Friday, October 23, 2009

Chaos Theory, Health Reform, and Medical Organizations

The Wall Street Journal today carried a book review on Chaos and Organization in Health Care (MIT Press, $29.95). Its authors are Thomas H. Lee, MD, and James J. Mongan, MD. They arek respectively, the network president and chief executive of Partners Health Care, the Boston-based parent company to Brigham & Women’s Hospital and Massachusetts General Hospital, as well as empire extending to a large number of medical clinics and hospitals in Greater Boston.

Partners Health Care’s mission is to bring chaos out of health care disorder in Boston, as well as greater Massachusetts, which already has a 3 year old universal health plan, also designed to minimize chaos. This is ironic. Boston has always considered itself the Hub of Medical Care – the most organized and progressive cluster of medical centers in the nation.

Drs. Lee and Mongan admit bringing workable harmony among Boston caregivers can be difficult. Medicine, it seems, is riddled with “gray zones,” where there is no perfect therapy, given the variability of disease, patients, and doctors themselves. If this is a problem in a tightly knit organization like Partners Health Care, rampant dysfunction must exist the nation as a whole, where independent physicians in solo practice or groups of less than 5 deliver 87% of the care.

Big groups like Partners Health Care may help bring order but they may also create top-down bureaucracies that squelch innovation and creativity. Ask any doctor what fellow doctor they admire the most, and it is likely to be a creative diagnostician – not a faceless organizational bureaucrat. Lee and Mongan face this dilemma and others like it head on. They say ingrained medical cultures and mindsets resist change and that big organizations are unlikely to bring down costs. In Boston and Massachusetts, Partners Health is the most expensive act around, partly because it monopolizes care and can dictate its price.

The two physician executives say that while big organized integrated groups may be an improvement over independent physicians, they offer no panacea. According to the reviewer, “The future of medicine will continue to be defined by experimentation and a fitful groping towards improvement – a long, slow, grubby process not timed by five-year plans emanating out of Washington.”

The Lee and Mongan book reminds me of another book with “chaos’ in the title, From Chaos to Care; The Promise of Team-Based Medicine “ (Perseus Publishing, 2002@) by David Lawrence, MD, chairman emeritus of Kaiser Permanente. Both books share the same thesis, we would do much better is large systems replaced thousands of small practices. This view mirrors conventional Washington wisdom. If we only had more Mayos, Kaisers, and Partners dotting the landscape, costs would down 20%, salaried doctors wouldn’t have incentives to do more, care could be standardized, and outcomes would improve.

Which brings me to chaos theory. In 2008. Dr. Edward N. Lorenz, a meteorologist who sought to predict the weather with computers but instead ended up fathering chaos theory, died at 90 at his home in Cambridge, Massachusetts. Lorenz was best known for describing the “butterfly effect,” the idea that a small disturbance like a butterfly flapping its wings in Brazil could cause a tornado in Texas. The flapping wings represents a small change in the initial condition of a system. This causes a chain of events leading to large-scale phenomena. Had the butterfly not flapped its wings, the final system might have vastly differed.

Dr. Lorenz realized perfect weather forecasting was a fantasy. Perfect forecasting requires perfect knowledge of wind, temperature, humidity, and other conditions everywhere around the world at one moment of time. Even a small descrepancy could lead to completely different weather.

The butterfly effect applies to all matters initiated by mankind – health systems. financial markets, epidemics, wars, global warming, forest management, mortgage crises, physician shortages, and health system costs and outcomes. Similarly, perfect health reform forecasting requires perfect knowledge of the needs, wants, expectations, and disease, cultural conditions of individual patients and independent doctors in every nook and cranny of the land.

It is a fantasy that one can predict and completely control social consequences and behaviors with organizations or computers. The variables are simply too many. As chaos theorists say, “Small variations of the initial condition of a nonlinear dynamical system may produce large variations in the long term behavior of the system.

I believe health care reforms – the tweaks, tucks, rules, regulations, programs, accountable health organizations, protocols, algorithms, taxes, and other solutions will bring adverse and unpredictable consequences.

Reverse chaos theory may be at work here. Instead of the Washington tornado clipping the wings of patient and physician butterflies, the reverse may be true. Health care expectations – the wings of individual patients and independent doctors – may continue to cause the tornado in Washington.

Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform ( is available at,, and for $31.95 (hardcover), $21.95 (softcover), and $6.95 (electronic). For information on speaking fees and arrangements, call 860-395-1501.


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