Professional Identity: Who am I? And who are you?

Last night I acted as a mentor at the annual Career Exploration Expo sponsored by my graduate program. Many of the students had questions about developing a professional identity. This makes sense, of course, because graduate school is an important time for discovering and developing a professional identity.

People enter our program (and many others) With a wide variety of backgrounds and interests. They choose from a variety of classes that fit their interests and goals. And then they try to map their experience onto job categories. But boxes are difficult to climb into and out of, and students soon discover that none of the boxes is a perfect fit.

I experienced this myself. I entered the program with an extensive and unquestioned background in survey research. Early in my college years (while I was studying and working in neuropsychology) I began to manage a clinical dataset in SPSS. Working with patients and patient files was very interesting, but to my surprise working with data using statistical software felt right to me much in the way that Ethiopian meals include injera and Japanese meals include rice (IC 2006 (1997) Ohnuki Tierney Emiko). I was actually teased by my friends about my love of data! This affinity served me well, and I enjoyed working with a variety of data sets while moving across fields and statistical programming languages.

But my graduate program blew my mind. I felt like I had spent my life underwater and then discovered the sky and continents. I discovered many new kinds of data and analytic strategies, all of which were challenging and rewarding. These discoveries inspired me to start this blog and have inspired me to attend a wide variety of events and read some very interesting work that I never would have discovered on my own. Hopefully followers of this blog have enjoyed this journey as much as I have!

As a recent graduate, I sometimes feel torn between worlds. I still work as a survey researcher, but I’m inspired by research methods that are beyond the scope of my regular work. Another recent graduate of our program who is involved in market research framed her strategy in a way that really resonated with me: “I give my customers what they want and something else, and they grow to appreciate the ‘something else.’” That sums up my current strategy. I do the survey management and analysis that is expected of me in a timely, high quality way. But I am also using my newly acquired knowledge to incorporate text analysis into our data cleaning process in order to streamline it, increasing both the speed and the quality of the process and making it better equipped to handle the data from future surveys. I do the traditional quantitative analyses, but I supplement them  with analyses of the open ended responses that use more flexible text analytic strategies. These analyses spark more quantitative analyses and make for much better (richer, more readable and more inspired) reports.

Our goal as professionals should be to find a professional identity that best capitalizes on  our unique knowledge, skills and abilities. There is only one professional identity that does all of that, and it is the one you have already chosen and continue to choose every day. We are faced with countless choices about what classes to take, what to read, what to attend, what to become involved in, and what to prioritize, and we make countless assessments about each. Was it worthwhile? Did I enjoy it? Would I do it again? Each of these choices constitutes your own unique professional self, a self which you are continually manufacturing. You are composed of your past, your present, and your future, and your future will undoubtedly be a continuation of your past and present. The best career coach you have is inside of you.

Now your professional identity is much more uniquely or narrowly focused that the generic titles and fields that you see in the professional marketplace. Keep in mind that each job listing that you see represents a set of needs that a particular organization has. Is this a set of needs that you are ready to fill? Is this a set of needs that you would like to fill? You are the only one who knows the answers to these questions.

Because it turns out that you are your best career coach, and you have been all along.

In praise of getting things wrong and working toward better

“An expert is a man who has made all the mistakes which can be made in a very narrow field” -Niels Bohr

I’ve been reading “In the Plex,” a book about the history of Google by Steven Levy. I highly recommend this book, because as I read it I am increasingly aware of the ways in which Google’s constant presence invisibly shapes our daily lives. Levy makes a point in the book of attributing some of Google’s constant evolution to its obsession with failure. In search terms, isolating failures is relatively easy- if people soon return to the search page, reframe their query, or continue down through lower ranked results their search was a relative failure. Failures are identified and isolated by Google and then obsessed over until the PageRank algorithm can be appropriately tweaked in a way that passes rigorous testing protocols.

In this way, Google is similar to an increasing number of failure- focused initiatives, including some of the engineering based models that have been applied to healthcare and more. These voices are increasingly the source of innovations that are continually shaping and reshaping our future. But the rhetoric of failure and success of its evangelizers can be hard for us to wrap our heads around, as people who naturally fear, avoid and focus on failure in a negative way.

Over the weekend, while I was practicing Yoga I told one of my kids my favorite part of the practice (note: not a good time for chatting). I love that Yoga is a process. One day you will be able to do something that you may or may not be able to do the next day, and vice versa. My practice involves quite a bit of balancing on one foot, and there are days when that balance feels effortless and days when that balance feels impossible. But the effortless days only come because I continue to practice despite the disappointments of my wobblier days. Yoga instructors sometimes talk about the power of intentions and working in ways that align with our intentions. One of my kids pointed out that the wobbly days, as I call them, are exactly the reason why she hates Yoga. She’s believes that she’s no good at it, and because of her assessment she will avoid it. You can probably guess that this conversation is far from over between us.

We see attitudes like these affecting people (including ourselves) every day. Some people theorize that the lower representation of women in STEM (Science, Technology, Engineering and Math) fields is due to a larger proportion of women than men who doubt their abilities or judge their abilities more harshly. We hear about graduate students who experience what is sometimes called the ‘imposter syndrome.’ I remember some students in my graduate classes who chose not to participate in class for fear they would sound stupid. I’ve heard of medical practitioners who were so worried that they would make another mistake that they were afraid to practice. As a writer, I know that the power of self doubt can cause writers block, but I also know how much easier it is to edit or rewrite.

I would encourage all of you to embrace your failures, your mistakes, your shortcomings, your missteps and your errors and see them as part of a process and not an endpoint. These stumbling points are the key points of growth- the key moments for us to learn and to redirect our actions to better suit our intentions. To err is human, but to learn from our missteps is surely something greater.

Great description of a census at Kakuma refugee camp

It’s always fun for a professional survey researcher to stumble upon a great pop cultural reference to a survey. Yesterday I heard a great description of a census taken at Kakuma refugee camp in Kenya. The description was in the book I’m currently reading: What Is the What by Dave Eggers (great book, I highly recommend it!). The book itself is fiction, loosely based on a true story, so this account likely stems from a combination of observation and imagination. The account reminds me of some of the field reports and ethnographic findings in other intercultural survey efforts, both national (US census) and inter or multinational.

To set the stage, Achak is the main character and narrator of the story. He is one of the “lost boys” of Sudan, and he found his way to Kakuma after a long and storied escape from his war-ravaged hometown. At Kakuma he was taken in by another Denka man, named Gop, who is acting as a kind of father to Achak.

What is the What by Dave Eggers

What is the What by Dave Eggers

“The announcement of the census was made while Gop was waiting for the coming of his wife and daughters, and this complicated his peace of mind. To serve us, to feed us, the UNHCR and Kakuma’s many aid groups needed to know how many refugees were at the camp. Thus, in 1994 they announced they would count us. It would only take a few days, they said. To the organizers I am sure it seemed a very simple, necessary, and uncontroversial directive. But for the Sudanese elders, it was anything but.

—What do you think they have planned? Gop Chol wondered aloud.

I didn’t know what he meant by this, but soon I understood what had him, and the majority of Sudanese elders, greatly concerned. Some learned elders were reminded of the colonial era, when Africans were made to bear badges of identification on their necks.

—Could this counting be a pretext of a new colonial period? Gop mused.—It’s very possible.
Probable even!

I said nothing.

At the same time, there were practical, less symbolic, reasons to oppose the census, including the fact that many elders imagined that it would decrease, not increase, our rations. If they discovered there were fewer of us than had been assumed, the food donations from the rest of the world would drop. The more pressing and widespread fear among young and old at Kakuma was that the census would be a way for the UN to kill us all. These fears were only exacerbated when the fences were erected.

The UN workers had begun to assemble barriers, six feet tall and arranged like hallways. The fences would ensure that we would walk single file on our way to be counted, and thus counted only once. Even those among us, the younger Sudanese primarily, who were not so worried until then, became gravely concerned when the fences went up. It was a malevolent-looking thing, that maze of fencing, orange and opaque. Soon even the best educated among us bought into the suspicion that this was a plan to eliminate the Dinka. Most of the Sudanese my age had learned of the Holocaust, and were convinced that this was a plan much like that used to eliminate the Jews in Germany and Poland. I was dubious of the growing paranoia, but Gop was a believer. As rational a man as he was, he had a long memory for injustices visited upon the people of Sudan.

—What isn’t possible, boy? he demanded.—See where we are? You tell me what isn’t possible at this time in Africa!

But I had no reason to distrust the UN. They had been feeding us at Kakuma for years. There was not enough food, but they were the ones providing for everyone, and thus it seemed nonsensical that they would kill us after all this time.

—Yes, he reasoned,—but see, perhaps now the food has run out. The food is gone, there’s no more money, and Khartoum has paid the UN to kill us. So the UN gets two things: they get to save food, and they are paid to get rid of us.

—But how will they get away with it?

—That’s easy, Achak. They say that we caught a disease only the Dinka can get. There are always illnesses unique to certain people, and this is what will happen. They’ll say there was a Dinka plague, and that all the Sudanese are dead. This is how they’ll justify killing every last one of us.
—That’s impossible, I said.

—Is it? he asked.—Was Rwanda impossible?

I still thought that Gop’s theory was unreliable, but I also knew that I should not forget that there were a great number of people who would be happy if the Dinka were dead. So for a few days, I did not make up my mind about the head count. Meanwhile, public sentiment was solidifying against our participation, especially when it was revealed that the fingers of all those counted, after being counted, would be dipped in ink.

—Why the ink? Gop asked. I didn’t know.

—The ink is a fail-safe measure to ensure the Sudanese will be exterminated.

I said nothing, and he elaborated. Surely if the UN did not kill us Dinka while in the lines, he theorized, they would kill us with this ink on the fingers. How could the ink be removed? It would, he thought, enter our bodies when we ate.

—This seems very much like what they did to the Jews, Gop said.

People spoke a lot about the Jews in those days, which was odd, considering that a short time before, most of the boys I knew thought the Jews were an extinct race. Before we learned about the Holocaust in school, in church we had been taught rather crudely that the Jews had aided in the killing of Jesus Christ. In those teachings, it was never intimated that the Jews were a people still inhabiting the earth. We thought of them as mythological creatures who did not exist outside the stories of the Bible. The night before the census, the entire series of fences, almost a mile long, was torn down. No one took responsibility, but many were quietly satisfied.

In the end, after countless meetings with the Kenyan leadership at the camp, the Sudanese elders were convinced that the head count was legitimate and was needed to provide better services to the refugees. The fences were rebuilt, and the census was conducted a few weeks later. But in a way, those who feared the census were correct, in that nothing very good came from it. After the count, there was less food, fewer services, even the departure of a few smaller programs. When they were done counting, the population of Kakuma had decreased by eight thousand people in one day.

How had the UNHCR miscounted our numbers before the census? The answer is called recycling.

Recycling was popular at Kakuma and is favored at most refugee camps, and any refugee anywhere in the world is familiar with the concept, even if they have a different name for it. The essence of the idea is that one can leave the camp and re-enter as a different person, thus keeping his first ration card and getting another when he enters again under a new name. This means that the recycler can eat twice as much as he did before, or, if he chooses to trade the extra rations, he can buy or otherwise obtain anything else he needs and is not being given by the UN—sugar, meat, vegetables. The trading resulting from extra ration cards provided the basis for a vast secondary economy at Kakuma, and kept thousands of refugees from anemia and related illnesses. At any given time, the administrators of Kakuma thought they were feeding eight thousand more people than they actually were. No one felt guilty about this small numerical deception.

The ration-card economy made commerce possible, and the ability of different groups to manipulate and thrive within the system led soon enough to a sort of social hierarchy at Kakuma.”

Reflections and Notes from the Sentiment Analysis Symposium #SAS14

The Sentiment Analysis Symposium took place in NY this week in the beautiful offices of the New York Academy of Sciences. The Symposium was framed as a transition into a new era of sentiment analysis, an era of human analytics or humetrics.

The view from the New York Academy of Sciences is really stunning!

The view from the New York Academy of Sciences is really stunning!

Two main points that struck me during the event. One is that context is extremely important for developing high quality analytics, but the actual shape that “context” takes varies greatly. The second is a seeming disconnect between the product developers, who are eagerly developing new and better measures, and the customers, who want better usability, more customer support, more customized metrics that fit their preexisting analytic frameworks and a better understanding of why social media analysis is worth their time, effort and money.

Below is a summary of some of the key points. My detailed notes from each of the speakers, can be viewed here. I attended both the more technical Technology and Innovation Session and the Symposium itself.

Context is in. But what is context?

The big takeaway from the Technology and Innovation session, which was then carried into the second day of the Sentiment Analysis Symposium was that context is important. But context was defined in a number of different ways.

 

New measures are coming, and old measures are improving.

The innovative new strategies presented at the Symposium made for really amazing presentations. New measures include voice intonation, facial expressions via remote video connections, measures of galvanic skin response, self tagged sentiment data from social media sharing sites, a variety of measures from people who have embraced the “quantified self” movement, metadata from cellphone connections (including location, etc.), behavioral patterning on the individual and group level, and quite a bit of network analysis. Some speakers showcased systems that involved a variety of linked data or highly visual analytic components. Each of these measures increase the accuracy of preexisting measures and complicate their implementation, bringing new sets of challenges to the industry.

Here is a networked representation of the emotion transition dynamics of 'Hopeful'

Here is a networked representation of the emotion transition dynamics of ‘Hopeful’

This software package is calculating emotional reactions to a Youtube video that is both funny and mean

This software package is calculating emotional reactions to a Youtube video that is both funny and mean

Meanwhile, traditional text-based sentiment analyses are also improving. Both the quality of machine learning algorithms and the quality of rule based systems are improving quickly. New strategies include looking at text data pragmatically (e.g. What are common linguistics patterns in specific goal directed behavior strategies?), gaining domain level specificity, adding steps for genre detection to increase accuracy and looking across languages. New analytic strategies are integrated into algorithms and complementary suites of algorithms are implemented as ensembles. Multilingual analysis is a particular challenge to ML techniques, but can be achieved with a high degree of accuracy using rule based techniques. The attendees appeared to agree that rule based systems are much more accurate that machine learning algorithms, but the time and expertise involved has caused them to come out of vogue.

 

“The industry as a whole needs to grow up”

I suspect that Chris Boudreaux of Accenture shocked the room when he said “the industry as a whole really needs to grow up.” Speaking off the cuff, without his slides after a mishap and adventure, Boudreaux gave the customer point of view toward social media analytics. He said said that social media analysis needs to be more reliable, accessible, actionable and dependable. Companies need to move past the startup phase to a new phase of accountability. Tools need to integrate into preexisting analytic structures and metrics, to be accessible to customers who are not experts, and to come better supported.

Boudreaux spoke of the need for social media companies to better understand their customers. Instead of marketing tools to their wider base of potential customers, the tools seem to be developed and marketed solely to market researchers. This has led to a more rapid adoption among the market research community and a general skepticism or ambivalence across other industries, who don’t see how using these tools would benefit them.

The companies who truly value and want to expand their customer base will focus on the usability of their dashboards. This is an area ripe for a growing legion of usability experts and usability testing. These dashboards cannot restrict API access and understanding to data scientist experts. They will develop, market and support these dashboards through productive partnerships with their customers, generating measures that are specifically relevant to them and personalized dashboards that fit into preexisting metrics and are easy for the customers to understand and react to in a very practical and personalized sense.

Some companies have already started to work with their customers in more productive ways. Crimson Hexagon, for example, employs people who specialize in using their dashboard. These employees work with customers to better understand and support their use of the platform and run studies of their own using the platform, becoming an internal element in the quality feedback loop.

 

Less Traditional fields for Social Media Analysis:

There was a wide spread of fields represented at the Symposium. I spoke with someone involved in text analysis for legal reasons, including jury analyses. I saw an NYPD name tag. Financial services were well represented. Publishing houses were present. Some health related organizations were present, including neuroscience specialists, medical practitioners interested in predicting early symptoms of diseases like Alzheimer’s, medical specialists interested in helping improve the lives of people with diseases like Autism (e.g. with facial emotion recognition devices), pharmaceutical companies interested in understanding medical literature on a massive scale as well as patient conversation about prescriptions and participation in medical trials. There were traditional market research firms, and many new startups with a wide variety of focuses and functions. There were also established technology companies (e.g. IBM and Dell) with innovation wings and many academic departments. I’m sure I’ve missed many of the entities present or following remotely.

The better research providers can understand the potential breadth of applications  of their research, the more they can improve the specific areas of interest to these communities.

 

Rethinking the Public Image of Sentiment Analysis:

There was some concern that “social” is beginning to have too much baggage to be an attractive label, causing people to think immediately of top platforms such as Facebook and Twitter and belying the true breadth of the industry. This prompted a movement toward other terms at the symposium, including human analytics, humetrics, and measures of human engagement.

 

Accuracy

Accuracy tops out at about 80%, because that’s the limit of inter-rater reliability in sentiment analysis. Understanding the more difficult data is an important challenge for social media analysts. It is important for there to be honesty with customers and with each other about the areas where automated tagging fails. This particular area was a kind of elephant in the room- always present, but rarely mentioned.

Although an 80% accuracy rate is really fantastic compared to no measure at all, and it is an amazing accomplishment given the financial constraints that analysts encounter, it is not an accuracy rate that works across industries and sectors. It is important to consider the “fitness for use” of an analysis. For some industries, an error is not a big deal. If a company is able to respond to 80% of the tweets directed at them in real-time, they are doing quite well, But when real people or weightier consequences are involved, this kind of error rate is blatantly unacceptable. These are the areas where human involvement in the analysis is absolutely critical. Where, honestly speaking, are algorithms performing fantastically, and where are they falling short? In the areas where they fall short, human experts should be deployed, adding behavioral and linguistic insight to the analysis.

One excellent example of Fitness for Use was the presentation by Capital Market Exchange. This company operationalizes sentiment as expert opinion. They mine a variety of sources for expert opinions about investing, and then format the commonalities in an actionable way, leading to a substantial improvement above market performance for their investors. They are able to gain a great deal of market traction that pure sentiment analysts have not by valuing the preexisting knowledge structures in their industry.

 

Targeting the weaknesses

It is important that the field look carefully at areas where algorithms do and do not work. The areas where they don’t represent whole fields of study, many of which have legions of social media analysts at the ready. This includes less traditional areas of linguistics, such as Sociolinguistics, Conversation Analysis (e.g. looking at expected pair parts) and Discourse Analysis (e.g. understanding identity construction), as well as Ethnography (with fast growing subfields, such as Netnography), Psychology and Behavioral Economics. Time to think strategically to better understand the data from new perspectives. Time to more seriously evaluate and invest in neutral responses.

 

Summing Up

Social media data analysis, large scale text analysis and sentiment analysis have enjoyed a kind of honeymoon period. With so many new and fast growing data sources, a plethora of growing needs and applications, and a competitive and fast growing set of analytic strategies, the field has been growing at an astronomical rate. But this excitement has to be balanced out with the practical needs of the marketplace. It is time for growing technologies to better listen to and accommodate the needs of the customer base. This shift will help ensure the viability of the field and free developers up to embrace the spirit of intellectual creativity.

This is an exciting time for a fast growing field!

Thank you to Seth Grimes for organizing such a great event.

 

Free Range Research will cover the Sentiment Symposium in NYC next week #SAS14

Next week Free Range Research will be in NYC to cover the Sentiment Symposium and Innovation session, and I can’t tell you how excited I am about it!

The development of useful analytics hinges on constant innovation and experimentation, and binary positive/negative measures don’t come close to describing the full potential of social media data. This year’s symposium is an effort to confront the limitations of calcified measures of sentiment head on by introducing new measures and new perspectives.

As a programmer, a quantitative and qualitative analyst, a recent academic, and a fervent believer in the power of the power of mixed methods and interdisciplinary research, I am eager to cover the Symposium as both an enthusiastic and a critical voice. The new directions that will be represented are exciting and interesting, and I expect to gain a better feel for many cutting edges analytic practices. But the proprietary and competitive nature of the social media marketplace has led to countless overblown claims. I do not plan to simply be a conduit for these. My goal will be to share as much as possible of what I learn at the Symposium in a grounded and accessible way, as timely as possible, offering counterpoints and data driven examples when possible, on both my blog and through my Twitter handle @FreeRangeRsrch

I hope you’ll join me!

 

today in research & zen: “What is known as ‘realizing the mystery’ is nothing more than breaking through to grab an ordinary person’s life” Te-Shan

Planning another Online Research, Offline lunch

I’m planning another Online Research, Offline lunch for researchers in the Washington DC area later this month. The specific date and location are TBA, but it will be toward the end of February near Metro Center.

These lunches are designed to welcome professionals and students involved in online research across a variety of disciplines, fields and sectors. Past attendees have had a wide array of interests and specialties, including usability and interface design, data science, natural language processing, social network analysis, social media monitoring, discourse analysis, netnography, digital humanities and library science.

The goal of this series is to provide an informal venue for a diverse set of researchers to talk with each other and gain a wider context for understanding their work. They are an informal and flexible way to researchers to meet each other, talk and learn. Although Washington DC is a great meeting place for specific areas of online research, there are few informal opportunities for interdisciplinary gatherings of professionals and academics.

Here is a form that can be used to add new people to the list. If you’re already on the list you do not need to sign up again. Please feel free to share the form with anyone else who may be interested:

Medical Errors: detecting them, preventing them, and dealing with their aftermath

This is primarily a report on an event, but I’ve added links, stories and examples to my notes.

The event:

Bioethics lecture on Error: https://www.eventbrite.com/e/conversations-in-bioethics-tickets-10276951639

Brief description: “Join distinguished national experts John James, PhD, former chief toxicologist at NASA and founder of Patient Safety America, Brian Goldman, MD, emergency physician-author and host of the CBC’s White Coat, Black Art, Beth Daley Ullem, MBA, nationally-recognized advocate for patient safety and quality and SFS alum, for a lively discussion and Q&A moderated by Maggie Little, Director of the Kennedy Institute of Ethics.”

At the Beautiful Kennedy Institute, Georgetown University

The follow-up:

For those who are particularly interested in this topic, the Kennedy Institute has an upcoming Bioethics MOOC starting 4/15: http://kennedyinstitute.georgetown.edu/about/news/bioethics-mooc-spring-launch.cfm

Why Create this resource?

What follows is a long resource- an in depth summary of the lecture I attended last night, complete with many links to other resources and a few stories and examples. Like the members of this panel, I have experienced a dramatic medical error. In 2012 my mother was on life support after experiencing a period of time with no oxygen to her brain. Her heart had stopped twice, and she was unresponsive. I am her only child, and I had essentially moved into the hospital with her in order to be her advocate. It was my decision whether or not to continue life support, and the main deciding factor was whether or not she was brain dead. She was given an EEG test, and it did not look good. There was a delay before I heard the results of the test, and I spent that delay researching her EEG patterns to try to understand what was going on. The next day the medical staff involved in her case sat me down and told me she was indeed brain dead. It wasn’t until my cousin had announced her passing on Facebook, I was saying my final goodbyes, and my aunt was on the phone with the funeral home that the doctors on the case realized they had miscommunicated. Another patient in another hospital was brain dead, but my mother was not officially brain dead. Her brain activity appeared to be seizure activity, and it wasn’t clear if there was anything else going on. The group apologized, and we were forced to reverse the story and try to explain to friends and family (and ourselves) that she was not actually dead, but she was still very close to it. There was a tide of “Go get em!” cries, which were difficult to deal with when we did indeed have to remove life support a few days later.

After this event, one of the physicians involved in the miscommunication focused my attention on a collaborative project. We began work on a grand rounds presentation for the hospital. We planned to talk about errors in general and, more specifically, what could be learned from this error. I did quite a bit of reading and research. We had some great discussions, and I started to attend a medical discourse group in my graduate linguistics department. At some point I will probably return to the notes from that collaboration and assemble a blog post about them.

It is because of that experience and that project that I assembled the resource below. I sincerely hope that you find it interesting and useful.

Please note that this is based on many pages of notes. Unfortunately my notes did not attribute points to individual panelists. I apologize for that omission.

Prevalence and Detection

An estimated 100,000 lives are lost each year from preventable medical error (according to 1999 landmark Institute Of Medicine report), but this data is old (1984, New York State) and focused on errors of commission. There are many other kinds of errors, including omission, context, diagnostic and communication. Measuring preventable deaths is easier than measuring mistakes overall, but mistakes that do not directly lead to death cause plenty of heartache every day as well.

One more recent attempt to detect medical errors involved isolating common trigger words that accompany medical mistakes in medical files and then having the cases reviewed by medical professionals to see if the deaths were indeed preventable. By this method, the estimate was closer to 210,000 preventable deaths. This method was more comprehensive, but records don’t have the right parameters or standardization to make this process ideal. Some estimates are as high as 440,000 deaths per year.

Regardless of the exact numbers, for physicians, there is a near 100% possibility of making a mistake at some point. This fact alone should change the paradigm from avoiding errors altogether to openly anticipating and working with errors as they happen.

Aftermath

After a medical error occurs, heartache abounds. But contrary to social conventions outside of the medical establishment, contact is often strictly controlled and regulated after the incident, and the physician is rarely able to say “I’m sorry.” This can cause a lack of closure for both the patients and the doctors. The aftermath of one of these errors forms a second layer of trauma for all of those involved.

The first target for any kind of error is often the individual who made the mistake, not the system that enabled the mistakes. The system quickly closes around this individual. The hospital risk administration sets in. Privacy walls are erected, and it becomes very difficult to take responsibility for one’s errors. A perfect storm of system and culture clash together, resulting in ill-advised words and actions on the part of those involved. At such a sensitive time, the words of care providers are often burned into the minds of the deceased patient’s advocates and family members. Blame is often tossed around indiscriminately. The survivors are often left feeling confused. One of the panelists remembers her physician counseling her with “I really don’t know why God needed your baby more than you did.”

The medical providers at this point are isolated from their patients and often prohibited from discussing these incidents with each other. At such a vulnerable moment, they are left to deal with it alone, taking each incident as a private failure when mistakes are a universal human condition. If other providers hear about the incident, they will often exacerbate the problem by not making eye contact, demonstrating their vicarious shame, reinforcing the problem as a repudiation of all a doctor is supposed to be.

System level Problems

The medical system is large and complicated enough to really enable errors. There are so many medical professionals, patients, laypeople and touchpoints, and the body itself is quite a complicated system- some of which is better understood and some of which is still largely undocumented territory. The medical system is evolving fast from the mom and pop doctors of the past to the large complexes of today. The modern medical system has its hand in businesses that no one would have imagined before. Some hospitals boast dental facilities, nursing homes, outpatient clinics, and even foster care facilities. The changing rules for insurance payments and the increasing role of legal actors also have a significant influence on the system.

In order for hospitals to make money, many end up adjusting the patient care ratios. Some stretch these ratios to the breaking point, putting medical staff in a position where they can barely keep up. The pressure for productivity is much higher now than it was in the recent past. Many facilities are over capacity, and space is at a premium. This can put medical staff in an awkward position where there are constant workarounds and makeshift solutions. These kinds of problems can lead to  errors of context. The same patient may be treated differently in the ambulatory care area of the same wing than in the rapid assessment area. In the words of one panelist “geography is destiny in the E.R.” Movement in space within a medical facility is both physical and cognitive.

Scheduling is also a huge issue in medical facilities. Long stretches of work without sleep are a better known precursor to many medical errors.

Technology

Technology is integral to the modern medical system and has saved many lives. But technology training and interface design are extremely important. One panelist reported that a medical professional confessed to him years after his son’s preventable death that the MRI machine was new, and no one onhand knew how to use it properly. Others have reported on the influence of signal fatigue- it is very hard amidst a constant stream of signals to ferret out the most important among them.

Technology was a real point of frustration for me when I had my first child. I was induced in the evening and felt increasingly strong contractions all night. When the nurses came to check on me, I reported that I was in labor, but the pattern on the monitor was not consistent with what they would call labor. Once I started to push I called them back and requested an exam, and fortunately, although my doctor and the doctor on call were not available, they were qualified to catch the baby.

Medical culture

One of the panelists told the story of a physician who began his shift by calling together his team, warning them that he did not get much of a night’s sleep the night before, and asking them to watch his back a bit more closely than usual. This runs starkly contrary to typical medical enculturation. Medical culture makes it harder to admit mistakes or to be human. One panelist commented “We’re very defensive about our mistakes.” This is emblematic  of a culture that can’t handle its own humanity. This repulsion by error is compounded by a system that doesn’t comment but rather expects good performance. The “no news is good news” ethic means that a physician can go his or her entire career without ever hearing any feedback, and that can be a good thing.

In medicine, the smartest person in the room is quickly the person in charge. One of the panelists, Brian “didn’t want to be a high-maintenance student” as a resident by asking too many questions or requesting help too often. This attitude wound up fatal for one of his patients. Errors are a reminder of human fallibility, and medical professionals are supposed to be infallible. Brian talked more about this in a TED talk. In it, he spoke of batting averages. We assume that error is a natural part of other jobs, but what is an acceptable batting average for a surgeon? A mistake can mean that one was lazy or incompetent or had a lapse. Which one does the physician want to admit to? None! Instead, they often live in terror when one mistake happens that another will soon follow. One panelist said the words he most fears as a medical professional are “Do you remember?”

Instead of the culture of shame and blame, we could benefit from being scientific about error: exhibiting genuine curiosity about errors, measuring them, and developing and testing treatments for them. One panel member mentioned a surgeon who developed a kind of flight data recorder for surgery: http://www.icee-con.org/papers/2008/pdf/O-100.pdf . Apparently this surgeon has been dubbed “the most dangerous man in surgery.”

Isolation and selective training

People are trained in the context of the settings where they have worked. Different settings see different kinds of challenges. Shouldn’t there be a better system for sharing challenges and solutions across institutions?

Handwriting

It is pretty incredible that such a high stakes field rests on human handwriting. This is made worse by the lack of value placed on making handwriting legible and on the decreasing abilities of a technologically savvy population to decipher human handwriting. How many of you can read cursive?

Science or Art?

One interesting aspect of medicine is the way it is a field composed of scientists who view themselves as artists. This is evident in the total lack of standardization in medical care. You will have a different experience, even with the same condition, across locations and providers. Even within a single hospital individual doctors act as subcontractors, providing individualized service as only they can, despite the common environment. Sometimes there are standards or guidelines set for specific areas of medicine with a goal of instituting consistency. But the adaptation of these standards and attitudes toward these standards are far from universal. The standards take shape differently across locations and providers.

The panel members mentioned the success of VA hospitals in this area. They are better at standardization. Vertically integrated healthcare can be much more progressive.

Areas for improvement

So what kind of changes would improve the system? Some prominent authors liken error models to those in the airplane industry. This is tricky, because medicine is far more complicated that aviation- although both are high stakes fields that require inhuman levels of perfection among human actors. But even if the systems are different, they can still learn from each other.

Atul Gawande is a well known author The Checklist Manifesto. He has been advocating for many of the checklists and safety features that are standard in the aviation industry to be applied to medicine. He also wrote a piece about what medicine can learn from The Cheesecake Factory.

Some suggested areas for improvement include instituting redundancies, collapsing hierarchies and patient centered care.

One panel member was involved with error prevention at more of a business level. She mentioned the power of adding redundancies. Adding redundancies should be common practice and is common practice in other high stakes fields. Redundancies should be worked into routines and checks, although models of modern efficiency seem to be moving away from them. She also mentioned the powerful potential of dashboards and the importance of comparative information. One great example of the power of comparative information is “Solutions for Patient Safety” http://www.solutionsforpatientsafety.org/ . This is a group of 78 pediatric hospitals that share a common dashboard. Using the dashboard the hospitals can see how they stand in terms of infections and other errors compared to the rest of the network. It’s a teaching model- the best teach the rest about the measures they’re using to combat each problem. The panelist mentioned that we buy healthcare products without comparative information, but information on dashboards can really increase accountability.

Collapsing hierarchies would make it more culturally acceptable to report medical errors. This could also be augmented through multidisciplinary peer reviews, involving everyone from providers across medical specialties and training to janitors and other people present at the time of care.

One of the panelists wrote a patient bill of rights. An audience member commented on the need for patients to feel more powerful and have more power in medical situations. He noted that the playing field between doctor and patient is inherently unequal. As soon as you remove your clothes and put on the patient smock you begin to feel powerless. He noted that some medical providers will take advantage of that vulnerability. The foundation of patient centered care is informed consent. If you don’t understand your options, you cannot make an informed choice.

One specific example of an area where patients are unable to make informed decisions was off-label prescriptions. Prescriptions are often prescribed off-label, meaning that the patient is not part of the population base for which the drug was tested. This was the case for me when my first child was born, and I was induced with Cytotec. When she was born, a healthy 8 lb 3 ounce baby aspirated meconium and ended up in the NICU while I was treated for hemorrhage. I knew nothing of the drug or the potential consequences. In fact, I had chosen an unmedicated chidbirth and eschewed interventions altogether.

Another example of an area where patients can’t always make informed decisions is that of cost. There has been quite a bit of buzz lately about the ridiculous hospital bills patients receive upon discharge. I can’t tell you how paranoid I am about any supplies used on myself or my kids in the E.R. having seen some of those bills. A close friend of mine recently had an incident where an inexpensive scheduled dentist appointment turned into over $2000 in charges, due immediately. That incident led to an extensive series of phonecalls between myself and the dental office, debating consent.

An audience member spoke about the importance of patient advocates.  Apparently there is a growing business of professional patient advocates. I think that this is wonderful, because historically the only qualification necessary for a patient advocate was that they not be the patient. I’ve had the experience of reading transcripts of doctor patient visits that included advocates. Certainly not all advocates are built alike! This role is more deeply explored in the book “High Performance Healthcare

Opportunities for Linguists

There are two main applications for linguistics that are most evident in this discussion. One is the potential for computational linguists and natural language processing experts to mine the textual data available in  electronic health records as they become increasingly available. The other is the opportunity for discourse analysts to conduct research on the actual communication between everyone involved. Discourse analysts can both develop and institute more structured protocols, such as the double verification before certain medications and procedures, and raise awareness regarding instances when less than optimal communication styles can lead to mix-ups or other mistakes. Discourse analysts who specialize in apologies could be particularly effective advisors in training medical professionals to talk with patients and their advocates and family following medical errors. This is a strong interest of mine, and I’m lucky enough to attend regular medical discourse discussion groups with the head of my graduate department, Heidi Hamilton. Her work is a real treasure trove of medical discourse, well worth investigating further.

On a personal note, it is also very healing for victims and survivors to build narratives around these incidents that help to give them a wider context and meaning. I wrote about that process here: http://freerangeresearch.com/2012/05/22/ot-on-loss-and-grief-and-the-power-of-storytelling/

You may notice that I decided at that point not to give the medical error a place in my mom’s story. That was an important decision for me that helped me to heal.

Moving on

The three panelists had all lost people due to medical errors. I’ve also been the victim of medical errors. We were able to find some healing in the process of going deeper into the errors and the medical system that enabled them. You have also probably suffered in some way as the result of a medical error. It is also important to note that all of us have also had our lives made better by medicine at some point, and we probably also all know people whose lives were saved by medicine. It is an imperfect system, but it is a system with a lot of strengths.