The Standardization Tax, Part 3: The Two Load-bearing Walls

Standardization and handoffs lead to knowledge lost

Post 2 in the series was about doubting your own judgment and attention enough to follow a checklist. This post is about doubting it enough to ask the patient what they want, and to trust knowledge you didn't personally build. It covers two kinds of load-bearing variation: the wall built by patient choice (Wennberg's preference-sensitive care and the shared decision-making it requires) and the wall built by a physician's earned knowledge of a patient over time, i.e., continuity of care. Standardizing either wall away doesn't reduce waste. It reduces choice or erases knowledge whose value nobody understood until it was gone.

  • 9 mins

The Standardization Tax, Part 2: Why We Need Standardization

standardization can be an important tool to reduce errors

Before The Standardization Tax series argues against a certain kind of standardization, this post gives standardization its due. It opens with the true story of a five-step checklist Dr. Peter Pronovost developed at Johns Hopkins, which cut central-line infections in Michigan ICUs by 66 percent and saved thousands of lives. That success came from eliminating plain human error, not judgment. The post then turns personal: learning, during psychiatric training in the U.S., to ask every patient about alcohol and drug use as routine rather than a judgment call — and years later, watching another psychiatrist skip that same question during a mock board exam, for reasons which reflect the author's own earlier blind spot. The line is clear: variability in care can come from mistakes. And if standardization can eliminate those mistakes, then we should go for it.

  • 6 mins

The Standardization Tax: Not Every Tradeoff Is Worth It

continuity of care is a given in rural medicine

What would a pre-med student think if she heard how many doctors today say that they would steer their own kids away from medicine? They blame increasing corporatization, shrinking autonomy, and burgeoning documentation burden. These stem from increasing standardization in medicine. This post, the first in a series, introduces the idea that while standardization has benefits — catching errors, controlling costs, protecting clinician time — it also has a cost. Not all eliminated variation is waste.

  • 6 mins

Anecdote, Story and Speech: What Every Leader Should Know

What makes a story a story is transformation

A phone call from a crying teenager, a residency training director who didn't ask a single clarifying question, and six words that changed how one physician has led ever since. This post opens with the story, then takes it apart. Drawing on a distinction learned in a storytelling class — an anecdote is something that happened, a story is something that happened and changed someone, a speech adds a call to action — it argues that physicians aren't bad storytellers. They were trained out of the middle term. The case presentation is built to strip away transformation. Leadership requires putting it back. Includes the line between using a story to illuminate your ask and using it to smuggle one, plus a two-sentence exercise for finding your own.

  • 9 mins

One Year of Writing and the Question I Keep Coming Back To

write every week

I wrote my first post on Voice That Moves one year ago. Except for a short break this summer, I have published a post every Sunday. This anniversary post highlights eight posts from the past year – on the communication gap between doctors and business executives, the discipline of hope, healthcare's strange economics, the truth about office politics, lessons from a national speaking competition, physician well-being and agency, the evidence behind servant leadership, and leading peers without formal authority. One question underlies my writing: how do you help those trained to heal learn to lead? There’s no tidy answer here…just a year spent working on it one post at a time.

  • 4 mins

The Most Important, Invisible Thing Regular Meetings Do

The important, invisible thing that regular meetings do

A clinic administrator announced a set of changes in the local newspaper. The staff who would carry out those changes found out the way everyone else in town did — over coffee, from the paper.

For days, people complained in hallways and parking lots. It went nowhere. Then, at the pointless monthly committee meeting, one senior physician said it out loud, in the room, in front of everyone. That naming set events in motion that eventually removed the administrator.

How did that happen? Because of every "pointless" meeting session that came before it. The committee had been building the team's connective tissue the whole time — badly, by accident, and without anyone naming it.

  • 8 mins