When equality is the norm – the language changes

– How do you greet people in the elevator in Swedish, Jacques Malan asked me when he was in Stockholm to teach the ECG course.

You don’t, I responded. We don’t greet strangers in Sweden. The next day he confirmed what I had told him. In Sweden people just stare at the ground when they enter the elevator. It’s a behavior we are somewhat ashamed of, but don’t know how to change.

I’ve always been interested in learning languages. It’s fascinating how every new word adds to the vocabulary and challenging to try to make sense of grammar rules while speaking. But what I find even more intriguing is the cultural language. How just translating the words doesn’t translate the meaning. I struggle to express gratitude and appreciation in American English, since even the most common thing is referred to as ”amazing” or ”awesome”, which in Swedish would translate into ”not too bad” or ”pretty good”. Being overwhelmingly positive is difficult for a Swede who thinks moderation is bliss.

The interesting thing about our own culture, is that it’s hidden to ourselves. We don’t know that views or habits are unique to us. A funny example is the Swedish house tour. When you come to someone’s house for the first time, you will be shown around the whole house, often including untidied rooms and storage rooms. I thought that was how everybody did it and was surprised when invited to homes in India and Egypt, to only be shown into the living room. When staying with friends in the US our hostess was very reluctant to show my husband their bedroom. I thought all these people behaved strangely. Therefore, when invited to a Belgian friend here in Sweden I was delighted that she showed me their messy storage room. – Aah, you do the house tour in Belgium, too? I asked. – No, never, she replied smilingly, but I know you do in Sweden.

When we went to live in Botswana for half a year I wanted my kids to feel what it is like to be different, to increase their understanding for people who are different from themselves. They all went to a private school run by South African owners, but the teachers were mostly Zimbabwean. Zimbabwe is known for having well educated teachers and, just as a coincidence, my older kids had all had a wonderful Zimbabwean teacher for their first years of school in Sweden.

Emilia, our youngest, was only six at the time and a bit afraid to go to school on her own. She refused to let me go when class was about to start. Her teacher came to Emilia’s seat and squatted by her side:

– Emilia! Do you love teacher? Emilia lowered her eyes shyly.

– Do you know teacher loves you? The teacher wanted an answer and Emilia nodded slowly.

-Teacher loves you verrrry much. All the children here love you. They will be very sad if you don’t come to school. Do you promise to come to school?

Emilia didn’t really know what to say. I also think she had trouble understanding the teacher’s accent.

– And during break time, teacher will buy you some chocolate. Would you like that?

Emilia definitely understands chocolate and agreed to stay if I stayed, too. The thought of getting candy from the teacher is tempting when you come from a culture where kids can only eat candy on Saturdays and there is constant debate about whether it’s acceptable for schools to serve cake to celebrate a special occasion. But of course Emilia’s teacher didn’t know that her kind offer would stir up a controversy in Sweden.

After some spelling exercises the teacher called for attention. – Now we are going to talk about the nuclear family, she said. I listened attentively, thinking that this would never happen in Sweden, where the term ”nuclear family” is a provocative term to many people.

– Who is in the nuclear family?

The children’s raised their arms and took turns answering.

-Father. -Mother. -Brother. -Sister. -Baby. -And me.

-Right, the teacher said.

– She says that all the time, Emilia whispered in Swedish. But what does she want us to write?

The teacher moved on.

– And who is the head of the nuclear family?

I didn’t know. But the children did.

– Father!

– Yes! the teacher confirmed and nodded smilingly in my direction. It was probably because I was sitting there and smiling to myself.  – Father is the head of the nuclear family. And what does mother do?

Yes! That’s what I wanted to know. The children knew that, too.

– She takes care of the family!

– Yes, but how does she take care of the family?

The children hesitated with their answers and the teacher helped them out.

– She cooks. She cleans and makes sure the house is neat and tidy. She irons your clothes. She cares for the family.

The teacher explained how the nuclear family is little, but the extended family is big. Who is in it? All the aunties and uncles and cousins and grandparents. And who is the head of the extended family?

– Grandfather!

– Yes! What is grandfather the head of? Repetition is great for learning.

– Grandmother! someone said. Is that correct or wrong? l wondered, but I never got to find out.

– Grandfather is the head of the extended family.

The class broke up for break time and I went home thinking that if I were to raise my kids in Botswana, I would send them to Sweden for feminist camps every summer. This experience increased my understanding for immigrants from more conservative countries whose children are taught Swedish values in school.

Cultural_map_WVS6_2015

It is interesting how we Swedes see ourselves as a culture of moderation. In reality, when it comes to values, we are extremists. Our self image of being tolerant and open-minded makes it difficult to realize that we don’t understand other, less individualistic, cultures. One year after coming back from Botswana I read in the newspaper about how some Swedish mosques were being radicalized. The example offered was how they had started to preach that men were the heads of the family and women should take care of the household. I thought of Emilia’s and my experience in Botswana.

We have generous parental leave in Sweden. For 390 days, the maximum parental allowance is SEK 946 (USD 137) a day, as of 2013. For the remaining 90 days, the daily allowance is SEK 180. Sixty days of leave are allocated specifically to each parent, and cannot be transferred to the other. In addition, one of the parents of the new-born baby gets 10 extra days of leave in connection with the birth or 20 days if they are twins. (ref: https://sweden.se/society/gender-equality-in-sweden/)

Men only take about 24% of the total parental leave, which is a great concern to most political parties. In Swedish we wouldn’t ask a man if he intends to stay at home with his child, but when and for how long. I have several male colleagues who took a year of parental leave, but I would say about four-six months is most common. An executive of my hospital said that it’s ideal to have a child during your internship, since whenever you choose to come back from parental leave, the hospital has to offer you the same rotation you were doing when you left.

But it isn’t only the gender gap that is shrinking in Sweden. Our culture is changing into something that others would probably call extreme feminism. Gender pedagogy has made its way into our preschools and schools.  http://www.genus.se/english/news/Nyhet_detalj//what-is-gender-pedagogy-.cid912417.

I don’t feel comfortable with the ”feminist discourse”, which makes gender an íssue when in reality it shouldn’t be. In Sweden I would hesitate to call myself a feminist. It is in the encounter with other cultures that I realize how the Swedish language has been influenced by feminist values. When a male colleague from another country greets me and says ”You look good” it sounds strange to me, until I realize that in Swedish a man shouldn’t comment on a woman’s look.


My apologies

I read the article in the New York times, because someone on Twitter was upset about how emergency physicians were portrayed in it. So I tried to figure out what the article was about. I think it is about how the advice doctors give to patients can have life changing effects. It’s a scary thought. We often worry about patients not following our advice, rather than the opposite. I remember a young patient patient with a functional disability who did martial arts. Because of a shoulder joint instability his orthopedic surgeon had recommended him to stop training and competing. His whole life revolved around his sport. It’s where he spent all his free time and where he had all his friends. Saying that he should stop was easy for his doctor and made sense from a medical point of view. But life style choices are so much more difficult than weighing medical evidence. I could write a blog post on that. Maybe another time. It’s an important subject for all medical providers. For the public, too, I think that’s why the column in the New York times was published.

This post is, however, about something else. It’s about how Twitter exploded with comments by emergency physicians upset with the article, demanding an apology from dr Caplan and from the New York Times. I tried to raise another perspective, but failed. – ”No matter how you slice it, the article does not show respect for our skill set. Universally demeaning…”

”Thoughts on the danger of a widely read column telling stroke pts to be afraid of the ED?” 

This seemed to be the common interpretation of the article. Or common among ED physicians that is. I read the comments to the article and found very few comments about poor performance in the emergency department. Instead the most common theme was about the importance of universal health coverage and how everybody should have the right to a second opinion. Some shared their experience of stroke or expressed gratitude for being informed about the condition itself. The biggest fear of the emergency physicians – that patients would be scared to go to the ED in case of a stroke – seems unjustified.

There are many ways of interpreting an article. I have read articles about emergency medicine in Sweden that I have thought well balanced, respectful of other specialties and positive in general, only to hear that other specialists have been terribly upset with the people writing the article or portrayed in it. It makes me very careful about what I say to journalists. I therefor thought it almost unnecessary when a journalist offered me to read my quotes for an interview recently. One of the quotes, where I was trying to make a certain hospital sound like a good example of how to set up EM training, had been phrased in a way that I myself found very critical of the previous organization. I’m glad I got the chance to change it, rather than having to apologize and explain after it had been published.

The comments dr Caplan makes about emergency physicians and the emergency department definitely sound disrespectful to me. At the same time they don’t make sense. They don’t apply to the case described where the advice to avoid physical activities was given by ”doctors”. It’s hard to imagine, and it doesn’t say in the article, that those doctors were emergency physicians.

The negative comments don’t fit into the context and it looks to me like the journalist chose to put them there because they were provoking and added some spice to the story.

And here is the lesson I learned from this case: I am constantly disrespectful to my colleagues. I could easily have uttered the same kind of comments, especially if they were extracted from a longer conversation. I want to do better.

Skärmavbild 2015-05-06 kl. 23.13.53Dr Caplan says that if you have a stroke, you should see a neurologist specialized in stroke. For a young person with a stroke, I most certainly agree. But I am tirelessly arguing that neurologists are not experts in acute headaches, bringing up examples of when patients being triaged to their section of the emergency department (the way it works in some European countries) ”is dangerous”. Of course the problem is not that they are neurologists. The problem is ”that neurologists get little emergency training”. We call them ”organspecialists”, as opposed to us emergency physicians whose specialty springs from the patient’s need. We ”have had a hard time getting the message across” that stroke patients can have stroke mimics and need to be assessed before they are entered into the thrombolysis algorithm, a treatment that the neurologists can’t even properly evaluate the evidence behind. When I hand my patient over to them for thrombolysis, I ”worry about the quality of treatment” we as a hospital provide for the patient.

When I read this last paragraph I first thought that my point had been lost. That is not disrespectful. It’s true! And this is what I say to everyone who is willing to listen. When talking with fellow emergency physicians the stories of other specialists’ inability to understand emergency medicine are more colorful and vivid. It feels so good to be among peers who understand. This is why I objected to the Twitter discussion. Because there were only emergency physicians there, confirming each other’s belief that this article was about disrespect for emergency physicians and would decrease the public’s trust in their work in the emergency department. No neurologists were involved in the discussion, no gas station attendants and no people without medical training at all, sharing their interpretation of the article.

Everyone has the right to feel offended by whatever they feel offensive. It’s all in the eye of the beholder. (I wonder what dr Caplan thinks about dr Newman’s response that seems so balanced and polite to me.) But if this was just an old neurologist speaking his mind, I don’t think the whole community of emergency physicians would have been so upset. There must be an underlying problem. Is there a distrust between different specialities? I try to tell patients that their primary care physician is the most competent specialist to assess and coordinate their health care needs, but I hear a lot of doctors bad-mouth primary care physicians. Is there a disregard of certain specialties? Do we see some specialties as less cool, less complex or even less valuable? Do we express those thoughts to our colleagues? To our students? To our patients? What does that do to their trust in the medical profession as a whole?

That’s the discussion I wanted to bring up yesterday, but 140 characters wouldn’t allow it. I sincerely apologize to anyone who felt offended. By me, that is.


Go on and fool me

I have a low threshold to pain. When I walk by a room and happen to see a patient squirming and crying in pain, I feel a compulsive urge to make sure that someone is dealing with the matter. As mostly, the best source of information is the patient, so I put my hand on their shoulder and say – I can see that you are in a lot of pain. Is anyone helping you out here?

If the answer is no, I offer a warm blanket and go and ask the nurses to provide some analgesia. Sometimes that means paracetamol or ibuprofen, sometimes it means opiates. For patients in severe pain it can mean all of the above and in high doses. For heroinists I order doses that the nurses refuse to administrate.

The same goes for patients who need prescriptions for their pain medications. Some of them have incredulous explanations for needing one, like being robbed of all their pills. Or they have pain that I can’t find an anatomical or physiological explanation to. I don’t care. I send them home with a small prescription or with the amount of pills they need until they should be able to get hold of their regular doctor or primary care physician.

I try my best not to judge how credible or trustworthy my patients are when it comes to describing their pain or their need for medication. Because that judgement will undoubtedly be based on my prejudices. And I would rather be a fool than a bigot. I know that my suspicions of drug-seeking behavior would be directed towards men of non-Swedish origin with low education, making me a sexist, snobbish racist. That is not who I want to be. So I choose to trust my patients.

Before I send the prescription, however, I check my patient’s medical records. Our system covers most of the clinics in Stockholm, so I can count how many pills have been prescribed in total. Sometimes there is a note, or even a warning, that the patient seems to be over consuming pain medicines. I have never seen that statement followed by a treatment plan, or even a discussion with the patient about the problem, though.

So I tell the patient that he or she seems to be using more pills than ordered, and maybe even more than what they have just told me. I inform them that it says in their medical records that they might have a dependency problem. Often I’ll apologize on behalf of our health care system for putting them in this situation. I understand how living with chronic pain wears you down, both mentally and physically. How the pills, which offer some relief at first, stop working and how easy it is to increase the dose in desperation, until suddenly the pills themselves have given you another problem. Like far too many other patients they have not been given the holistic, team based care they need. Instead some doctors have prescribed large quantities of addictive drugs. And now when that suspicion of overuse and dependency has been raised, it’s going to be very difficult for them to get any medicine at all.

If the patient admits that they have a problem, I offer them a referral to a dependency clinic. When they don’t want that I strongly recommend them to make sure that they only ask for prescriptions from their primary care physician and that they limit their usage to the doses prescribed. Then I document this conversation in their records.

It is very rare that the patient gets upset about my way of handling this. To the contrary, they often thank me for treating them with kindness and respect. It could be that they are just being manipulative and happy that they got what they came for. So maybe I’m fooled from time to time, but I know that I’ll never mistrust and mistreat that patient in severe pain who can’t speak eloquently enough for herself.


It’s time we had that talk

You are my patient. Whatever I do serves to make you feel better. Sometimes I can offer you treatments that achieve that straight away. Other times you have to go through painful procedures and treatments with exhausting side effects to increase your chances of feeling better in the future. Whenever that is.

Figuring out what investigations and treatments are indicated for a certain condition is mostly not that difficult. There are certainly disagreements between specialists, but I’m good at finding information and coming up with a solution that makes sense from a medical perspective. It is determining what is right for you that is the great challenge of my work. You are central in this process and I can just guide you through it to the best of my knowledge. When we have time, when we speak the same language, when you are capable of engaging in our conversation; this is the most rewarding part of being a doctor for me.

But when you haven’t been informed about the seriousness of your underlying condition; the tumor that is growing and spreading in your body or the COPD that is gradually choking you, I see no other option but to give you a treatment I would not want for myself. When you fall acutely ill, there is no chance for me to ask about your wishes. I have to save your life so that you can makes those decisions for yourself. Unfortunately the doctors who see you after my initial treatment often miss out on the opportunity to makes sure that the care we are offering is what you want and something that makes you feel better.

More importantly they fail to offer you an alternative. You might very well be given the choice between life and death. I find this strange as we all know that no matter what we do, you are at the end of your life. What I want to know is if you are willing to have us prick your arms until you look like a pin cushion? Should we continue to force tubes down your throat even when you say no? Are you willing to take the risk of drawing your last breath in the CT scanner, forced to lie down when you are struggling to breath?

Some people will undoubtedly say yes to all of those questions. If you are one of them, ask your doctor to write it in your medical records. I will be happy to do my very best to prolong your life by whatever means I have. But if you have doubts, make sure to bring this up with your family and a doctor you trust. Talk through the alternatives. Make sure that everyone involved understands what is important to you. Do you prefer to die from a simple pneumonia in a quiet place? Do you want me to focus all my effort on making you comfortable even if that means the end of your life?

I doesn’t matter to me what you choose. What matters to me is that your voice was heard and that I can hear the echo.


Learning how to present in the flipped classroom

All doctors have to be teachers. Even if you don’t have students or residents around, you have to teach and instruct your patients. Most of us also have to deliver at least an occasional public presentation. We get limited training at this, which is why we decided to run a course, focusing on learning by doing.
I’m a pretty relaxed person and this is a very relaxed course with the main aim of Swedish EPs getting together and enjoying themselves. We’re running it on a cruise ship because it’s cheap and partly over the weekend, so people might even be willing to do this in their spare time and pay for it themselves, neither of which Swedish doctors at any level hardly ever do. We expect about thirty people, which will be enough for two groups.
There will be three sessions, each 2-3 hours long, i.e. hopefully short enough to keep people’s attention. Since the presentations will cover different topics, there should be some learning from that too.
This is a great opportunity for me (and the two other organizers) to learn, so we do take the content very seriously. The plan is something like this (I’ll make a video to describe it later).

October cruise

Pre-course learning:
Around 4hs of material, mainly videos on how to present and teach
Prepare a Pecha Kucha lecture, 6 min and 40 sec, on a topic in the curriculum. (We’ll offer a list, anything from Guillain Barré to a procedure)
On site learning:
Everyone watches the video and rates its qualities,anonymously on a web based polling system.
Presenter gets four minutes to present (without slides)
- why he chose the topic and how he chose to focus and limit the talk (very difficult when given an open topic)
- thoughts about the introduction
- teaching goals and how they were stressed in the presentation
Then we have an open feedback discussion. I expect all of this to take around twenty minutes per person.
After-learning
After the course everyone will be able to use all videos in their teaching programs. We’ll probably have to offer people the chance to update their videos on the ship, or they’ll never get to it.
We will also add some other elements like bedside teaching, how to give feedback, the unwilling learner etc. Some of it can be done in advance as part of the pre course material. Then we’ll run a few foamy hangouts with international EM teachers and here their views.
I’d love to hearn anyone’s thoughts on this. Thank you everyone who has contributed already with great links for the pre course material.

Varför lean is mean i min värld

Jag rekommenderades att läsa The goal, en bok om förbättringsarbete. Den är skriven som en novell och spännande att läsa. Min erfarenhet är att förbättringskonsulterna inte förstår vad jag pratar om. Nu förstår i alla fall jag bättre vad de pratar om. Framför allt tror jag att den här läsningen har givit mig en förståelse för varför de lean-projekt jag drabbats av har gått snett.

I The goal är huvudpersonen en företagsledare som får frågan om vad som är målet med företagets verksamhet. Detta är något jag brottats med sedan jag var i Botswana. För mig var det självklart att jag var där för att rädda liv och för att minska sjuklighet. När en australisk akutläkare sa att det inte var så, utan att vi var där för att utbilda lokala specialister i akutsjukvård, blev det uppenbart att vi inom sjukvården inte har samma mål. Väl hemma igen såg jag det i hela sjukvårdsstrukturen. Kardiologerna ser som sitt mål att minska kardiell sjuklighet och dödlighet, medan kirurgerna har målet att operera de som behöver opereras. Sjukvårdsledningen har inte förmått att hålla ihop sjukvårdsorganisationen och ge oss ett gemensamt mål att sträva mot.
För mig är det självklart att det gemensamma målet ska vara en förbättrad hälsa för vår population. Det innebär att kvalitetsmåtten ska vara patientorienterade. Om man gör 1000 gastroskopier på gamla människor med lågt blodvärde och en dör en dyr och plågsam död på IVA på grund av en esofagusperforation med efterföljande mediastinit (ett känt lex Maria-fall), måste man vara säker på att den positiva effekten av de övriga 999 gastroskopierna var större. Det innebär att om dessa undersökningar inte påverkade behandlingen så att sjukligheten och dödligheten minskade, utan bara gjordes för att ”det är så man gör”, har sjukvården missat sitt mål. Inom akutsjukvården letar vi potentiellt livshotande diagnoser. För att hitta en blodpropp i lungan, måste vi göra skiktröntgen på en stor mängd patienter där undersökningen inte visar någon propp. Dessa patienter har inte fått någon positiv effekt av vår utredning, men däremot en liten vårdskada i form av ökad risk för cancer framöver. Det är den sammanvävda nyttan, minus skadan, för den här patientgruppen som är vår nettoeffekt, om målet är att förbättra hälsan för vår population.
Det tar ett tag för huvudpersonen i The goal att komma fram till att ett företag har som mål att tjäna pengar. Ju effektivare de kan producera bilar, desto mer pengar kan de tjäna. Deras marknad kan växa och de kan expandera. För ett privat sjukhus är upplägget egentligen detsamma, även om det är ett serviceföretag i stället för ett produktionsföretag. Där är målet att tjäna pengar och det gör man genom att producera sjukvård.
Låt oss ta ett exempel. På glesbygdsvårdcentralen söker en 40-årig man med hosta, pip i bröstet och 38 graders feber sedan 6 dagar. Distriktssköterskan undersöker patienten, konstaterar att han är opåverkad, inte har förhöjd andningsfrekvens eller puls och att det piper på båda lungorna. Eftersom detta räcker för att ställa diagnosen akut bronkit, informerar distriktssköterskan patienten om att hostan kommer att hålla i sig flera veckor, att antibiotika inte har någon effekt och att patienten inte behöver träffa doktorn just nu.
En identisk patient söker vård på universitetssjukhuset. Han hamnar i triaget och blir bedömd av sjuksköterska och undersköterska. Blodprover skickas iväg. En underläkare träffar patienten och samråder med specialistläkaren på akuten. En lungröntgen beställs med frågeställningen lunginflammation. Eftersom patienten låter lite tät på luftrören, skriver man ut astmamediciner och för säkerhets skull antibiotika. Man remitterar också patienten till vårdcentralen för uppföljning.
I det första fallet har väldigt lite sjukvård producerats, bara ett distriktssköterskebesök. I det andra fallet har man producerat ett akutbesök med specialistbedömning, röntgenundersökning och medicinering. Om målet är att producera sjukvård, finns det inget fel i det sistnämnda fallet. Förbättringsarbetet på akuten har syftat till att snabba på processen och vårdtillfället kan ha producerats synnerligen effektivt. Men om målet är att förbättra hälsan för population, är den här handläggningen direkt felaktig. För patienten blir det ingen skillnad i utfall, men för vår population innebär överförskrivningen av antibiotika en negativ hälsoeffekt. Ett onödigt akutbesök på akuten innebär också ökad risk för sjuklighet och dödlighet bland de övriga patienter som vistas där. Den positiva nettoeffekten för populationen hade varit större om sköterskan i triaget hade slutbedömt patienten. Så vilket är målet?
Jag är alltså osäker på vilket målet är för den sjukvårdsorganisation jag arbetar i. Tyvärr är jag också osäker på vad det är vi ska producera. När jag var i Botswana förundrades jag över att de utländska akutläkarspecialisterna tyckte att det var självklart att vi skulle försöka att använda samma metoder som på våra hemsjukhus, i den mån det gick. Vi beställde skiktröntgen enligt samma protokoll man skulle ha använt i Sverige, trots att resurserna där var begränsade. Jag skämdes över hur vi slösade bort landets resurser på dyra undersökningar som hade liten sannolikhet att göra nytta för patienterna, samtidigt som andra patienter dog av sådant vi borde ha kunnat förebygga. Det kan inte vara upp till en individuell doktor att bestämma vad man ska göra på akuten och hur man ska prioritera mellan patientgrupper, utan det måste ske på en högre nivå. Liksom Toyotas bilfabrik inte ensamt kan bestämma att man ska börja producera motorcyklar i sin organisation, kan vi inte låta akutmottagningarna producera primärvård. Ändå gör vi på akuten det, hela tiden. Varför? För att vara snälla mot patienten som skickas hit och dit, för att vi inte har förtroende för primärvården, för att vi inte ser som vårt uppdrag att bestämma vilka patienter som ska utredas på akuten.
De fabriker som började med lean, eller theory of constraints som The goal handlar om, hade definierade processer. Ett visst antal komponenter skulle köpas in, levereras, bearbetas, monteras och skeppas iväg. Det fanns redan ett kvalitetssäkringsmoment i processen. Alla visste vad slutprodukten skulle vara och vad som kännetecknade en produkt av god kvalitet. Den aspekten har inte alls berörts i de lean-projekt jag drabbats av. I The goal gör författaren klart att ett serviceföretag har mycket mer komplicerade processer än ett produktionsföretag och att man först måste definiera dessa. Det arbetet är mycket mer invecklat än att hitta flaskhalsar eller onödig väntetid, men det är en förutsättning för att övrigt förbättringsarbete ska lyckas. När jag frågar sköterskor och läkare på akuten om mål eller kvalitet, gör de inte ens någon skillnad på dessa utan svarar att båda är att patienten lämnar akuten inom fyra timmar. De tycker att det är det enda budskapet de fått av ledningen. Eftersom ingen av dem förstås håller med om den definitionen, har de inget större intresse av att genomföra vad förbättringsgruppen föreslår. De fragment som ändå drivs igenom gör mer skada än nytta och förtroendet för förbättringsarbetet körs i botten.
För mig är det uppenbart vad som gått snett. Ledningen för akuten har inte lyckats formulera ett mål för verksamheten. Man har inte definierat vilken vård som ska produceras, utan detta löses på dagsbasis i verksamheten med enorm variation som följd. Eftersom vi saknar en definition av god kvalitet och validerade kvalitetsindikatorer för att mäta kvaliteten på vår produkt, kan vi varken definiera problem, analysera dem eller utvärdera om de förändringar vi gör löser problemen. Självklart finns det inga förutsättningar för framgång. Det enda som är obegripligt för mig är hur de konsulter man tagit in inte förstått problemet, utan stenhårt fokuserat på att de har lösningen. Ett bra förbättringsarbete är roligt och väcker entusiasm hos de som är med och utvecklar sin verksamhet. När lean uppfattas som mean, är det fel på det sätt man bedriver förbättringsarbetet. Då måste man gå tillbaka och fundera var det gick snett.