Has Sensemaking Collapsed When It Comes To U.S. Healthcare?

By MIKE MAGEE

This past week my wife and I were at a family event to celebrate my brother-in-law’s 70th birthday. Our extended family has more than a few doctors. A physician nephew who had read CODE BLUE and had a strong interest in health policy asked if I felt I (and others) were too hard on doctors. My response was yes, but that it was intentional and came with the territory. Combining scientific, sometimes life and death expertise, with high-touch compassion, understanding and partnership has always been a “big ask” but that was what we and others had signed up for as “health professionals.”

But can a health professional be “professional” in a fundamentally misaligned health system? And, if not, does a health professional have a responsibility to engage in an effort to reform and transform the system to behave professionally?

Professionals are generally members of a vocation with special training, highly educated, enjoy special trust and work autonomy, abide by strict moral and ethical obligations, and in return are generally self-regulating. Their academic training is expected to reliably provide those they serve with special skills, judgement, and services. When they deliver, society responds with confidence and trust and durable long-term relationships.

My nephew and many of his contemporaries have come to believe that this is neigh impossible under the current heavily corporatized, profit driven, inequitable, under-insured, and widely inaccessible system. They have begun to voice that being an ethical and competent professional in an unprofessional system is not possible, and not their fault.

System redesign guru, W. Edward Deming, the father of Quality Control Management, and the man credited with assisting the Japanese in transforming their auto industry, had this to say about transformation in 1993: “The prevailing style of management must undergo transformation. A system cannot understand itself. The transformation requires a view from outside…The individual, once transformed, will: set an example; be a good listener, but will not compromise; continually teach other people; and help people to pull away from their current practices and beliefs and move into the new philosophy without a feeling of guilt about the past.”

Six years later Don Berwick MD, Emeritus President of the Institute For Healthcare Improvement and now Harvard Health Policy professor, delivered a classic speech, “Escape Fire: Lessons for the Future of Health Care”,  sponsored by the Commonwealth Foundation. In it Don recounted the events surrounding the tragic fire at Mann Gulch, Montana which claimed the lives of 13 “smokejumpers” on August 5, 1949. He reviewed the lessons learned in a system analysis by Professor Karl E. Weick of the University of Michigan, in his paper titled,“The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster.”

Berwick explained, “Sensemaking is the process through which the fluid, multilayered world is given order, within which people can orient themselves, find purpose, and take effective action. Weick is a postmodern thinker. He believes that there is little or no preexisting sense of organization in the world—that is, no order that comes before the definition of order. Organizations don’t discover sense, they create it…In groups of interdependent people, organizations create sense out of possible chaos. Organizations unravel when sensemaking collapses, when they can no longer supply meaning, when they cling to interpretations that no longer work.”

Now roughly a quarter century ago, Berwick concluded, “I love medicine. I love the purpose of our work. But we are unraveling, I think…Sense is collapsing… We need to face reality…Why did it take the Mann Gulch crew so long to realize they were in trouble? The soundest explanation is not that the threat was too small to see; it is that it was too big. Some problems are too overwhelming to name. I now think that that is where we have come in health care; I have been radicalized.”

Clearly the visions we have been using are under-powered, and we seem to be heading in the wrong direction with information technology and AI fully prepared to make permanent a system that is moving patients to despair and doctors to early retirement. What are the questions my nephew and his health policy colleagues should be asking now?

1. How do we make America and all Americans healthy?

2. What is our national health care plan, and who is in charge?

3. How do we balance national and state responsibilities?

4. How do we maintain balanced humanistic and scientific care, and preserve patient and health professional autonomy over complex life and death decision making?

5. How do we advance healthy behaviors while providing high touch access to health professionals for acute and moderate issues?

6. How do we use information technology and AI to expand human and social, rather than just financial, capital?

7. How do we prioritize investment in human contact between patients and health professionals over wealth enhancement and brick and mortar expansions?

8. How do we put a smile (independent of money) back on the faces of doctors, nurses and patients?

9. How do we separate hospital and physician profit driven research from direct patient care?

10. How do we move to geographic annual budgeting of comprehensive care and eliminate individual billing/reimbursement operations?

Mike Magee M.D. is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside the Medical-Industrial Complex (Grove/2020).

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