Bernadette Keefe MD

“the point is to be together, to mix our differences”

                          @Bionicohand at @iMaginationCtr


In the #HCLDR community twitter chat conversation on ‘Positive Deviance” that was held on October 6th, 2015, (blog post by Colin Hung and transcript) an astute comment was made by Dr. Justin Smith (@TheDocSmitty) in response to

T1 What examples have you seen of Positive Deviance in Healthcare?

“Sometimes it’s hard to recognize positive deviance because healthcare is so siloed. (We) Don’t talk to other providers or departments enough”

While the #hcldr community was able to come up with a few examples, the majority felt that it was tough to name ‘positive deviants’ and that it was difficult for such persons and initiatives to rise to recognition given the restraints and hierarchies of our healthcare system. Dr. Smith’s comment about ‘silos’ resonated with the group.

If there is one movement that describes the current wave of disruption in industries from media to healthcare and in-between, it is the breakdown of barriers and democratization of processes. However, to accomplish a smooth transition to a more workable, inclusive system, that will also yield improved outcomes, we need a change in culture; a meeting of the minds. For healthcare stakeholders with disparate positions, we must now tear down our own walls; break down and abandon our silos. It is commonly recognized that many healthcare related communication issues and misunderstandings arise from stakeholders speaking and acting from isolated positions.

Amidst ongoing conversation about healthcare silos and the problems that they might be creating, comes the timely release of Gillian Tett’s, “The Silo Effect: The Peril of Expertise and the Promise of Breaking Down Barriers”. While Gillian Tett comes from a financial background (as U.S. Managing Editor and columnist at the Financial Times) she has been more widely recognized as a superb thinker and writer. (See NY Times book review and APM interview)

 Some of Gillian Tett’s thoughts include:

  • We create silos and boxes to create order out of the chaos (of information overload, tasks to be done, pending issues etc)
  • With that creation we can (and do) overdo ‘the boxes’, creating rigidity and tunnel vision.
  • Silos are ‘social ghettos’. (They) prevent your brain from noticing that there are other valid and valuable perspectives or at the very least there is indeed more than one way to look at the world.
  • At the Financial Times, Tett used social media (specifically Facebook) to break down some of the silos she recognized there.

Healthcare Tribes: Silos and Walls


Before I built a wall I’d ask to know

What I was walling in or walling out,

And to whom I was like to give offence.

Something there is that doesn’t love a wall.”   ‘Mending Wall’ – Robert Frost 


Healthcare (patient care) has suffered from the siloed system of the classical practice of medicine. While the sub and sub-sub specialization of the 1970s – 2000s yielded enormous breakthroughs in treatments, this process had the negative effect of fragmentation of patient care. Equally worse is the nearly toxic combination of professional differences in who and how to treat patients coupled with (in the U.S.) a competitive business environment which has led to a less collegial relationship among physicians, ‘turf’ wars etc. None of this is good for patients and, in the end, not healthy for physicians themselves.

All of the above is now admixed with the fast approaching formal establishment of a new payment model: value based care. This invites the essential but undeniably uncomfortable discussion of which physician fields and medical practices have/ bring the most value to patients.

How to improve?

Institute more interdisciplinary research and education and more mutual respect, and humility. In medical education more empathy and kindness to learners is warranted. (This filters to patients.) Consider MUCH more of the following:

  • Joint conferences.
  • Joint journal clubs
  • Joint research
  • Cross-service educational, clinical rounds.
  • Joint bedside rounds
  • Non practicing MDs now in biz/tech need to refrain from the all too easy MD/healthcare system bashing (Ok to critique) & recall what being in the trenches was like~

Always easy to OVER-criticize from a distance


Read this: (“Dear doctors, be kind to each other”)

Watch the following video:

Victoria Brazil – Timing, Tribes And STEMI’s

Victoria Brazil – Timing, Tribes And STEMI’s from Social Media and Critical Care onVimeo.

“hello, my name is Victoria, my tribe is great and so is yours” –

Victoria Brazil MD Final words of her Opening Keynote of #smaccGOLDconference

Health Information Technology & other health related technology

Often there are extreme points of view when the topic of healthcare and health related technology arise; either the doctor IS your smartphone, technology IS a panacea OR technology is ruining the doctor – patient relationship, technology underperforms, etc.

The truth is somewhere in the middle. Technology employed in the healthcare field is invaluable, and the better conceived it is (suited to its users), the more valuable and ‘panacea-like’ it becomes. Too often however, there is not enough user input at the beginning of the tech development process. Issues are also created when the technology developed is not addressing the pressing needs.

Likewise, we are, and will, learn more about determining when a technological solution suffices and when human interaction / intervention is needed.

There was an interesting post recently “Did Anyone Ask The Doctors”? This post questioned whether the information technology developers asked the opinions of physicians when developing their software systems. The answer is probably no but likewise most physicians have been sadly unengaged in the technology changes happening since the mid 1980s. We see the unfortunate results of that now in in healthcare information technology space regarding both electronic medical records and the new ICD-10 coding, which we need but is not ideal.

 Drug Companies

Some commonly held positions held in the U.S. include: drug manufacturers ‘Big Pharma’ are ‘bad’, out of touch, don’t care, just in it for the money, etc.

How to improve?

– Pharma could reach out to the community of patients regarding both their research and advertising.

– Regarding research, there must be an open book transparency so that research can be validated (or not).

– Patient participation in the planning of research could, and should be welcomed.

– There could be fairer drug pricing for example, negotiation with drug companies on Part D Medicare.

– Advertising, at its best, is educational and patient oriented, thus fostering health literacy (example of this below).



Patients are experiencing multiple pain points, including:

  • Often limited access to data
  • Inadequately represented in research endeavors
  • Lack of time with and incomplete communication with physicians
  • Not enough shared decision making or, often patients are not given enough data or tools to make effective shared decisions. This results in incomplete buy-in and, what is inaccurately termed, non-adherence.

How to improve?

  • Release data from data silos
  • Involve patients in more research AND have transparency of their data and study results.
  • Provide better educational materials for patients online to enable more effective self care between healthcare provider contacts.
  • Create patient care teams to expand the healthcare provider network on behalf of patients, as described in, “Cowboys and Pit Crews” – Atul Gawande MD.
  • Additionally both patients and physicians might appreciate this post.

Politics / Governance

All healthcare professionals and patients need to be much much more involved in the political process as the ballot box determines how healthcare systems function. All of us, as citizens, must educate ourselves as much as possible regarding relevant legislation and issues in the political sphere that involve healthcare. The Government needs to share, contribute, and engage with citizens frequently to elevate health literacy and healthful habits in the citizenry. Likewise, government needs to resist the efforts of lobbyists to undermine public health initiatives.

Opportunities and Tools to Breakdown Silos & Engage Tribes

Healthcare Media ‘Diet’

An interesting book was published in 2012 titled, ‘The Information Diet: A Case for Conscious Consumption”, by Clay Johnson. He made the following comment about the similarities between eating food and consuming information:

“Our bodies are wired to love salt, fat and sugar…. Our minds are really wired to be affirmed and be told that we’re right… Who wants to hear the truth when they can hear that they’re right? Who wants to beinformed when they can be affirmed?

A discussion of a general media diet is beyond the scope of this post, but I bring up this book because all of us consume a healthcare media diet too. I posit that what we choose to consume day in and day out in the medical, health and healthcare space determines our perspective, our opinions, and actions within healthcare. 

How to improve? 

Reflect on what we choose to read and who we choose to listen to. Curate well.


How to improve?

Major medical conferences – Automatic reduced rate for patients (see ‘Patients Included’ charter for conferences), and for physicians in different medical specialties.A mix of other healthcare professionals and patients might temper some of the ‘bandwagon’ behavior often exhibited at major medical conferences. This is especially important with the release of new drugs, where often, the ‘shine’ wears off under the cold light of reflection after these conferences.

Smaller mixed / boutique conferences – Be wary of elitism. Even though these are generally more diversified, try to strive for a greater demographic.

Events such as Hackathons – To end up with a relevant product it’s important toinclude end users.


How to improve?

  • Open access – after a 2-6 month lag period
  • Transparent, better peer review
  • Strive for utmost relevance in publishing 

Social Media (our social media diet)

Colleagues and Conversation 

Over the past year, the #hcldr community ( has held multiple tweet chats that have been useful for breaking down silos and bridging ‘tribes’. Two have focused on listening (here and here), one on questioning (here), and two on the human condition (here and here).

There are countless other healthcare communities on twitter, which offer superb information and invaluable opportunities for engagement with a wide group of healthcare stakeholders around the world. The @healthhashtags website keeps statistics on many health, illness, and healthcare related twitter conversations and events around the world.

Our Networks

Steve Jobs recognized the value of social interaction in the process of innovation. In his role as CEO of Pixar Animation Studios, he made sure the physical design of the Pixar Headquarters encouraged mingling and interaction. Recently ,a study was undertaken to see if that same social interaction value was found when the mingling and conversation was on social media. The study revealed that while twitter users and non-users submitted the same number of ideas, the ideas of the twitter users were rated much more favorably by other employees and experts.


The diagram description from the article is as follows:

“In the diagrams, circles represent Twitter users, and an arrow from one user to another user indicates that the first user is following the second user on Twitter. Even though both employees A and B follow approximately the same number of Twitter accounts, A’s network is far more diverse than B’s . That is to say, the people whom employee A follows on Twitter are, for the most part, not following each other.”

The compactness ratio of the two networks can be measured. Network ‘A’ is much less compact (a looser network) than network ‘B’. The researchers found that loose twitter networks (such as seen in ‘A’) are better for idea creation because thoughts from a more diverse community are accessed. The ‘B’ network, where most people follow each other and only each other, results in more redundant information.

The ‘B’ type of network is a more siloed network; great for sharing information in a close knit group, less valuable for creation of ideas, innovation, and sharing outside of one’s ‘silo’.

How to improve if the goal is to become less siloed ?

  • Broaden and diversify our networks, while simultaneously curating them.
  • Support generalist tweet chats (along with other healthcare tweet chats). These usually have a wider variety of healthcare stakeholders in the conversation: patients, physicians, health technology, marketing, executive, pharma, etc.
  • Support, engage and incorporate persons from varying healthcare ‘tribes’ on twitter.
  • In general ,on twitter: Listen more, tweet mindfully. Never spam.


“Cafes are on corners – for a reason

Let’s each draw up a chair in that bustling corner café, where we can intersect with one another and observe at leisure. We’ll acknowledge the grand diverse world in which we live. We’ll discuss and often argue about the devastating and confounding issues around health and healthcare, and how each of us, in our uniqueness, our different perspectives, can and must collaborate to achieve the outcome we all desire: the best possible health and wellness for all.

“We are all apprentices in a craft where no one ever becomes a master.” – Ernest Hemingway

The topics for #hcldr chat on 10/20/15:

  1. What areas of healthcare are most prone to silos and siloed thinking, & what are the negative aspects of this?
  1. What are best ways to break down silos and better utilize tribes in healthcare?
  1. What healthcare tribe do you belong in, if any? Are you ‘tribal’? Would you like to change that or do you see as a good thing?
  1. How do you see the role for twitter in breaking down healthcare silos & boundaries and providing bridges between tribes?



‘The Silo Effect’ by Gillian Tett ~ Book Review here

Building Up and Breaking Down Silos –

Hierarchies and Boundaries

Victoria Brazil: Timing ,Tribes and STEMI’s (video) Re: Teams working together

Cowboys and Pit Crews – Atul Gawande

A New Silo – A New Obstacle

Dear doctors: Be kind to each other

Opportunities & Tools for Collaboration

A Healthy Information Diet: The Case for Conscious Consumption

Personal Learning Networks: Learning in a connected world

The Outsiders Advantage

Great Innovative Leaders Live in the Interstitial Spaces

Structured serendipity: How Great Ideas Emerge here

What An Opera Singer, Food Critic and Cancer Survivor Bring To Innovation

Do You Really Want To Break Down the Silos

How Twitter Users Can Generate Better Ideas 


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