Make a difference

Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.

Atul Gawande¹

Much remains to be done to achieve the vision of an effective, equitable, safe, and patient-centred health care system. In a recent Commonwealth Fund survey, only 40% of family physicians across Canada said that the Canadian health care system worked well,² ranking seventh among the countries studied. It is easy to feel powerless when faced with systems, and to throw in the towel.

Yet, as Atul Gawande explains so well in his book Better,¹ you don’t have to make a great discovery to make a difference. According to the author, it takes diligence, moral clarity, and ingenuity. Gawande cites the examples of Virginia Apgar and LeRoy Matthews, who made outstanding contributions through very simple actions based on their observations. In the early 1950s, Apgar devised a score that is still used to assess a newborn’s need for medical intervention. Matthews challenged the poor prognosis of children suffering from pancreatic cystic fibrosis by asking parents to “clap” on their children’s chests every morning to loosen the tenacious mucus clogging their airways. Gawande concluded his book by inviting us to cultivate the ability to make a difference in our own environment by becoming positive deviants.

The concept of positive deviance first appeared in nutrition research in the 1970s, when it was observed that some very poor families nonetheless had well-nourished children. Positive deviance is “an approach to behavioral and social change based on the observation that in any community, there are people whose uncommon but successful behaviors or strategies enable them to find better solutions to a problem than their peers, despite facing similar challenges and having no extra resources or knowledge than their peers.”³

Since the beginning of my presidency, I have met a number of positive deviants who have made a difference in their communities by refusing to accept the status quo and by believing in their communities’ ability to take action. One of these stories is about a population that is often vulnerable and a living environment that is still neglected: seniors living in residential and long-term care facilities. The positive deviant is Dr Barry Clarke from Halifax, NS, and his project, Care by Design, is now a well-established program in the Capital District Health Authority.⁴ Dr Clarke received the Nova Scotia College of Family Physicians Award of Excellence in November 2012 for his work. Like many physicians, he was concerned about the transfer of long-term care facility residents to the emergency department for acute problems that did not require emergency department services.

Dr Clarke formed a small team and, with the support of the Capital District Health Authority, conducted a study of 240 transfers from long-term care facilities to emergency departments.⁴ They observed that in 50% of cases, the floor staff was not able to reach the patient’s physician before the patient was transferred. He and his team thought up a system: rather than assigning family physicians to patients in a random fashion, he proposed that physicians adopt a floor to facilitate the coordination of care and the introduction of a predictable on-call system. The program now includes, among other things, practice guidelines, continuing professional development activities, and performance measures to support continuous quality improvement. Researchers from the Department of Family Medicine at Dalhousie University in Halifax joined the team to conduct a formal evaluation of the system.

How can we cultivate the ability to become positive deviants? Atul Gawande makes 5 suggestions: ask unscripted questions; do not complain; count something—observe something you find interesting; write something; and change. That is what Dr Clarke did. When I read Better for the first time, the concept of positive deviance was mostly theoretical to me. But when I started to meet you and other health care professionals, all equally committed to providing high-quality care, the concept took shape. We cannot all be Virginia Apgar or LeRoy Matthews, but we can make a difference. It does not take genius. It takes diligence, ingenuity, and tenacity.

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