When I question the etiology of what seems to me to be an inefficient clinical practice, the response, “that’s the way it’s always been done around here,” is frustrating. Recall the story, “Five monkeys in a cage,” in which a monkey climbs a ladder for a banana and is sprayed with cold water, effectively dissuading other monkeys from doing the same thing. When one of the monkeys is replaced, the new monkey attempts to climb the ladder and is attacked by the remaining ones, as the unpleasant memory of being sprayed with cold water remains vivid. Eventually all the original members are replaced, but no one dares to climb the ladder to reach the banana.

Most practitioners of evidence-based medicine already possess the right mindset to eliminate waste and inefficiencies to improve not only patient care but our work-life satisfaction as well. The results of quality improvement initiatives that germinate from small primary care practices challenge the notion that we are slavishly bound to maintain the status quo even though we may not have the resources of large integrated health systems or academic medical centers. In a recent study, almost three fourths of physicians noted unanticipated improvements in efficiency and standardization and higher levels of patient satisfaction and retention after implementing quality improvement initiatives.1 

Since almost 75% of primary care is delivered in practices with fewer than 10 physicians,2 all physicians need to be familiar with techniques that enable them to implement successful quality improvement projects. Lean methodology is an example of a process adopted from the manufacturing sector that examines current processes, such as a request for a blood test, and proceeds to map all the steps from the initial request to when and how the patient is notified of the results. Individuals subsequently examine what steps can be eliminated that don’t add any value to the process so that the desired state is achieved, leading to better patient outcomes and less redundancy. I promise no one will spray you with cold water as you reach for the “banana” on behalf of your patients while simultaneously trying to improve your quality of work life.

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