Tuesday, August 11, 2009

Tribal nature of medicine and EMR implementation

This is in response to a request, "Please write more about the tribal nature of medicine"... [And how it impacts EMR adoption]...

Some people are surprised to learn how tribal medicine is, especially those who don't work in healthcare. This was once parodied in the TV show "Scrubs", where the Internal Medicine residents were "Jets" and the surgeons were "Sharks", and they reinacted a medically-themed version of the "West Side Story" dance...

One of the reasons "Scrubs" is so popular with medical people, however, is because it really rings true. The show is actually written by a bunch of doctors who have been successful by making a TV show that parodies the culture of medicine.

So, back to the tribal nature of medicine.

Medicine is full of tribes : The "Doctor" tribe, the "RN" tribe, the "LPN" tribe, the "Pharmacist" tribe, the "Respiratory therapist" tribe...

Doctors even further separate into "Inpatient doc tribe" and "Outpatient doc tribe"... and even among "Inpatient doc tribe", they further separate into "Medicine tribe", "Surgeon tribe", "Cardiologist tribe"...

Nurses have similar tribal divisions, between "Floor nurse tribe", "ICU nurse tribe", "OR nurse tribe"...

The point I'm making is that virtually everyone who works in medicine feels a part of some tribe. Their membership depends partly on their clinical training, and partly on their physical location. It sometimes approaches a quasi-military structure, with various ranks, a semi-formal hierarchy, and a specific method-of-interaction between people of different ranks.

Why bring this up? Because as you start to navigate the culture changes needed to successfully deploy and implement and EMR, you will examine your clinical workflows and be forced to deal with some hard tribal questions : "If the doctor tribe used to do step A, and the nurse tribe used to do step B, and NOW the nurses can't do step B anymore, will the doctor tribe accept doing step A AND B?"...

And when you announce to the doctors that they will need to do step A and B, you will quickly learn about the tribal nature of medicine. Often, discussions about workflow changes and negotiation will dissolve into "MD versus RN", "ED RN versus inpatient RN", "MD versus Clerk", "Clerk versus Respiratory therapist", and so on, and so on, and so on...

This is often the hardest part of managing cultural change in medicine - How do you balance the needs of one tribe versus another?

My feelings about this : A good leader teaches other clinical leaders about two things :

1. The art of teambuilding (breaking down tribal barriers)
2. The art of negotiation (nobody walks away from the negotiating table unhappy.)

To help with teambuilding, the first step is to gather some people from a wide swath of clinical departments : Doctors, nurses, pharmacists, clerks, lab workers, respiratory therapists, and anyone else you can get who is passionate about doing something different. Appeal to them to participate in this new tribe : "By being a part of this new tribe, you can help improve patient care through technology."

Take that group, and to help break down tribal barriers, create a new tribe for those clinical leaders. In our hospital, we've worked hard to create a culture for those clinical leaders, and we look at them as a new tribe.

Once you can get the members of this new tribe to commit to the art of negotiation (in the name of good patient care), it becomes much easier to negotiate workflow changes that satisfy both of their representative tribes.

So far I've remarkable success with this approach, and I'm continuing to pursue this as a model to help with the multiple governance issues which arise from EMR implementation.

This again is something a good CMIO can help you with, but until then, I'll just keep writing. :)

As always, feel free to ask questions! :) Keep 'em coming! :)


Matthew Bowdish MD said...

The Allergy Tribe prefers to be called the A/I Mesosystem

Wayne Cerullo said...

Dr. Dirk - Your perspective on "tribes" is simultaneously insightful, powerful, witty, fresh, and, yeah, true!

You skewer the "medical tribe" (culture?) taboo of acknowledging that the practice of medicine is more fruitfully (and accurately) understood as a highly-charged battle of wits than as a unified team of care-givers. (I'm not denigrating anyone here -- just acknowledging that the outside community (like patients) have an ill-informed but evolving view of the medical establishment, which is comprised of human beings, like any other institution.

So... if there is to be a "new" tribe to supplant the old, established, easily defined ones, what is it and what is its enemy?

(Tribes don't exist to do what individuals can do -- they exist to overcome threats too large addressable only by a team. You know, mastodon hunting)

Dirk Stanley, MD, MPH said...

Sorry I didn't see this until now - Wayne, thanks for the compliments!
I don't think there's going to be a "new tribe", per se - There will still be the doctor tribe, the nurse tribe, the pharmacist tribe, and their various sub-tribes. But there definitely seems to be the "new currency" which some "new tribemembers speak", and the older tribemembers are having trouble adjusting their culture to the new demands.
In any case, it's useful to understand the medical tribes when you have to handle education and training and support of your medical establishment.