This week’s journalist is Curtiss Luong, a graduate student working for morLab at the University of Toronto. He is a moderator of this blog, and you can reach him at

In December 2012, I spoke with Dr. Michael Carter, a professor in the Mechanical and Industrial Engineering department at the University of Toronto, about healthcare in Canada.  Thoroughly entertaining, Dr Carter had some valuable insights on the state of healthcare systems in Canada.

Q: Operations research in hospitals – why is it important?

A: Simplistically, there’s a rule that says that healthcare is 20 years behind manufacturing and 15 years behind service industries. For example, lean is an important set of principles that has been used in manufacturing since the 80′s, but the health care industry in Canada has just recently, maybe 5 years ago, discovered lean. Most manufacturing-related companies understand supply chain management, capacity management, schedule optimization, etc. Healthcare has very little of that stuff.

Q: Why do you think that is?

A: Problems in healthcare are often quite similar to other industries, but there are a few key differences. One big difference is called the silo mentality. Basically, nobody is really in charge. If I went to the CEO of General Motors and convinced them that they could save them a million dollars, and my argument was sound, it would happen tomorrow. In a hospital, they would have to talk about it; the CEO of a hospital cannot simply legislate change. The doctors all work independently. Doctors are not paid by the hospital and nothing happens unless the doctors want to be there. And it’s sort of like…if everyone on the assembly line at GM was in charge and decided what they want to do today the odds on producing a car at the other end would be very slim.

Q: How is the approach to solving problems in healthcare challenging?

A: One of the things that I think that is particularly challenging is figuring out how to actually demonstrate an answer. Often, we’ll go in and we’ll tell someone: I solved this with linear programming, the answer is 5, and I can prove it. But how do you actually convince someone with no background in engineering or math that your answer is right? And so I spend a lot of time on the presentation, the discussion, convincing people that my solution is actually a good way to do it. Doctors are generally very quantitative. You give them evidence and you demonstrate it is correct, they’ll do it! But there’s a lot of art and skill involved there.

Q: Can you give an example demonstrating the art and skill required in engineering analysis and problem solving?

When you work on a manufacturing problem, you bring things down to dollars. In healthcare, although cost is always a criteria, people don’t make decisions based primarily on cost…for obvious reasons. So we are constantly looking at trade-offs and making difficult decisions.

One important thing that I’ve learned, and it took me years to figure it out, is that if I have a new way of doing things in a hospital, it has to be better for the doctors. And by better, quite often, it means that it has to make them more money. And if it isn’t better for them, it will fail, and nobody will know why. And it has to be better for the nurses. We’ve developed systems that would be so much better for the patients, but it’s going to take an extra 2 minutes a day for the nurses, and it will fail, and nobody knows why. And it has to be better for administrators, public perceptions, government mandated metrics, etc. And so we have all of these perspectives, and they all have to be better, or it won’t work. And the interesting part is that healthcare systems are often so bad that it is still possible to find a good solution. I can usually do some analysis, some optimization, and figure out a good way to do things. But then we have to sit down again and ask: does this work for the nurses. If not, let’s hire another nurse. We don’t really need an extra nurse, but let’s hire an extra nurse. Because now, the nurse’s hours will go down by five minutes a day, and it’ll be better for the nurses. And that extra is still going to save us millions of dollars, but if we don’t do it, it won’t work. And it’s absolutely imperative to look at things from every perspective. What’s really interesting is that if you ask anyone, they’ll say “What’s really important is quality of patient care”; but, what’s really important for them they won’t say.  Hours of work, dollars … all of these other things are incredibly important.

Read part 2 here!

4 thoughts on “OR Journalism Series:
Dr Michael W. Carter, Part 1

  1. This is a smart interview. That is lucidly manifesting the flawed decision making mechanisms inside hospitals. Worse, there are many players in hospitals that can easily revert one decision if their personal comfort and interests are put in jeopardy.

    Thanks for your informative interview Curtiss.

  2. Thanks Vahid!

    One thing that I did notice is that this first part of the interview as very pessimistic…perhaps overly so! There are a lot of good things going on right now, and I think Part II of the interview will hopefully showcase that side of things.

  3. Interesting part I of the interview.

    I would like to say that decision making in hospitals is not flawed but challenging. This challenge is due to the management model adopted by hospitals. Unlike GM which might be following a top to bottom hierarchy, hospitals tend to follow a flat model because giving doctors autonomy is crucial part of healthcare.

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