Black Box Thinking

Matthew Syed wrote a wonderful book in 2015 called Black Box Thinking. Now I’m not going to attempt to recreate all of the key themes and learning points from that book – he’s a double Olympian and best-selling author with a column in The Times. I’m a dude in the suburbs with a laptop and an English GCSE. But like many of these books the key message is right there at the start.

Syed’s point is that the key to developing excellence, whether individual or systemic, is establishing a feedback loop between your actions and the outcomes as well as process by which you can, critically, learn from your mistakes. In that first chapter the example given of excellence in this area is the aviation industry with their in-flight black boxes, no blame culture and detailed post-accident investigations. This feedback loop and desire to learn rather than blame or make excuses is why flying has become so safe. But Syed also gives a contrary example – a system that should have similar motivation (saving lives) and capability (highly educated staff & lots of data) – but where the culture and egos mean learning is much slower. The medical profession.

OK, so this really is where I stop trying to summarize his book. And, more importantly for your attention span, get to the point of how this relates to me. I had a rocky week with my care team and for the avoidance of doubt – they fucked up. More than once. In an unacceptable way. Let’s do a little bullet point summary:

  • Week 1: sent me a letter booking my oncology call for 0900 on the Wednesday. No call by 1145. I call my CNS and she says she can see my papers are in the stack and i’ll be called by 1300. I wait. At 1430 i call back. different CNS. HHHHmmmm this shouldn’t have happened – I’ll call the doctor he’ll call you right away. No call the rest of the day.
  • Later in Week 1: CNS calls me. says she is confused. she doesn’t understand but from what she can see I’ve been transferred onto the palliative care pathway and this must mean my cancer has spread. She adds that my request to be transferred to community care for my pain management has been approved. I had what it’s fair to say was a sense of humor failure. But luckily I knew enough about how this process works and haven’t had any scans since my initial staging work. So i told the CNS she must’ve been mistaken. She insisted she wasn’t and that she was looking at the paperwork. I explained that what she was going to do was hang up, get her shit together and call me back. She agreed that was a good plan and said a doctor would call me back. To her credit she called back 30 mins later, explained there had been a mix up at her end due to the funding source for my treatment and confirmed that there was no change in my care or diagnosis. Again, to her credit, she apologized and said the mistake was hers.
  • Week 2: sent a letter booking my oncology call for 1015 on the Wednesday. nothing by 1130. same as last week. call the nurse….your papers are next in the pile…the doctor will call within 15 mins. 90 mins later a call comes through. No hello or introduction, asks for Mr Smith…i say that’s not me…doctor tells me it is me (bullish move to tell me who i am – gotta respect his confidence) and that we spoke earlier that morning. I say no and ask the caller’s name and what the complaint procedures are. They hang up.
  • Doctor calls back 15mins later. It’s clearly the same guy. Tries to pretend it wasn’t him. We wade through that. I ask what is going on with my oncology calls. Doctor tells me we spoke last week. I says we didn’t on account of that not having happened. we go round in circles. I ask him what happened with the previous call and he says he was looking at my number when he was trying to contact the patient before me and that he didn’t hang up but got cut off. I ask about the CNS call telling me i was being moved onto the palliative pathway. He gives a viable explanation for this but one entirely different from the explanation given by the nurse. I ask how all these screw ups have happened and he says they won’t happen again.

Now all of that is bad. very bad. If this were a paid for service with alternative providers i don’t think you’d go back. And there is a certain concern that comes from knowing that the people responsible for making sure the drugs going into you are effective and safe can’t, in the very best interpretation of events, remember names, times and numbers. But what makes it worse is that at no point did any of the staff identify clearly what had allowed these mistakes to happen or how they might be prevented from happening again. All i heard was egos and apologies. That is how you repeat mistakes until something very bad happens. Let’s re-imagine the the call from the CNS but now i’m 40 years older and English isn’t my first language – how might that call have impacted me? Or let’s imagine it goes the other way and their penchant for mixing up numbers results in somebody with a much worse diagnosis and outlook than me getting a call to tell them my good news. imagine the impact of that.

It was a bad week for learning culture and black box thinking.

But it was an ok week for me. Bloods all good. Cycle 3 kicked off without the need for on the day bloods. And now, ten days later I’m almost at the halfway mark of chemo.

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