This is a plea for the health care community to acknowledge that some of the most important problems clinicians, executives, and academics face in improving health care are not sexy, not exciting, and not career defining, but nonetheless have a major detrimental impact on the care we give to our patients. Unless the boredom barrier is acknowledged, we believe that efforts to solve these problems are doomed to fail.
These are the problems that make your heart sink when someone mentions them, the problems that impede and frustrate the smooth running of the health care system. They are the persistent headaches that you just can’t get rid of: never having the right information about a patient who’s just been referred; the pain of coming up with a nurse roster that works month in, month out; the struggle to implement a new IT system that should make everything easier but somehow never does.
There exist solutions to these problems in principle, including many that have worked at a small scale. We also know a lot of the challenges to making these solutions work in practice. The most common challenges are in the details of how an initiative is implemented, whose time and goodwill are required to make it happen, and how it is incorporated into existing workflows. Obstacles such as lack of clarity about team roles, resistance among senior clinicians and staff, lack of time, and low motivation and high perceived burden abound.
The Boring Truth
Beyond the implementation challenges, there is one truth not openly acknowledged: Solving some of health care’s problems in practice is JUST PLAIN BORING. Dealing with them is time-consuming, requires a grasp of arcane detail, adds extra administrative burdens, and necessitates spending time thinking deeply about things that are simply not exciting — especially when compared to actually taking care of your patients, working on a new clinical trial, or playing with the new technological gizmo that should solve your problems in one miraculous go.
Solving intractable problems might be interesting to some, but they often are not intrinsically interesting to many whose input is needed to solve them. Take the problem of transferring information between primary and secondary care: The most clinically interesting parts of the solution are the negotiations between disciplines on what minimally necessary information should be shared. And then the technical design of any tool that facilitates the negotiated exchange of information will interest those clinical champions who nurture a secret geek within them.
However, success cannot happen without understanding the needs, constraints, and workflow of frontline staff. This means trying to persuade this busy staff to come to iterative technobabble meetings, having endless patience for repetitive conversations, and training people who would often rather be anywhere else. This long-term attempt at engagement is boring to do for the implementer and boring to undergo as a put-upon implementee.
No One Likes a Bore
The most valued research relates most closely to pure medicine: new treatments or diagnostics and etiology of disease. Of course we enjoy working on the interesting problems as much as anyone else and will continue to do so. But it seems pointless to do all this interesting work when the important but boring problems materially affecting the quality of health care that we provide remain unsolved year after year, are the hardest to get funded, and come with little or no recognition for tackling them.
This becomes a vicious circle; the lack of status attached to tackling or even solving boring problems compounds the fact that they are not interesting to solve, making it easier and easier to just give up. For doctors, nurses, and academics, there will always be competing and more interesting and rewarding priorities for their time. Eventually, one may rise high enough in one’s career that the impact of these intractable problems on daily life fades and can be forgotten, to be despaired at anew by the next generation. Perhaps this will happen to the two of us in a few years. Life goes on, but leaving such problems unsolved wastes millions of dollars a year in inefficient systems and worsens the outcomes and experiences for patients.
Get on Bored
How to overcome the boring? We suggest seven strategies that, taken together, might help to reframe and reposition boring problems in clinical and academic practice. We sum them up in seven P’s:
- Profess: You can’t solve a problem by pretending there isn’t one. So step 1 is to admit that the problems are boring and solving them can be even more boring. Acknowledge it.
- Personalize: Manifest the importance of these problems by using personal stories from the frontline staff struggling with them day in, day out.
- Prioritize: Give people dedicated time away from their day jobs to tackle these problems. Do not underestimate how time-consuming and draining they are.
- Protect: Never let anyone work on more than one boring but difficult problem at a time, and always have at least two workmates working on the same problem to prevent burnout and loss of motivation.
- Praise: Create status for tackling these problems and have local leaders acknowledge their importance.
- Publish: Encourage high-impact journals to publish on boring problems and encourage funders to consider the potential enormous benefit of solving them.
- Pride: Frame solving these problems as a hard but moral task — be proud of improving health care by taking on these non-sexy tasks. Enter Don Berwick’s “Era 3” of medicine by tackling the boring challenges.
Health care professionals need to initiate a conversation about what is needed to break the boring cycle. But as a first step, let’s admit the inconvenient, boring truth.
Acknowledgments: We gratefully acknowledge the useful comments and discussion with Brad Gray (Senior Fellow Emeritus, Urban Institute) and Martin Utley (Director of the Clinical Operational Research Unit, University College London).
This post originally appeared in NEJM Catalyst on April 4, 2017.