A litmus test of naiveté

by Joel

Root Cause Analysis (RCA) is a good example of thought processes in medicine. According to the Association for Healthcare Research and Quality, “RCA is one of the most widely used approaches to improving patient safety, but perhaps surprisingly, few data exist to support its effectiveness.” When something is not effective, there isn’t much data to support the notion that it is. That’s how you know something is not effective. The data does not support the notion that it is.

To repeat, RCA is widely used, but in spite of that, data created by it does not support the idea that it is effective. Yet it continues to be widely used medicine. They continue to say that it is a good method for uncovering problems.

It is important to understand why medicine never will figure out that it doesn’t work in medicine, because it is the same way that the think about medical procedures and treatments.

Medicine is focused on processes, not outcomes. The records they create often end with what their end-action was, not with what the results were. The patient can have been disabled, but they will be sure it was not a result of what they did. It also means that as long as they, say, implant a hip replacement correctly, they can record that the operation was perfect with no complications and move on without making a connection between the deteriorating health of patient after patient and the hip replacements no matter how many of that surgeon’s patients get the complications.

They pretend to try to find problems, but they don’t want to do anything that would upset the status quo. Especiallly their own. One of their mantras is “don’t go looking for problems.” You can see the influence of this kind of thinking in everything from state medical boards to operating rooms to root cause analysis. You can use root cause analysis as a litmus test for it.

Root Cause Analysis (RCA) Every try to get an iatrogenic injury diagnosed?works for airlines because pilots and flight attendants report problems. Otherwise they go down with the plane. Doctors and nurses don’t go down with the plane. They are better off hiding problems, so that’s what they do (see Medical Reporting on this site).

Anyone who does not appreciate the extent to which that effects everything that happens to patients has failed the litmus test. I’ve never met anyone in medicine who appreciates that. Ask a hundred patients with iatrogenic injuries to show you their records and you will be unlikely to find a single one with any record of the injuries. Try it. I have. I have asked hundreds.

Hospitals are not Airplanes

This is how bad this is in medicine. Pilots do not drop passengers in remote locations and then prevent anyone else from picking them up in order to hide problemsPilots do not drop passengers off in remote locations and then make sure that no other pilots pick them up in order to hide problems. Health care professionals do the medical equivalent of that while managing to to remain in collective denial of the fact that they are doing that. The extent to which the care giving community manages to remain in denial of this truly is stupifying. The way they dismiss, and even destroy, information they don’t like and latch on to what they do prevents any eroding of that ignorance, and prevents their recognizing what they do in general to the patients they injure.

All those suits are “frivolous,” right?

Victims of adverse events in medicine invariably find that there is no record of what happened to them. They cannot even get their injuries treated because no one will create a diagnosis that could verify that iatrogenic injuries exist.

How is root cause analysis going to root out anything under those circumstances? There is no record of what went wrong and the people who were on the scene are a loyal team dedicated to making sure no one finds out what did? In medicine people who report problems get excommunicated (see Loyalty on this site). It is a system that eliminates the only people who would have tried to create transparency and accurate information about the problems harming patients.

We just need More

Yet some say there just needs to be more transparency, as though there already is any. The amount there is, when things go wrong, for all practical purposes is none.

To get more of it sometimes they call for creating a culture rich in reporting. This is naiveté upon naiveté spiraling out of control. The idea of a culture rich in reporting is a naiveté that deserves its own pages.

There is no such thing as transparency, or even honesty, when health care professionals are the source of the information about adverse events.

Anyone who needs that to be footnoted, and/or doesn’t already understand it doesn’t have a clear enough view of the landscape in medicine to understand the problems let alone propose solutions. Unfortunately, we have not yet met anyone in medicine who does.

See Conflict of Interest In Medicine.

Decade after decade the rates of unnecessary death, disablement and crime do not improve no matter what safety initiatives are established by caregivers because it is not in the interest of our caregivers to know what the fundamental issues are. For instance, that last problem I mentioned, the crime rate in medicine, if that is not in your viewfinder, whatever is has been so well filtered through the selfserving lens of medicine that you are looking at the landscape in the dark. What you study will not address the root causes of the problems. Your work will not reduce the rate at which disasters occur in the future (as the last decades have proved) no matter how much varnish is applied on top of them to make things look better from the perspective of the caregiving community.


Root Cause Analysis - a litmus test for naiveteThere will be yet more calls to bring to medicine the RCA of the airline industry, and calls for more transparency, and calls for establishing a culture rich in reporting and/or a culture of safety and/or a culture of respect and/or more fantasies about black boxes, etc. All of these will be considered within medicine only if it is assumed that no one in medicine is guilty or at fault, which removes crimes committed against patients from the discussion, often with the statement “That’s another thing entirely” when in fact it is the primary thing to consider to make progress on any of these fronts.

Laws may be passed. Intiatives written. Interviews granted. Books published. Grand proposals created by people with impressive degrees. Bureaucracies may be created to manage things better. And the rates of unnecessary death and disablement and bankruptcy will not fluctuate. Neither will the crime rate (but no one will notice that).

And then it all will start again with someone calling for yet another inanity that would require that caregivers be selfless enough to violate their own interests and objective enough to recognize how self-interested they are. They don’t believe information about the outcomes they produce let alone understand the underlying causes. They are better off preserving the status quo, no matter how bad it may be for the patient community, and massage their beliefs to suit that end. And they are the ones upon whom the new measures will depend for information for things like RCA.

All of these measures are the equivalent of caregivers saying “we’ve got to do something about the boils on people dying of the plague” and focusing on the boils because the plague itself is anathama and “another thing entirely” and cannot be considered.

Bottom Line

What is the least, the absolute least, that a patient should be able to expect in medicine? Start with that. Do something about that. No one has yet. All the rest of it is superficial until mechanisms are in place to address that. They are the same mechanisms that are necessary to address the rest of what is wrong, but no one in medicine wants mechansisms that will discover let alone solve the findamental problems. That would change the status quo.

See Crime in Medicine

Invariably patient safety initiatives are set up on the assumption that no one is at fault. That puts a raft of root causes beyond discovery. When it is assumed that everyone is innocent, those who are not get away with murder. We need data mining that at least will uncover murder and other unfriendly acts no matter how much medicine wants to dismiss, deny and cover them up.


Perhaps the most salient lesson to be learned about medicine from the example of Root Cause Analysis comes from listening to people in medicine continue to say that Root Cause Analysis is the best way to discover problems and fix them. After all of the years of experience proving that is not they continue to believe it. Like 20 years of implanting metal on metal hip replacements without figuring out how bad those are for patients, until a surgeon got one himself and discovered it on himself. Or the century and a half of trying to get them to wash their hands enough without ever succeeding with that, but still continuing to believe that they can do it.

Patients need to understand better than to be lulled into false senses of security when treatment providers tell them things like that everything is safe and fine because they use Root Cause Analysis. Or when treatment providers tell them data on safety that is no more well founded than their ideas about Root Cause Analysis.

See: Engineering a Safer World (MIT Press, January 2012)
by MIT Professor Nancy Leveson