Unintended Consequences
Believe it or not, there really is a way to transform our tragically broken healthcare system into one that’s sustainable. We don’t have to sacrifice quality for quantity, as we have been. I want to share thoughts and experiences in this blog that I believe can help lead to a better way... and learn from your feedback and experiences.
It wasn’t until I quit my job as Chief of General Surgery at the University of Missouri in December 2009, when my brain was able to begin to truly understand the concepts of Systems Science. I went on a one-week vacation to a resort in Arizona. I was supposed to be relaxing, playing golf and not thinking about the stress of healthcare. I was reading a novel called State of Fear, a science fiction thriller about global climate change and ecoterrorism by Michael Crichton.
I was fascinated with the amount of scientific background that was included in the story. During a heated discussion toward the end of the book, John Kenner (a main character) was challenging the ability of humans to control our biologic environment. The example he used was the National Park Service in the United States.
Created by Ulysses S. Grant in 1872, the initial effort included two million acres that were set aside and became Yellowstone National Park. In 1903, Theodore Roosevelt visited the park and wanted to preserve the beauty and natural environments of the protected land. After his visit, the National Park Service was formed – the primary job of this new bureaucracy was to maintain the park in its original condition.
In the best interest of preserving the park and its animals, the park managers thought there was a problem regarding the elk population. They thought the elk needed to be protected because their numbers were dwindling, so they began to kill off the elk predators, the wolves, and do things to help make sure the elk were not dying off.
Within a short period of time there were numerous unintended consequences related to the park rangers’ attempts to control the natural environment – the elk population grew out of control and they ate so much of certain trees and grasses, that the ecology of the area began to change. They ate the trees that beavers used to make dams, so the beavers vanished. With the beavers gone, the meadows dried up, the trout and otter vanished, soil erosion increased, and the park ecology continued to change due to the unnatural interventions.
By the 1920s it became clear that there were too many elk, so the rangers began to kill them, resulting in another devastating blow to the environment. Within a decade the teaming wildlife of Yellowstone was almost gone. Unfortunately, these attempts to control the environment went on and on and on.
As I read these pages, something in my brain clicked – new synapses were connecting in my higher cerebral cortex; I thought, “This is healthcare! THIS IS HEALTHCARE!” These simplistic, command and control attempts to “fix” healthcare are not working and almost always lead to unintended consequences. It’s like the front line of healthcare, including doctors, nurses, and patients, are the wolves being controlled by those who make the rules. But, when these rules are simplistic attempts at controlling a complex, biologic system, they can never work as intended.
From the codes developed for the fee-for-service payment model, to financial incentives and penalties used in an attempt to reduce hospital readmissions, to the perverse incentives that result in care provided only when it is covered or approved by an insurance company – our healthcare leaders are attempting to control the system by applying simplistic, reductionist, command and control types of rules that cannot work in a complex, biologic world that is constantly changing.
Just as Einstein and other physicists discovered the incompleteness of Newtonian physics, we are just beginning to understand the incompleteness of our current research and management methods in healthcare. We’re entrenched in our traditional management and research principles, which are based on the understanding of static, isolated, mechanical systems (known as Reductionism). In those systems, a cause is always followed by a predictable outcome. But in our real, complex, biological world, the same cause can have multiple potential outcomes, some of which are not predictable (known as Systems Science).
Getting back to Yellowstone, it wasn’t until 1995 (nearly eighty years later) when the wolves were re-introduced into the park. Within a few years, positive changes began to happen. This brief video documents the impact of returning a biologic system to a more natural state. How long will it take in healthcare before we apply Systems Science principles and give the authority and resources back to front-line clinicians and patients to allow us to measure and improve meaningful outcomes that measure the value of care in each definable, whole patient care process? Hopefully soon.
That was just the beginning of the changes taking place in my brain, more than a decade ago, that ultimately allowed me to truly understand Systems Science and apply these principles to real patient care.
This blog is about the reimagining of healthcare through the lens of Systems Science. For the past decade, our small hernia team, assisted by many collaborators (including the input from patients and family members), has been applying systems science principles to real patient care. I believe applying these principles to healthcare will be necessary to achieve a sustainable healthcare system globally.