Sunday, September 27, 2009

Malpractices of the multitude revisited: "An outstanding job of educating themselves about clinical issues"

At numerous posts at Healthcare Renewal, we have pointed out what we feel to be a serious gap in the credentials of many in biomedical leadership roles.

The gaps are in the form of a near complete lack of any scientific or biomedical education and experience, except perhaps a high school chemistry and biology class or two.

We often receive comments back, usually from "anonymous" posters such as here to our opinions that this expertise gap impairs the judgment of such leaders on medical matters:

... No. I've met individuals with management training who do an outstanding job of educating themselves about clinical issues. And I've met individuals with clinical training who do an outstanding job of educating themselves about management and business issues.

I feel this "anyone can be an expert" sentiment is an important issue to bring outside of the comments section of our posts.

I raised probing questions in response to such messages here in my post "More On Healthcare Management By Domain Neutral Generalists: CIO's Running Hospital Pharmacies and Home Healthcare Divisions?"

Here are my most recent questions to the above anonymous medical self-education proponent:

Re: "I've met individuals with management training who do an outstanding job of educating themselves about clinical issues."

What, exactly, is it that individuals with management training who do an outstanding job of "educating themselves about clinical issues" are professionally or even reasonably qualified to do?

Could they pass medical boards?

Could they reasonably interpret a complex medical article in, say, The Annals, and make truly informed, wise decisions based on that reading?

Could they reasonably evaluate therapeutic alternatives in complex cases, say, someone with a new heart valve who's just developed fever and a lower GI bleed?

In an emergency could they provide medical care? (mot in the legal sense, just in the skills sense.)

If not, why not, and what do you mean by "outstanding job?"

In comparison, I have no MBA or formal business training (other than working for years in my father's pharmacy as a stocker and cashier) but did a good job managing a department of 50+ and a budget of $13 million for an international pharma, solving severe business problems that had been impairing R&D and managing my budget consistently to within 0.5% of EA.

Is there perhaps an asymmetry between medicine and business?

Finally, I ask:

What percentage of a typical medical training curriculum (such as for a Pharm.D. here or a physician here) can a person with a management background absorb through self-education, and is the medical training curriculum therefore irrelevant? Should we just go back to the days of self-trained practitioners? If not, why not?

The critically thought-out answers to these questions expose the territorial invasion of medicine by ill-suited outsiders and dilettantes quite well.

Echoing an observation I wrote about once before in my eight part series on mission hostile EMR's, but addressing it to medical administration where it also applies:

Medical administration reminds me of dentistry in its early days, especially when medical administrators lacking biomedical expertise refer to themselves as "medical professionals."

B.T. Longbothom, author of the second dentistry book published in the U.S. ("A Treatise on Dentistry", 1802), gave an excellent description in his preface of problems at the time. His observations apply to medical administration in our present age:

The word "dentist" has been so infamously abused by ignorant pretenders, and is in general so indifferently understood, that I cannot forbear giving what I conceive to be its original meaning: viz, the profession of one who undertakes and is capable not only of cleaning, extracting, replacing by transplantation and making artificial teeth, but can also from his knowledge of dentistry, preserve those that remain in good condition, prevent in a very great degree, those that are loose, or those that are in a decayed state, from being further injured, and can guard against the several diseases, to which the teeth, gums and mouth are liable, a knowledge none but those regularly instructed, and who have had a long, and extensive practice, can possibly attain, but which is absolutely necessary, to complete the character of a Surgeon Dentist.

Hardly anyone spoke out.

More than thirty years later, untrained practitioners were as prevalent as ever. One of the leading dentists of the time, Shearjashub Spooner, in his "Guide to Sound Teeth, or, A Popular Treatise on the Teeth" (1836) warned the public of a phenomenon I believe now applies to medical administration:

One thing is certain, this profession must either rise or sink. If means are not taken to suppress and discountenance the malpractices of the multitude of incompetent persons, who are pressing into it, merely for the sake of its emoluments, it must sink, - for the few competent and well educated men, who are now upholding it, will abandon a disreputable profession, in a country of enterprise like ours, and turn their attention to some other calling more congenial to the feelings of honorable and enlightened men.

I understand that point of view.

-- SS

5 comments:

Anonymous said...

What, exactly, is it that individuals with management training who do an outstanding job of "educating themselves about clinical issues" are professionally or even reasonably qualified to do?

Could they pass medical boards?

Could they reasonably interpret a complex medical article in, say, The Annals, and make truly informed, wise decisions based on that reading?

Could they reasonably evaluate therapeutic alternatives in complex cases, say, someone with a new heart valve who's just developed fever and a lower GI bleed?

In an emergency could they provide medical care? (mot in the legal sense, just in the skills sense.)

If not, why not, and what do you mean by "outstanding job?"
=============================
That's a nice straw man you're erecting there. No one has said that managers can practice medicine. I've met managers who can and have passed medical boards. I've met many who read the same journals physicians do and discuss them at length with clinicians.

The funny thing is that we agree that the best managers must have an excellent understand of the clinical and biomedical issues they are managing. You and others seem to think the only way to get that is through a complete medical training identical to what physicians get. I disagree. But, really, even that discussion is irrelevant.

It's irrelevant because your solution of having all health care managed by physicians is as divorced from reality as having it managed by Martians. Medical schools, schools of nursing, and most schools of allied health can't even produce the clinicians necessary to provide care, much less manage the work, too. Medical schools would need to triple in size to accommodate both the physician shortage and the projected growth and replacement of managers. If nursing schools are to play a part, they already have to triple in size to just meet demand for nurses.

So, it's a nice idea, but about as relevant as pixie dust and leprechauns.

MedInformaticsMD said...

Anonymous writes:

I've met managers who can and have passed medical boards.

Quite doubtful. Managers lacking formal medical training and clinical experience cannot even qualify to sit for medical boards, e.g., as at this link. I think it more likely that you've just made this up.

What puzzles me is why you waste bandwidth on a blog by, for and of critical thinkers with such statements.

It's irrelevant because your solution of having all health care managed by physicians is as divorced from reality as having it managed by Martians

You comment is, in fact, irrelevant because it ignores what I have written about my belief that biomedical credentials are sorely needed in positions of top management in the biomedical sector.

If you lack the intellectual horsepower to differentiate this very specific statement from the true straw argument that "my solution is all health care managed by physicians", then you need to perhaps learn about characteristics of rational debate at this link.

IT Guy said...

Annonymous isn't wasting bandwidth, you are. Your "argument" is pure strawman.

This was the original argument:

I've met individuals with management training who do an outstanding job of educating themselves about clinical issues. And I've met individuals with clinical training who do an outstanding job of educating themselves about management and business issues.

You responded with this:


Could they pass medical boards?

Could they reasonably interpret a complex medical article in, say, The Annals, and make truly informed, wise decisions based on that reading?

Could they reasonably evaluate therapeutic alternatives in complex cases, say, someone with a new heart valve who's just developed fever and a lower GI bleed?

In an emergency could they provide medical care? (mot in the legal sense, just in the skills sense.)


You ignored the original statement and twisted it into an assumption that only a trained and certified physician can know enough about clinical issues to be a manager. While that may be true (not likely, but possible), you certainly provided no evidence. Why does a hospital administrator need to pass medical boards? Why would they need to interpret a complex medical article? Why would they need to evaluate therapeutic alternatives? Why would they need to provide any sort of medical care? In fact, all they really need to be able to do is tell someone like you to provide the medical care.

Go to the that rational debate link you posted and click on Straw Man. You're an expert on creating Straw Men. You should at least try to understand what you're doing.

MedInformaticsMD said...

IT guy-

Welcome to Blogger.com. I see from your profile that you have been on blogger since ... October 2009.

You wrote:

This was the original argument: I've met individuals with management training who do an outstanding job of educating themselves about clinical issues. And I've met individuals with clinical training who do an outstanding job of educating themselves about management and business issues.

And my response was that the two are not symmetrical; I questioned the real value of such self education. "Self-education" in biomedicine creates those who know just enough to be dangerous.

In fact, Abraham Flexner concluded as much in the report that reformed medical education back in the early 20th century. I put links up to medical and PharmD curricula to show the risibility of the idea that one can "self educate" one's self in biomedicine to the extent needed to lead biomedical organizations optimally.

In fact, I wonder if many of our healthcare leaders today could even pass the courses taken in premed or prepharm. There's a reason medicine selects out the brightest.

Self education in IT or management, on the other hand, is more reasonable, as applied work in those fields does not require the rigor and knowledge base required in biomedicine for acceptable leadership. I would still argue that formal education (e.g., MSIS, MSIT or MBA) helps achieve even better leadership, but is not essential.

"Anonymous" wrote "your [i.e., MedInformaticsMD's] solution of having all health care managed by physicians is as divorced from reality as having it managed by Martians"

Either "anonymous" lacks the intellectual capabilities to understand the arguments at Healthcare Renewal about biomedical leadership, or is not really reading those arguments.

You commit similar errors - and apparently hold a mistaken premise - when you write "You ignored the original statement and twisted it into an assumption that only a trained and certified physician can know enough about clinical issues to be a manager."

Since you and "anonymous" seem to be unshakably hooked on that premise about the arguments here, I am closing this thread. Any further comments should be emailed directly, and if they make any sense may be posted.

You also wrote:

"In fact, all they [healthcare management] really need to be able to do is tell someone like you to provide the medical care."

Just as at McDonald's all they need to do is tell the hired help to keep flipping those hamburgers...Regarding the posts here about the common but dangerous belief that medicine can be run by generic managers lacking biomedical training and insight, I rest my case, for that is the statement you've just made.

To non-medical readers who might be confused by the above: when a person starts out from a false premise, and then they or others maintain that their previous words (i.e., anonymous's statement "your solution of having all health care managed by physicians") do not mean what they plainly mean, you [the listener or reader] are being played for a fool.

-- SS

MedInformaticsMD said...

Note: my comment above that "Self education in IT or management, on the other hand, is more reasonable" applies to merchant business-oriented general management, not management of highly specialized biomedical industries and organizations.

-- SS