Is Reforming Health Care into a Single System Realistic? The Hedgehog Guru and the Doctor Fox

The system is there is no system.

Steve Jobs (1958-2011), Apple Computer Founder

The most ingenious method of becoming foolish is by a system.

Anthony Ashley Cooper (1671-1713), English Peer

“A Successful and Sustainable Health System – How to Get There from Here”

Harvey V. Fineberg, MD, PhD, title of article in March 15, 2012, New England Journal of Medicine, President, Institute of Medicine

March 16, 2012 - In a famous 1953 essay, “The Hedgehog and the Fox, “Isaiah Berlin, an English liberal philosopher, divided the world into two schools:

1) Hedgehogs who view the world as a single defining system.

2) Foxes who see the world through the lenses of a variety of experiences which cannot be boiled down into a single system.

In a Shattuck Lecture, sponsored by the Massachusetts Medical Society, Harvey F. Fineberg, MD, a modern day liberal philosopher, redefines the Isaiah Berlin definition.

Fineberg believes the Hedgehog can deploy a variety of the Fox’s experiences and distill them into one national system.

Based on his present and past experiences as President of the Institute of Medicine, Provost of Harvard University from 1997 to 2001, and 13 years as Dean of the Harvard School of Public Health, he offers this solution to our health system.

“To achieve a successful and sustainable health system, we must be able and willing to try many different things. But therein lays a unifying idea: do many things. No single stroke will solve this problem. A successful and sustainable health system will not be achieved by supporting prevention, it will not be achieved by championing competition, it will not be achieved by comparing the effectiveness of different practices, it will not be achieved by striking commercial influence from professional decision making, it will not be achieved by changing the way we pay doctors, and it will not be achieved by just reengineering the system. It requires all these changes and more. We need the cleverness of the fox and the persistence of the hedgehog. We must be willing to adopt many strategies and use them to reach one big goal.”

Fineberg may be right. Most national leaders think a unified system is the ultimate solution. In his persuasive essay, Fienberg cites 20 sources for inefficiencies of U.S. health care, and he lists 17 potential uses of Health IT as a unifying solution. Presumably, once these inefficiencies are addressed, and Health IT corrects them, all will be well.

But what if Fineberg is wrong? What if the Foxes are right? What if no national system will achieve a solution unifying all peoples, all physicians, all hospitals, all communities, and all regions?

An Apocryphal Story

This question brings to mind the apocryphal story of a beleaguered clinician battered by health reform’s realities- loss of income, rising expense, declining prestige, managed care second-guessing, and constant critical scrutiny by distant third parties.

Seeking a solution to his problems, the clinician travels across this diverse pluralistic nation at great expense to Boston to see the Great Guru.

The clinician asks: “Oh, Great Guru, what is the solution to my problems?” The Guru responds,” The solution to your problems is a national health system!”

“What,” says the incredulous clinician, “I’ve traversed the length of this great land in my old car because I could not afford a new one with gas at $6 a gallon, through snow, sleet, rain, and wind storms,floods,droughts,and tornadoes, sleeping in my car to save cash to pay off my medical school debts, and you tell me that the solution is a national system?”

With a bewildered look on his face, the Great Guru replies,” “The solution is not a system?”

Tweet: Hedgehogs see a single sustainable system as the answer to our nation’s health problems. Foxes see solutions at the local level.