In April I attended the BMJ/IHI Forum on Quality and Safety in Healthcare in London. Maureen Bisognano, President and CEO of the IHI was one of the main speakers.
Maureen discussed an area of healthcare we haven’t been fantastic at improving in recent years; funnily enough, she didn’t talk about innovation, but exinnovation – this term referring to what we can reduce, minimize, throw-away and do without to make healthcare run more smoothly, economically and effectively.
So much of modern healthcare involves doing more – starting from a stance of scarcity; more equipment, more time, more money, more tests, medicines, etc – part of this stems from the human necessity to do more, explore and expand – this is the basis of evolution, learning and improvement.
Yet, sometimes we don’t realize what we already have. We forget that not only are we surrounded by plenty, oftentimes we are surrounded by too much – too much information, too much clutter, to many investigations and procedures.
And this is where Bruce Lee comes-in. In 2015 Maureen Bisognano was discussing something that Bruce Lee, the legendary martial artist discussed in the 1960’s – One of his famous mantras was ‘It is not daily increase, but daily decrease – hack away the unessentials’ Lee was talking about the superfluous, often over-indulgent and at times flouncy movements of some martial arts – Lee was interested in effectiveness, not wasting time and effort perfecting moves that he didn’t feel added to the outcomes.
In how many areas of modern healthcare do we do too much? Unnecessary procedures, reports and documents – how many times is a patient asked about their history, their symptoms, how many superfluous investigations are performed, bed, ward and hospital moves? How much less could we do to become more effective?
The shortest distance between two points is a straight line – sometimes we need to wander, we need to take the scenic route to arrive at our destination; how often could we achieve for our patients equivalent and even better outcomes by exinnovating, stripping away that which is not essential?
Dr Rod’s Odd Blog (almondemotion) 
I loved this blog, Rod. Stripping away the inessentials was indeed what Bruce Lee was about. He’d have loved this article! Can you please give some practical examples?
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Hi Nig,
I can’t tell you how many times over the years I have repeated this phrase to myself – ever since 1986 when I first read the Tao of Jeet Kune Do, this has been part of my life philosophy – long before it was anything to do with healthcare.
When I became a doctor in the late 1990’s, doing more with less was not part of the language – it was a time of expansion, optimism and growth. The world has changed, the recession, although bringing with it innumerable woes to scores of people, has changed the focus of society and with it the way we approach healthcare.
Hacking away the unessentials is doing more with less, it is offering better care with less, it means fewer unnecessary investigations and treatments to arrive at the same result, less waste; If I can treat my patient in one day when previously it would have taken five, that is a win for the patient and the system as a whole – in particular, by reducing my patient’s exposure to the potential harm of hospitalisation, everyone wins.
When an older person is sick and takes to their bed with say, pneumonia, every day that passes, despite whatever treatment is offered, weakens that individual, reduces the likelihood they will ever walk or become independent again – that is why, on my ward, patients are encouraged to be dressed and out of bed as soon as possible – we hack away at the concept of disease or illness; the less time the patient, their relatives and the system see that older person (or anyone, for that matter) as being a patient (from the Latin, suffering), the quicker they can recover.
This philosophy is also congruent with me being a specialist in older people – often here, less is more, reducing the strength of the antihypertensive can prevent my patient from falling, or the pain killer, from them becoming confused, by using direct non-jargonized language I can better convey what is happening.
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Interesting post.
Talking about how many times a patient is asked their history is something I am familiar with having reason to attend the local E.R. many times over the years.
Now, I have a standard set of typed notes recording name, address, next-of-kin, Cardiologist, Endocrinologist, Neurosurgeon (from my 2 spinal surgeries), and so on…. in my little backpack which I take everywhere. I’d like to think if I had a heart episode as I did in Aug 2018, they’d send a copy of the report to my Cardiologist.
2nd page lists allergies (and in large letters…. Morphine (seizure in 2004)…..as well as the dozen or so other allergies, including several antibiotics and their severe reactions).
Next….. Sensitivities……
Surgeries….
A list of the 12-15 health conditions with the most important….my heart condition….. at the top of the list.
To be honest, some ER physicians have been absolutely delighted with the information set out in a clear, concise and logical order, but a recent 3 day stay when I was admitted to the local hospital on Boxing Day last week nearly drove me insane.
I suspect on this particular occasion, no one read the notes. I went through the same explanation several times to various E.R. nurses, doctors etc. When you’re in excruciating pain and barely able to talk, I daresay they want instant answers to their questions, but they could have gained a far better insight by also reading the simple notes (after their questioning).
I had given the ‘set’ of info to the E.R. and it came up with me to the ward when I was admitted. It stated quite clearly that I was Gluten and Dairy intolerant (as well as a few other foods like oranges). So what do they give me for the first 2 days as a liquid only diet? A small bottle of milk, a small carton of yoghurt, a chocolate flavoured milk high energy drink and orange juice. Each of which would give me a fairly adverse reaction, let alone the whole lot all together.
When I sent it away….2 days running….. the Dietition (or Kitchen Manager?) came up to me and asked what I could eat/drink.
I said it’s all stated on the paperwork that is attached to the nurse’s daily Obs. Would take less than a minute to scan the list of allergies/sensitivites. The third day when they let me eat, they bought wheat bix, a bottle of milk, chocolate flavoured milk energy drink, yoghurt, orange juice………and some apple juice. I drank the apple juice only and asked for some fruit. Apple and/or banana would do.
After listing that I was pre-diabetic, of course they also brought me jelly (loaded with sugar) for lunch, which I never eat either.
(just thought the story would put a smile on your face). Actually, I could relate many amusing hospital stories).
The solid food dinner on the 3rd day was steamed vegetables and fish. I started to eat the fish to then discover, it was raw on the inside. I only ate the veg. Then they bought me another plateful with the same fish. It was raw in the centre too, so I refused to eat it. Back comes the Kitchen Manager who said it had been in the oven for an hour. I don’t care I said, it’s raw in the centre, I’m not eating it. (I’ve had food poisoning and hospitalised twice in my life, no way I’m eating cooked fish which is raw in the centre). Fresh Sushi, which I love, is a completely different ‘kettle of fish’ (as the saying goes).
I’m a great supporter (and practice) living my day Mindfully though. I love Thich Nhat Hanh’s philosopy and teachings. I live very simply and pace my day (with bad to severe chronic pain and other symptoms).
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Wow – interesting insights; funnily enough, I received a worried set of texts from my brother today thinking that I had written a blog – rather than your comments & wondering why I had kept all my medical maladies from him. Suffice it to say, we had an interesting exchange, with me thinking I had been hacked (before I read your response) – thank you.
Most of the time people are just trying to do their job and with what they perceive is a standard rule-book, not realising that person-centred cannot ever be consistent with standardisation. One day… I am sure I have written about hospital meals somewhere!
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I’d love to read your post on hospital meals. If you ever remember when you wrote it, please don’t hesitate to let me know (in reply to this comment).
The other option might be to put a widget on your blog with a search box, but I do understand if you don’t wish to do this. I like to keep my own blogs fairly clutter free and concentrate on my photography sharing.
I am thoroughly enjoying reading your old(er) posts at the moment. Thank you for sharing your insights as a Doctor/Medical Practitioner.
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https://almondemotion.com/2016/12/02/textured-mush/ 🙂
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Thanks for the link, Rod.
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