This Doctor is Upset About Something, But It Doesn’t Really Sound Like Lean


Earlier this year, we had rantings from two doctors about Lean in the esteemed New England Journal of Medicine… except what they described didn't really sound like Lean (as I wrote about here and here – and also see Dr. John Toussaint's rebuttal). Also see this piece that I just discovered by Dr. Patty Gabow and Ken Snyder.

Now, there's a story written by an emergency medicine physician, Dr. Brad Cotton, that appears in a publication called “Emergency Medicine News” — FIRST PERSON: ‘We Fired Our Hospital'

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What appears on the front page of their publication in the June 2016 edition isn't news — it's a first-hand story and an opinion piece. This is the “most trusted” name in “news” for emergency medicine professionals? Good grief.

In the article, Dr. Cotton describes the poor treatment he's received from a 40-something internal “Lean consultant” named Dean.

If what Dr. Cotton describes is true, I stand by him in his concerns.

But, there are things I'll be critical of here, about his writing and behavior.

In the story, Dr. Cotton describes a typically hectic E.D. scene where he's “six patients behind” and he's spent some time talking to a patient's mom in an attempt to comfort her and explain the situation… a perfectly human and caring response.

Then, Dr. Cotton describes an interaction that I'd hope would never happen… it's certainly not the way I'd act as a Lean consultant:

“And that's when Dean confronted me. “He wasn't your patient! You are six patients behind!” Dean was the hospital's MBA consultant for LEAN management.”

It's the least important detail here, but Lean is not an acronym.

More importantly, It's hard for me to imagine a Lean consultant getting upset at an ER doc about falling behind, etc. I generally don't see people operating that way. Does such behavior rank really high in the “respect for people” scale? Is that the right way to engage people in improvement?

It does strike me that Dr. Cotton constantly refers to Dean as an MBA. That's probably a statement of fact, but it implies that Dr. Cotton doesn't respect MBAs (although maybe they've treated him badly). The tone of this whole piece seems to reflect a lot of distrust and disconnect between physicians and management, which is really sad to see (and its fairly common).

Dr. Cotton continues:

“Last week I had embarrassed him in our department meeting by asking how applicable it was to take a process meant for assembly line production of cars and apply it to the very cognitive, very complex management of living human beings in the ED.”

Is Dr. Cotton being respectful and trying to work with Dean? This comes up all the time, the question about how patients aren't cars (as I've written about), but it's hardly “embarrassing” to have this pointed out. Maybe it was in Dr. Cotton's tone. And I wonder if it wasn't Dr. Cotton who was embarrassed in that exchange.

Hear Mark read this post (as part of this podcast):

It's also telling that Dr. Cotton doesn't understand that manufacturing can also be “very cognitive” and “very complex.” It bothers me when people look down their noses at manufacturing when they've usually never set foot in a factory. Is that respectful?

“I had also asked Dean what they do when the line runs too fast, and a scrap car is produced. Producing scrap was not an option for us, I had said.”

Dr. Cotton really exposes his ignorance about manufacturing. An assembly line runs at a steady pace. It's not possible to run the line “too fast.” That said, an assembly line is usually highly engineered to make sure each of the jobs is achievable within that “cycle time” or line rate.

Healthcare overburdens people all the time, which, again, is sad. Factories (at least Lean factories) don't do that.

There's not a “scrap car” produced. It's silly to think that a car is “scrapped” and thrown away. Again, ignorance about manufacturing there. What's more likely is that some sort of defect is found (and it's not because people were having to work too fast).

What happens is an employee “pulls the andon cord” to point out the problem. Management thanks them for this and then works together to resolve the problem — either a short-term fix or a root cause fix that prevents recurring problems from popping up again. That's exactly what we need MORE of in healthcare… being able to put quality first instead of pressuring people to work faster. Virginia Mason Medical Center, for examples, calls this their “Patient Safety Alert System” and it's that Lean concept put into practice in healthcare.

Dr. Cotton then writes about Dean, the consultant, coming into the ED as a patient having heart problems. Dr. Cotton implies that Dean is a drunk… something that's not very professional, not very respectful, and something not worthy of publication, even if “Dean” is not his real name.

Dr. Cotton recounts the lecture he supposedly gave to Dean:

“Dean, unlike like your cardiologist, who doesn't make my job harder, you do. It was the right thing to spend time talking with you while you were a patient. It was the right thing for me to take that kid over to his mom the other day. It could have been the last time he saw her.”

I agree with Dr. Cotton that Lean and a Lean consultant shouldn't make his job harder. I've written before about how what we might call “loving care” can be as important as the efficiency of care.

He continues:

“We can't see four to five patients per hour, what with the acuity here and a 30 percent admit rate. The emergency medicine literature says we can't. Too fast means mistakes, and I can't just scrap mistakes — someone dies.”

Was Dean setting standards that couldn't be achieved? Was Dean (or management) pressuring people to work faster and telling them to put speed above clinical quality? If so, I'd be upset too. But, behavior like that isn't Lean, it's L.A.M.E. (or Lean As Misguidedly Executed). Prof. Bob Emiliani calls stuff like this “Fake Lean.”

Dr. Cotton and his colleagues felt disrespected and I couldn't blame them for that. He writes about how his group of emergency physicians “fired the hospital” (per his dramatic title) and walked away because they didn't like the conditions.

He concludes:

“Do we as a whole need to speak up and say there is a limit to how much we can tolerate and still remain professionals? It is past time to take emergency medicine back from the Deans, LEANs, and MBAs.”

Again, one of the core tenets of the Toyota Way management system and Lean is “respect for people.” In the Lean philosophy, we're supposed to work with people and not antagonize them. It makes me wonder what Dean's side of this story would be, though?

If consultants or MBAs or “C-suiters” (or “the suits” — I'm surprised Dr. Cotton didn't use that pejorative) aren't treating doctors professionally, that's not Lean. As a Toyota executive told me earlier this year, “If people are upset, it's not really Lean.”

But, maybe Dr. Cotton needs to think about respect, look in the mirror, and first heal himself? Does Dean, as the consultant?

As a Lean community, we should reflect and ask:

  1. Do situations like this happen?
  2. If so, why?
  3. What can we do about it? How can we pull the andon cord and prevent situations like this?

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. Comment from LinkedIn:

    Theo Liskamp: Would it be Lean if a consultant was around the production area (E.D.) making comments on how professionals did their job? As you already pointed out, I would say it is very unlikely, and definitely very un-Lean. But it is a way to get people upset about Lean, unfortunately. Sadly, the disdain on manufacturing is fairly common too.

  2. In case anyone out there is wondering, the Dean in the story isn’t me, and would never be me. This sounds like a highly dysfunctional situation where the people involved do not understand their roles in the process and are making things worse, not better. Fake Lean indeed.

    • For the record, I didn’t think it was you, Dean.

      It’s sad that there are so many bad situations out there where doctors don’t trust executives. There are many bad relationships out there, really dysfunctional. Executives often blame the doctors too easily. Maybe as bad as the old GM / UAW relationship used to be? But the NUMMI plant story shows that it’s possible to make significant progress with “bad workers” when you put a better management system in place.

      Without a decent level of trust, is there any hope for Lean, even if the consultants aren’t antagonizing doctors and staff? How many MBAs (or nurses) with zero experience with Lean are being given a day of training (or a weeklong certification or belt) and then get told to “go make the organization Lean”? I wouldn’t expect that to go well.

  3. There are definitely two sides to every story. I have seen people tell outright lies about a facilitator, so it wouldn’t surprise me if Dean’s behavior was exaggerated. One huge concern of mine in this article is that the physician gave enough information for someone to identify Dean if they were so inclined. Violating HIPAA doesn’t win any trust points for sure.

    I’m a big one for the buddy system. Having someone there to spot check your presentation to give you feedback. Sometimes we don’t realize how our body language or the way we say something comes across to people. Your buddy can also double as your witness to back you up in sticky situations.

      • Yes, a coach. Someone who can give honest, constructive feedback.

        There are a few docs coming to mind I’ve worked with that would benefit from this kind of coaching, especially now that patient perception of care determines reimbursement.

          • That would be an interesting study. I wonder what the age and experience breakdown would be too. Docs who have worked in solo private practices usually know the value of patient perception because unsatisfied patients leave and don’t refer new patients which hits their bottom line directly. In the age of social networking and rating sites like Healthgrades and Yelp, disgruntled patients (as well as customers of other industries) have a much further reach when voicing their dissatisfaction.

          • It might be useful to put patient satisfaction surveys into perspective. I doubt that patients can accurately and reliably indicate clinical quality unless something has gone so wrong to the point that it is apparent to the patient. In my experience as a physician, I have never met a patient whose opinion I would believe 100% about the clinical quality of a physician or an institution.

            If we look from the angle of the Kano model, I think patient reports can be a more accurate guage of how well the institution/provider is doing on the “must-be/dissatisfier qualities” (customer service/respect etc) rather than on “one dimensional/satisfier qualities” (effective and safe treatment). I think if the discussion were framed that way, doctors might be more accepting.

            • I think patient satisfaction is just one part of the overall equation. I think that matters… like you said, not feeling like you’re disrespected as a patient.

              That said, I’d be slightly more concerned, as a patient, about patient safety (avoiding preventable harm) and my clinical outcomes and quality.

              We need to work on all of this.

  4. Other LinkedIn comments:

    Jeffrey M. Lewis, MBOE, BSN, RN, LSSBB
    Mark, thank you for writing. I am a nurse. I was trained in lean thinking through the MBOE program at Fisher. I went to multiple manufacturing sites as a part of my educational experience. I was blown away by the level of complexity and humbled. There is much to learn. I am still learning.

    Allen Frady
    Playing devils advocate, the assembly line to patient care analogy only works if every single car in the line is defective but with an unknown defect. The assembly line worker would simultaneously be an electrical engineer, a mechanical engineer, a metallurgy expert, a structural engineer and be required to diagnose and fix every car on the line…on the fly.

    My response:

    Allen Frady – Lean is not about assembly lines and Lean is not about building cars. So, of course, building a car or diagnosing a defect is NOT the same as treating patients. That doesn’t make Lean irrelevant… it makes Lean that much more important and necessary given the high stakes involved in healthcare.

    Viorel Verka, MBA-HCA, MD
    “It does strike me that Dr. Cotton constantly refers to Dean as an MBA. That’s probably a statement of fact, but it implies that Dr. Cotton doesn’t respect MBAs (although maybe they’ve treated him badly)”

    Really? Would you respect an MBA, who when you’re sick and dying forbids your doctor to talk to your family because he wants to move to the next money making billing instead instead? All doctors are sick and tired of being compared to line workers fixing factory junk and recalls.

    My response:

    No, I wouldn’t respect a person who treated me that way. What good does it do to label him as an MBA other than trying to smear other MBAs like myself who would act quite differently than Dean.

    Viorel Verka, MBA-HCA, MD

    No car is as complex or can have so many defects as a human being. Comparing ill people to cars is plain stupid, and their treatment to car building on automated lines is idiotic. I have not used this kind of language in a post likely, however, comparing people to Disney cartoons and junk is well beyond anything acceptable and should stop.

    My response:

    I’m not saying patients are like cars. The only people who get upset about the idea of learning from Toyota (or other industries that use Lean, but do not make cars) are those who aren’t able to conceptualize the idea that Lean is not about how to build cars. The lessons from Toyota are leadership lessons and problem solving lessons, not car-building lessons.

  5. More from LinkedIn:

    Anthony McGivern:

    There are plenty of excellent things to learn from other industries/sectors, that can enable us to improve the performance of our own. On a separate note (as Lean doesn’t necessarily ‘belong’ to any one sector) if the concepts of Lean are well understood by someone, they can be applied anywhere.


    Nui O’Malley:

    I have struck that attitude before when I was the manufacturing manager of a Prenail factory, I had the upmost praise for my team to work day day out as a cognitive team and using lean manufacturing as one of their tools. To get these items manufactured on time, under budget and with exceptional quality. Some people do not get the concept, lean manufacturing can be applied to all areas of our life it is a fantastic tool.

  6. As a practicing physician and a business owner who also creates, manufactures and sells medical products, I can understand this ER physicians experience. The comparison of caring for patients to manufacturing widgets has many similarities but the differences are what fail the comparison. First the manufactured widgets don’t bring their family with them. These extra widgets add complexity to the already stressed expected time line. Widgets don’t write the hospital about you not spending enough time with them to answer the questions not related to reason they are in the ER. The assemblies of the widgets are never subject to malpractice litigation that physicians must always think about.

    But, with all that said I do believe that each process in a hospital should be evaluated for wasted time and energy. In my OR, we strive to minimize wasted energy but still need help to more fully appreciate our workers

    • Thanks for your comment, Dr. B.

      I’m the first to recognize that patients aren’t cars and hospitals aren’t factories.

      This is where I seems Lean thinkers and physicians (like Dr. Verka, who commented on LinkedIn) talk past each other unfortunately.

      Patients aren’t cars, yet there are Lean principles that apply in healthcare… part of it is looking at processes for wasted time… it’s about how we solve problems, how we engage others, how we manage, our culture, etc.

      Airplanes aren’t cars, but Lean works there.

      Airplanes are patients. Cars aren’t lattes (but Lean works at Starbucks).

      Me saying we should learn from Toyota doesn’t mean I think we should treat patients like cars, disrespect doctors, or put speed before quality. Lean is about the opposite of those things.

      Lean — real Lean — would be a great solution to the things that Dr. Cotton, Dr. Groopman, Dr. Hartzband, and others complain about in the current state of healthcare.

      I could brainstorm 100 ways in which patients are different than cars, but that doesn’t fix anything in healthcare. Taking time to understand Lean principles and applying those to healthcare (in a way that honors what healthcare is) can make a huge difference.

  7. The story has enough holes in it to be all or mostly fabricated in my mind. But, assuming for a moment the story is true, Dean wouldn’t be the first Lean expert from manufacturing that is challenged to the point of contempt by the variation in healthcare.

  8. Here is a Letter to the Editor response from an emergency physician, Dr. Mark Jaben:

    Letter to the Editor: Lean is not What Makes an Organization LAME

    In part:

    People are not cars! Of course not. Lean evolved from Toyota’s experience, but it is really about the way people organize themselves to get work done. Lean is built upon continuous improvement and respect for people. Both are essential to overcome the inevitable tension that exists between an organization pursuing its goals and individuals doing their work. Successfully navigating this dilemma explains why Lean works, not just in assembly-line manufacturing but also in software development, legal offices, nonprofits, government, and even health care. Lean is about how people function together.


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