Sunday, March 04, 2007

Mission-Hostile Management: "Chaos" as the UK NHS Implements "Modernising Medical Careers"

A year ago we posted bout the problematic new system, called "Modernising Medical Careers," (MMC) that UK National Health Service (NHS) managers had put in place to match junior physicians with specialized training positions (called specialist registrar positions). Concerns at the time centered on importance in the matching process of applicants' responses, in the form of very short essays, to standardized questions posed on a web-site. It seemed there would be no way to check the accuracy of their answers, that the relevance of the questions to one's ability to practice in a given specialty was questionable, and that the whole system devalued traditional measures of clinical competence and educational performance.

I wrote last year's post with some trepidation, fearing that I may have not adequately understood the context of the new system in the UK (although I spent some time in the UK in the 1990's gaining experience with the generally excellent medical education system there.) Now MMC is up and running, and the results don't seem pretty, perhaps validating my concerns. Per the BBC,

Doctors' training was revamped in 2005, with the aim of speeding up progress so juniors could reach consultant level in an average of 11 years, rather than the current 14.

However doctors who have been through their initial stage of training under both the old and the new systems are all competing for a limited number of specialist training posts.

Remedy UK says early results from a survey of over 1,300 doctors suggest an overwhelming majority do not think the system is a fair way of selecting new doctors.

There are also concerns that the website set up under the Modernising Medical Careers system to co-ordinate job applications simply cannot cope.

Problems reported range from people being unable to upload application details to not being able to access the site to see if they have an interview - which started just two days after being announced via the site - and the potential staffing problems on wards caused by junior doctors heading off to interviews at the same time.

Doctors also report that some highly experienced colleagues had not been selected for interview, and that the way the system is organised means only a limited number of posts are available for doctors with the most experience, including those who have taken PhDs.

Jamie Wilson, a London-based psychiatry student - one of many who has contacted the BBC to raise concerns about the system - said: "The whole system is a shambles, and the applications process is chaotic."

A spokesman for the BMA said the reason for the problems boiled down to the new training system being rushed in.

"It's a huge task to get these tens of thousands of doctors into new jobs."

He added: "There is evidence that very competent and able doctors have had no interviews at all."

But a Department of Health spokeswoman said: "Medical employment, like any other employment, is competitive."

[However,] doctors are set to take to the streets to protest about what they say is a "shambolic" system which could see at least 6,000 without training posts.

A grassroots movement is organising the march in London on March 17, and claims 1,000 doctors have already signed up.

When doctors threaten to march in the streets, things must be getting really bad.

In two articles in the Telegraph (here and here), there was additional emphasis on the new system's apparent inability to identify the most experienced and qualified physicians.

[A Professor of Plastic and Reconstructive Surgery said] They have spent an enormous amount of money creating this new system and the whole thing is spiralling into chaos. It is quite immoral to inflict this on motivated young doctors. I cannot find a single doctor who is happy with this flawed process and ultimately it is the patients who will suffer.

Bernard Ribeiro, the president of the Royal College of Surgeons, wrote to all members on Thursday listing five 'fundamental difficulties' in the system.

'For 18 months I have tried to get this system modified and the number of surgery places expanded,' Mr Ribeiro said. 'I have not succeeded. This system must be reviewed urgently.' [Note that in the UK, surgeons are referred to as 'mister.']

Problems listed by the royal college are: 'woolly' questions on the application forms; concern that qualifications have not been taken into account; concern about the adequacy of training for assessors; inconsistent rating and errors in reporting the results.
As I noted earlier, one wonders if this chaos reflects the preference by modern managers, be they in the UK or the US, for computer based solutions for every problem. The tendency to believe automation is the magic solution to every problem may create particularly unhappy results when the computerized system is set up by people who seem to have little understanding of the clinical and educational context in which it is to be deployed. But modern management philosophy in the US (and I suspect in the UK) seems to believe managers can succeed even if they have little knowledge of the specific context and values of the organization which they seek to manage. It seems to be a recipe for the mission-hostile management that we now see so often in health care.

To get an idea how upset UK junior doctors are, see NHS Blog Doctor.

1 comment:

MedInformaticsMD said...

But modern management philosophy in the US (and I suspect in the UK) seems to believe managers can succeed even if they have little knowledge of the specific context and values of the organization which they seek to manage. It seems to be a recipe for the mission-hostile management that we now see so often in health care.

Exactly right. The defects of this thinking have been well-known for decades. See, for example, the work of Rob Kling at Indiana on "social informatics." See Information and Communication Technologies in Human Contexts.

Social informatics refers to the interdisciplinary study of the design, uses and consequences of ICTs that takes into account their interaction with institutional and cultural contexts.

The principles of SI can be summarized as: 1) the context of information and communications technology (ICT) use directly affects its meaning and roles, 2) ICTs not value neutral – they create winners and losers, 3) ICT use leads to multiple and often paradoxical effects; 4) ICT use has ethical aspects, 5) ICTs are configurable, 5) ICTs follow trajectories, often favoring the status quo, and 6) ICTs co-evolve before and after implementation, all are social activities. Most important of all is critical thinking about ICT projects, that is, developing the ability to examine ICTs from perspectives that do not automatically and “implicitly” adopt the goals and beliefs of the groups that commission, design, or implement specific ICTs. Critical thinking also entails developing an ability to reflect on issues at a number of levels and from more than one perspective.

Too often, not SI principles but a belief in “technologic determinism” is the driving force behind clinical IT project conception and management, that is, that the implementation of ICTs is sufficient to cause organizational and individual change in healthcare delivery and the practice of medicine. A close relative of technologic determinism is the “magic bullet” theory, where people believe they are change agents if they initiate or develop IT because they think IT itself has the power to create organizational change. These people describe IT as a “magic bullet” - and believe that they have built the gun.

Unfamiliarity with the findings of SI research, and beliefs in technologic determinism, directly contribute to healthcare IT failure.

The willful ignorance of these principles is astonishing, largely due to a "real computer men don't do soft stuff like social informatics" bias.

The waste of potential, resources and time that results from this negligence is a very serious matter.