Adam Gopnik, writing of the “Le Petit Prince,” discusses Antoine de Saint-Exupéry’s moral of struggling against abstraction in the context of the fall and occupation of France in World War 2.
“The French tradition that moved, and still moves, pragmatic questions about specific instances into a parallel paper universe in which the general theoretical question—the model—is what matters most had failed its makers. Certainly, one way of responding to the disaster was to search out some new set of abstractions, of overarching categories to replace those lost. But a more humane response was to engage in a ceaseless battle against all those abstractions that keep us from life as it is.”
This discussion has felt particularly relevant recently as I’ve been thinking and working on practice transformation and improvement, as part of the Duke Primary Care Transformation Fellowship. There is a continual tension between creating, organizing, and processing concepts about the way we think things work in a practice and the evidence we are confronted with when examined objectively. Frequently, when utilizing tools that allow abstraction of various clinical functions—process mapping, diagramming, workflows— my team will come upon questions to which none of us know the answer. Usually this involves a part of the clinic we don’t work in or engage with on a person-to-person level. For example, how does a call center staff person decide what information to solicit when a patient calls with a clinical request? How do they decide if, when, and whom to message and with what urgency?
Moving from abstraction to “life as it is” is important lest systemic changes be enacted without a clear understanding what system we are changing. In my experience, there are two helpful tools in navigating this, and they, like all good ideas, are simple. The first is to “go and see.” Just go and see what is happening. Visit the areas that are lynchpins in your process maps. Give faces and names to the spokes on your fishbone diagram. This allows an appreciation for the work that has been done from a policy standpoint, from a training standpoint, and from an execution standpoint. It breaks down the biases and assumptions of abstracting the clinical system. Secondly, playbooks can be very helpful in creating a step-by-step guide to how work is done. This cuts the other way, allowing individuals to experience the concept of standard work and apply it with granularity to their work. Creating specific playbooks, say for how to manage a refill request through the call center, also makes the authors engage with each individual process within the standard work, providing more opportunities to “go and see.”
The challenge and joy of working in medicine is that it is an applied science, a craft, and an art all rolled together. We are constantly moving between abstraction and application, empiricism and intuition. Yet the success of clinical transformation depends upon seeing “life as it is” and utilizing approaches that allow us to ground interventions in the best accounting of reality that we can grasp. After all, as Gopnik notes, and I think The Little Prince would agree- “You can’t love roses. You can only love a rose.”
Joshua Lancaster is a fellow with the Primary Care Transformation Fellowship Program. Email joshua.lancaster@duke.edu with questions.
Editor’s note: Blogs represent the opinion of the author, not the Department of Family Medicine and Community Health, or Duke University.