I work in a medical school. A non-clinician, I spend my days surrounded by “medicine in formation” – be it the students I teach, the array of clinician colleagues I am blessed to work with, or the hospitals and clinics I pass as I walk through campus. Care happens where I work… as well as some other darker things. Mistakes, neglect, mental illness, politics, hypocrisy….But at the center lies care – the fight to provide excellent care for others, the fight to keep care in place and in professionals. The fight for the soul, spirit and art of medicine.

It’s a valiant fight in a complex machinery of healthcare delivery. It’s a fight happening in quite possibly every clinic, hospital and medical school in the country, if not the globe. It takes many forms – clinical science, the movement for patient safety, professionalism committees, public reporting of patient satisfaction scores, Medicare penalties for hospital readmissions… You’re probably wondering what I have to do with all this as a non-clinician.

I am trained in communication. And I don’t mean, “I talk, therefore I am trained in communication.” Because that would be like saying, “I breathe, therefore I am trained to be a pulmonologist.” No one in their right mind would say that, right? No, I mean, TRAINED. As in, I conduct research on it, I write about and am published on it, I possess considerable theoretical knowledge around how we construct meaning and our worlds together, and I spent a great deal of my adult life in indentured servitude in graduate school becoming an expert in it. So as a ‘doctor of philosophy-communication’ I am an unusual person in a medical school. Most clinicians will freely admit that communication is the CORE clinical skill and then in the next breath say that we spend too much time and money in medical education on it.  Students will say that they already know how to communicate so why do they need to take classes in medical school in communication? Why indeed?

Of course, on the flip side, we can look at reports from the IOM, JAHCO, and AAMC, not to mention AHA and many other professional organizations which clearly point to the fact that a lack of communication skill/performance in the medical profession lies behind staggering malpractices, nearly all medical errors, and deficits in patient safety and satisfaction. Yet, communication, the foundation of care, is treated with ambivalence, and some times and by some people, cavalier disregard, in medicine.

So I think ‘cavalier disregard’ is the main enemy in the fight for care. I spend most of my working life demonstrating the connection between care and communication. How do I do that? By focusing on words and actions – small (but really powerful) things that any person can change about themselves with reflection and reflexion. Then I connect them to clinical decision making and actions. That’s when things get real. FAST. That’s when we see mistakes, omissions, suppressions. That’s when we see all the challenges to care emerge before our very eyes. This is where I enter the fight for care.

Recently, I asked a communication colleague of mine to observe a team exercise where I work. As we processed observations with clinical faculty, my colleague asked me if it was really communication work I was doing, or was it cultural change?

How can I do one without doing the other? If you change your words and actions, you are changing cultural practice. As soon as you label a phenomenon, you provide it with cultural force – structures rise up around it, more language evolves around it, policy emerges and law…Date rape is a good example.  So the next series of posts, based on my reflections on the fight for care as it exists where I work, are going to tackle some words we use, in the hopes we can change our world of care.  Because to label something, is to call it into being and make it visible, and there is so much in the mystical, mythical and magical world of medicine that lies invisible to the majority of us.

Case in point: Names. Next time you are in a clinic, watch who uses your name. Then call the people who care for you by name. Often. See them, see you.

With thanks to Horia Varlan, loop_oh,ninatoessinger, and dollen for their art!



One of my two favorite conferences in the world closed a couple of weeks ago – Mayo Clinic’s Transform, hosted by the Clinic’s Center for Innovation (CFI). If you remember, I covered this conference last year, after what can only be described as three days of awe inspiring conversations. This year, I had the very distinct pleasure of talking with Dana Ragouzeos, a designer with the CFI about the work she has been doing there over the last 18 months and the process the CFI uses as an embedded design team to transform health from the inside out (and back again too ☺).

Sterena: First of all Dana, can you tell us a little about your background and how you came to be doing the work you do now?

Dana: I started out studying writing, but moved into architecture. I liked studying people and patterns and telling stories through both pictures and words. I ended up choosing pictures (and models, and diagrams). I studied at a liberal arts college (Smith College), so design was always something more to me than what I put down on paper (we didn’t use the computer yet). It was about the process, the observations, the trial and error that got me there.

After school I worked in landscape architecture and urban planning offices and moved into a research role. I was researching aging facilities one day and realized I could make a bigger impact working in product and interactive design, where the timelines (from conception to implementation) were shorter and there was more of a premium on design research. So I began getting experience in product design and eventually went back to school. I chose Calif. College of the Arts (CCA) because they had an interdisciplinary program, and I knew I’d have the flexibility to pursue studies in design/medicine/and aging while there. My thesis work was on developing interactive tools for caregivers of dementia patients to connect and share resources. After engaging in that work, I knew I wanted to work in design for health and health care. Mayo Clinic was the only place I knew of that had invested in an embedded design group that could really get at the roots of our complicated medical systems and create solutions from the inside out. I love what we get to do here and with whom we get to work.

Sterena: So user centered and patient centered design are pretty hot right now, how would you describe the ways in which they differ?

Dana: At its core, “human-centered design” it is about putting yourself, the designer, second, leaving yourself open to be surprised, to be taught. Yes, we come to the table with years of training and experience, with preconceived notions, with some really great ideas. And in some cases those ideas find their way into the final design, but only once they’ve been fully vetted through the needs of the people who will ultimately interact with and rely on what it is you are creating. Design training at its best cultivates empathy, and in user-centered design that empathy is our most valuable tool.

Patient-centered design is not necessarily different, but there are elements of human-centered design that are heightened when working with patients. For example, there are parts of the patient experience that have not changed for decades or that have changed in surprising ways. There are reasons for everything, and there is a lot of history with many stakeholders attached to it. In every project, it’s critical to know that history or we quickly get dismissed as out of touch.

Another element of patient-centered design is that we have to constantly remind ourselves to not just address the needs of the patient, but their hopes, dreams, desires, and goals. It is easy to lose sight of that in medicine where it is crucial to identify and address the needs of the patient in the most timely and accurate manor. A third element of patient-centered design is the role of the team: the design team, the care team, and the patients’ teams. No one has all the answers in medicine, and no one person has all of the answers designing for medicine. An intelligent team to rely on, that will listen and contribute, is critical. Successful communication and teamwork are difficult and have to be practiced, no matter how much we try to convince ourselves otherwise.

Sterena: How do these design ideas interact with other principles in healthcare design such as evidence based design or even experience based design then?

Dana: You can’t really have one without the others. Our approach naturally covers all of these. We have financial experts, medical providers, IT analyst/programmers, project managers and administrators integrated into our design team to make our approach truly holistic.

Sterena: What are some of the Clinic’s projects that you have seen emerge from this commitment?

Dana: In one project, called the Toolkit, we turned our focus on Mayo Clinic employees. Innovative concepts emerge all over the clinic, but it can be hard to see them to fruition if doing so is not integrated into your day-to-day job and rhythm of work. We wanted to make our tools and methods available clinic-wide so that concepts didn’t die and people felt empowered and equipped to move them forward. Instead of just making some templates and videos to post online, we conducted individual and group discussions and observations throughout the clinic. We concluded, among other things, that people needed a place (both physical and online, but mostly physical) where they could come together, and they wanted to connect with other people with whom they wouldn’t otherwise connect. This was more important than any tools or templates. We built out a physical space, along with some online tools, that would help them do that. The key is that the Toolkit is never done. It was built collaboratively through experimentation with Mayo employees, and it continues to evolve according to their needs and wants.

Another is the Outpatient Practice Redesign project we’re working on. It’s a long-term project aimed at improving the patient experience and reducing cost. We’re using experimentation as part of our research, which is a very human-centered way to work. We discover patient and practitioner needs, like more flexible scheduling or a team-based approach to patient education. We then work with our stakeholders (providers, patients, allied health staff…) to conduct lo-res experiments around how that might happen. That’s one of the things that makes our work different. We experiment, and we do so alongside our stakeholders. The most sustainable healthcare solutions are those that recognize and address the integration of people, information, and systems in a nimble way. We are successful when we include stakeholders in our research, experimentation, and design. So, our experimentation involves long hours in the clinic, working alongside staff and adjusting our approach when we learn that’s necessary.

Sterena: So what do you think are the challenges and limitations of such design solutions? What evidence do we have that user focused or centered design works?

Dana: Getting buy-in takes time. All projects need momentum to be successful, and it is hard to maintain momentum when it is equally important to include key stakeholders in the process. That is also why it is valuable to be an embedded group. Because we understand the culture and have relationships, we can move faster. That’s why it’s such a valuable investment that Mayo has made in CFI.

The evidence that our approach as an embedded human-centered design group works exists in people’s language. We work with people that understand and embrace the concept of prototyping. The word “experience” has found its way into our institutional visioning language. People seek us out and understand the value of design research and visioning in their projects. These things were not as evident a few years ago. Those are huge wins. Our biggest successes are not only in 3D or 2D solutions, they exist in language.

Sterena: In closing, tell me, what would be your dream project?

Dana: I have a lot. Here are two. If you need me to really just pick one I can. Or if you want a few more, I can do that too ☺ :

1. Redesigning medical education and training

Medical training is thorough and produces some excellent practitioners that go into this work out of a genuine desire to help people. But as we look at the current big problems in how we practice medicine, it becomes evident that we have to turn our focus onto how we educate, train, and cultivate our care teams. There is a lot written about how we could redesign medical education so that we don’t have to put band-aids on our current systems. It’s a huge undertaking, but I believe in our methodology of starting fast and small, and I believe in the passion and excitement that exists in educating and learning.

2. End of life care

I believe strongly that we owe it to ourselves as a society to completely rethink and create widely available, accessible, and acceptable ways to thrive through this part of life.

I couldn’t agree more! (and look forward to attending Transform 2012 :))

With many thanks to fdecomite, katerha, wonderlane,  and hello, I am Bruce for their beautiful images!


…Or so they say….

It is hard for us to admit here at Sterena, that indeed, it has been almost 9 months since our last submission.

You probably thought we had disappeared off the face of the Earth, and to some degree, you would not be far wrong! But we’re back now and due to our journeys near and far, across continents clinical, we have some exciting stories and whimsical thoughts to share.

We promise to write by the end of the week (outrageous thought!) to start our summer series and embark on some of the many thoughts and times we have been involved in over our hiatus!

See you back soon!

With deep appreciation for the art of anoldent!


The tumult and the shouting dies;

The Captains and the Kings depart:

Still stands Thine ancient sacrifice,

An humble and a contrite heart.

(Rudyard Kipling, Recessional, 1897)

It’s been almost two weeks since the attendees and speakers of Mayo Clinic’s Transform Symposium wound up conversations and dispersed to their day jobs as physicians, internet researcher, writers, caregivers, engineers and business people. The Captains, Kings and Queens have all departed and still the humble and contrite heart on which all health(care) is based, remains. Waiting, still waiting, for something to change.

A fine colleague of mine, Dr Gwyn Barley, asked me the other day what I had seen or heard in terms of what symposium participants the future of health(care) would/should/could be. I had been turning this over in my mind for the last ten days or so, after I asked Transform’s lead facilitator and chair, Dr David Rosenman (@davidrosenman) of Mayo Clinic, how he would know the impact of the conference. You know the feeling after you’ve attended an inspiring and inspired meeting of people with extraordinary minds and energy? You’re all charged up, want to go out there and JUST DO SOMETHING TO CHANGE THE WORLD. But the world makes itself present almost immediately before you can marshall and direct all that energy to start something new. So I wondered what we would all achieve, all 500 of us at that conference, in the next 12 months that would flow directly from that conference and into health in everyday life.

Two words came to mind – BEHAVIOR MODIFICATION. Now, I am not just talking about us changing all those things that eat away at our health – the non-exercising, the non-sleeping, the non-eating right….. the list is endless. I mean behavior modification at a systemic level (which of course requires us relinquishing all those non-activities I just mentioned). Behavior modification like that desired by…

The Critical Thinkers, such as…

Esther Dyson (@edyson), who just wants us to check our facts and ask critical questions, of everyone and everything, especially ourselves when it comes to health.

Alice Tolbert Coombs, who wants us to consider ourselves resourceful, empowered and literate so we can ask serious questions about procedures, qualifications, experience, and the impacts of all of these for our health.

Tahir Amin and Priti Radhakrishnan, who drive I-MAK and want us all to participate in the patent system, encourage real innovation and support lawful and legitimate trade in generic medicines.

Jamie Heywood (@jamie_heywood), better known as the cofounder of PatientsLikeMe, who wants us to ask this inspiring question, “Given my status, what is the best outcome I can hope to achieve and how do I get there?” And to keep asking it, of everyone, in our quest for care and health.

Macharia Waruingi, a global health revolutionary, who demands we check our facts, our research methods, and our researchers and to critically examine all outcomes, knowledge and practices flowing therefrom because as he argues, people know more than they can tell and we have a responsibility to support their voices so we may have health on all our terms.

The Care Collectivists, like…

Sanne Magnan, who wants us to connect health systems to environmental and community systems and to think collectively and holistically about all the forces that produce good health.

Patch Adams, who urges us to embed compassion into caregiving practice and to consider health as a collective commodity and of collective origins so the source of our health as those being cared for is directly related to and impacted by the health of those providing that care.

Rebecca Onie, Sonia Sarkar and the crew at Project Health, to whom I am going to send as many college students as possible, dedicated to providing assistance and advocates for those in need of basic resources, also known as the social determinants of health in communities.

Sona Mehring of CaringBridge which I believe should just be as ubiquitous as Facebook for all the unending care it provides for those in need, and which urges us once more to consider the care giver and their overall health as they attempt to support others.

Mrs Q (@fedupwithlunch), blogger heroine of the school lunch movement and avatar after my own heart, who believes we should ask more questions about where the food going into our kids comes from, not to mention the generational impact of same on population health.

Thomas Goetz (@tgoetz), who believes in the power of positive data to change our decisions and courses of action; to make our health, our own story.

Sidna Tulledge-Scheitel, dedicated to figuring out how to support people for all the minutes of their life not spent in their primary care practitioner’s office through the use of community based technologies.

Sharon Gibson of Cisco who co-led and re-directed a lifeconnections center in San Jose based on employee desires for innovation, health and sustainability and who believes that we need to be discussing health and people and not healthcare and patients. RIGHT ON.

The Transformative Technologists of…

Catherine deVries, who advocates for community appropriate technology (a la Atul Gawande); technology which is disruptive because it is energy efficient and flexible, not to mention extremely affordable. After all, developing communities should not be the technology landfill for more advanced industrial nations and healthcare systems.

Susannah Fox (@susannahfox), Internet Geologist Extraordinaire, who wants information to come to where we are and be portable, personalized and most importantly, and participatory. NOW.

John Wilbanks (@wilbanks), Game Changer, who makes us think about fundamental choices around our use of the Inter-net (check out Wired’s article on the Web is Dead) and the radical divides that we still struggle and need to work on as we try to harness our technological gifts for health. The answer is not anonymity by the way (c.f. PatientsLikeMe). I’m a HUGE supporter of Creative Commons, so of course, John is one of my new heros.

Ian Eslick (@ieslick), patient narrative advocate (hooray!), who wants us to expand our understandings of science, like Macharia, to include all voices and to take diverse forms of knowledge seriously in order to support health in specific populations.

Sandhya Pruthi, who in 15 minutes taught me a lot about breast cancer via a computer based education tool and to David Rosenman’s point, in that moment, transformed a future health story.

Dean Ornish, who I really need to email or google to find his awesome work on the power of sustainable changes in diet and lifestyle as treatment for some of our more troubling chronic conditions like heart disease. I need to distribute that information through my family, stat.

The Daring and Disruptive Designers such as…

Patricia Moore, design heroine, who wants to shatter the myths we have about the elderly and like many designers, wants us to reconsider how design excludes and fails many demographic groups. I bow to her as an ethnographer for her awesome work traveling the country as an elderly woman for 3 years to ground her practice.

Jesse Dylan, artist, open source warrior and defender of citizen rights who wants us to demand true innovation as do the folks at IMAK, and to reinstate collaboration as many others argue, as central to the discovery of transformative practices and products for health.

Sekou Andrews, Disruptive Designer of the Social, wielding the power of words and performance, reminding everyone of the importance of inter-action and small children in our continued and necessary re-education in the importance of paying attention to the world, free of our stupefying adult minds.

Robert Fabricant (@fabtweet) and all the crew at frog design, believers and curators of white elephants who continue to ask how we can encourage people to move towards sustainable behavior through design and what engagement looks like. After his presentation, I tweeted Carlos Rizo(@carlosrizo) and Mark Scrimshire (@ekivemark) who run healthcamps on how to embed a health-hack-a-thon into a healthcamp.

Jill Morin and James Rasche of Kahler Slater who advocate for Total Experience Design and ask us what experiences should define us and how design can make them manifest.

Michael Celender, Lew McCreary, Lorna Ross and Chris McCarthy, who collectively and individually believe in the power of finding others who think differently and encourage collaborative design between individuals, departments and organizations, so that we focus on a patient’s potential not need when designing something for them. All to ultimately design better organizations.

David Rose of Vitality (@davidrose), for whom I ate M&Ms for an experiment on glowcaps, one of his range of enchanted objects (love that term!). We all need enchanted objects to help take care of ourselves and as a not normally compliant person, the cap actually worked! David thinks about the user and then some. Just amazing.

Finally, the Place-based Progressive Practitioners (you know who you are)…

Lyle Berkowitz, who wants us to think differently about electronic medical records and puts in place actionable, context sensitive screens and widgets in his dedication to the user. Lyle also patiently kept me geographically oriented during our 2 hour tour of the Clinic, when all the buildings and statues began to merge into one and minus the mountains of the west, I wandered around in circles. ROCK STAR.

Tye Farrow of Farrow Partnership Associates, who architects some of the most jaw droppingly beautiful health facilities I have ever seen. His dedication to taking unnatural environments and transforming them into regenerative contexts will blow your mind. He builds hope, on a large scale, and through his medium, health.

Chaki Ng, who building on Susannah’s directive for information to go where you are, takes this and technology together to make health interactions go where people are, in our own ‘streams’, both individually and organizationally.

Sharon Schindler Rising, Centering Healthcare Institute, whose idea and stories of moving care into groups almost made me cry. Her dedication to activating self care, community building, and empowerment on an everyday level of health, I know, transforms lives. Her profound belief in collective wisdom, like many others above, and her individual commitment to honor it and put it into action, make a mother like me want to clone her and have one of her sites for CenteringPregnancy in every single town!

James Levine of Mayo Clinic and Muve was just awe-inspiring although I found the treadmill office desk a little unnerving. His work on making us move, all the time for health, deserves a medal as he addresses all those non-activities I mentioned earlier and really asks us to make some concrete changes. NOW. EVERYWHERE.

I know what you’re thinking. That’s a lot of smart, creative, dedicated people, right there. And that was only the speakers! We should be able to transform health, right? Maybe it won’t happen in 12 months. Or maybe, just maybe, if each one of us took the spirit and ideas of these people and just did one thing, before we had to front up next year in Rochester, something might shift. 500 people is a lot of people and as Margaret Mead would say, “never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.”

But how will we know? Oz Huner of NexJ and I wondered about whether if we had an unconference for the first part of the conference, chose some projects and then aligned all this talent against them, we might have some kind of longer term working groups come up with things transformative. But maybe that is not disruptive enough. Maybe there is power in just sending these ideas into the either so that they find their way into other people’s hands, hearts and minds, like they did ours. Maybe that in and of itself, attracts the critical minds of caring collectivists and transformative technologists who as soon as they meet a disruptive designer might just come up with a place based progressive practice.

So what will I do over the next 12 months (beside working with clients) to play my part in transforming health(care)? Here’s a few thoughts, and feel free to hold me to them in 12 months…:)

1. Work with a very dear physician colleague-mentor of mine who is soon to retire to bring his dream of telehealth and clinical genetics practice to rural areas to fruition. If you know of anyone who can help, please have them email me!

2. Participate in innovating clinical skills education in a closed system/employee physician organization to begin to transform the ways in which care is communicatively performed in current and future practicing physicians. If you know of an organization up for the challenge, I’d love to hear from you :).

3. Start a micro journal where those with new, innovative, and creative ideas for improving clinical practice and health via participatory technologies can share their ideas with a wider audience outside traditional, mainstream publication venues. Keep watching this space!

That should be enough for the year, don’t you think? So what are you going to do? What changes would you like to see coming into and out of the Transform Symposium?

Remember, your children are watching and as Sekou reminds us, coming….

When the captains and the kings/queens depart, remember the humble and contrite heart of health…

With special thanks to luc.viatour, Horia Varlan, Jeff Kubina, lrargerich, fdecomite and Mara~earthlight~ for their phenomenal images!


@kblucy @sterena

Meaning is always rented, never owned.” (Vygotsky, 1980)

What would you do if a woman – 96 years old, frail and small – lying in a hospice bed asked you to help her eat ice cream because her hands were too arthritic?

What would you do if a woman – 67 years old with dark hair and silver glasses – sitting in a hospice bed asked you to help her drink the orange juice you had poured because her Parkinson’s was so severe?

Now, would your decision change knowing that if you answered “yes”, you were violating organizational norms?

My decision did not change. I answered in silence with a smile and a head nod. For me, it made perfect sense to help someone eat and drink even though I was not “trained” to feed in this type of setting.

Recently, an article described an interesting consult between a patient and a provider making sense of such a situation. The provider and the patient were close family friends but met unexpectedly after many years in the hospital. As the provider finished the consult and started to chart, the patient said, “Tell me something. Is this the first time you have cared for someone from your world outside of the hospital?” It was the first time for the provider. The patient suggested that he get used to it. The provider agreed with “certainly.” Thirty years later, he realized that he never has.

What does it feel like to care for someone from your world outside of the hospital?

What does it feel like to care for someone not from your world inside hospice?

Making sense is something we do every minute of every day. But our culture tends to over emphasize words, discourses, and abstract symbolic systems in making sense of diverse worldviews. With so much “talking”, we forget the importance of physical, embodied interactions such as those when our worlds collide in unexpected and confusing environments, or what Karl Weick refers to as equivocal environments.

Equivocal environments such as caregiving settings are the catalysts that motivate us to organize and make sense. This organizing is often done in ways that seek to reduce equivocality, or the uncertainty in which we often find ourselves. Uncertainty, however, is not always a bad thing.

Silence, for example, helps reduce equivocality through covert actions like a gaze, a gesture, a smile, an uncomfortable movement of which we are often unaware but which carries significant information to an other. For many, silence is seen as an obstacle to social relations, or as the absence of meaning. Furthermore, silence is often uncomfortable and sought to be avoided through our uses of “um” and “ah.” Generally, our norms surrounding silence are negative where people feel silenced, are silenced and considered the “elephant in the room.” Therapy, after all, is about uncovering silent elephants considered negative to psychological health. But silence also opens gaps in equivocal environments where care, rather than the world you’re from, matters.

The consult between the provider and patient and my decisions at hospice highlight challenges and opportunities for care giving. At a time when life produces complex and confusing situations, we must not forget sensemaking that incorporates the whole body and in particular the sounds, touch, smells, and feel of organizational life. Sensemaking is about holding on to some forms of Being while simultaneously letting go of others.

Holding on and letting go describe two keys points in managing the unexpected: expectations and categories. According to Weick, people who constantly rework, refine and replace their categories notice more and catch the silences, the whispers and the utterances of daily life.

In doing so, we become better able to care for someone no matter where they come from.

With thanks to jcolman and cogdogblog for the images.

Carey Candrian

Over the holiday, my mom’s good friend lost her father. When I asked how they were doing, my mom said that although it was devastating, they all know he is in a better place and they are “lucky” he left peacefully and didn’t have to suffer. A week before, I used the same word after a family’s test result came back negative. Wow, we are so “lucky” I kept saying….

Returning to Colorado, I bought a new book by Joanne Lynn that I’ve wanted to read. The book, Sick to death and not going to take it anymore! Reforming health care for the last years of life begins Chapter two with the following quote: “Facts are like geography – they shape the possibilities. Interpretations are like politics – they create the human structures and meanings.” After reading this, I thought about our (and my) use of the word “lucky” in creating human structures, interpretations and meanings of our experiences and how it was similar and different to a system built on participation…

Lynn’s overarching question from the outset is “why do we tolerate a health-care system that leaves people in pain, confused, bankrupted, demeaned, and frightened?” What should we do aside from relying on luck?  For Lynn, “we need most a shared vision of good care, innovative approaches for achieving this vision, and the will to make the changes happen.” That said, I am going to discuss four ideas or practices that are gaining momentum. Ideas that allow care to be different, collaborative, and participatory, instead of lucky…

Atul Gawande has been busy publishing his most recent book, The Checklist Manifesto that is an extension of his earlier article in the New Yorker about checklists for surgeons, similar to the checklists pilots use. Gawande addresses the need for such checklists by putting medical errors into perspective by stating, “Annually, medical errors disable at least 7 million people and kill 1 million worldwide – the equivalent of six sold-out 747s crashing every day, killing everyone on board.” Sure, treating a patient suffering from multiple conditions is far more complicated than flying a plane, but this statistic certainly puts things in perspective. According to Malcolm Gladwell, “Gawande thinks that the modern world requires us to revisit what we mean by expertise: that experts need help, and that progress depends on experts having the humility to concede that they need help.” The solution? No, not more training or technology but checklists. “Did we get the blood ready?” “Does everybody in the room know each other’s name, so we’re working as a team?” Why a checklist? Well for Gawande, steps are being missed and complications are occurring that are avoidable. Even more, these lists are facilitating people to work less as individuals and more as part of a team. In so doing, the boundaries around expert, expertise and professional begin to be defined and celebrated by the willingness to work together, rather than alone. And this matters for increasingly complex practices, drugs, diagnoses and patients.

Although checklists might seem silly, according to Gawande, they do matter for a complex system that cares for highly complex patients. Valderas et al (2009) in the Annals of Family Medicine discuss the norms and expectations of caring for individuals with multiple coexisting diseases. In the United States, the authors underscore “about 80% of Medicare spending is devoted to patients with 4 or more chronic conditions, with costs increasing exponentially as the number of chronic conditions increases” (p. 357).  The words “comorbidity” and “multimorbidity” are often used synonymously when discussing these issues. But the important thing to consider is knowledge about the role of psychological issues in medical patients with multiple chronic diseases. Clearly, this is challenging for providers, families and patients because complexity in these patients has not been clearly defined, thereby designing interventions to improve their care is difficult at best.

Increased interventions and improving care is making great strides, especially in light of Kaiser Permanente’s idea of “Thrive” and “Total Health.” Both ideas shed light on the innocuous details of health care environments – plants, waterfalls, windows, patient rooms, transparent hospital gowns, a blaring news station in the waiting room and so on. “Total health” becomes a method for designing and building new facilities or renovating existing ones. These efforts are not necessarily about decorating or adding more flair, they are about outcomes. For example, access to natural light, noise level in the halls, privacy of rooms, or views or nature. Together, the new designs enable workers to do their work more effectively (and make it more pleasurable) and allow design to be about building healing rather than curing environments. Design takes a new spirit by building in a way that not only improves the lives of patients and families but also for providers, who do this work.

Improving the working conditions for providers brings awareness to the many hands called upon to deliver care. Hands we often take for granted like helicopter EMS. According to Rogue Medic and an article written by Michael Abernethy, MD, Bryan Bledsoe, DO & Dale Carrison, DO, HEMS transport is the only medical procedure that holds a much higher morbidity and mortality for the providers than it does for the patient. Why don’t we hear about the risks and mortalities? What don’t we help develop safer procedures? Is a safe transport considered “lucky”?

Finally, returning to Lynn’s question at the beginning, many of us do not tolerate a health-care system that leaves people in pain, confused, bankrupted, demeaned, and frightened. The examples above show that changes – and good ones indeed – are taking place. Sure, there is plenty of work to do but the conversations have started and we can either dwell in the misery many of us feel about our health care system and health care reform, or we can find some light and hope in what is taking place. I remain a little more optimistic because there is a difference between a system that relies on luck and individuals working alone and a system that fosters participation and celebrates what happens when people work together to deliver care…

The whole is always greater than the sum of its parts.

With thanks to geko, ben anoufa and Adam Foster/Codefor for the images.


September is here this week which means we are counting down the days til Medicine 2.0 in Toronto! I have been going through the schedule and have already received facebook, Linkedin and twitter invites to connect from people attending the conference, so I thought I would write about what I am looking forward to most about the conference and why…. here goes….

1. Meeting Jen McCabe Gorman and Berci Mesko – these two visionaries have spurred my thinking and interest in health and medicine 2.0 for well over a year now and I have been avidly following their progress. They have taught me much and inspired me more, so I am excited to hear more about what they are upto (webicina and contagionhealth) and meet them in person!

2. Learning more about Organized Wisdom– this endeavor is hands down, one of my favorite technological attempts to reach across the relational divide between health seekers and health providers. I especially love their engagement of our usual communicative routines to facilitate a health community online.

3. Hearing E-Patient Dave speak – Dave is giving the keynote on the first day and I have made travel arrangements to cross the entire country in time to hear him speak (this is a conference first for me!). I have been reading his blog for over a year as well, and he, like Berci and Jen, has taught me much!

4. Participating in the Un-conferences – as a communication scholar, I tire easily of the usual conferencing format. It’s capacity to disengage and disconnect people from ideas and each other is unsurpassed. Hence my strong support for the unconference…. as slightly intimidating as it is, there’s just something infectious about spontaneity (and not in a public health kind of way….or maybe it should be!).

5. Attending the presentation “Success in Virtual Clinics for Hispanics: Lessons Learned from Forumclinic Users” – I am especially interested to hear about their virtual community efforts and practices, and hopefully meet the folks who worked so hard to put these efforts together. Community is hard enough off line, and even with participatory technologies with us, we still can’t always guarantee the people factor.

6. Hearing Pat Rich from the Canadian Medical Association tell us about “Asklepios and Mydoctor.ca”. I have written about Asklepios before so I am excited about hearing about their progress and how the social network has been received by practising physicians.

7. Participating in and listening to our co-presenters in the panel Web 2.0 approaches for clinical practice, clinical research, quality monitoring on Friday September 18. The thing I like about this panel is that is sounds very grounded in clinical practice and experiences, which as an ethnographer intrigue me. I really look forward to our conversations!

8. Dividing myself in half so I can attend the panel happening at the same time as the one I am participating onBuilding virtual communities and social networking applications for patients and consumers. These communities sound extraordinary and so I am not sure how I am going to clone myself in time to hear the presentations. I will seek out the presenters though to hear more, hopefully at one of the social events or gathering times.

9. Attending the NextHealth presentation later that day – I have been trying to find out more about this effort ever since I saw a video online of one of Jen McCabe Gorman’s presentations on same…. should be exciting!

10. Finally – attending the last session on “Ethics 2.0: Implications for Connected Health (Panel with interactive audience response system)”. I love these kinds of discussions and I appreciate any attempts to think about what our technologies are doing to us, not just what they enable us to do with them. Connected health really challenges some of our modernist ideas around the individual, privacy, ethics etc. I also want to hear more about the work of the eHealth Strategy Office at the University of British Columbia. So there you have it! I will, of course, cloning efforts successful, be attending more than I have written up here; but these are the ones I will make sure not to miss…. if you haven’t seen the schedule for the conference, click here. This is the conference I am looking forward to most this year!

With thanks to myrrien, chrisheuer and maggi_94 for their wonderful images!!

To your good health!

Kirsten Broadfoot

@kblucy & @sterena


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