I wasn’t expecting to learn anything related to product management and software development in a book about how we age and care for aging family, but I did. I have just finished reading Being Mortal by Atul Gawande, who also wrote and conducted the research and transformational changes in The Checklist Manifesto. (Image credit: Public domain: https://commons.wikimedia.org/wiki/File:Stethoscope-2.png)
From doctor-knows-best to patient-knows-best. Gawande talks about the changing role of doctors over time. In our grandparent’s era, ‘doctors knew best’. That was the age of the authoritarian doctor who made the decisions and was trusted to do so. Now, in contrast, for the most part, doctors are considered technical experts who can share information, but decisions ultimately rest with the patient. The idea is that the patient knows best, when given all the facts. However, when patients face important crossroads in their treatment and there are many uncertainties, neither approach works well and both lead to escalating interventions and, often, miserable people.
Both lead to suffering. The authoritarian path didn’t work well for patients because it didn’t take the patient’s fears and hopes into account at all. Without the patient’s preferences, doctors recommend actions within their own sphere of expertise. Surgeons recommend surgery rather than hospice because surgery is what they know best. But Gawande, who was trained in the current technical-expert-sharing-information model of doctoring, illustrates how information sharing goes just as wrong when it comes to delivering the experience that patients would want. He tells several stories from his own practice, where patients clearly said, I don’t want to suffer, and I don’t want pointless heroics, but then choose to proceed through many, many rounds of painful procedures with very low probability of success. Why is that?
Software development has the same duality. In software development, we also have this same duality. The authoritarian model: Which employee is the ‘owner’ of this product? They should make all the decisions about what to develop, and be responsible for the consequences. Or, alternatively, the ‘Information’ model; let’s have the expert (product manager) gather the facts and present choices to leaders and other stakeholders; or lets develop objective metrics to guide us. And similarly, it can feel like we see-saw between decisions made with too little information and decisions that feel like the information was there, but it was never pulled together into the right decision. So I was very interested in why neither approach is working for doctors and patients, and what might be a better approach.
Why the informed patient model still fails. Gawande’s analysis of the informed patient that still makes the wrong decisions is that they don’t have the experience or the medical model to make the decision, even when they have all the facts. So, assuming you aren’t an astronaut or experienced physicist, think about it this way. If I put you in a space capsule, ask you where you want to go (which is what the doctors-know-best doctors forgot to do), and I tell you a bunch of readouts and their percentage likelihood of being correct, and then ask you whether to launch, you still aren’t going to be able to make a good decision, because you don’t have a model in your head about how all those measurements add up. Gawande specifically talks about how a patient might be imagining that a particular procedure with a high likelihood of success could extend their life by years, when in reality it is likely to be weeks, not years. The patient doesn’t have the experience to put all the information together into a coherent model and make a good choice.
So now what? So, is there a middle ground? Gawande describes a model where doctors gather even MORE information about what a patient WANTS by using four questions that come from the world of hospice. Then, the doctor combines the patient’s answers with their professional experience to guide patients in making decisions that are consistent with the patient’s own desires.
Learning from hospice nurses. The four questions are also interesting. 1. What do you understand about your situation? 2. What do you fear? 3. What do you hope for? 4. What trade offs are you willing and not willing to make?
Ask, tell, or guide? A middle path to product development. In the world of software development, many organizations (including the one I work for) hire Product Managers to lead product development. In specific, Product Managers are responsible for deciding what features should be added to a product and with what priority. So the question is “Are Product Managers owners (the authoritarian model), expert consultants (the information sharing model), or expert guides (the new model Gawande proposes)?”
I would posit that the same insight Gawande has about doctoring is the right insight for product development. Product Managers don’t own their product. The product isn’t FOR them and there are too many critical stakeholders for them to be owners. But they also can’t present information and expect decisions from business leadership, precisely because the business leaders don’t have the full context and understanding of the detailed workings of the product and market. The product managers DO have that context.
My key insight from Being Mortal is those four questions that hospice nurses taught doctor’s to use to help them guide their patients. I am curious about whether those questions can be adapted to gather the right information, especially from business leadership and organizational stakeholders that don’t directly interact with the product, to allow Product Managers to wisely incorporate their requirements into good decisions.
So here are the four questions again
- What do you understand about your situation?
- What do you fear?
- What do you hope for?
- What trade offs are you willing and not willing to make?
Frankly, they almost work as is. I would only change the phrase ‘your situation’ in the first one to match the context. It could be ‘what do you understand about our goals’, ‘what do you understand about our revenue position’, ‘what do you understand about our strategy for …’
I am going to give these a try. Let me know if you do too!