Fighting stereotypes and politics that impede informatics leadership

Scot Silverstein, MD

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Unfortunate stereotypes and suggestions about how to respond

We all know doctors don't do things with computers. We all know doctors are not team players. We all know doctors are greedy. We all know informaticists are too academic or are techies. We all know doctors don't or can't...[fill in the blank].

No, we don't 'all know' such things. As I wrote in a letter to JAMA ("Barriers to Computerized Prescribing"), the following are unfortunate and incongruous stereotypes, propaganda, and myths actually heard by this author and associates from others. Such statements are sometimes innocently asked as questions, but are too often used as invectives with a motive of maintaining influence and territory. Such claims usually originate from MIS leaders and personnel, senior executives with financial motives, and rarely other clinicians (see "tinkerers"). Managed care itself is engaged in its own propaganda battle against physicians and medicine.

The general response to these statements makes an analogy to other stereotypes and propaganda about people. I generally ask the statement-maker if they would hold the same to be true about a religious or ethnic group. After they blush or get indignant at the thought, I remind them that clinical personnel come from a wide variety of backgrounds and have a variety of skills and inclinations, both from before and after medical training. I also remind them that a medical degree does not erase all of that, like computer disk reformatting. I also remind them that medical training and practice generally imparts resilience, leadership skills, collaboration, and other valuable traits that are quite transferable in cross-disciplinary settings.

This generally suffices to show the inelegance of these comments, but a few additional points are linked to some of the claims and stereotypes below. If any of these points of glasnost enable people to respond to such questions or invective fruitfully, the mission of this Web site will have been accomplished.

(Incidentally, the site "Medical Burnout" is also strongly recommended by this author as a must-see. It is written by a physician in Austin, Texas. This site gives excellent exposure to the strategies and tactics used against physicians by the Managed Care "Medical-Industrial Complex.")

Examples of stereotypes and politics that impede medical informatics leadership:

We don't need Medical Informatics here

Medical Informatics is too academic

Medical Informaticists are "techies"

Medical Informaticists need to be seeing patients

Doctors don't do things with computers

Doctors don't have enough experience

Doctors don't have IT leadership skills

Doctors don't understand business

Doctors don't have personnel management skills

Doctors are not team players

Doctors can't manage projects

Doctors don't think strategically

Doctors in clinical computing projects should report to MIS

Doctors are cheap

Doctors are stubborn and uncooperative

Clinical IT would work if it weren't for doctors

We don't need medical informatics here (a corollary of DDDTWC, "Doctors don't do things with computers.")

Bill Gates, Chairman of Microsoft, on process change: "It's impossible to properly reengineer a process using technology in an area without the oversight of someone who can bridge [the different] teams." (from Business @ the Speed of Thought, Warner Books, 1999)

On leadership and experience:

Beside the fact that medical training in and of itself is superb leadership training, here is one reply I give to those who oppose leadership of clinical IT by informaticists with statements such as "Doctors don't have IT management experience" and "Doctors can't do...[fill in the blank]."

I respond "It should be remembered that a license to practice medicine is a privilege earned as a result of intensive study and abdication of the rights of leisure. Becoming a physician requires intelligence and extreme discipline. Basic training in the Marines is far easier than the year of perdition of being a medical intern. Basic training is only eight to sixteen weeks with fairly regular hours for sleep. The internship year alone is a physical and emotional marathon that runs 24 hours a day. Doing specialty training is often even more demanding. Do you really think there's something in most clinician's backgrounds, with their high ability levels, advanced scholastic achievement needed to get into medical or other professional school, survival of rigorous military-style medical training, responsibility levels, and other items in their resumes that makes them unable to perform or rapidly learn to perform [fill in the blank] in leadership of clinical IT?"

Some organizations understand these issues and have become world leaders as a result. Albert Yu of Intel, in Creating the Digital Future, writes "I consistently promote people [to leadership] based on how fast they learn rather than how much experience they have. Fast learners, when given a big task, tend to learn even faster and typically succeed even with no prior experience. Gadi Singer [for example], a bright design engineer ... learned very quickly in managing an organization with hundreds of people. In three years he has become the best design technology manager we've ever had."

Doctors don't understand business:

Considering the devastation to venerable American medical institutions, founded hundreds of years ago, under present "professional businessperson" leadership, and what distinguished University of Pennsylvania Health System president Dr. William Kelley so aptly calls "a success in reducing the cost of healthcare but the end of the ability to create the future of medicine," I have my doubts about this.

I'd say there's a good chance that healthcare managed by medical professionals may have turned out better than the so-called "system" we have today, with tens of millions of uninsured people, venerable teaching institutions forced to sell their hospitals or close their doors altogether, and rampant medical errors due to inadequate infrastructure investments (including clinical IT and the informatics professionals necessary to leverage it properly).

Doctors don't have personnel management skills:

This statement reflects a serious misunderstanding about the medical education process.

Any residency-trained physician will have such skills in abundance, gained (at minimum) as a 2nd, 3rd, and 4th year resident and/or postdoctoral fellow. During that time they supervise and evaluate trainees, usually two or three interns plus a few medical students in hospital, ICU and ER-based settings. A resident will take over a new group of trainees every six to eight weeks, as they "rotate" throughout the healthcare system. The Resident is also "on-call" with his team every 3rd or 4th night (the team works the entire day and night and the next day as well). This is often under "combat conditions" where true life-or-death situations are commonplace, with near-zero margin for error, especially in municipal hospitals. The performance of the resident and his or her trainees can harm or end lives or result in serious litigation, and the evaluations of the trainees can end their careers. Responsibility and accountability are major issues.

In many ways, medical training is tougher than basic training in the marines, which only lasts a few months and includes sleep. Yet, in HR (and MIS) departments, it seems the medical training doesn't get parsed into "personnel management skills." Someone who's managed a McDonald's might be considered to have superior "personnel management skills" to a residency-trained physician. This is quite unfortunate, as it results in significant leadership losses to healthcare-related endeavors such as implementation of clinical IT.

On the 'team player' issue:

"Doctors are not team players" is a statement often made by those who for territorial reasons (e.g., inability to share territory) oppose clinical leadership of MIS personnel or resources in clinical computing projects. I hear this stereotype so often, I believe it's become a dogma. Yet, rarely is the term's meaning thought about critically or debated. Does 'team player' mean collaborative? Does it mean obedient? In business, the term actually came into use to refer to the concept of different specialties working together in unison instead of from specialty silos. For example, it was recognized there might be gains if R&D and marketing worked together, compared to the usual situation where specialized R&D personnel presented their work to marketing, and then specialized marketing personnel performed marketing tasks, with minimal interaction and cross-fertilization of ideas. Unfortunately, the "team" concept has apparently become distorted (perhaps through inappropriate association with sports metaphors) to focus on personal behavior and styles.

In healthcare IT, MIS control issues have translated into "doctors are not team players" probably due to the fact that clinicians, trained in critical thinking and independent judgment, don't happily allow those who have no credentials in clinical medicine (and who have over the past few decades presented clinicians with consistently unusable clinical computing tools) to make radical changes to the infrastructure of medicine, e.g., in information management. In fact, it is almost silly for MIS personnel to believe that clinicians should acquiesce to such interference by those who have no professional credentials in clinical medicine. (If one wishes to apply sports metaphors appropriately, clinicians need to be the coaches of such teams, not the players.)

When hearing that doctors are not team players, I usually ask which team the speaker is talking about. I remind them that perhaps it is they who are not on the team - the clinical team that saves lives. (Clinicians have been widely reported to favor misrepresenting patient's conditions to insurance companies and MCOs to ensure their patients get proper care that would be denied under profit-oriented policies. That's an excellent example of team sportsmanship - risking one's career to uphold one's ethical obligations to patients.)

I also mention that a 'team' is different from a chain gang where 'team players' obediently follow a leader, as I and others have observed in MIS organizations. Such pseudo-teams stifle creativity and initiative. As a manager for a large software company once admitted, "teamwork is a lot of people doing what I say." Prevalent pseudo-team ideas and collectivist ideologies are antithetical to the traditional American values of individualism that built this country, and seem more consistent with out-of-place ideologies that have consistently failed to foster real progress in other parts of the world.

In fact, clinical personnel from their earliest training experiences are part of a true team, a team of healthcare professionals responsible for patient's lives. They routinely depend on other team members to make critical healthcare decisions - for example, the nurse in the ICU, the resident on night float, the consultants in medical subspecialties, the clinicans covering for a colleague. A cardiac arrest situation in an acute-care setting is another example of a true team at work.

That MIS is unable to tap into this true team spirit seems mostly a problem of MIS having no clinical background or credibility and being unable to present itself appropriately to clinicians, that is, as offering true value-added services that facilitate (rather than make more burdensome) caring for the sick. Medical Informaticists can help MIS do that, but with that comes the necessity of authority, something many CIO's seem unwilling to give to clinicians.

Many clinicians associate MIS with the bureaucracy, the same bureaucracy that makes taking care of patients more difficult and that exploits the healthcare system for its own financial gain. In reality, MIS needs to become a part of the clinical team, rather than the other way around.

On clinicians reporting to MIS:

This is a potentially troublesome form of control of the medical profession by non-medical personnel. It is strongly discouraged. A somewhat distorted arrangement and reversal of roles between primary healthcare practitioners (clinicians) who enable care and ancillary support personnel (MIS) who facilitate care.

For example, if conflicts arise over clinical matters such as information security or ethical concerns, the clinician reporting to MIS would find him/herself in a potentially compromised position. MIS personnel are not qualified to make leadership decisions on clinical matters unless they are qualified healthcare practitioners themselves (rare). Such reporting may also dilute the trust in the informaticist by other clinicians, to everyone's detriment.

Reporting to non-medical personnel should be done only if the chemistry between the two parties is very good, and the senior party is well-rounded and has experience (with good results) in working as a direct supervisor to medical personnel. Unfortunately, this is not very common.

A much more reasonable and satsifactory arrangement is for clinicians working on healthcare IT projects to report through Medical Affairs or a similar clinical body, matrixed to the MIS department or its leadership if necessary. The best solution of all is a separate "Clinical Information Services" department, as suggested in my MIS prescription.

On medical informaticists being "too academic":

This stereotype can be used to instill fear, uncertainty and doubt into executives by those without scholarly credentials or with poor scholastic achievement. I find it a very odd phenomenon that learning, once revered in this society (and still revered in medicine), is now perceived negatively by many, especially in healthcare settings.

Remarkably, several healthcare IT Recruitment firms have published interesting views on healthcare IT leadership. In medicine, where strict standards of education and training apply, and where education is a source of authority, these views are quite atypical. "I don't think a degree gets you anything," says healthcare recruiter Lion Goodman, president of the Goodman Group in San Rafael, Calif. Healthcare IT recruiter Betsy Hersher of Hersher Associates, Northbrook, Illinois, agreed, stating "There's nothing like the school of Hard Knocks." ("Who's Growing CIO's", Healthcare Informatics, Nov. 1998, p. 88). Such views reflect a huge gap in thinking between clinical medicine and healthcare information technology.

It's almost as if the Simpsons cartoon, a satire where ignorance is a virtue and expertise a disease, has been taken seriously. I usually respond to this stereotype by asking the person "too academic for what, exactly?" I ask if my background prior to informatics, as manager for one of the largest municipal public Transportation Authorities in the United States (with 26 labor unions to work with and many other clearly non-academic features), is cancelled and nullifed by my having stepped into the Ivory Tower. Others often have such experiences from before or after informatics training.

Even if one has spent one's entire career in academia, I remind people, so did many scientists such as those who have enabled gene discovery, harnessing the atom, discovering penicillin, and other "academic" activities. The purpose of education is to facilitate insight and discovery, and knowledge and appreciation of self and the larger world.

Most ironically for those who hold the "I don't believe a degree gets you anything" belief regarding computers, no other class of artifact in the history of technology has been sired by a more educated and scientifically-trained group of people. Practically every one of the principal figures in the development of the computer, including Alan Turing, John Von Neumann, Howard Aiken, John Mauchly, Grace Hopper, Arthur Burks, John Atanasoff, Jay Forrester, Maurice Wilkes, Frederick Williams, and Tom Killburn taught and did their research at universities, mostly holding Ph.D. degrees in physics, math, or electrical engineering. Indeed, it should not be forgotten that the most celebrated pioneer of the digital computer from the Victorian era, Charles Babbage, was the Lucasian Professor of Mathematics at Cambridge University, a chair once held by Sir Isaac Newton and occupied in our own time by Stephen Hawking (from "Technology and Creativity", Subrata Dasgupta, Univ. of S.W. Louisiana, Oxford Univ. Press, 1996).

In contrast to apparent current trends in healthcare, United Technologies, an industry conglomerate in automotive and aircraft manufacturing, understands the education issue well. They wrote in an April 7, 1999 advertisement in the Wall Street Journal that "The information revolution has put competition into overdrive. Now more than ever, the race belongs to the smartest. Read: skilled, schooled, possessing pedal-to-the-metal determination. United Technologies fast-tracks its employees by investing over $50 million each year in its Employee Scholars program. Tuition, books, and paid time off for people aiming at a degree are provided, as well as a generous stock award on graduation."

The trend in healthcare away from education and scholarship in its leaders is of great concern.

Doctors & informaticists can't manage clinical computing projects:

This MIS belief is truly surprising. Clinical personnel are trained to manage the care of the patient (people's lives), using one of the most valuable management skills of all: critical, precise, logical thinking and the medical diagnostic process. Other "project management skills" needed to work with information technology can be mastered in a relatively short time if needed. Actually, many clinical leaders have already managed projects at the departmental or organizational level.

On the other hand, MIS personnel don't know medicine and it can't be learned in a short course or seminar. It therefore is irrational and detrimental to everyone to keep informaticists in minor or ancillary roles in clinical computing projects.

On informaticists needing to maintain clinical activities:

This is one of those "one shoe fits all" statements, and can be used to marginalize the informaticist in that executives may view a practicing physician as a "semi-executive" or non-committed executive.

This type of statement is particularly noisome when coming from MIS personnel. What do such people truly know of medical practice? I once had a discussion with several MIS leaders who were proudly confident that this was an axiom. I was struck by the absurdity of the "everyone's an expert in medicine" mentality and the arrogant intrusion into medical affairs by medical support personnel.

When presented with this statement, I usually ask if CIO's are expected to do daily programming, COO's are expected to count inventory in stockrooms, or CEO's to perform hands-on, day-to-day tasks. While maintaining practice keeps a physician sharpest, the "gestalt" of medical training and practice is not soon forgotten. On the issue of the perceptions of other physicians, physicians are not children with binary cognitive abilities. A physician-advocate who helps them will be perceived as a friend and colleague, whether practicing or not. "It's the person, not the job." On the other hand, a physician "semi-executive" who is powerless due to negative perceptions of other senior executives cannot be a good advocate.

Informaticists who wish to be perceived as executive leaders should see patients if they want to, not because they "have to".

More to come.

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