Monday, November 3, 2008

Systems think - Groupthink, Systemsthink , and Health Reform

As the nation gets set to embark on a new health reform era under a new president, doctors across the land worry about what lies ahead. Is a nationalized system dominated by large groups finally at hand? Or will the current chaos persist?

I don’t know, but personally I worry about the hazards of two mindsets - groupthink and systemsthink.


In a 1972 book Groupthink, Irving L. Janis, a Yale psychologist, explained how groups of experts could make colossal mistakes. Experts in groups worry about their personal reputations, their role in the new government, and whether if they deviate too far from the consensus of their peers, they will be ostracized as reckless mavericks. Very few professional economists, who number about 200, for example, warned of the current economic disaster while it was in the making.

There is little room for dissent among experts. An example in health care might be Democratic health experts who have yearned for so long and so desperately for government controlled Medicare-for-all system. To doubt the inevitability of such a system is moral heresy. To say that such a system might deprive citizens of freedom, choice, and individualism it to follow the doctrine of cruel conservatism. To point out that you cannot simultaneously have a robust economy and a pervasive welfare state, or suffer the fate of the stagnant economies of Europe, is unthinkable.

Groupthink exists on the conservative side of the ledger too. To stray from the thought that an unregulated free market with a completely consumer-driven model is to preach the doctrine of centralized command and control socialism is dangerous if you are to be a member of the conservative club.. To say consumers might not have the judgment and information to make responsible health care decisions is anathema.

To assert, as I do, that American want a mix of government control and individual choice, as long as someone else pays for it, is cynicism of the first order.


Which brings me to systemsthink. Read or listen to experts on both government and free-market sides of the aisle, and you will invariably run across systems’ advocates. They say the answers in health care lie not in individuals, be they physicians, patients, or policymakers, but in large organizations deploying systems.

The best explanation of systemsthinking I have run across was not in some arcane academic or management book, but In a sports article in the November 2008 New York Times Sports Magazine by Jeff MacGregor, “Here Goes Nothing: Brett Favre, Freethinking Huckleberry in the N.F.L Industrial Complex, Tries to Make Something Happen One More Time.”

The Jets’ System – and its various subsystems – is just one of 32 such systems currently deployed across the N.F.L .industrial complex. These systems are all differing – systems for offense, systems for defense, systems for special teams. A system of systems.

It’s all very complicated and scientific and dull. For 25 years, the N.F.L – roughly parallel to the rise of the computer – the System has been ascendant. At once the weapon against chaos and a holy talisman against chance. They system is against intellectual human confusion and statistical weakness. It offers digital probability and plausibility. The System promises to abate risk and assuage uncertainty.

Systemsthinking pervades health care too – at Kaiser Permanenti and other large multispecialty groups, among experts in board rooms and corridors of health plans, hospitals, pharmaceutical companies, and academic medical centers.

Systemthink is understandable and necessary. Human beings, patients, physicians, hospital executives, and payers need systems discipline. We all need some system = socme context in which to operate, thrive, survive, and improve.

But as is the case with Brett Favre, there has to be room for individualism and heroism too. – for self-expression, grace, spontaneity, independence, and intuitive thinking and performance. Artists and athletes like Brett Favre and high performing physicians need a system in which to function. But the System needs the Art of Medicine too, wherein physicians can be free of the constraints of the system and its computer models. I worry in the future we will rely too much on groupthink and systemsthink and algorihmicthink, and too little on Humanthink and self-reliance.


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