Health Care: The Blind Men and the Elephant

From The Physician Executive in August of 2007.

In health care, management and policy are a couple of steps removed from patient care. Physicians and other health care workers have insights that sometimes fall on deaf ears. But this is the era of Babel in health care; I don’t believe we have a common language yet, so we can actually understand what each of us are saying.

Health policy is a large enough field that, as in medicine, specialties are starting to emerge. When I speak with health policy types and health economists, they often see the world through the glasses of their area of interest. I know of an economist who specializes in transplant allocation. Another health economist is a state secretary of health (how rare is it that government hires a real specialist for any post, instead of a politician?) Some people are dedicated to providing care for the poor, other would like to preserve choices and options, which are usually relevant to the wealthiest and most privileged.

These different perspectives yield emphasis by turns on primary care or specialties, ambulatory or hospital care, cognitive versus procedural practitioners… Health wonks are like blind men trying to figure out what an elephant looks like.

Biological organisms are not mechanical, and this has an impact in various aspects of the health system. I recall an Operations Manager who couldn’t understand why the clinical staff didn’t follow medical guidelines the same way his computer staff created patient files. (This represents the mis-application of Six-Sigma to the wrong level of outcomes.) One of the most dynamic classroom discussion I experienced was when a bunch of mid-career professionals tossed around my assertion that “protocols” and “guidelines” are not the same thing. We settled on protocols for processes and guidelines for diagnosis or treatment. It’s too bad that medicine cannot be based entirely on empirical evidence, as an epidemiologist (I think) commenter to this blog asserts.

The complexity of people as biological and social organisms leaves us with so many unknowns, I am amazed at how much information we have that is actually actionable. But health care remains governed by careful judgment informed by some data, to help navigate the unknowns.

Experience can be a fickle teacher. So much of our perceptions are shaped by personal experiences, and then confirmed by the consequent bias. If we have a bad experience a physician, we are looking for confirmation in any trace of behavior of every subsequent interaction. So outliers can begin to distort our opinion of things: the greedy doctor, the uncaring insurance company, the bean-counting administrator, the abusive patient or the ignorant bureaucrat… These people exist for sure, but the vast majority are working stiffs who show up for work and try to do the best they can before getting home to their families and an over-leveraged mortgage.

In all this, it is the emotional context of health care that is the most ignored. The fear and despair that physicians and nurses see is forgotten in epidemiologists’ regressions, economists’ differentials and executives’ spreadsheets. No, the golden age of medicine is gone and good riddance, but something else this way comes and we don’t yet know what it looks like. Let’s just make sure it works for the middle: the normal patients, health care workers and administrators who show up every day and stay for every shift, no matter how terrible the things they see.