Unqualified decision-making: a major obstacle to clinical computing progress

Scot Silverstein, MD

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1. Unqualified decision-making
2. "I don't think a degree gets you anything"
3. Management's semantic confusion and blur
4. In conclusion

Unqualified decision-making: the wrong people making the wrong decisions at the wrong time

In almost every missed opportunity, failure, or tragic catastrophe, it seems there are two divisions in the Dramatis Personae: those who should be making decisions via their knowledge and expertise, and those who often make the decisions due to their position of authority. The latter often do not share the knowledge and expertise of the former.

The Space Shuttle Challenger disaster was a dramatic example of this problem. Expert engineers fearful of launching in freezing temperatures, due to concerns about technical malfunctions, were overruled by their managers with disastrous consequences and loss of life.

In a healthcare example, scientists at the Food and Drug Administration may be "harassed" by managers and risk disciplinary action if they raise questions about the safety of drugs being evaluated for licensing, according to a consumer health advocate ("Public Citizen blisters FDA on ethics", USA Today, March 23, 2000, p. 9D). A 1998 survey by the consumer group claimed 27 instances in which FDA medical officers thought a drug should not be approved but it was, over their objections. The group also says FDA physicians cited 14 times when they were told not to present negative data about a drug at FDA advisory committee meetings.

Houston, we've got a societal problem: An article by senior writer David Harriman of the Ayn Rand Institute in Marina Del Ray, California, captures the reasons for this increasingly problematic asymmetry very well. In "Voyage of discovery is reduced to MTV science", May 29, 1999, Mr. Harriman, a former Defense Dept. physicist, notes that the most popular high school textbook of physics in use today ("Physics: Principles and Problems", Zitzewitz and Neff) is MTV-style science. It has pictures on every page at the expense of text, and an overriding theme that science is an incomprehensible hash of arbitrary assertions. The book teaches that "there is no single scientific method" and that "knowledge, skill, luck, imagination, trial and error, educated guesses, and patience all play a role in science." The painstaking observations, systematic experiments, mathematical analyses and brilliantly logical inductions that lead to scientific discoveries are dismissed in a cavalier manner. Theoretical underpinnings necessary to understand physics and science are omitted or trivialized.

Despite their lack of understanding, however, students are encouraged to express opinions about very complex issues. The message is that students should feel free to have an opinion on complex matters such as new facilities for particle-physics research or health risks of electromagnetic fields. The potency of expert knowledge coupled with reason is minimized, implying that science is no better than voodoo or witchcraft.

On a related note, I am troubled by a 10-year-old relative's 5th grade math textbook. I was dismayed to read the following instructional sidebar (Scott Foresman: Math, Addison Wesley Longman, 1999):

Problem solving: Solve each problem. Choose any strategy:

- use objects
- act it out
- look for a pattern
- guess and check
- use logical reasoning (emphasis mine)
- make an organized list
- make a table
- solve a simpler problem
- work backward
This is followed by a series of poorly-worded, algebraic-like problems on proportions and ratios.

It appears students are being taught the ideology in science that rational, expert knowledge is irrelevant and any opinion is as good as any other, and in math that logical reasoning is just one rather undistinguished method to solve problems and ranks lower than "guessing" or "acting."

Dangerously, the concepts of inadequacy of qualifications and incompetence are becoming lost. I recently heard a story about an MIS director who suggested saving costs by wiring the cardiac telemetry monitoring systems in intermediate-care settings through the POTS (plain old telephone system), with all the potentials for failure, noise, signal loss, etc. that would entail if it were even possible. Another individual strongly opposed an informaticist's concerns that using multiple, varied ISP's (as opposed to a single ISP) for physician dialin to EPR's and clinical repositories could potentially weaken clinical information security. In both of these cases, most others considered these views simply as "alternate opinions" with the same credibility as views of a trained expert. In actuality, this type of story illustrates a deeper problem.

Alan Sokal, an American professor of physics at the University of New York, troubled for some years by an apparent decline in the standards of intellectual rigor, proved by a simple experiment that ideologies of relativism and anti-objectivism (the "postmodern common wisdom") are proliferated with great eagerness and insufficient critical thought. Articles can be accepted even if they are peppered with deliberate absurdities. All this happened when he published a plausible-sounding paper "Transgressing the Boundaries: Towards a Transformative Hermeneutics of Quantum Gravity." This paper was an utter hoax, but was taken very seriously and published by Social Text, a leading North American academic journal of cultural studies for social science pundits, in April 1996. Ironically, this was a special double issue devoted to rebutting the charge that cultural-studies critiques of science tend to be riddled with incompetence. As Sokal wrote:

For some years I've been troubled by an apparent decline in the standards of intellectual rigor in certain precincts of the American academic humanities. But I'm a mere physicist: if I find myself unable to make head or tail of jouissance and diff'erance, perhaps that just reflects my own inadequacy. So, to test the prevailing intellectual standards, I decided to try a modest (though admittedly uncontrolled) experiment: Would a leading North American journal of cultural studies --- whose editorial collective includes such luminaries as Fredric Jameson and Andrew Ross --- publish an article liberally salted with nonsense if (a) it sounded good and (b) it flattered the editors' ideological preconceptions?

The answer, unfortunately, is yes...like the genre it is meant to satirize...my article is a mélange of truths, half-truths, quarter-truths, falsehoods, non sequiturs, and syntactically correct sentences that have no meaning whatsoever...Interested readers can find my article, "Transgressing the Boundaries: Toward a Transformative Hermeneutics of Quantum Gravity," in the Spring/Summer 1996 issue of Social Text. It appears in a special number of the magazine devoted to the "Science Wars."

The full text of the article, along with considerable related additional material, is available from Prof. Sokal's web site.

In a classic example of magical thinking in healthcare, practitioners of "therapeutic touch", a widely-used nursing practice rooted in mysticism but alleged to have a scientific basis, claim to treat many medical conditions by using their hands to manipulate a "human energy field" perceptible above the patient's skin. This practice was shown to be about as effective as snake oil of the previous century. This was done using simple, logical techniques demonstrating that practitioners were unable to detect an investigator's "energy field" and that the claims of therapeutic touch were groundless ("A Close Look at Therapeutic Touch", Rosa et al, Journal of the American Medical Association, April 1, 1998).

Wendy Kaminer has raised a serious issue in her book Sleeping with Extraterrestrials: The Rise of Irrationalism and Perils of Piety (Pantheon Books/Random House, 1999) regarding decision-making in our current society. She writes about a "blind antipathy to reason being central to many best-selling pop spirituality and personal development books and much New Age rhetoric." She notes that "emotionalism and reason are not considered differing perceptual modes to be held in careful balance but are [considered] competitors in a zero-sum game" in such philosophies. "Thinking with our hearts" rather than with our minds in making decisions has become a mandate, she observes. Rational thinking becomes irrelevant since the world is not at all deterministic. Kaminer even points out that such philosophies have alarmingly insinuated themselves into the workplace in a drive to increase productivity, citing companies such as Boeing, RCA, and Scott paper using New Age Management consultants (p. 24).

Carl Sagan also wrote extensively about this ideological deterioration in his book The Demon-Haunted World: Science as a Candle in the Dark (Random House Publishers, New York, 1995).

As Larry Laudan observed in Science and Relativism (1990), "The displacement of the idea that facts and evidence matter by the idea that everything boils down to subjective interests and perspectives is...the most prominent and pernicious manifestation of anti-intellectualism in our time."

One obvious problem with belief in a "relativism of truth," where facts and evidence do not matter, is that it is an internally contradictory philosophy that undermines itself. Believers state that truth, even about physical and scientific matters, is relative and dependent on an observer's point of view, but this statement is itself made as a statement of unconditional truth about such relativity. Personally, I learned to detect and avoid such nonsensical logical conundrums in the fourth or fifth grade through considering the internal contradictions of statements like "I am not here" or "Everything I say is a lie, but I'm lying."

In considering whether to ascribe this relativism movement to some new-found discoveries about the universe, as opposed to an explanation based on simpler human issues, invoking Occam's razor may be useful and appropriate. Occam's razor and its derivatives are principles attributed to the 14th century logician and Franciscan friar, William of Ockham (ca. 1285-1347).

Occam's razor proposes that "when you have two competing theories which make exactly the same predictions, the one that is simpler is usually the better." A straightforward medical interpretation of the "relativism of reality" issue is that adherence to such beliefs may be a symptom of arrested intellectual development or perhaps of a self-contained delusional system. The latter possibility is consistent with the observation that it is difficult, if not impossible, to hold a debate with such individuals or to convince them to change their beliefs on many issues, even with excellent substantiating evidence.

The phenomenon of unqualified decision-making is a symptom of these types of ideological debasement. In an era when technology is becoming increasingly more complex, this phenomenon causes the wrong people to be making decisions on complex matters outside their knowledge, ability, and judgment. Not surprisingly, they often do this quite poorly. This phenomenon, in healthcare computing, is perhaps the biggest obstacle and impediment to effective utilization of expertise and rational thought in improving healthcare via information technology.

Further, I suggest that such thinking about leadership (which allows expert clinicians, for example, to be overruled by non-medical support staff) is actually causing medicine to drift from its scientific foundations.

I don't think a degree gets you anything

Several healthcare MIS Recruitment firms have published interesting views on healthcare MIS leadership, views that most clinicians will not identify with. "I don't think a degree gets you anything," says healthcare recruiter Lion Goodman, president of the Goodman Group in San Rafael, California about CIO's and other healthcare MIS staffers. Healthcare MIS 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).

In seeking out CIO talent, recruiter Lion Goodman "doesn't think clinical experience yields [hospital] IT people who have broad enough perspective. Physicians in particular make poor choices for CIOs. They don't think of the business issues at hand because they're consumed with patient care issues," according to Goodman.

This innocent, possibly plausible-sounding reversal of thinking about primary enablers of care not having broad enough perspective to lead facilitators of care (support personnel whose clinical medicine experience is nil) is in my opinion at the root of healthcare information technology failure. Or, more precisely, this philosophy may indeed plant the seeds of failure. The business of healthcare organizations is the delivery of medical care. Many physicians have excellent perspectives on business, whereas the CIO with any perspective at all on clinical medicine (e.g., those who are also clinicians) is quite rare.

What does a degree "get" you? Anecdotal stories aside (an approach to "proof" often used by the poorly-educated), a meaningful degree affords values essential in critical thinking, concentration, disciplined analysis, wrestling with complexity, and the pursuit of understanding, to paraphrase Miles Everett, as quoted in High Tech Heretic (Clifford Stoll, Doubleday, 1999). This concept was understood even thousands of years ago. Quoting a somewhat older source: "A wise man is strong; yea, a man of knowledge increaseth strength" (Proverbs 24:5).

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).

There is another article about MIS leadership that causes me significant ideological concerns, written by the same recruiter, Hersher, in the Jan. 2000 edition of the journal Advance for Healthcare Information Executives. In the article "Career counsel: what is leadership and how important is it to your career?", the reader is asked to accept that:

"Management and leadership are often uttered in the same breath. We tend to assume that to be a good leader, you must also be a good manager…the truth is that exceptional leaders are not necessarily good managers, and vice versa…leadership is the ability to create a vision of where an organization or project needs to go and sell that vision to the decision-makers ..."
Key characteristics of "effective leaders" are then presented, sounding rather like a description of charisma and shmoozability.

This seemingly plausible reversal of factors that we "tend to assume" about good leadership has a dark side to it, one I believe is being experienced in healthcare computing today. That a person who is not a good manager (i.e., does not have the proper knowledge, skills, abilities, or competence) can, in this schema, be an "exceptional leader" is somewhat of a non-sequitur that sets off alarm bells to the critical mind.

If the criteria for leadership call for a charismatic figure who needs not be a "good manager" (i.e., who can be a terrible manager), and if the same retained firms also express views such as "I don't think a degree gets you anything…there's nothing like the school of Hard Knocks", this may be an invitation to allow charismatic know-nothings or incompetents into MIS leadership positions -- in effect, this could be an ideological justification for the Peter Principle.

I can say with reasonable certainty that one does not become, say, a neurosurgical department chair via such thinking. And, there is a huge difference between a visionary with expertise and an incompetent suffering from a "megalomaniacal hallucinosis."

A provocative paper in the December 1999 issue of the Journal of Personality and Social Psychology amplifies these concerns further. In "Unskilled and Unaware of It: How Difficulties in Recognizing One’s Own Incompetence Lead to Inflated Self-Assessments" by grad student Justin Kruger and Dr. David Dunning, a professor of psychology at Cornell, it was observed that people who do things badly are usually supremely confident of their abilities -- more confident, in fact, than people who do things well. One reason that the ignorant also tend to be blissfully self-assured, the researchers believe, is that the skills required for competence often are the same skills necessary to recognize competence. The incompetent, therefore, suffer doubly, the authors report. In essence, it takes competence to recognize competence (or incompetence).

As a result, in addition to making poor decisions, inadequate "leaders" may actaully prevent others with strong competence and leadership skills from becoming employed or from rising to leadership roles, through non-recognition of others' competence (or fear of it), insecurity, self-protective maneuvers upon criticism of poor decisions, or other negative factors. Bad leadership is in many ways like cancer. It can spread rapidly throughout a department or organization once a poor or incompetent leader assumes power.

Dunning's paper may help explain a phenomenon that has long puzzled me: the charismatic but clearly incompetent person given positions of leadership and promotions even in the face of failure. Those who are non-technologically or non-scientifically inclined (e.g., business-oriented hospital boards of directors, CEO's, recruiters) may mistake confidence for competence in potential leaders. Dunning's observations may also help explain how otherwise sensible people fall for financial or other frauds run by "confidence artists."

These factors suggest that extreme rigor should be exercised in leadership decisions, not the latest subjective leadership "fad" that just may also happen to serve recruiters (e.g., through enlargement of the candidate pool) or serve the territorial ambitions of a particular occupation (such as MIS). This is especially true in a field as critical to society as healthcare.

A decline in the quality and competence of leadership is a trend some have observed to be occurring in many computer-related disciplines: for example, by IS writers such as Infoworld’s Bob Lewis, who was a professional research scientist in neurobiology, then changed careers to MIS two decades ago; in books such as "Seven Lean Years: the new High-tech Underclass" by a former NASA engineer (http://www.os2hq.com/articles/seven.htm); and by myself and numerous informatics and scientific colleagues.

Perhaps this explains why Medical Informaticists seem to have difficulty obtaining substantive leadership roles in healthcare through MIS recruiters. We’re perhaps taxonomized as "managers", not as leadership material.

These reversals of thinking about education and leadership can quite effectively keep healthcare IT a closed cartel restricted to businesspeople while critical-thinking, action-oriented clinician informaticists are excluded. In fact, in acting as a traditional cartel, the healthcare MIS groups and their allies often seriously impede healthcare IT progress through elimination of fair competition based on ability and expertise. According to such recruiter thinking as above, doctorate-level clinicians with expertise in medical informatics who've run a practice, and perhaps have other managerial experience, would not have a broad enough perspective compared to an at-best masters-level businessperson who has no clinical experience at all.

This may also be an excellent example of the territoriality issue in action. Unfortunately, this territorial battle is being waged at the expense of patient care. As one physician-reader remarked, "this is a sad, sad commentary on the state of computer use in medicine. Non-clinical support personnel now feel they can tell us, how dare we as physicians dictate to our support staff what information tools we need to take care of patients."

I've also observed a corresponding cultural gap with respect to basic qualifications set by healthcare MIS managers for systems development and implementation leaders. For example, the criteria of "right personality" and "team player" and "ability to complete work on time and on budget" predominate over "experience in the application area" and "technical expertise." Indeed, the latter 2 criteria have been described as nearly optional by some healthcare CIO's [e.g., "High-priced, hard-to-find", J. Morrisey, Modern Healthcare, 1998;9:28-31].

Another subtle example taken from the MIS literature of misunderstanding, trivialization, and disrespect of the medical profession by MIS personnel is an article that equates the difficulty of interfacing two computers with the difficulty of performing neurosurgery ["Systems in stitches", R. Fusaro, Computerworld. 1998;8:84].

Considering the need for intellectually demanding problem-solving approaches in complex fields like medicine and healthcare information technology, such devaluation of education and "dumbing down" of healthcare leadership roles is a concerning phenomenon. While there must be a balance of skills and temperaments, no amount of soft skills and creative language can compensate for a lack of hard skills in a technical field. In medicine, non-negotiable criteria for leadership include the need for high ability, broad knowledge, and broad clinical experience and expertise. One does not even get a medical license without proving significant knowledge and ability. A belief that "a degree gets you nothing" in a field at the intersection of two of the most intellectually demanding disciplines in the modern world, medicine and computer science, straddles the frontiers of the nonsensical.

This issue seems to have become almost a running insider's joke in the information technology industry. For example, in a glossy journal directed at corporate executives, an article "How to Speak Geek" has a subtitle that reads, in part, "how to impress your CIO at the next IS steering committee meeting." The article emphasizes that "You [as an executive] reign as an all-knowing Oz in a world of cowardly lions...but...technology isn't your strong suit. Yet today technology plays a critical role in every facet of company decision-making, whether it be improving customer service or making a manufacturing line more efficient." Yet, the best recommendation of the article is to "give a primer... light enough to make the dreaded subject interesting," to allow executives to "simulate a depth of knowledge that others can only pretend to possess." ("How to Speak Geek", CIO/Enterprise Magazine, April 15, 1999.)

This trivialization of education and expertise, in an article that explicitly points out the crucial role of information technology, contrasts many current business and MIS management philosophies with rigorous scientific and engineering approaches to problem-solving.

It is difficult to imagine such attitudes appearing in Medical journals.

No mention is made of serious, real solutions: substantive education, as is obtained by clinical informatics personnel who obtain professional training, or relinquishing authority to the right people with the proper background so they can make the right decisions without undue interference.

To look at this issue from a slightly different perspective, as a former programs manager for a regional transit authority serving an area of several million people, this author has seen the results of less-than-ideal prudence in risk-prone fields, such as fatal train wrecks, bus accidents, and the like. The belief that formal education and technical expertise "gets you nothing" is certainly advantageous for the recruiting business, by increasing the pool of available "candidates." It is also advantageous for people who would not make the sacrifices to advance their education and talents (or who just didn't have the ability), who wish to live off the hard work and labor of those who did make such sacrifices (such as clinicians). Unfortunately, this ideology is exceptionally inappropriate for a field as critical, complex, and risk-prone as medicine. This thinking could quite possibly become a contributory or causative factor in future "train wrecks" in healthcare.

In "Hospitals face complex task preparing for Dec. 31, 2000", Wall Street Journal, Mar. 29, 1999, Timothy Zinn, a Chicago healthcare computing consultant, stated "we as an industry have been slow to recognize the ramifications of information systems, because patient care is the name of our game." This statement is not entirely accurate. The "we" reflects the wrong people doing such recognition. Medical informaticists have been talking of the value of IT in healthcare for decades. It is also reflective of muddled thinking, like Lufthansa saying "we have as an industry been slow to recognize the ramifications of computing, since travel is our business." (See my letter to the editor submission about this article.)

As an aside, it was reported in the Wall Street Journal on March 23 and March 24, 1999 that only 1 in 5 current U.S. high school seniors have taken trigonometry, and only 1 in 4 have taken physics. The number of U.S. students opting for careers in mathematics, physics and engineering also dropped sharply in the 1980's. The trend away from science, math and engineering, which teach real-world problem-solving methodologies based on scientific, mathematical, and observational principles, is itself cause for great concern.

In thinking more about these "I don’t believe a degree gets you anything - leaders need not be good managers" type of statements in healthcare computing journals, I realize that such statements are likely not statements of objective fact. At least, they are not factual statements that I can easily substantiate throught the literature. Rather, they are statements of ideology.

Ideological views can be relatively benign, such as "there should be decent healthcare available for all." However, such statements can also potentially have a more insidious side, such as "there should be no private property", "not everyone is equal under the law", and "there must be equal outcomes (not just equal opportunities) in education."

Statements such as "I don’t believe a degree gets you anything" and "leaders need not be good managers" seem more consistent with an apparent increasing debasement of standards of western rational thought noted by numerous authors (e.g., Kaminer, Sokal, Sagan) as referenced above, not to mention my own observations and that of a number of my colleagues, unaccomplished as we may be in such matters.

Certainly, such statements in national healthcare journals (regarding our specialty, leadership of a field at the intersection of two fields as crucial to society as medicine and IT) are as worthy of scrutiny, challenge and justification with hard, objective data as would be a statement in The Annals of Internal Medicine that "I don’t believe medical education gets you anything" regarding patient care (Unhappily, I can’t say with certainty that that kind of thinking is not occurring in the Hallowed Halls of Managed Care ...)

Could ideologies like "I don’t believe a degree gets you anything" be the prelude to the burning of books in the street? While this sounds patently absurd, after reading an encyclopedia of the 20th century I received as a New Year’s present, and seeing what’s happening in the corporatization of medicine today (e.g., HMO's opposing disclosure of physician financial "incentives" to patients, Phila. Inquirer, business news, 1/25/00), I’m not so sure anymore.

Management's semantic confusion and blur on evaluation of personnel

The preceding material serves as a preamble to understanding the root causes of the "wrong people making the wrong decisions" issue. Medical informatics concerns itself with language issues, semantics, word relationships and other knowledge representation issues that are of critical importance in healthcare. Perhaps it's because of this training that I propose there is a serious problem in today's employment thinking and decision-making process that has to do with language and semantics.

It seems there is a blurred understanding, especially in human resources and recruitment thinking, between words such as "management" (which may involve leadership, administration, or both), expertise (which involves ability, good judgment, knowledge and experience), and other such terms. Management itself runs a spectrum from excellent management, to good management, fair management, poor management, and mismanagement. This spectrum is frequently forgotten or blurred into the belief that "good-enough management is sufficient."

This blurred understanding of words leads to significant real-world management problems. Leaders must have expertise, while administrators need not. I, for one, would not want to be the leader of, say, a nuclear energy plant without having expertise in nuclear physics and nuclear power generation. Experts have high ability, high knowledge, good judgment and high experience levels. Novices, enthusiasts, and "whizzes" are not experts. Confusion between enthusiasts and true experts, with a depth of relevant education, broad fund of knowledge, relevant experiences, and ability to apply critical thought processes and multidisciplinary insights, is common in information technology. Such confusion can be harmful, potentially allowing unqualified people to attempt tasks beyond their means. In medicine, allowing chiropractors to attempt neurosurgery sounds absurd, but such suboptimal arrangements are not yet recognized in healthcare information technology settings.

In addition, the area of expertise is critical. For example, people who are experts in one field may often not be very good in other domains. MIS personnel who are experts in business and management computing often do not do well, and are sometimes spectacularly bad, in clinical computing situations, as seen in some of the stories about healthcare IT failures. A common problem is that economic self-interest and ego issues may cloud such personnel's thinking and prevent critical self-appraisal.

Focusing now on expertise and its consituent components, this term is not without its own semantic problems. Expertise does not exist without high ability, good judgment, knowledge and experience, but it seems today's recruiters, leaders and HR personnel in healthcare (and probably beyond) focus solely on "experience" as line-items on a resume, as if the other factors are "otherwise equal." High ability, for example as seen by previous multidisciplinary accomplishments, is of little import, or may paradoxically be seen as deleterious, non-egalitarian and therefore taboo, or simply "different". Good judgment and the capability for clear, logical thinking offers no advantages over sophistry since the latter has become highly tolerated (or worse, unrecognized) until the dam literally breaks.

In effect, evaluation of job qualifications has become simple-minded and perverse, considering only the lowest common denominator, "experience". Further, "experience" itself has become narrowly defined and not transferable across narrow silos (in informatics terms, a broken semantic network!)

As a result of this blurring of the meaning of 'expertise', a person who's worked at Brigham's Ice Cream, for example, would not have "enough experience" to work at TCBY Frozen Yogurt! (For non-USA residents, that's "The Country's Best Yogurt".) Another result is an invective used by CIO's and other MIS personnel that medical informatics personnel "don't have enough experience". Yet another result is the difficulty of a person who, for example, knows certain HBOC-brand healthcare IT applications to get a position with healthcare organizations that use a competitor's product, such as Cerner, analogous to a Chevrolet engineer being disqualified from getting a job in a Ford plant.

In a commentary about a Mar. 2, 1999 article in the Wall St. Journal on the working world, a reader wrote that "For employers to feel that someone with a degree in liberal arts and biology has no more marketable job skills than someone out of high school is unfortunate indeed...in its zeal for immediate technical skills, the job sector has come to place more value on the ability to navigate through Microsoft Word than the ability to create something worthy and meaningful with Microsoft Word (R. Miller, "Too well-educated to do the job?", WSJ, March 18, 1999).

Tragically for healthcare, this misguided employment culture strongly applies to medical informatics professionals today. As one MD-turned-recruiter wrote me, "What is happening to MDs trying to change careers is providing a window into broader issues about professionals in society today - narrow training, pigeonholing in the marketplace, difficulty making lateral and cross-industry transition, what a handicap it is to be creative, entrepreneurial, or cross-disciplinary in the current marketplace, and the wasted intellectual capital represented by the high caliber of individuals who can't find ways to fruitfully plug themselves into the marketplace. I continue to be amazed at this general phenomenon...the remarkable quality of a number of candidates I've met, and the lack of recruiters' ability to get them in the door of good companies. The interesting part of the story is that when I am able to get access to high level execs in some of these companies (not just IT, but devices, pharmaceuticals, etc. also) they are dismayed at the quality of those that they hire. They know that something is wrong in how the recruitment process is working. (eg, one of the major device cos. just devoted the time of 1 FTE in Human Resources to 'finding innovative ways of identifying and recruiting good talent into the company.') I am also approaching several media channels about doing feature stories on this topic."

Another symptom of blurring in word meanings and the muddled thinking that results is what my friends and I call "management mysticism" or faddism. Management mysticism is characterized by flowery rhetoric about process, team players, missions and visions, reengineering, TQM, learning organizations, [latest buzzword here]. Yes, I've been through many such courses and seminars. I have not been impressed. Basics of common sense and smart people doing smart things, and doing the "right things" versus "doing things right", are forgotten. "Feeling good" has become more important than "doing well." Management mysticism can result in the wrong people being put in positions of leadership, who then make major decisions about technology. Management mysticism also excludes or marginalizes those whose minds makes them the "correct people to make the correct decisions at the correct time". (In fact, some executives become some engrossed in this management rhetoric that they may actually lose sight of concurrent, ongoing mismanagement.) Wise leaders let their experts do the things that experts do best, to paraphrase Theodore Roosevelt. However, in today's work environment, there are too few of those individuals and many more reactive, "toxic" leaders - toxic to creativity and initiative - who tend towards autocratic behaviors.

One recent astonishing example of severely muddled management thinking led to the unprecedented $1.5 billion bankruptcy of the Allegheny Healthcare System in Philadelphia. The Creditor's Motion filed in US Bankruptcy Court for the Western District of Pennsylvania opens with the understatement, "the debtors and debtors in possession in these cases have demonstrated outright ineptitude and callous disregard for fiduciary duties in the pre- and postpetition operation of their businesses and the sale of their operating assets." This bankruptcy is reported as the second largest healthcare bankruptcy in US history.

Other examples are occurring in the for-profit sector as well, for example, Oxford Health Plans of Connecticut. "Oxford in one year underestimated what it would have to spend on medical costs by more than $300 million...They thought they could do almost anything better than anyone else, but they were novices at developing [healthcare] software...Questions from regulators were an annoying intrusion from bean counters." (Wall Street Journal, Apr. 29, 1998, p. A14.)

Sill another example of increasing healthcare mismanagement chaos involving data issues is the seizure of California-based MedPartners by the California State regulators overseeing health plans. This was done in the wake of the sudden bankruptcy at California's FPA Medical Management in July 1998 and criticism of the state for failing to forestall that debacle. MedPartners was seized after an audit raised fears that yet another large healthcare plan collapse was possible (Wall Street Journal, March 15, 1999, p. B4). As the story relates, state examiners discovered that MedPartners Provider Network in Long Beach, Calif. could not even provide accurate information about a large backlog of unpaid claims nor a dollar estimate of the claim's value, a most fundamental data debacle. The Calif. Medical Association also found itself struggling to recover over $15 million that FPA Medical Management owed doctors who had treated patients and were not paid. (It's apparently become fashionable for business people to view physicians as a no-interest lending bank.)

Not surprisingly, turmoil followed the MedPartners seizure, throwing the huge southern California health care market and the fate of many physician practices into confusion, according to the AMA in a report (Turmoil follows takeover of MedPartner network, AMA News, April 5, 1999). A state conservator filed a bankruptcy petition for the Medpartners network in U.S. Bankruptcy court, which was opposed by the MedPartners parent company who filed their own motion in Bankruptcy court. "This is such a convoluted mess, one doesn't know anything for sure until the lawyers have sorted it out," said Jack Lewin, MD, executive vice president of the California Medical Association.

Clearly, many business people have not mastered management computing in healthcare, let alone clinical computing. Medicine is of unparalleled information complexity, as many business computing people are learning the hard way, or as I put it, "Medicine is not McDonald's." No matter what the final outcome of unfortunate situations such as these, one thing is certain about such scenarios: patient care, which should be the core concern of the healthcare system, is certainly not served.

In effect, unclear, muddled thinking results in suboptimal management and leadership for healthcare computing. "Leadership" has lately become a generic category of "experience", disembodied and detached from expertise in the areas to be led. So, if one is a "business computing leader", one can be advanced to a "clinical computing leader" without knowing much about medicine. This is what often occurs in today's hospitals, where a new name for the Data Processing Department manager has been adopted, Chief Information Officer (CIO), without any discernible advance in expertise. People with this title often burn out and leave after a few years (or get asked to leave) and go to another hospital or healthcare organization. Numerous healthcare IT recruitment firms ("headhunters") exist to fuel this trade. Of course, informaticists and others with clinical backgrounds are usually excluded since they "don't have enough experience."

Mismanagement, micromanagement, and other adverse symptoms that result from muddled thinking, management faddism, autocratic behavior, blurred distinctions between expertise, skills, ability, experience, and so forth, takes people beyond their "safety zone" of competence. This in turn leads to the wrong people making the wrong decisions at the wrong time.

In conclusion:

Confusion in the meaning of words such as "management", "leadership", "administration", "ability", "knowledge", and other terms in the taxonomy of human characteristics beneficial in accomplishing tasks has led to a distortion of the adage "everyone's entitled to an opinion" to "anyone's opinion on anything is a correct opinion." Right and wrong have become relative in our post-modern culture. Unfortunately, the same has not happened to high technology, especially digital electronic information technology which is as unforgiving of error as ever.

A recent story indicated that three rocket launch failures costing U.S. taxpayers three billion dollars can be traced to human error, according to the U.S. Air Force's top space official ("Human error cited in 3 rocket failures", News Journal, Wilmington, Delaware, June 16, 1999). This included a rocket explosion and booster failures. Errors written into a rocket's software was a probable cause of at least one of these accidents. As is painfully obvious, a binary zero is 0, a binary 1 is one, bugs cause crashes (quite literally, in this example) despite anyone's "opinion", and incorrect management decisions lead to debacles.

This is bad enough by itself, but in addition expertise and critical thinking have become obsolescent concepts. Therefore, one does not require expertise or even superficial knowledge of an area to make important decisions in that area. A managed-care clerk without a college degree may overrule a neurosurgeon. A CIO without medical credentials may have a medical records department reporting to them. Healthcare IT progress may be impeded by non-technical senior executives overruling CIO's and MIS personnel on business computing issues, or CIO's and MIS personnel overruling clinical informatics experts on clinical computing issues.

The "unsinkable ship" went down very fast, as accurately predicted by its designing engineer when he knew the extent of the damage. A few more lifeboats, absent due to his having been overruled for cosmetic reasons, would have been very handy ... as one large IT consulting group (CSC) states, the increasing dependence of the world on technology will require a new management "culture of expertise".

Next: On the Web-based health movement: consumers as informed self-care managers.

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