To champion an unremarkable health system means pursuing results within a corridor of “decent enough” results that do not merit concern, thereby offering a baseline for system improvement and allowing for the identification of surprising data that may surface in future monitoring. Pursuing such unremarkability in healthcare maximizes the health and welfare of everyone and can support quality improvement across all institutions.

Introduction: Our Remarkable Bias

We applaud that which is or seeks to be remarkable. We tend to marvel at what registers as remarkable in ratings – for example, those healthcare organizations excelling on certain clinical or operational indicators. Yet I contend that we should strive for an unremarkable health system, one that performs “okay enough” consistently on all indicators.

“Okay enough” on all performance indicators that matter to the patient is better than being remarkable in a few. “Unremarkable” is a wonderful word, and this essay explains why.

After three COVID-19-free years, I succumbed to the illness in December 2023; then, after a five-day respite from all symptoms, I was felled by an RSV infection, leaving me fever-ridden for almost all my waking hours. After my persistent fever and muscle aches subsided, I had a burbling cough and, to “rule out something stupid” – what my family doctor told me is his preferred code for cancer – I got a chest X-ray done that illuminated opacities in one of my lungs.

It turns out that new lung opacities have been widely reported among those showing up for chest X-rays after a COVID-19 infection (Rousan et al. 2020). Yet I was alarmed that radiologists at two hospitals who saw the X-ray marked me as “urgent” for a CT scan to rule out a malignant neoplasm, which if caught in its early-enough stages might be manageable.

The fact that I did not need to dart off to Buffalo or Detroit for a CT scan – my CT scan came within five days of the X-ray in Toronto – offered me no solace. I was anxious about developing “something stupid.” I could not sleep for two days prior to getting my results. Through the hospital's patient portal, I navigated to the radiologist's reports minutes after it had been uploaded.

My results were hewn in a two-page report peppered with the adjective “unremarkable.” What a delightful word! May we all have unremarkable chest X-ray results.

What “unremarkability” means

“Unremarkable” means that the radiologist does not observe anything particularly unusual requiring immediate investigation. It conveys that the chest X-ray appears within the expected parameters. It provides a concise way to communicate that the imaging results are within an “okay enough” range but still require monitoring. This then helps the ordering physician to quickly understand the overall interpretation of the imaging.

“Normal” is different from “unremarkable.” “Normal” implies that the results are as expected for a perfectly healthy individual. As such, “normal” is not the norm for someone needing a chest X-ray. “Unremarkable” indicates that there may be minor variations but nothing terribly concerning – nothing “stupid” in other words. This then sets a baseline for comparison to future imaging. Describing the current chest X-ray as “unremarkable” provides a reference point. This helps identify any changes, anomalies or new findings in subsequent imaging.

An unremarkable health system

To champion an unremarkable health system is to pursue results within a corridor of “decent enough” results that do not merit concern, to offer a baseline for system improvement and to allow for the identification of surprising data that may surface in future monitoring. What a joy it was to feel unremarkable! For unremarkability is what matters to the patient – to be told that your condition is deserving of careful monitoring but there is nothing remarkable about you. And so it should be with every key indicator's performance: deserving of monitoring but exhibiting a functionality that lies within a window of “decent enough.”

We are told that indicators need to be SMART: specific, measurable, achievable, relevant and time-bound. A health system strategy I, therefore, recommend is that we ensure that our SMART indicators do not give us cause to worry. We need to strive to be unremarkable.

So enamoured was I with this new radiological nomenclature that I began, soon after my chest X-ray results, to wish people “unremarkable travel” and “unremarkable days.” When I explain why I offer this good wish, my message resonates. An amazing experience can be boring.

It is well established that in complex, data-driven industries, a holistic view of performance across multiple key performance indicator (KPI) categories is often more important than maximizing performance on a few select metrics. Maintaining a “balanced scorecard” helps organizations make more informed, strategic decisions (Brown et al. 2006: 34). A for-profit company, such as a financial services firm, needs to track a diverse set of KPIs balanced across areas such as revenue, costs, deals closed, employee productivity and customer satisfaction. A balanced scorecard approach is also widely used in the retail and manufacturing industries – and in healthcare too.

Yet many organizations' annual reports and, more conspicuously, their social media accounts boast of indicators on which they are performing stupendously. Social media sites such as LinkedIn encourage beaming self-promotional posts; you discover far more about wild workplace successes than extreme workplace toxicity. We tend to reward “are-we-not-great” posts; employees exhibit loyalty (or yield to peer pressure) to festoon these posts with heart emojis. An online post about having done “reasonably okay” – say, a report card of all Bs – does not cut it on social media. But one A+ on a rarefied indicator? You are golden.

Outside healthcare, chasing unremarkability is important for higher education too. An elite university's public relations team promotes its reputation and admissions selectivity indicators in US News and World Report and Times Higher Education rankings more than routine, “boring” (but important) indicators reported each year – such as retention rates (first-year students who return for their second year), faculty-to-student ratios or institutional spending per student. Would any university promote unremarkability?

Unremarkability for quality improvement

Unremarkability matters more in healthcare than in other sectors. For as much as we are inclined to recognize institutions that are extraordinarily strong in one or a few select indicators, we need to celebrate and emulate those institutions that perform sufficiently well across the board. What are these places doing right? A patient transferred from the emergency room at one hospital to a critical care unit at another and then to palliative care elsewhere would much prefer that all three institutions show unremarkability on all indicators versus shining on some clinical KPIs but flailing on others, such as patient satisfaction or patient safety measures.

Imagine an annual unremarkability list profiling the most humdrum hospitals and health systems in the world: all Bs all the time. This would demand a paradigm shift. Our media and health policy wonks tend to evaluate a health system's remarkability in just one or two domains. A provider-centric system tends to celebrate clinicians who win episodic prestigious awards in their narrow field as opposed to paying more scrutiny to organizations that fare consistently okay on all indicators of importance to patients and their families.

What would happen if we compared the degree to which we had an unremarkable health system with other systems? Are we doing “okay enough” on all health system indicators that matter to patients more so than, say, a health system that outperforms all others on some cost-related indicators but fares poorly on other indicators? How can we incentivize a healthcare system to be consistently unremarkable and thereafter measure and monitor deviations from unremarkability? Might this model change the expectations of what constitutes innovation? Many investors in the stock market prefer what are called “SWAN” companies: “sleep-well-at-night” firms. A SWAN firm shows unremarkability. By contrast, FTX, the bankrupt cryptocurrency exchange run by a disgraced fraudster, was historically touted in the financial media and in venture capital circles as visionary and always remarkable (Ramey and Fanelli 2023).

Conclusion

To be unremarkable, and to think in terms of the pursuit of unremarkability, requires a culture change in many sectors. Our society encourages people and institutions to be remarkable, to outclass one's peers in ferocious competition. But to lift all boats, there are some industries – notably in healthcare – where doing okay enough all the time maximizes the health and welfare of everyone and supports quality improvement across all institutions.

When allocating return on investment for any health system, I wish for a strategic plan the primary orientation of which is unremarkability. What a beautiful word!

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