Learning A3 thinking to become a better doctor
In January, as part of my third year at Michigan Medical School, I took a month-long course focused on A3 thinking (Dr. Billi recently wrote about it). I saw the initiative as an opportunity to learn to think like a leader, but also to learn how to identify problems I would not otherwise have seen or been able to think about proactively.
I had been exposed to the A3 model in the past and saw it as a structure to help organize my thinking. I also found it compatible with the scientific thinking we rely on as physicians. With every patient, there is the obvious problem (for example, hypertension), but also the underlying causes of that problem, which must be investigated and addressed. With this in mind, it is hard not to see the similarities between a patient history and A3 thinking.
The course began with gemba walks: I went with Dr. Billi to various hospital departments during meetings to see how different teams were already using lean in their daily work. Dr. Billi and his team scheduled very interesting meetings for me to attend and learn how the hospital works, from quality improvement meetings to one-on-one meetings with people at the top of the hospital administration. It was fascinating to see the process and how everyone was dedicated to making positive changes. I also took a two-day lean workshop as part of the course, which helped kick off my own A3.
In the first week of the course, I was tasked with identifying a problem. I decided to focus my A3 on patients with end-stage liver disease and to examine whether there was a delay in appropriate palliative care consultations. End-stage liver disease has a poor prognosis, with a life expectancy of two years on average without a transplant. However, some patients never make the list, and many who are on it do not receive a transplant in the end. This creates an opportunity for palliative care – allowing patients to discuss their values and goals around their health care without the prognostic restrictions of hospice care.
I shared my A3 with health care professionals, patients and several other people. Everyone was interested in improving their communication in the face of serious illness, since we all inevitably have to go through it, with patients or with their loved ones. What I discovered is that, at the moment, palliative care is very well designed for oncology patients, but we have not established best practices for its role in end-stage chronic diseases. What I hope to do going forward is create case studies on palliative care in chronic diseases to show primary teams what to expect from a palliative care consultation and the value it can bring.
When I look back on my course, I think the greatest benefit of the A3 model is that it encouraged me to go and see: taking part in rounds allowed me to talk to people at every level, something I would not have done as well or as extensively without the guidance of the A3 model. Humble inquiry places enormous emphasis on making sure you have the right question.
Speaking of asking the right questions, it was great to meet with Dr. Billi every week to go over the A3. His questions (asked without implying what he thought I should do) guided me as I changed and refined the A3 and advanced my investigation of the problem. The coaching process helped me think differently from my traditional approach and dive deep into the problem. This is where we can draw another parallel between A3 thinking and “medical thinking”: the process of humble inquiry, which A3 thinking teaches us, is crucial to our relationship with patients. A good part of being a physician today lies in addressing lifestyle issues and trying to understand why people move, eat, sleep, take their medication and so on. There is no doubt that developing my humble inquiry skills will make me a better caregiver.
The benefits of A3 thinking do not end there. Knowing that there is a process for solving problems empowers people, and lean thinking has given me the tools to deal with this and with future problems. In fact, one of the best things about having this course in medical school is that, without it, I might have assumed I would not be able to solve a problem like the one I chose for my A3. There is value in showing medical students that they have the ability to identify and solve big problems from the very beginning of their careers. In my opinion, that is where the power of this course lies.
As a future physician, I have the honor of helping one patient at a time, but I believe it is also my responsibility to improve outcomes for many patients at once through quality improvement. Learning to see and solve problems is a fundamental step in that direction.
