A disclaimer of sorts


This blog – and my writing in general – is starting to get more public attention, so I think it’s a good time to remind everyone of something. I’m not special. This is not false modesty or some self-esteem issue. It’s a fact, and it’s a fact that makes me happy. I like working with brilliant people. I don’t know anything that everybody else who has worked in development for ten years or so doesn’t. When other people who work in this industry read the blog, they’re not amazed by my insight or any such. Mostly, they nod in agreement. (That’s why the comments section is so friendly.)

I am the person who has the time and inclination to write down the stuff that everybody knows. I’m not ashamed of that. Codifying accepted wisdom is a useful role. It helps outsiders understand the system, and helps insiders find their common ground. It gives everyone a clear, shared view, and that can catalyze change and system improvements.

In health systems, I believe that the people already in the system – doctors, nurses, patients – already have most of the information they need to make the system better. That’s the core of continuous quality improvement. In our international aid system, I believe that the people who actually implement projects hold a lot of valuable information. I am proud to be part of bringing it out and recording it.

I’ve got the time to write this blog, and I think that writing it makes me better at what I do. It’s a constant examination of my work – the assumptions behind it and the impact it has. I benefit from that, and I think that the projects I work for also benefit. I hope that reading this is useful to other people. But don’t mistake this for something unique.

People who work in development are amazing people. They think about their work all the time, obsessively. They try to figure out how to do as little harm as possible, and they search all the time for ways to improve their impact. Most of them are smarter than me, and know more. Most of them are too busy doing their work to want to blog about it. I’m the one who likes to write. That’s all.

photo credit: tellumo
chosen because it’s a truly awesome disclaimer

Physician training has very little impact

Jishnu Das writes about research on physician training in low-resource countries. His disheartening conclusion is that the training has very little impact on improving quality of care.

The research was as follows:

Our approach has been to try and decompose the quality of medical advice into two components—what doctors know and what doctors do. What doctors know—measured by testing doctors—represents the maximum care that a doctor could provide. What doctors do—measured by watching doctors—represents the care they actually provide to real patients. We call the first “competence” and the second “practice quality”.

And the depressing conclusion:

In Tanzania we find that two additional years of school and three additional years of medical school buys an increase of only 1 point in the percentage of essential tasks completed. Results are similar for other countries.

Training doctors has been a standard way to improve the quality of health care for years. It’s a major shock to discover this minimal impact. I wonder if the quality of training make a difference? Perhaps competency based training would make a difference.

While this is depressing research, it’s not necessarily telling us things we didn’t already know. If you want to change a physician’s behavior, you don’t just give her training. You change the system she is part of. Good projects health projects recognize that, and so do American HMOs.

Lesson: Don’t try to change individuals, try to change the system they are part of.

Premature babies at risk

Very premature babies aren’t getting the follow-up care that they need. Premature babies are very often born to women who have risk factors, including low-income and drug use. This means that medically fragile, high needs babies are going home to women who may not have the resources to care for them or even get appropriate medical care.

The best answer would be an integrated medical system, where hospital care is automatically connected to social services and outpatient care. Right now, parents have to find follow-up services themselves in most places, assisted perhaps by a booklet or a list of phone numbers.