Conversation with Simon Dodds

@SDawlatly What is the purpose of showing a patient that you have listened? What is the intended outcome? We rarely ask this question.


8 thoughts on “Conversation with Simon Dodds

  1. Hi Samir – good idea to use a wider bandwith channel than Twitter. The essence of “purpose” is two-fold. Achieving the intended outcome(s) and avoiding the unintended outcome(s). In healthcare we frame the latter as “primum non nocere” – first do no harm. We have a fear of unintended outcomes and that fear often dominates our decision making. This fear has a cost. A frightening cost. First we engage in OCD-like behaviour called “check-and-correct”, and second we engage in “back-covering bureaucracy” which is an attempt at a defense from later criticism. We are saying “we only did what we are told so if it didn’t work then go talk to those who told use to do it” or “look the evidence shows we did our best … so it is not out fault”. Unfortunately these two behaviours amount to little more than “scraping the burned toast” and in so doing we commit a bigger sin. An error of omission. We omit to consider how we could create a system that does not deliver avoidable harm. This is particularly prevalent thinking amongst healthcare professionals who are not aware that it is possible to design systems to be effective (achieve intended outcome), safe (avoid the unintended outcome) and efficient (using just enough resource). It comes as a BIG shock for many to learn that this is possible – and that they were never offered the opportunity to learn how. Then they get sad when they realise how much time and effort (and money) has been wasted; and angry when they learn that no-one else knows how to teach them. Righteous indignation about sums it up. Then they sink into depression because they are caught between blissful ignorance and know-how: the zone called painful awareness. That is where FISH comes in. It is the first step on a path to know-how that I call Improvement Science. I know it is possible and I know how to do it because I have done it enough times. I am now learning how to show others how to learn it. And the first question that is asked in an improvement-by-design exercise is “What is the purpose that this design will deliver?” And that is a toughie because we are 100% focused on solving problems. The burned toast. What we are not asking is “How do we design and build a toaster that we can trust to make great toast – on time, first time and every time.” That is a design assignment. That is what I show those who want to learn how to do it. Those who do not want to learn (for whatever reason) I cannot help.


    • A lot to take in. bear with me. But a couple more questions. I have doubts that the same approach can be adopted to primary care with the miasma of undifferentiated burnt toast brought by patients. I don’t believe there is a panacea – are my fears well founded?

      The system I work in is clearly flawed, dye to the influence of measuring outcomes and values in order to get paid. What merit in trying to change, say qof?

      on a personal level I will try to explain my approach a bit later in the context of the kind of problems that my patients present with and cogitate on the above as well.

      You can share any of this to twitter if you so wish, by the way…


  2. Patients present with problems to be solved. Undifferentiated as you say. The purpose of the primary care step is to have sorted patients into those that primary care can solve and those that it refers on to solve (NB. I do not mean “cure” by the term “solve”). If the design of the process by which that triage-and-treat is done is flawed then extra work is generated (as outlined above). The combination of the required work and the extra work overburdens the available resources (i.e. GPs) and the natural reaction is (a) ration or restrict access or (b) add more GP capacity (and cost) = “cost of scraping the burned toast”. The unnatural reaction is to redesign the triage-and-treat process to reduce or remove the design flaws that generate the extra work. And we do not do that because (a) we do not know it is possible and (b) we are not trained how to do it of we did. So the GPs get slowly roasted too. Is that how it feels? Payment-by-Results is actually Payment-by-Activity and the tariff price includes the cost of the OK toast and the cost of scraping the not OK toast: so paradoxically there is a perverse financial incentive to burn and scrape more toast! It is very poor design. QoF is similar in design I believe. To test that hypothesis what would happen if patients monitored their own chronic conditions like BP and only contacted their GP if they had a problem? How would that affect QoF? Would the NHS pay the GP when the patient is doing all the “work”?


  3. Apologies Simon for the late reply – busy weekend with the family. I trust you have ticked the box to noftify you of a response?

    I think, that I agree with a great deal of what you say – and it is easier to do with the benefit of more than 140 characters. Although I am not yet up to speed with all of your IS terminolgy, I find your analogies particularly helpful. I still, however, have my doubts over how well IS can be applied to General Practice, due what it has become – slow roasted, so to speak.

    Let me give you some examples and try to apply the toast analogy and you can tell me if I am getting the hand of it?

    1. A patient comes to see me because her Dad dies. She wants a sick note. It transpires that her Dad abused her when she was a child and so she is suffering a lot of emotional torment as a result.
    burnt toast = needs sick note, was abused
    Scraping done be me = gives sick note, refer to rape and sexual violence project
    why toast was burnt = paedophilic dad, only GP’s can give sick notes
    Better toaster = pick up abuse earlier or prevent child abuse? Some other agency created to give out sick notes?

    2. Patient on hypertensives comes with a cough, I note that we’ve not measured BP in over a year – he tells me he’s been unemployed 3 years, barely covering mortgage with benefits, goes 3 or 4 days each week withoubut food, lives on less than £20 a week and so the last thing he’s worried about is his blood pressure
    burnt toast = unemployed and depressed as a result, self-neglect
    Scraping = empathy, find foodbank for him
    why toast was burnt = ill health (3x MI – whilst working abroad) coinciding with economic downturn
    Better toaster = job creation, better public health (but how to reach es-pats in Iraq?)

    3. Asked to write a report on patient for ATOS/Capita as she has been off sick with anxiety and depression for more than 17 weeks
    burnt toast = lack of effective treatment or is it gatekeeper of GP for eligibility of benefits
    Scraping – notes review, form filled
    Why toast burnt = previous abusive relationships, the welfare state
    Better toaster = prevent domestic violence, reform the welfare state?

    I think the IS model can be applied well to certain things, but I’m not sure that all the psychoscial existential stuff that comes our way will be fixed by it unless communities where people have someone other than there GP to turn to can be created.

    I tend to be pretty good at scraping toast and pointing out the limitations of what trying to treat non-medical issues, but it would be nice to have some nice well toasted bread on which to spread my prescription/referral butter.

    Please correct me if I have got the wrong end of the stick


  4. You have the right end of the stick. What you have described is burned toast. The concept that is useful here is the Circles of Control, Influence and Concern. World Peace is a laudable goal – it is boiling the ocean though. Eating the Elephant is done a mouthful at a time. Start inside your circle of control and spread the word. If enough people do only that then the ocean of emotional pain will get a bit shallower.


    • So therein lies part of the problem. As a new GP partner, still in his probationary period, I perceive my Circles of Control and Influence to be woefully small in comparison to that of my Concern – at the moment, anyway. That leads to frustration and perhaps turns my attention towards developing better toast-scraping techniques.

      And what happens to my patients that drives them to seek help from me will never be under my control or influence will it? Am I condemned to a life of frustration?


  5. Read this and thought you’d like it…

    We saw in Chapter 1 how from 1922 to 1940 about 3,000 children a year continued to die from diphtheria although it was preventable by immunization, because the main thrust of medical effort was directed at individually presented symptoms; early diagnosis by throat swabs, treat­ment with antitoxin, admission to diphtheria wards of hospitals, and emergency tracheostomy. By a few heroic cures, the profession distracted its own and the public’s attention from failure to prevent by simpler, less costly and far more effective means. At the same time it claimed immunization as an exclusively medical procedure. Not for the last time, doctors claimed territory they were unable or unwilling to occupy.


  6. The example you give is a good one – a paradigm shift – as described by Thomas Kuhn 20 years later. Our circles of control are bigger than we often perceive. Particularly if we favour the Victim role. Victims discount is that they do not believe they can solve problems that in reality they are quite capable of solving, See the blog entry on the Victim Vortex at We all have a choice. Play the games or not.


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