation and the chains of discrimination. One hundred years later the Negro lives on a lonely island of poverty in the midst of a vast ocean of material prosperity. One hundred years later the Negro is still languished in the corners of American society and finds himself in exile in his own land. So we’ve come here today to dramatize a shameful condition.”

He went on to call the Declaration of Independence and Constitution a “promissory note,” pledging the blessings of life, liberty, and the pursuit of happiness to all people.  But, King said, “It is obvious today that America has defaulted on this promissory note insofar as her citizens of color are concerned. Instead of honoring this sacred obligation, America has given the Negro people a bad check which has come back marked ‘insufficient funds.’” It was only after he laid out what he saw as the reality of persistent racism in the present that he went on to share his beautiful, hopeful dream of a better future.

If we look at some of Dr. King’s other speeches and writings, the context becomes even clearer.  In his 1967 speech “The Other America,” for example, he notes “we will never solve the problem of racism until there is a recognition of the fact that racism still stands at the center of so much of our nation, and we must see racism for what it is.”  However, in “Where Do We Go From Here,” written that same year, he laments that not everyone sees the same reality. “Whites, it must frankly be said, are not putting in a similar mass effort to reeducate themselves out of their racial ignorance. It is an aspect of their sense of superiority that the white people of America believe they have so little to learn.”

Yet learn we must, adults and children, White and Black. We must understand our American history and our American present if we hope to create a better American future of the type Dr. King dreamed of. How we do that – what we teach and how – is a complex subject, and a debate we should have. But that debate needs to be honest.  Dr. King may have had a wonderful dream, but he was not subject to illusions.  We should not misuse his words to defend a position he would not support. Today is a day to honor Dr. King’s legacy. Let’s make sure we get it right.

COVID Orphans

December 27, 2021

Since early in the pandemic, there has been a myth that kids are not affected.  It is true that severe COVID-19 illness, including need for hospitalization, is less common among children than adults.  That doesn’t mean it doesn’t happen: we have been averaging around 15 kids in the hospital on any given day, with up to a third requiring intensive care. And it remains unclear whether the phenomenon of MIS-C (multisystem inflammatory syndrome of COVID-19) that affect primarily children will have the potential for long-term effects like its cousin, Kawasaki syndrome.

But there are known serious and long-lasting impacts of COVID-19 on kids.  First, the rate of overweight and obesity has skyrocketed: the rate of increase in BMI among children under 19 years has doubled in the past 2 years compared with pre-pandemic increases (which were already alarming).  There has also been a dramatic acceleration of mental health problems in children and teens, including eating disorders, anxiety, and depression.  At our hospital we have seen an over 30% increase in emergency department visits for acute mental health issues, and a 50% increase in children and adolescents requiring hospitalization for a mental health condition, similar to our peers across the country.  And keep in mind, in the year before the pandemic suicide was already the second leading cause of death among youth ages 10-24.  This has led the American Academy of Pediatrics and the Children’s Hospital Association, along with other organizations, to declare a mental health crisis for kids.  Having seen it first hand, I think the often-overused word “crisis” is not too strong here.

On top of this, we now know of one more devastating effect of this pandemic: a recent study in Pediatrics estimates that over 140,000 US children – 1 in 500 – has lost a parent or primary caregiver to COVID-19.  As with the mental health crisis, kids from underserved communities, including Black, Latino/a, and Indigenous youth, are disproportionately represented among these COVID orphans.

These impacts on the physical, mental, and social well-being of kids are of the type that are likely to be life-long.  We keep wondering when this pandemic will “end.” But for too many kids, the answer is not for a very, very long time.

DRIVE for Results

August 27, 2021

It may be true, as Heraclitus said, that change is the only constant, but the pace of change is variable.  The current environment is one of exceptionally rapid and momentous change.  A key lesson from the COVID-19 pandemic has been the importance of agility for organizations of all sizes.  For large healthcare organizations, which tend to be relatively change-averse and less than nimble, this has created unease and dissatisfaction with the speed and quality of decisions affecting both current and future operations.

What gets in the way of rapid and effective decisions?  Often, it is lack of clarity about how the decision is to be made.  For important decisions, especially in large or complex settings, it is most helpful to have an explicit framework to guide the process.  One that I have found useful is described by the acronym DRIVE.

Decision.  What exactly is being decided? Who has the ultimate authority to make the decision?  Is it an individual or a group, and if a group, how will the decision be made – consensus, majority vote, etc.?  Are there any parameters that will define limits on the decision (e.g., budget, regulatory considerations)?

Recommendation.  Often the decision will be to accept or reject a recommendation, or choosing one of several recommendations.  Who will be charged with making the recommendation and presenting it to the decision maker?  (For a relatively straightforward issue, the recommendation is likely to be made by the decision-maker themselves.)  What is the timeframe for developing the recommendation?  Since the drafting of a plan (or several plan options) is a creative process, the recommending body should have the right expertise to inform the product, but be small enough that the work is not slowed down.  The recommendation should include a summary of the input provided (see below), and it may be helpful to have someone play the role of “devil’s advocate” to ensure that the full range of input is considered.

Input.  This may be the most critical element to define.  Whose input will be sought as the recommendation is developed and the decision ultimately made?  This group can and should be broader than the one drafting the recommendation, and should be able to reflect the perspectives of all key stakeholders, as well as the appropriate content expertise.  On the other hand, it need not be exhaustive; those providing input should be able to speak on behalf of individuals or areas other than their own.  For example, a decision regarding changes in the operating suite should be informed by input from both employed and independent surgeons, as well as those who do primarily inpatient vs. outpatient cases, but not necessarily every single surgeon on staff.  Explicitly identifying what input is being sought and from whom will help avoid information gaps during the process, while heading off complaints about missing perspectives from people who may disagree with the ultimate decision.

Those whose input is sought need to understand their role, which is to provide information that may be relevant to a decision that has yet to be made.  While not every piece of input will be incorporated into a decision, every piece of input should have the potential to influence that decision. If the recommendation is already finalized or the decision made, seeking additional “input” would be disingenuous.

Vetting.  The development of the recommendation is often an iterative process.  After an initial round of input, a draft recommendation is developed, and can be refined based on additional rounds of input.  Once the recommendation is final (or close to it), it is often useful to vet it with another group of stakeholders before the decision is made.  This could include a subset of those who provided the earlier input, or others not previously involved may be brought in.  The purpose of this vetting is twofold.  The first is to prepare the recommendation to be brought forward to the decision-maker for action.  It provides a final opportunity to ensure that no important perspectives were omitted, and to gauge reaction from key stakeholders.  If there are any whose assent will be critical, this is a good time to solidify that.  The second purpose is to start to get thoughts on how the decision will be communicated, and to identify key execution risks that need to be considered.

Execution.  Any decision is only as good as its execution.  Who will be responsible for carrying out the decision?  What key dependencies are there?  What risks have been identified, and what are the plans for mitigating them?  How will the progress be monitored?

While this degree of planning and specification may seem like overkill, it has several important advantages.  First, while we cannot eliminate all the sources of bias that come into play when human judgment is involved, a rigorously defined process can help minimize their effect. Second, as mentioned above, laying out the process including who was involved at each step can aid in obtaining buy-in from those who may not agree completely with the decision.  Finally, having a process greatly facilitates delegation of decision-making. Once the delegator and the delegee have agreed on the various steps, the latter should be empowered to proceed without fear of being second-guessed on how they came to their decision.

Here is an example I recently went through. Due to truly unprecedented summer patient volumes, and pandemic-related staff turnover, we were facing staffing challenges for many roles in various parts of the organization.  Several executives were developing plans for the workforce in their area, but a consistent, organization-wide approach was needed, and quickly.  Here was the process:

D. The COO would be the ultimate decision-maker on a plan to add staff in all patient-facing roles where we had identified shortages, with immediate, short-, and long-term components.  As long as the plan was consistent with our contract obligations, and it did not put us significantly at risk for failing to meet our financial goal of break-even for the year, she could make the decision without my approval.

R. The recommendation would be drafted by a subset of the executive leadership team (COO, CFO, CNO, CHRO), to be ready for a final decision by the COO within 5 days.

I.  In addition to the recommending group, input would be obtained from labor relations, senior director of talent strategy, nursing leaders, legal, finance, and the equity and inclusion team.

V.  Draft recommendation would be vetted with the full executive leadership team (me and my direct reports).

E.  Execution would be org-wide, with particular involvement by the HR team.  Key measures of progress and success would be a decrease in critical staffing shortages, new hires (including position fill rates, time to fill, and workforce diversity), and budget variances.

With this clarity, those involved had their marching orders, and a plan was developed and a decision made within a week – practically warp speed for us!  There was widespread buy-in from HR, front-line managers, and the unions, and based on anecdotal information obtained during rounding, appreciation from front-line staff that the senior team was addressing their primary source of stress.

Don’t Deny It

June 30, 2021

United Healthcare became the most recent insurer to announce a policy of denying payment for what is deemed “unnecessary” emergency department visits.  Within days of its announcement, it said it was delaying the policy change in response to an outcry from healthcare providers and patient advocates. (Anthem put forward a similar policy in 2018, which it subsequently modified substantially under pressure.) While the goal of having the right care in the right place at the right time and at the right cost is reasonable and necessary, the punitive approach being pursued by payers is ill-conceived, unfair, and likely to be counterproductive.

First, let’s be clear about the problem.  I’ve seen no data to suggest that any significant proportion of ED visits are unnecessary in the sense that the patient didn’t actually need medical attention.  Rather, a substantial fraction of visits to the ED (estimates range from around 20% to over 60%) are for problems that could be managed in a different setting (e.g., primary care, urgent care). Because charges for ED visits are typically far higher than for those other settings (I say charges because there is some disagreement about whether the cost of such visits is actually higher, but that’s a blog for another time…), having that care provided in a different setting when appropriate could decrease health care spending while maintaining the effectiveness of the care and perhaps improving the experience.

So why do people go the ED when they could go someplace else?  Policies based on a financial disincentive seem to be predicated on the idea that people are intentionally misusing the system: I know I could go someplace else but my insurance is paying for it so what the heck.  But research has shown that ED visits for non-urgent problems are correlated largely with lack of accessible, quality alternatives; lower levels of health literacy; or a true belief that something is or at least might be an emergency. (Chest pain is an emergency whether it ends up being a heart attack or indigestion.)  In all my years of practicing emergency medicine, I encountered far more people being gamed by the system than those trying to game it.

Which is why such policies are ill-conceived – they don’t address the root cause which is lack of real access to lower-priced options.  They are also unfair.  Unfair to providers because emergency departments are legally and morally obligated to treat all who come to them.  Threatening not to pay them for the services they provide puts them at risk.  Unfair to patients because non-payment may prevent those without alternatives from getting care they need.  And barriers to accessing other sites of care are more prevalent among those with public insurance and those in higher poverty neighborhoods and those with more people of color. Denial of payment becomes one more source of inequity.

What’s worse, such policies are unlikely to achieve their goal of reducing spending, and may even increase it.  To start with, the vast majority of denied claims end up getting paid.  For example, in 2020 when Aetna was sued for inappropriate denial of emergency claims in California, the court found that 93% of the denied claims should have been allowed according to Aetna’s criteria.  However, the process requires the provider to appeal, generating a ton of paperwork and additional expense.  Second, the process for validating the “appropriateness” of the claim is likely to drive unnecessary utilization.  Approval of the claim is based in part on “the intensity of diagnostic services performed” and treatments provided (for example, visits in which IV medications or fluids are given are automatically approved).  We know that a good deal of diagnostic testing is unnecessary; this policy would incentivize additional testing as a way to justify the visit.  It would also incentivize therapeutic escalation – for instance, IV fluids instead of the equally effective oral rehydration.  All of this would actually add to the cost of care.

Excessive spending for care in emergency departments that could reasonably and safely be provided elsewhere is a problem.  Better and more equitable access to less expensive alternatives (effective triage lines, expanded primary care and urgent care hours, virtual care) would be a better approach than punishing patients and providers by denying payment.

Equity – It’s Not a Dirty Word

June 2, 2021

Last week marked the one-year anniversary of the murder of George Floyd.  After the initial shock of his brutal killing, captured on video, and the subsequent global protests against police brutality in particular and widespread racism in general, there seemed to be a change in the air.  White people, including business and political leaders, were openly using phrases such as “white supremacy” and “systemic racism” for the first time I can recall.  They went beyond the usual offering of thoughts and prayers, making commitments to real change.  Granted, actions matter more than words, but at least the words finally seemed to acknowledge the depth and extent of oppression of Blacks and other people of color.  Equity became the watchword of the day.

That in itself, in a way, represented an advance in how we talked about things.  Earlier generations fighting for civil rights tended to talk about equality.  Just treat everyone the same.  But in the wake of centuries of the accumulated effects of unequal treatment, it makes more sense to think about equity.  If equality is treating everyone the same, equity is treating everyone in a way that is based on their need.  Many of us have seen the cartoon depiction:

And here we are, just one year later, and hope is fading fast.  The New York Times, for example, recently documented the sharp decline in support for the Black Lives Matter movement among whites, to levels significantly lower than before Floyd’s murder.  Voter suppression laws likely to disproportionately affect BIPOC voters are spreading faster than kudzu across the South.  And even as Derek Chauvin was being tried in Minneapolis for the murder of George Floyd, an officer in nearby Brooklyn Center was being charged in the killing of Daunte Wright.

It isn’t just that the talk hasn’t translated into action.  In many quarters, the very concept of equity is being portrayed as itself discriminatory and somehow un-American.  Here is an example from the libertarian magazine Reason, commenting on Vice President Kamala Harris drawing a distinction between equality and equity:

“For decades, these two divergent philosophical and public policy concepts were represented by a battle over adjectival phrases. Should we strive for equality of opportunity, or equality of outcome? Though intellectual and political enthusiasm for the outcomes-based approach did have some high-water moments in the 1970s, the long twilight struggle against 20th century totalitarianism produced a rough if sometimes reluctant governing consensus that states powerful enough to promise economic and racial parity were far more likely to produce mass immiseration. Striving for equality under the law—removing legal discrimination by government—was less ambitious, but more doable.”

The author makes two claims: first, that proponents of equity are actually striving to achieve equality of outcomes for all (which he portrays as vaguely foreign and socialist), when the real goal should be equality of opportunity; and second, that equality under the law is sufficient to guarantee it.  Both of these are incorrect.

Let me start with the second.  Unequal treatment of Blacks, other people of color, LGBTQ individuals, and others does not depend on a government stamp of approval.  Segregation in the South, enshrined in law, was equaled by or even surpassed by that achieved in the North despite the lack of “legal discrimination by government” there.  Discriminatory lending by banks, discriminatory hiring practices by companies and unions, and discriminatory treatment by teachers, retailers, and police have produced as much social and economic misery for Blacks as Jim Crow laws. Simply removing officially sanctioned racism has not and will not produce equal opportunity.

Equity refers to true equality of opportunity.  It means identifying not only legal but other barriers that BIPOC individuals face as the result of centuries of racist laws and other practices, and addressing those barriers.  I’ll use the example of the COVID vaccine.  There are no legal barriers that impede access to the vaccine based on race.  However, there are numerous other barriers, including location of health facilities, availability of transportation, and access to information about the vaccine. Equitable vaccine access would mean targeted outreach and resources to overcome these barriers.  It’s the equivalent of providing a second box to be able to see over the fence.

Even true equality of opportunity – equitable opportunity – does not guarantee equality of outcomes for each individual.  I’m not sure that would even be desirable – after all, we are all individuals and wouldn’t want to be exactly the same.  Moreover, there is a need to account for individual effort, desire, etc.  To go back to the cartoon, the person getting the two boxes might not be interested in the game.  She may choose to use the wood from the boxes to build a lemonade stand.  She may even sell the boxes to someone else and use the money to by a ticket to get into the ballpark!  The point isn’t that every single person is ultimately going to watch the game from behind the fence.  It’s that anyone who has the desire and is willing to put in an equal effort to do so will not be prevented from doing it due to factors outside their control.

So while equity does not mean every individual has exactly the same outcome, it should, if done right, lead to equality of outcomes across groups.  Differences in effort and desire should even out, and the results should be roughly similar when examined over populations.  To use the vaccine equity example, equitable vaccine access does not mean that every person is vaccinated.  It means that when we look at groups in the population, the rates of vaccination should be the same.

And that is why when we see disparities in high school graduation rates, or home ownership, or vaccinations, we conclude there is inequity.  But that is not because of some nefarious totalitarian goal of imposing uniformity on everyone.  If we could quantify the accumulated effects of systemic and structural racism, we could perhaps precisely define and measure opportunity and determine if we have achieved equity in those opportunities.  I’m not entirely sure how one would do that.  How much vaccine outreach is enough?  Given the inability to measure the desired goal – equitable opportunity – we use disparity in outcomes across groups as a proxy measure for whether there was equitable opportunity to achieve those outcomes.

Equity is not a dirty word.  It is not un-American.  I would argue it was part of the basis of our founding.  The Declaration of Independence states “We hold these truths to be self-evident, that all men [sic] are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”  We don’t all have the right to be happy, but we all have the same right to pursue that happiness.  That’s equity.  We haven’t lived up to that ideal in the centuries since that document was written, but we shouldn’t give up on trying.

Hiring the Best and the Brightest (and the Most Diverse)

May 24, 2021

In early 2018, I signed onto what was then called the CEO Action Pledge on Diversity and Inclusion, joining about 120 other CEOs around the country (the number is now approaching 2000) in committing to promoting equity and inclusion at Children’s Minnesota.  Two years later, after the murder of George Floyd and the accompanying nationwide protests, many companies – including major employers in Minnesota – have gone beyond that to make specific pledges around increasing the diversity of their workforces and especially their leadership teams.  Perhaps not surprisingly, there has been some pushback.  Ever since the term affirmative action was first introduced in the early 1960s, there has been criticism of it, with arguments generally falling into two categories: that it is unfair to the majority group and amounts to reverse discrimination, and that hiring decisions should be based entirely on merit.

While I don’t agree with the unfairness argument, I understand it.  I have personally been in the situation where someone might have very similar qualifications to mine for a particular role, and I was not selected because the “tiebreaker” was race or sex.  In situations like that, I know I will lose out every time.  I can intellectualize the fact that for the vast majority of my life I have been the beneficiary of those tiebreaker considerations, and that the qualifications I have are in part the result of the accumulated effects of generations of that advantage in opportunities that my ancestors have had.  But if I am honest, I have to admit that while in the end I am convinced that is correct, it doesn’t feel great when it happens.

As to the second argument, I couldn’t agree more that hiring decisions should be based entirely on finding the best person for the job.  And that is completely consistent with efforts to advance diversity and inclusion in our leadership teams and our workforce as a whole.  To assume otherwise – that increasing diversity is somehow antithetical to hiring based on merit – is in itself racist.  When our executive leadership team was all white, white people weren’t asking if any of them got their position based on their color.

The first step in hiring the most qualified people is finding the most qualified applicant pool.  Traditional hiring and recruitment practices tend to limit the number of people identified, yielding a homogenous group of candidates and risking missing out on a good deal of potential talent.  The university I attended was, until 1969, all male, and nearly all white.  How could they claim to have the best and the brightest minds in the country when they only considered applications from at most one-third of the potential students out there?  (Michelle Obama, a fellow alum, is a great example of the kind of talented individual that would never have been on the radar screen in the earlier era.)  Casting a wide net, using a recruitment strategy that intentionally looks beyond the “usual suspects,” results in a candidate pool that is both more diverse and more likely to include those most qualified for the job.  For a large employer like us, that includes recruiting at schools serving a broader range of students (such as historically black colleges and universities, or HBCUs), or job fairs or Web sites geared toward more diverse job-seekers, such as People of Color Careers.  While this takes more work than traditional approaches, a hiring manager should not be satisfied unless the candidate pool is sufficiently diverse.

As an aside, is anyone else bothered by how we misuse the term “diverse”?  The word is often used to refer to someone who is from an underrepresented group, as in “Dr. X is a diverse candidate.”  An individual cannot be diverse! By definition, diverse refers to a group. My suspicion is that people (mostly white) who are still uncomfortable talking frankly about bias have adopted “diverse” as a euphemism.  It’s OK to say “Dr. X is LGBTQ” or “Dr. X is Native American.”

OK, anyway, so after identifying a diverse group of candidates, the next step in hiring the best person for the job means carefully considering what it takes to be the best for the job.  One must think of any hire both as an individual and as part of a team.  When evaluating an individual, for the sake of ease and efficiency, we often rely on easy-to-measure indicators like grades, test scores, or specific prior positions held.  But how meaningful are they?  The research on how well IQ tests or grades predict job performance is complex, but to the extent there is a correlation, that correlation diminishes substantially when accounting for other factors.  More importantly, we need to be thoughtful about what is required to do a job successfully.  For decades, medical students were selected primarily for their ability to memorize large amounts of information and do well on tests.  In an Internet era when anyone with two thumbs can find the differential diagnosis of any imaginable symptom on their phone, the ability to sift information critically, and communicate effectively and with empathy and compassion are probably better predictors of a good physician than organic chemistry grades.  To be clear, this is not about lowering standards.  It is about ensuring we use the most appropriate standards to identify who is most likely to succeed at a particular job.  It is about questioning the “usual” standards that may not only be poor markers of job success, but may have the unintended consequence of excluding individuals who may be as or even more likely to succeed.

In addition to a candidate’s individual qualifications, in most instances we are hiring someone to be part of team.  This raises the question of who is going to best contribute to making that team successful.  A growing body of research has shown that more diverse teams have higher performance.  Teams with more diverse members – including diversity of background, experience, perspective, and style, as well as specifically racial, ethnic, and gender diversity – are more likely to focus on facts, process those facts more carefully, and be more innovative.  In healthcare specifically, diverse patient populations are better served by more diverse care teams.  Selecting the best candidate for the job, then, involves not only establishing the appropriate standards for individual success, but accounting for the current make-up of a team and seeking to increase the diversity of that team to promote group success.

After casting a wide net and defining the desired characteristics, the final step is creating an equitable selection process.  Everyone has inherent biases; the selection process must ensure that these are minimized.  For years, symphony orchestras in the US were nearly exclusively male.  After adopting blind auditions (with musicians performing behind a screen) starting in the 1970s, the proportion of female musicians rose dramatically.  (While the evidence supporting the effect of blinding has been criticized, there is no disagreement that gender diversity in classical music has increased, with no sacrifice of quality.) Blinded evaluations are not always feasible – at Children’s Minnesota, our approach to addressing bias includes ensuring that the interview panel for leaders is itself diverse.

These strategies work. Since signing on to the CEO Action Pledge, we have made progress in diversifying our leadership.  Both the top Executive Leadership Team and the larger Strategic Leadership Team are 60% women and 30% BIPOC.  (I acknowledge there are other dimensions of diversity.  These are simply the dimensions we have focused on primarily so far, and for which we have the best data.)  And, I can say that they are the most effective and talented leadership teams I have ever worked with. I have and always will pick the best person for the job; no one on my team has ever been hired because of their color.  But without those intentional efforts in recruitment and hiring, some of these amazing people might never have made their way here, and Children’s Minnesota would be the worse for it.

Journey to Zero

April 19, 2021

What is the acceptable number of people to be harmed by healthcare?

When I started my pediatric training in the mid-1980s, my answer would have been “what are you talking about?” No one was talking about patient safety.  To the extent we acknowledged medical error, it was that there were some “bad apples” who committed malpractice, but not a huge issue.  And of course, people did sometime make mistakes – humans aren’t perfect after all – but that wasn’t really a problem, just an unfortunate fact we had to accept as the price of advanced medical care.

Then, in 1999, the Institute of Medicine published a landmark report, “To Err Is Human,” that showed that medical error is in fact rampant and preventable.  Tens of thousands of Americans were dying each year at the hands of those who intended to help them.  Not because those were bad people, but they were operating in imperfect systems.  Healthcare is complex, and like any complex system, failures can occur.  Yes, to err is human.  But the answer isn’t to accept error as a necessary evil.  It is to design systems that prevent error from occurring despite human failings.  The answer to the question I posed at the top is “zero.”  It’s never acceptable.  Which is why our patient safety effort at Children’s Minnesota is called Journey to Zero.  Our goal is that no one is ever harmed by the care we provide.  We aren’t there yet, and maybe we’ll never get all the way to zero.  But at least theoretically we can improve our systems to the point of no harm, and we won’t stop trying until we do.

The idea is to design the system to make it as hard as possible to make a mistake, and as easy as possible to do the right thing.  Consider such incredibly complex, high-risk, and high-stakes industries as nuclear power and aviation.  “Routine” airplane crashes and nuclear plant explosions would not be acceptable, and they don’t happen.  These industries are not perfect, but they are getting awfully close to it. They have developed a set of principles and practices that have been borrowed by healthcare to make our systems better and avoid preventable harm.  Tens of thousands of people area alive today who might not be if healthcare hadn’t followed their lead.

OK, let’s switch to a different topic.  What is the acceptable number of Black people to be harmed by law enforcement?

Police killings of Black people are really not that different from plane crashes or medical errors.  The law enforcement system isn’t trying to kill people.  It doesn’t want to kill people.  It doesn’t have to kill people.  And yet it is killing people.

And the problem isn’t “a few bad apples.”  The problem isn’t “mistakes are made.”  The problem is the system.  It is a system whose harm is disproportionately affecting Black people, the definition of systemic racism.  But it’s a system in denial about the nature of its problem.  Like healthcare in the 1980s, it relies on an adversarial approach to identify individuals to blame for bad outcomes.  Not only does this not solve the problem (as I said in regard to healthcare, even skilled and well-intentioned individuals can and do cause harm in an imperfect system), but it creates an environment in which calling out the problem is seen as a personal attack and it elicits a defensive response.

Our law enforcement system needs to start a Journey to Zero.  It needs to acknowledge that police killing of Black and other people of color is a systemic failing, and embrace systemic change.  As in healthcare, law enforcement needs to create a culture of safety, elements of which include:

  • shifting away from assigning blame to an individual, to identifying root system causes for harm.  Some root causes here might include officers who are not part of the community they serve; emphasis on the use of force as an early, even preferred, means of addressing conflict; and failure to address ingrained attitudes and biases that portray Black people, especially Black men, as an inherent threat
  • empowering and incentivizing all to speak out, regardless of position in the hierarchy, and report problems rather than ignoring or covering them up
  • transparency about progress or lack thereof, with accountability at all levels

When we post the number of CLABSIs on each nursing unit, it’s not meant to shame the clinical staff.  When a staff member enters a safety learning report about a near-miss medication error, they get a thank you note, not a reprimand.  Similarly, if we talk about the need for reform of law enforcement, I hope that is seen as a criticism of policing, not of individual police. Over the last 4 years, an average of 227 Black people have been killed by police annually.  This is equivalent to a Boeing 757 crashing each year, every year.  It’s time to start that Journey to Zero.

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