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Mike Micklewright

Quality Insider

When It Comes to Health Care, Even the “Whys Guy” Forgets to Ask Why

Conventional answers don’t always give you the best results.

Published: Tuesday, October 27, 2009 - 05:00

In one of my recent Quality Digest published articles, “Why Root Cause Analysis Sucks in America,” I provided a list of 10 reasons why root cause analysis (RCA) in the United States is so awful. Number 2 on the list of 10 is: 2. We don’t practice it at home. Why should we do it at work?

More than 25 percent of our children are on antipsychotic drugs, antidepressants, Ritalin, and other ADHD drugs under the banner of “mental health.” Antianxiety drugs are rampant and there has never been any proof that they have ever cured anyone of anxiety. To quit smoking, we can chew gum, buy a patch, get hypnotized, or take drugs. To lose weight, we can go on a myriad of diets, some even claiming no exercise is necessary, or we can just get our stomachs stapled. To get us out of an economic slump, our government issues us checks. If our marriage is in disarray, we get a divorce. If we do not get along with other countries, we go to war. We rarely get to root causes at home, in our neighborhood, or in our country. We are not accustomed to it. So we go for the quick fix—the new drug.  This gets carried over to work and we continue to buy the latest drug at work—ISO 9001, Six Sigma, lean tools, and products from India and China.

But what about physical ailments due to the natural process of aging? Do we rely on band-aids and not attack the root causes of those age-related problems? Do we blindly accept that “old age” is the root cause of our problems and accept whatever band-aids our doctor prescribes for us and let the public pay for it through Medicare and other government programs? Of course, we do. We blindly accept the root cause of physical ailments as being “old age” as it’s the cause of one’s death and ask no questions. Even though the process of aging is a cause or contributing factor to one’s physical ailments or death, there are other causes related to our lifestyle or culture that may be even bigger factors than age.

My story of blindly not questioning the expensive band-aids prescribed to me 

I like to exercise on my treadmill. With business down during the past year, I have had many chances to set new records (world and Olympic) for the number of miles traveled in a given month. (It’s a game I play with myself to keep me motivated to work out.)

About a year ago, I began developing a sharp pain in the arch of my right foot. I could hardly stand, let alone walk, at the end of a full day of training and standing in front of a group of business learners. I endured the pain for quite some time and began to think that the cause of the pain was due to bad shoes. I threw out a pair of business shoes that had been my favorite shoes and moved on to a new pair of shoes with increased padding. After some time, wearing those new shoes (as well as my gym shoes) with my foot still hurting, I threw out a couple more pairs of shoes. Throwing out perfectly good shoes was getting to be an expensive result of not dealing with my problem. Think about this in your work: how many times have you thrown out perfectly good materials, components, or people because your company did not get to the root cause of its problems? How many times have you done this in your own personal life at home? 

After a great deal of resistance, I finally gave in to my wife’s suggestion to go see the podiatrist. Going to the doctor and addressing a physical problem is the worst thing that a guy can do. It’s an admission of a weakness. Many of us would rather just tough it out. Actually, we are just a bunch of wimps hiding behind our masculine façades. It’s probably one of the reasons why women live longer and why women are generally better than men at getting to the root causes of problems. Additionally, women endure more pain than men will ever know (except for that one weird pregnant dude) by giving birth to our descendents, so they figure nothing can be worse than that.

The doctor, a very nice guy, was all over the place in his conversation (like I was in the paragraph above) and honestly I could not understand what direction we were ever headed regarding a diagnosis and “cure.” 

The podiatrist did finally take an X-ray and after review of the X-ray said that the pain in the arch of my foot was caused by my weight rolling to the outer edge of my foot as I ran. This was the answer to the first “why.” My weight was rolling to the outside of my foot because my large toe could not bend back during the running process. This was the answer to the second “why.” My toe could not bend back because I had an arthritic spur at the toe joint where my toe would bend back. This was the answer to the third “why.”  See figure 1. The good doctor did not formulate his reasoning into answers to the first three “whys” as I did above. I had to interpret his rambling rhetoric and place them into “5 Whys.” 

Figure 1: Arthritic Spur at Big Toe Joint

That’s where he stopped. He had essentially answered “why” three times, not five times, which is the guideline if we wish to get to the root cause of a problem. He did not ask “why” enough times to get to the point of blaming my system of living. Worse yet; I, the “Whys Guy,” accepted the diagnosis and the band-aids prescribed without ever questioning “why” an arthritic spur grew on my toe joint in the first place.

After the X-ray, the podiatrist pulled out the longest needle I had ever seen and stuck me in the heel several times with a cortisone shot. There can be no worse pain than that, save perhaps delivering a baby.

He then, almost without my consent and understanding of what he was really doing, had me remove my shoes and began to wrap my feet to make molds of my feet. He did this so that two sets of orthotic inserts could be made for my shoes. This would, of course, require a return visit to get the inserts fitted into my shoes, and perhaps obtain another cortisone shot, if I still had pain. Of course, as quality and lean professionals, we all know that the cortisone shot and the inserts are band-aids—very expensive band-aids—that we all had to pay for. (Sorry! But I bet I pay for a lot of your health care needs as well.)  However, when we are outside of our work world, we often tend to forget about what we preach at work with regard to getting to the root causes of problems. Besides, really people, what does quality have to do with health care anyway?

Upon my return to the podiatrist, I did indeed get the inserts fitted into my shoes and I did indeed get another cortisone shot. Even though the good doctor had barely mentioned the possibility of surgery during the first visit, I think, he was now more clearly suggesting surgery, but we would discuss that more during a third visit accompanied with a third cortisone shot. I made the appointment for the third visit.

I cancelled the third visit the day before I was due to arrive. I was uncomfortable with the path we were going down but I wasn’t sure why. In a way, I felt like I was being scammed. I felt like I was falling into his normal patient routine—three cortisone shots, two pairs of orthotic inserts, and one surgery to shave down the arthritic spur. Nothing was planned or prescribed that would stop the spur from growing again, because we never determined the root cause as to why the spur grew in the first place. We were only making me feel more comfortable—in the short run.

Meanwhile, my wife and I began to discuss other alternatives, including going to see one of her natural doctors, Dr. Hauser, a prolotherapist who had helped her avoid back surgery to repair herniated discs resulting from jumping on a trampoline with our daughter.

Prolotherapy is a nonsurgical ligament reconstruction and is a treatment for chronic pain. It is a treatment used for many different types of musculoskeletal pain, including arthritis, back pain, neck pain, fibromyalgia, sports injuries, unresolved whiplash injuries, carpal tunnel syndrome, chronic tendonitis, partially torn tendons/ligaments/cartilage, degenerated or herniated discs, TMJ, and sciatica. “Prolo” is short for proliferation because the treatment causes the proliferation (growth, formation) of new ligament tissue in areas where it has become weak.

I first saw Dr. Hauser in June. Dr. Hauser is a licensed medical doctor and a prolotherapist based in the Chicago area (www.caringmedical.com). I discussed with Dr. Hauser my symptoms and the actions that I had taken thus far with the podiatrist. I also told him that for some reason, I was experiencing less pain during the previous week. (20/20 vision into the past: It was summer and I was working at home a lot more because of the recession; and I was walking around either barefoot or in sandals much more than before. In other words, I was exercising my feet more.)

Dr. Hauser explained the theory of prolotherapy and that the difference between him and a podiatrist is that prolotherapy helps the body heal itself, which is what the body naturally tries to do anyway. He had me walk around the office barefoot and in sandals and observe that toes naturally contract (exercise) while walking. When one wears shoes, one’s toes do not contract—the natural toe/foot exercise does not occur. He explained that Africans who walk around barefoot all the time do not have the same foot ailments that Westerners do. He informed me that the arthritic spur grew because the body was attempting to heal itself by growing a natural splint at the toe joint, and at some point in the future, I would have absolutely no movement in my toe joint because the body would have completed protecting itself.

This was finally the answer to the fourth “why.” Why was the body naturally building a splint? The answer to this fifth “why” was because the foot was being stressed beyond its capability on the tread mill. The foot no longer had the capability to take the treadmill impact, because my walking process, on an every day basis, didn’t provide enough exercise to my toes because I wear shoes all the time, unlike my African counterparts. The answer to the sixth “why.” The alternative prolotherapist doctor helped me to get to the foot cause of the problem. The conventional podiatrist provided me with a bunch of expensive band-aids that helped me in the short-term and would have made things worse in the long term. Had I elected to have surgery, which negates the body’s natural healing attempt, the bone spur would have eventually developed again (this time with less bone mass to work with), the pain would have returned, and the expensive cycle would have started over again. Why? The root cause of a lack of toe exercise due to wearing shoes all the time would have never been addressed.

Dr.  Hauser said I had three options at this point: Continue down the path of the conventional podiatrist and continue to get additional cortisone shots and schedule surgery;  partake in prolotherapy to speed up the healing process and begin to exercise my feet; or as seen in figure 2, exercise my feet by doing at least 500 toe crunches each day with a product called Yoga-Toes (about $35, I believe), walking around barefoot more often, and buying a pair of Nike Free gym shoes, which simulates walking and running in bare feet.

I chose the third option.

Figure 2: Doing Toe Crunches With Yoga Toes

As a side note, patients are also further tempted to choose the first option, because this is the option that insurance companies would pay for. They would not pay for an option that attacks the root cause of a problem.

Interesting.

My feet are definitely feeling much better these days. I rarely limp any more, even after teaching on my feet for a long day or consecutive days. I don’t wear either of the expensive orthotic inserts that you bought for me (even though I paid for them, we all pay for them eventually). Positive results are really occurring and I am excited about the prospects. A true “cure” could be possible without the need for expensive surgery that we all would have to pay for—the cure being the strengthening of my feet/toes through exercise. Of course, surgery often leads to other complications that I am also avoiding. I’m also getting some much needed exercise on my toes and feet that will benefit me in the future. Dr. Hauser said that the body will naturally absorb some of the arthritic spur, or splint, as the foot gets stronger and it is no longer needed. I look forward to this as well.          

Had I continued to take the conventional medical approach that we are all used to, it would have netted a result of even weaker feet. By relying on orthotic inserts the rest of my life, I would have been babying my feet, I would have become dependent on my orthotic inserts, just as a drug addict (prescription or nonprescription) becomes dependent on his drug. Weaker feet would have resulted in less exercise and a weaker back and more medical conditions requiring more medical procedures, all at the expense of the taxpayers.

Whether the reader is open to alternative health care practices or not, one way or the other, as quality practitioners, we should all be appreciative of a doctor that does not just address the symptoms of our ills, but also addresses the root causes of our ills.

As we listen to the debate over health care reform take place in our country, it makes me think of all the waste in our health care system. I’m not even thinking of all of process waste, of which there is a ton; I’m thinking of all of the waste in the form of the extensive prescribing of band-aids for our physical and mental ailments in the form of prescription drugs and surgeries. Unless we take away the incentives that cause doctors to sell us drugs or surgeries as band-aids, and instead give them incentives that encourage them to find the root causes of our problems, we will never gain control over our medical costs. The most wasteful countries (and companies) are those who can afford the most waste. This is why the United States has by far the most expensive health care system in the world.

Discuss

About The Author

Mike Micklewright’s picture

Mike Micklewright

Mike Micklewright has been teaching and facilitating quality and lean principles worldwide for more than 25 years. He specializes in creating lean and continuous improvement cultures, and has implemented continuous improvement systems and facilitated kaizen/Six Sigma events in hundreds of organizations in the aerospace, automotive, entertainment, manufacturing, food, healthcare, and warehousing industries. Micklewright is the U.S. director and senior consultant for Kaizen Institute. He has an engineering degree from the University of Illinois, and he is ASQ-certified as a Six Sigma Black Belt, quality auditor, quality engineer, manager of quality/operational excellence, and supply chain analyst.

Micklewright hosts a video training series by Kaizen Institute on integrating lean and quality management systems in order to reduce waste.

Comments

RCA

Keshav Ram Singhal, Ajmer (India)

Root Cause Analysis is always beneficial, whether it is related to health or any other problem. Nice article. Thanks.

Prolo-what?

You are spot-on regarding the pursuit of the 5 Whys to get to the root cause of any medical problem and I like to believe I would also follow this course. In addition, I am all for trying simpler solutions prior to surgery - which should be a later or last resort where possible. However, I cringe ever-so-slightly at terms like "natural medicine". It sounds too much like an Appeal to Nature - a logical fallacy defined as "a claim that something is good or right because it is natural" Nature doesn't actually much care about humans.

There's really only one kind of medicine which should be used: that which has been shown to work. I had never heard of prolotherapy but found it on the Quackwatch web site as a "Questionable Treatment" with a link to a pages outlining why it was not covered by Medicare or Aetna for back pain. Sample statement: "...further studies are needed to show greater improvement in treating pain with prolotherapy because the statistical significance was only borderline when the experimental group was compared to the control group." As a statistical guy, I think you can appreciate that.

Shooting ourselves in the foot...

Excellent article, Mike - a superb example of how to properly use RCA in real life. I also developed a problem this year in one of my feet. Fortunately, we have a good sports medicine department here, and stretching exercises with massage seems to be doing the trick. (I'll also try going barefoot more - thanks for that tip.) But you made me really think about more fully investigating what caused it. You've given us a great foundation for digging deeper into any health-related condition that might pop up. How much unnecessary surgery and suffering could be avoided by asking a few "whys" up front.

Jeff