Thursday, May 24, 2007


The language of pain



There is a language of pain. We are taught it at medical school: throbbing, stabbing, lancinating, crushing, bursting, cramping, burning, stinging, aching, boring, gouging, …. In the learning of it we experience it too, convinced always that we have some fatal and incurable malady.



Pain has a timbre and a cadence; it has body and soul; it is alive and separate and malevolent.



It is unfortunate that patients come to us not knowing the language of pain. All they seem capable of saying is that it hurts; a lot. They can’t even always say where – somewhere. And when we treat the pain they are relieved but not satisfied: they want to know why: cause and motive.



Longevity Quotient







LQ = PA/CA x 100



Wednesday, May 23, 2007

knowledge Ends

Advancing technology makes it easier for individuals to plan, create and develop new products and then to market them. Knowledge is the most important and most valuable product, but knowledge has to serve some other external end.




  • Community
  • Longevity
  • Health
  • Education and Training
  • Creativity
  • Engineering
  • Posterity
  • Repair
  • R&D
  • Negotiation
  • Transaction fulfilment
  • Inventory management
  • Recruitment and retention
  • Architecting capability
  • Enforcement
  • Persuasion



The above list is in no particular other than the order in which they came to mind (How revealing!). Nor is it meant to be exhaustive.

"Top 10" Medications Involved in Adverse Events

1.     Insulin (8%);

2.     Anticoagulants (6.2%);

3.     Amoxicillin (s) (4.3%);

4.     Aspirin (2.5%);

5.     Trimethoprim-sulfamethoxazole (2.2%);

6.     Hydrocodone/acetaminophen (2.2%);

7.     Ibuprofen (2.1%);

8.     Acetaminophen (1.8%);

9.     Cephalexin (1.6%); and

10.  Penicillin (1.3%).


Sunday, May 20, 2007

Productive Effort

Productive effort is directed towards improving our tools and improving our tool use. This is captured as improved productivity.


Productive effort is also directed towards solving significant problems that could not be solved before due to lack of resources or lack of knowledge.


Improving our tool use involves using our tools more skilfully and applying our tools more appropriately in addition to finding creative, uncommon uses for existing tools.


As always we have to remember to do the right things before doing things right.

Thursday, May 17, 2007

On teaching patients to begin with the end in mind

Patients consult with symptoms = problems. They are often in search of solutions that remove the causes without due regard for what is possible.



Patients fail to consider that a determination of cause is not always possible and that knowing cause does not necessarily mean effective correction and that even effective treatments are not guaranteed effective in their specific circumstances. And there are always trade-offs, side-effects, costs. These have to be balanced against the anticipated benefits.



Ironically, in an age when healthcare providers are more effective than ever, patients trust their caregivers less than ever. Expectations are to a large extent misinformed. The essential question given this mismatch is who is responsible for educating patients?



I do not consider it my responsibility to teach the general public how to think. I have enough difficulty persuading my colleagues that their thinking is a skill that can be improved.

Saturday, May 12, 2007

Information Design

Clinical documentation serves several purposes:


To note facts and perceptions that are relevant to diagnosis, investigation or treatment that are too numerous to remember or too complicated

To note relevant positive and negative findings on examination or investigation

To note a rationale for acting or not acting

To plan a course of action

To note the specifics of patient interventions

To signify results

To coordinate multi-specialty care


Documentation serves to make memory unnecessary and helps to make thinking as explicit as possible. Intent, process and outcome need to be as transparent as possible. Clinicians do not, as a rule, explicitly consider the purpose of documentation on a case by case basis.




News: NHS Direct 'Health of the Nation' snapshot survey, Jan-Mar 2007


NHS Direct website ‘Top Twenty’ encyclopaedia topic searches. Jan-March 2007

  • Pregnancy - 115,008
  • Chicken pox - 82,201
  • Contraception - 51,886
  • Immunisation - 47,777
  • Diabetes - 46,850
  • High blood pressure - 45,966
  • Accidents first aid - 42,153
  • Irritable Bowel Syndrome - 37,757
  • Back pain - 37,296
  • Cystitis - 34,853
  • Under-active thyroid - 34,528
  • STIs - 33,621
  • Depression - 33,149
  • GP - 32,721
  • Healthy eating - 32,588
  • Flu - 29,234
  • Chest infection - 27,059
  • Thrush - 25,081
  • Ovarian cyst - 25,064
  • Glandular fever - 23,632


Monday, May 07, 2007

HBS Response 070507

Diagnosis is complex and inductive rather than deductive. The list of all possible diagnoses is long, much longer than one person can know. In seeking diagnoses, clinicians are looking for an action path: to prevent, treat, mitigate, palliate and/or prognosticate. Treating and healing are different things and sometimes simply naming a problem is enough for a patient.


What can managers learn? Not all things are knowable; not all things are fixable; humans are finite. Logic does not serve and experience always counts. All acts involve trade-offs, costs and benefits. And judgement is very fragile.


None of the above is actionable.


So, the essential lesson is this: life is uncertain, still you must act – in humility – because you are likelier to be wrong than right. Act and reflect. Outcomes direct actions, but intent is paramount. As Musashi observed, action is distilled intent.