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The Butler Model

January 26, 2009
by Joe Bormel
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The  Butler  Model

The Butler Model

We should rethink how we deliver clinical decision support

There’s an iconic image of the Butler, preferably British of course, who maintains a highly respectful manner, and is clearly focused on providing service.

A friend, Dr Scott Finley, started kicking around an idea a few years back. What if clinical decision support delivery was modeled after that butler?

Instead of starting with the premise of looking for opportunities to offer alerts and warnings, tied tightly to specific applications and points in workflow, a butler would function as a highly skilled and very quiet companion. He would be able to control if, when and how he interrupted the master, with a degree of sophistication. He would recognize ways to help, offer to follow up on tasks for the master, and recognize the master’s unique needs.

Earlier this week, Scott wrote:

I found an excellent butler-related quote from Anthony Hopkins regarding his performance in Remains of the Day. He may have gotten the idea from interviewing a real-life butler:

"You begin to feel like a butler, and things begin to happen. The

tone of your voice drops until it is just above a whisper. You're

tremendously polite, tremendously courteous. You listen and you

become invisible. You make a room even emptier by being there.

You don't fiddle about or elaborate or try to act.”

I particularly like the idea of making the room emptier by being there. That’s how the darn computer should behave.

Computer as Actor

The one concept that may help people understand better is that of "computer as actor." In other words, the reason for the butler model at all is that the computer is implicitly serving as a player in the system. It advises, listens, criticizes, etc., but its role is generally unplanned, unmanaged, and (especially, as realized) inappropriate in the clinical context. So it acts like its creator, generally a young programmer. Does "someone" acting that way really belong in the exam room?

I think Scott has a really neat idea here. We know that the current model, full of reflexive, knee-jerk alerts and reminders doesn’t work. We know that most software doesn’t recognize higher order tasks very well. So, it interrupts the user as soon as a concern arises, whether it is qualified or not. Whether it’s considered to be relevant. Generally in the same loud tone. And always with an inadequate recognition of context.

What would it look like if the GPS in our cars behaved like a butler? Well, for one, if the GPS said turn left and it heard your spouse say, “no, turn right,” the butler-based GPS would surely quietly revise it’s recommendation and say “You’d best turn right, master!”

What do you think of the Butler model?

Note: The Butler photos leading this blog post come from the Disney movie, The Parent Trap - here are two more flavor savers:

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