Friday, September 24, 2010

Interface Problems, Ill-Informed Leadership, Suppression of Whistle Blowing: A New Look at a Historic Case

Three issues that come up frequently on Health Care Renewal are problems with man-machine interfaces in health care information technology (IT), as in this post by Dr Scot Silverstein; ill-informed and mission-ignorant or hostile leaders, sometimes in a position to overrule health care professionals, as in this post; and whistle-blowers, and their silencing.

A truly amazing story just surfaced that deals with all these issues, albeit not in health care.  If it is true, and if it had been revealed earlier, maybe society would have become more concerned earlier with these issues, and maybe they would have not ended up plaguing health care so.

Let me first just go through the basic structure of the story to underline the parallels with health care issues.  Then I will quote the specifics.

(If you do not instantly recognize the story, I suggest going through this post sequentially, not jumping to the end, to make its impact more clear.)

The Structure of the Story

Introduction
A large corporation had just put on-line, with much publicity, a high-technology system that was advertised as bigger, faster, better than the competition. 

Confusing Interface and Terminology, Wrong Control Input 

A few days after becoming operational, those in charge suddenly noticed a looming and severe problem.  A technician was ordered to make an extreme control input to avoid the problem.  However, there was confusion about the terminology of the input.  While the system he was controlling was new, and had a new interface, it was operating in an area in which the old terminology, from a time in which the interface for the particular control worked in the opposite direction, was still in use.  So his extreme input was in exactly the wrong direction.  By the time the mistake was clear, and the control was reversed, it was too late, and the first stage of the catastrophe ensued. 

Ill-Informed Management Overrules the Professionals

It is possible that the catastrophe could have been ameliorated if a crucial part of the system were then to have been quickly shut down.  The highest ranking professional on duty ordered it shut down.  However, soon after the events above, a top executive in the corporation, who was nearby only because of all the hoopla surrounding the system's roll out, came on the scene.  He countermanded the order for the shutdown, possibly thinking continuing operation would cost less money and result in less bad publicity.  True disaster then ensued.

Whistle Blowing Suppressed

After the disaster, there were several government hearings.  The top executive denied any knowledge of the decision making that lead to the disaster.  A professional who had not been present when the decisions were made, but was told about them by those who were present, avoided mention of the events above, because the top executive had told him that if he were to have told the truth, the company would have been found negligent, its insurance would not have covered the disaster, and it would have gone bankrupt, and everyone would lose their jobs.  So he never told anyone except first-degree relatives.  The other people who were present for the events above did not testify, for reasons to be discussed below.

So this story has all the familiar elements.  But so have many others.  Why was the suppression of this version of the story (assuming its true, which is not proven) so important?

The Real Story

Let us go through the elements again, this time with quotes from the article in the London, UK, Telegraph:

Introduction and Context
All families have their secrets, but usually about things that don’t matter to anybody else. Not in the case of Louise Patten, though – or The Lady Patten to give her her full title, the wife of former Tory Education minister, Lord (John) Patten, though her own career as one of the first women board directors of a FTSE 100 company, and as a successful author of financial thrillers, means that she has plenty of achievements in her own right.

As a teenager in the 1960s, Patten was let in on a secret by her beloved grandmother, which, if revealed, she was warned, would result in two things. The first was awful – it would destroy the good name of her dead grandfather, Charles Lightoller, awarded the DSC with Bar in the First World War, and a hero again for his part in the evacuation of Dunkirk in 1940. But the second would change history, overturning the authorised version of one of the world’s greatest disasters, the sinking of the Titanic with the loss of 1517 lives in April 1912.

The tension between these two outcomes goes some way to explaining why, for 40 years, Patten kept quiet....

'After the collision,’ Patten goes on, 'my grandfather went down with the Captain and [First Officer] Murdoch to Murdoch’s cabin to get the firearms in case there were riots when loading the lifeboats. That is when they told him what had happened.'
Confusing Terminology and Interface

'Instead of steering Titanic safely round to the left of the iceberg, once it had been spotted dead ahead, the steersman, Robert Hitchins, had panicked and turned it the wrong way.’

At first glance it sounds extraordinary that anyone – much less the man put in charge of the wheel on the maiden voyage of what was then the world’s most expensive ocean liner – could have made such a schoolboy error.

'Titanic was launched at a time when the world was moving from sailing ships to steam ships. My grandfather, like the other senior officers on Titanic, had started out on sailing ships. And on sailing ships, they steered by what is known as “Tiller Orders” which means that if you want to go one way, you push the tiller the other way. [So if you want to go left, you push right.] It sounds counter-intuitive now, but that is what Tiller Orders were. Whereas with “Rudder Orders’ which is what steam ships used, it is like driving a car. You steer the way you want to go. It gets more confusing because, even though Titanic was a steam ship, at that time on the North Atlantic they were still using Tiller Orders. Therefore Murdoch gave the command in Tiller Orders but Hitchins, in a panic, reverted to the Rudder Orders he had been trained in. They only had four minutes to change course and by the time Murdoch spotted Hitchins’ mistake and then tried to rectify it, it was too late.

A Manager Countermanding the Professional

If the steersman Hitchins had made a human error, Bruce Ismay, chairman of the White Star Line, owners of the Titanic, and another survivor of the sinking, gave a lethal order.

'Titanic had hit the iceberg at her most vulnerable point,’ explains Patten, 'but she could probably, my grandfather estimated, have gone on floating for a long time. But Ismay went up on the bridge and didn’t want his massive investment to sit in the middle of the Atlantic either sinking slowly, or being tugged in to port. Not great publicity! So he told the Captain to go Slow Ahead. Titanic was meant to be unsinkable.’

However,
'If Titanic had stood still,’ she demonstrates, 'she would have survived at least until the rescue ship came and no one need have died, but when they drove her 'Slow Ahead’, the pressure of the sea coming through her damaged hull forced the water over the bulkheads and flooded sequentially one watertight compartment after another – and that was why she sank so fast.’

Whistle Blower Suppressed, the Cover Up

Why, though, I puzzle, would Patten’s grandfather, who sounds like a thoroughly honest and brave man, have lied and carried on lying? 'Because,’ she explains, 'when he was on the rescue ship, Bruce Ismay pointed out to my grandfather that if he told the truth, the White Star Line would be judged negligent and its limited liability insurance would be invalid. Ismay pretty much said that the whole company would go bust and everyone would lose their jobs. There was a code of honour among men like my grandfather in those days. So he lied to protect others’ jobs.’

But why didn’t her grandmother speak up after her husband’s death in 1952? 'She was worried about showing this heroic figure to be a liar. And my mother, who also knew the secret and was even uncomfortable with Granny having told me, felt even more strongly about it. She hero-worshipped my grandfather.’

So there this secret sat, locked in a family circle from which Patten is now the only survivor.
Conclusion

The story does seem amazing. I am hardly an expert on the sinking of the Titanic, so should not try to comment on its truth. It does have some plausibility, and provides an explanation for one of the most important and influential disasters of the 20th century that is still poorly understood and a cause for controversy.

In my humble opinion, if it were true, and had it come out earlier, this amazing story would have focused society's concerns on issues that have instead become scourges of our current era, and particularly important, if not frequently enough discussed causes of our health care dysfunction.

The Titanic disaster lead to major changes in numerous safety practices, leading to rules about the adequacy of lifeboats and radio communication, and even swimming proficiency requirements in higher education. (I had to pass a swimming test as a Brown University freshman that was a legacy of the sinking of the Titanic, I was told.) Most of these practices increased the survivability of accidents.

What if the focus was also on the causes of accidents? What if there was a groundswell of advocacy, starting in 1912, against pressure from business and financial leaders on professionals sworn to protect the public's health and safety, and against intimidation of whistle-blowers whose revelations could protect public health and safety? Maybe health care, and many other parts of life, would have turned out better?

34 comments:

Anonymous said...

People pay the price for the deceit of leadership. What is wrong with honesty, really?

Anonymous said...

That story sounds like a complete load of crap, being told by someone trying to sell some books.

Anonymous said...

I see the similarities. This is how hospitals are run, exactly.

The doctors and nurses will be courageous as possible when multiple patients are taken down by a flaw in their HIT systems, and the CEO wants it covered up, and then more patients will go down.

Roy M. Poses MD said...

Anonymous of Sept 25 -

Using this line of reasoning, we should dismiss just about everything written about the Titanic (and nearly everything else), since so much was written by people "trying to sell some books."

By the way, Walter Lord's The Night Lives On (http://www.amazon.com/Night-Lives-Stories-Unsinkable-Ship-Titanic/dp/0380732033 ), noted that some witnesses thought the Titanic turned toward the iceberg at some point, and some witnesses thought that the engines were rung back to slow ahead after being stopped. None of these observations were explained, but were dismissed as due to confusion and poor memories. However, these accounts fit with the narrative above.

Bartbuster said...

Using this line of reasoning, we should dismiss just about everything written about the Titanic (and nearly everything else), since so much was written by people "trying to sell some books."

I wouldn't reject it just because it's being pushed by someone trying to sell books, I'd also reject it because the person selling the books is making up a story that does not make any sense.

Do you actually think it mattered which direction the ship turned? If so, the book seller certainly doesn't say why it mattered.

The claim about the ship moving slowly is especially absurd. With more than 4 bow compartments breached the ship was going to sink, and everyone on board with knowledge of the ship's design was aware of that. Being towed to port was not an option. Can you explain why Ismay would order the ship to keep moving when he knows it's going to sink?

By the way, being a more proficient swimmer on the Titanic is like having extra sunscreen at Hiroshima. If you end up in the north Atlantic in April and you're not a whale or a fish, it does not matter how good a swimmer you are, you are going to die.

Roy M. Poses MD said...

Bartbuster,

You might want to take a look at some of the voluminous literature on this case.

It certainly mattered which way the ship turned, even if the time to impact was not as long as Patten says.

Many believe that had the ship hit the iceberg head on, the damage might have been confined to a few water tight compartments, and sinking would be delayed, possibly even avoided.

Also, it was not clear exactly who realized when that sinking was inevitable. It took time to assess the damage, and Ismay later said he thought the ship was "virtually unsinkable."

Note that I was not arguing that better swimmers would have been more likely to survive in this case.

Bartbuster said...

It certainly mattered which way the ship turned, even if the time to impact was not as long as Patten says.

It was completely dark and the crew had no time to evaluate which was the best direction to turn. If it matters so much which direction they chose, you should have no problem explaining why.

Also, it was not clear exactly who realized when that sinking was inevitable. It took time to assess the damage, and Ismay later said he thought the ship was "virtually unsinkable."

They would have done a damage assessment and it would have been obvious very quickly.

Bartbuster said...

Can anyone else explain how the teller of this tall tale could know that the Titanic would have survived had it turned in the other direction?

Roy M. Poses MD said...

Bartbuster,

All that I have read suggests that the bridge crew did see the iceberg. There are big questions about how far it was when they sighted it, and, as noted above, which direction the ship first turned. I have not seen any versions of the story suggesting it was so dark they did not see anything before the collision.

A damage assessment was not instantaneous. It was a big ship.

Regarding your last comment, see the link to the original Telegraph article. Her contention was that the iceberg was further away when first sighted than was generally perceived, so that the optimal steering maneuver may have had a chance of avoiding the iceberg completely. In addition, there are some opinions that had the ship hit head on, the damage would have been restricted to fewer compartments, and may have been survivable, or at least may have allowed more time before the ship sank.

Bartbuster said...

All that I have read suggests that the bridge crew did see the iceberg. There are big questions about how far it was when they sighted it, and, as noted above, which direction the ship first turned. I have not seen any versions of the story suggesting it was so dark they did not see anything before the collision.

All we know for sure is that they saw the iceberg in time to attempt to maneuver. There was no moon, the sea was very calm, and the ship was moving very fast. The idea that they saw the iceberg at a great distance and instantly had enough detail to determine which direction to turn is absurd.

A damage assessment was not instantaneous. It was a big ship.

It would not take very long to get reports from the front 5 compartments. The rest of the ship does not matter.

In addition, there are some opinions that had the ship hit head on, the damage would have been restricted to fewer compartments, and may have been survivable, or at least may have allowed more time before the ship sank.

Whether the ship would have survived had they hit the iceberg head on is irrelevant. The book seller's claim is that they turned the wrong way, not that they should have hit head-on.

Bartbuster said...

All that I have read suggests that the bridge crew did see the iceberg. There are big questions about how far it was when they sighted it, and, as noted above, which direction the ship first turned. I have not seen any versions of the story suggesting it was so dark they did not see anything before the collision.

All we know for sure is that they saw the iceberg in time to attempt to maneuver. There was no moon, the sea was very calm, and the ship was moving very fast. It was the worst possible conditions for spotting and avoiding an iceberg (fog would have forced them to stop). The idea that they saw the iceberg at a great distance and in enough detail to determine which direction to turn is absurd. But, let's assume they did determine the best response. We're now supposed to believe that a well-trained crew with excellent situational awareness would panic? Sorry, that smells like 2 pretty big pantloads.

A damage assessment was not instantaneous. It was a big ship.

It would not take very long to get reports from the front 5 compartments. The rest of the ship does not matter.

In addition, there are some opinions that had the ship hit head on, the damage would have been restricted to fewer compartments, and may have been survivable, or at least may have allowed more time before the ship sank.

Whether the ship would have survived had they hit the iceberg head on is irrelevent. The book seller's claim is that they turned the wrong way, not that they should have hit head-on.

Roy M. Poses MD said...

Bartbuster -

Note that Patten described, and I summarized 3 issues, not just the original steering decision.

I don't think we know enough about what happened to determine how far the iceberg was when it was first spotted, and how much time the bridge crew had. I do not see why Patten's version is less plausible than some others. Note my comment above that there was considerable ambiguity in the official version of what happened on the bridge. Since no bridge officer on duty at the time survived the sinking, we may not know more.

I am not sure that the officers knew right after the crash that their only problem was in the front compartments.

The issue about steering was had the initial steering input been different, could the damage have been less severe?

Bartbuster said...

Note that Patten described, and I summarized 3 issues, not just the original steering decision.

The only issues I saw were initial steering and maintaining speed after the collision. Both of which are pretty easily debunked. What was the third issue?

I do not see why Patten's version is less plausible than some others.

I just posted several reasons why it is less plausible than others. Not only is it less plausible, it is absurd.

Note my comment above that there was considerable ambiguity in the official version of what happened on the bridge.

Ambiguity is one thing, these claims cross over into fantasy.

I am not sure that the officers knew right after the crash that their only problem was in the front compartments.

Really? What do you think your first reaction would be after hitting an iceberg? Do you check where the iceberg struck, or do you make sure the wine wasn't damaged?

The issue about steering was had the initial steering input been different, could the damage have been less severe?

Yes, and my point is that they could not possibly have known at the time they decided which direction to go that they had made the right decision. It was dark, the sea was very calm, and they were going very fast. If they saw the iceberg in the distance they could not possibly have seen it clearly. If they saw the iceberg clearly they could not possibly have had enough time to avoid it.

Patten's wife's daughter's sister's cousin's best friend is clearly making it up.

(keep in mind that the person telling this tall tale is getting it third-hand (at best) and has incentive to make the whole thing up)

The only way I could see a crew member saying that they turned the wrong way is if the ship turned faster in one direction (due to prop torque), and they decided to go in the other direction. However, the book seller isn't making that argument.

Bartbuster said...

I am not sure that the officers knew right after the crash that their only problem was in the front compartments.

You just hit an iceberg. If the 5 bow compartments are breached your ship is going to sink. What other problems could the crew possibly be concerned with?

Roy M. Poses MD said...

Bartbuster,

Based on what I have read, they probably realized the iceberg scraped the side of the ship under the waterline, but I'm not sure how they could have known it only affected front compartments.

Bartbuster said...

OK, I suppose if the ship was crewed by doctors it would have taken them most of the night to determine how many compartments were breached. I concede the point.

Bartbuster said...

Just to be clear, your version of events assumes that the crew has excellent situational awareness when the iceberg is 1500' away in the darkness, but very poor situational awareness at the moment the ship actually hits the iceberg.

Roy M. Poses MD said...

Bartbuster,

It's not my version of the events, it's the version of a direct descendant of one of the officers.

I don't think the version as recounted in my original post above had to do with excellent situational awareness before the ship hit the iceberg.

Two points for the quip about doctors. I guess I deserved that for writing about the Titanic.

Bartbuster said...

It's not my version of the events, it's the version of a direct descendant of one of the officers.

It's not your version, but it's the version you bought.

I don't think the version as recounted in my original post above had to do with excellent situational awareness before the ship hit the iceberg.

If they didn't have excellent situational awareness prior to hitting the iceberg, how could they possibly know that they turned in the wrong direction?

I don't understand why you are having so much trouble grasping that concept.

From everything I have read the crew did not have time to evaluate the situation. They just made a desperate attempt to turn the ship. Under those conditions I don't see how anyone could possibly know that they turned in the wrong direction. They may not have turned in the "intended" direction, but that is very different from saying they turned in the "wrong" direction. "Wrong" direction implies that they knew they would have had a better chance of surviving if they turned the other way, and there is no way of knowing that without having excellent situational awareness at the moment the decision was made.

Bartbuster said...

Also, I still don't see why Ismay would order the ship to proceed without fully evaluating the damage. He sped into the ice field because he wanted to set a trans-Atlantic record. With that as the goal there isn't any incentive for him to limp into New York in 10 days instead of 10 days and 1 hour.

Roy M. Poses MD said...

Ah, I should have known better than to post about the Titanic.

Its story still provokes amazing controversy even 98 years later. For example, in Titanic's Last Secrets, by Brad Matsen, there is a chapter entitled "Titaniacs" which lists some of the controversial points, which are debated even by sober and expert engineers and historians, and some of the wackier conspiracy theories.

Having a small opportunity to look into a tiny portion of the literature on the Titanic, I do realize that this is another case in which what many of us thought was settled and thoroughly worked out history turns out to be much more controversial and ambiguous than we perceived.

Note that I never asserted that Ms Patten's version is the truth, only that it has some plausibility, and that it raises issues which now resonate with those we discuss on Health Care Renewal.

Finally, Walter Lord's The Night Lives On discussed uncertainty about the Titanic's maneuvering just before it hit the iceberg:
"At least two survivors gave testimony that Murdoch did intend to try to 'port around' the berg." (p. 66 of the Avon paperback.) Lord also noted some witnesses who said that the engine telegraph was set to slow ahead after the first stop engines order. So there really was controversy even back then about which way the Titanic was steered before it hit, and whether the Titanic resumed forward progress under power after the water started coming in.

Bartbuster said...

You are still missing the point. Which direction he intended to go does not matter. What matters is whether he had enough info to know which direction would have given them a good chance to miss the iceberg at the moment he started turning the wheel.

As for the connection to HIT, there is none. The Titanic story is nothing but a strawman, where you make up a story that fits your narrative, and then try to claim that it's the same as HIT. It's not.

Roy M. Poses MD said...

Bartbuster,

I think we will have to just agree to disagree at this point.

We will never know the answer to your last question, will we.

And by the way, who said anything about HIT, specifically? I didn't. Dr Scot Silverstein is our blogger who specializes in health care IT issues. I am not.

Roy M. Poses MD said...

Oops, I apologize.

I did mention health care IT, but it was not the main point of the post.

On the other hand, I did not make up any stories here. I just noted the parallel structures between Patten's story and the themes we have discussed.

Bartbuster said...

On the other hand, I did not make up any stories here. I just noted the parallel structures between Patten's story and the themes we have discussed.

You took a made up story about the Titanic that makes no logical sense and tried to equate it with a narrative about IT that you are trying to sell.

Roy M. Poses MD said...

OK, now that we have got to this level of what amounts to name calling, I think it is time to call a time out.

By the way, as noted above, the parallel with interface/ control problems was only one of three I tried to make.

Bartbuster said...

My last post wasn't name-calling at all. The story does not make sense. Your only defense for the logical holes I have pointed out are that "other witnesses said the same thing." Well, there's a reason the stories of those witnesses were rejected. They made no sense then, and they don't make any more sense now.

By the way, as noted above, the parallel with interface/ control problems was only one of three I tried to make.

NOTHING about that story makes any sense. Not the claim that they turned the wrong way, and not the claim that Ismay arrogantly kept the ship moving after the accident. The logical holes are just too big.

You need more than just a few questionable witnesses for people to buy your story, your story also has to make sense, and that one does not make sense.

I tell you what, if you can convince me there is any reason why Ismay would want to limp into New York in 10 days instead of 10 days and 20 minutes, I will admit that his actions after the collision probably caused the ship to sink much faster than it otherwise would have (even though that is STILL questionable). Good luck with that.

Bartbuster said...

By the way, this part of the story is just a flat out lie:

If Titanic had stood still,’ she demonstrates, 'she would have survived at least until the rescue ship came and no one need have died, but when they drove her 'Slow Ahead’, the pressure of the sea coming through her damaged hull forced the water over the bulkheads and flooded sequentially one watertight compartment after another – and that was why she sank so fast.’

The pressure of the water coming through the damaged hull did no such thing. The water entered the sequential watertight compartments because the weight of water in the first 5 compartments forced the bow down at an angle that allowed the water to flow over the watertight barriers. Within 20 minutes of the accident the captain already had a very accurate estimate of how long it would take his ship to sink.

Patten is lying.

Scot M Silverstein MD said...

I've been busy caring for my HIT-injured mother, now home after four months, so only just came across this thread.

I think it fair to say, from the HIT perspective, that there are parallels between the idiots who equipped the Titanic with insufficient lifeboats to handle passengers and crew, and the idiots who deliver unsafe health IT that presents a mission hostile user experience.

-- SS

Bartbuster said...

and the idiots who deliver unsafe health IT that presents a mission hostile user experience.

Yes, those terrible generalized "idiots" who deliver generalized "unsafe" health IT! I generally hate "them"!

Scot, you have to stop holding back! Name some names!

By the way, when someone fails to enter a med, or a condition, on a patient record, that isn't a HIT error, that's a user error.

Scot M Silverstein MD said...

Bartbuster said...

Scot, you have to stop holding back! Name some names!

I've left so many links to literature on this issue over the past 6 years on HC Renewal and at my academic site for the past 10+, all I can do is express disappointment at this attempt to "move the goalposts", a logical fallacious manner of argumentation.

By the way, when someone fails to enter a med, or a condition, on a patient record, that isn't a HIT error, that's a user error.

No.

In the most simple cases, yes. However the domain of HCI and many years of research prove you wrong in many other cases where an HIT flaw - such as a mission hostile user experience - is a contributory factor to error.

See for example the US Air Force on "SIGNIFICANCE OF THE USER INTERFACE" at http://hcibib.org/sam/. This was written in the 1980's; the HIT industry lags by only several decades.

For instance:

From the HIMSS EHR Usability Task Force, June 2009:

Electronic medical record (EMR) adoption rates have been slower than expected in the United States, especially in comparison to other industry sectors and other developed countries. A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available. Achieving the healthcare reform goals of broad EMR adoption and “meaningful use” will require that efficiency and usability be effectively addressed at a fundamental level.


-- SS

Bartbuster said...

No.

In the most simple cases, yes. However the domain of HCI and many years of research prove you wrong in many other cases where an HIT flaw - such as a mission hostile user experience - is a contributory factor to error.


Yes, actually.
Your claims of a general mission hostile user experience don't prove me wrong about anything. You have to actually show how the software causes an incident in order to blame the software. Just imagine how that claim would work in court after a properly trained user shows the jury how easy the software is to use?

Roy M. Poses MD said...

OK, now this is getting very tangential to the original post.

And to think, Bartbuster, that I thought your main interest was the Titanic.

At this point, I will not publish further tangential comments on this post. Sorry.

Scot M Silverstein MD said...

Bartbuster, I need prove nothing. The readership of this blog has long ago decided on my credibility.

That you cannot find the information you claim to seek on this blog is not my responsibility; you need to actually read and follow hyperlinks. If you were not so obnoxious I might have given them to you.

Roy, note that Bartbuster has a blank Blogger profile. Reminds me of the Meditech Sockpuppet.

I am closing out my comments on this thread.

-- SS