Regarding The Death Of My Father
In my book, Regarding The Death Of My Father, I wrote of my father’s death, then I concluded the book with an essay on the increasing levels of specialization in the medical industry, and how that automatically, almost mechanically, changes the relationship between doctor’s and patients:
Our medical system optimizes for certain straightforward situations. If you are a middle-age man with chest pain, you are lucky to be in the U.S. If you are a middle-age woman with vague neurological pains, you are out of luck. Our system is not designed for you. Over the course of two years, you will probably be sent to a dozen different specialists (or maybe twice that many), each of whom will have a different diagnosis for you. One will tell you that you have hypothyroidism, another will tell you it's Crohn's Disease, someone else will say it is fibromyalgia, or maybe Lyme Disease. Ask 10 doctors and you'll get 12 opinions, but you won't be offered a disciplined, structured process for narrowing those 12 opinions down to 1 or 2 action items that deserve to be prioritized. But assuming that the medical profession develops a disciplined, structured process for prioritizing specific follow-up actions, who will explain it to you, and who will walk you through the process, and who will organize all of the actual follow-up work? People who've never had a long illness don't realize what a nightmare the American medical system can be, not just because of the complex insurance situation, but also because it is so common for one doctor to send you to another doctor who sends you to another doctor, and all of them have the next 6 weeks booked solid, so in every case you are waiting a month or two for an appointment and so a year goes by and you've made only minor progress toward getting a real answer to your questions.
What will the American medical system look like in 50 years? Has the national leadership done a good job of leading the nation in a conversation about how the system will change? Anyone who has read much economic history knows that a team of narrowly focused specialists can often deliver a faster, higher-quality, lower-cost product than what is delivered by a master craftsman. Adam Smith gave us the example of a pin factory where every worker did a single thing and therefore did that one job better and faster than they could possibly have done if each worker were trying to make an entire pin, and the pin factory produced many more pins as a result. A century later, Henry Ford offered another example of essentially the same phenomenon by producing cars on an assembly line, with each worker doing a specific thing, and suddenly the cars were cheaper and better quality than those cars that were slowly built by master craftsmen. Surely something similar must eventually happen in the medical care system? The level of specialization continues to increase, but so far the work is still mandated, by legal edict, to follow a process that first took shape in the late 1800s, with a single doctor carrying nominal legal authority to authorize each step in the process. How long can that old system continue to work? Do we want it to continue? Will we be happy if the same process is still in place 50 years from now?
Since I’ve spent 21 years leading teams of software developers, and helping startups better organize their startup teams, I can tell you I’ve seen certain bad patterns repeat over and over again. In particular:
Company starts with just one software developer. The whole company is perhaps just 4 people, so it seems natural that everyone talks to everyone else, everyday.
The company gets larger. Now there is a full Marketing department, a Content department, an Operations department. The tech team grows to 4 or 5 software developers, but there is no one in charge yet.
It becomes common for the head of marketing, or the head of content, to grab a software developer and force them to work on whatever seems important. This leads to chaos. The work of the tech team is scattered on a dozen different initiatives, and each leader insists their initiatives are the most important.
Eventually, the requests for new initiatives need to be corralled into some formal process. One person who I saw handle this transition well was Mark Herschberg. During the era from 2001 to 2011, ShermansTravel had operated without a CTO, even though they had a CMO and a CFO and a CSO and a Chief Content Officer. The result was exactly the kind of chaos that I described above. The company had five software developers on the tech team, and those developers faced constant pressure from the various C-level officers. As everyone worked in one big room, the CMO could simply walk over to one of the software developers and say, “I need you to drop everything and focus on this one particular task, because Marketing really needs it,” and then two hours later the CCO might walk over and say, “Hey, we really need this for Content, please focus on this and nothing else.” I could write a whole book about how this undermined the company. But in early 2011 the company hired Herschberg as the CTO, and he brought order out of chaos. He developed a point system in which every C-level executive had a budget of a certain number of points, and every request became a ticket that had an estimate of points on it, and, for any particular two-week sprint, the various competing C-level officers could use their budget of points to buy the tickets that they wanted to see happen during that sprint. The crucial element to this was that Herschberg, being a CTO, could speak to the other C-level executives as an equal. The system worked impressively well.
Regarding the chaos of too many requests being sent to too many people, and all of them labeled “This is our number one priority,” I see the same thing now happening with our medical system, but sadly, there is no one in charge of the overall medical system, no one who can step in and say “Wait, we need a better system for figuring out what our number one priority is.”
You might be wondering why I’m diving into the details of the USA medical system on a weblog that is supposed to be devoted to questions of politics, democracy, leadership and accountability. I’m doing this because I think the problems in our medical system are a small version of the problems that are tearing apart our democracy. In particular, increasing complexity and specialization has changed the relationship between doctors, nurses, hospital management, and the patients, to a degree that causes everyone an enormous amount of stress, and thinking about how this system needs to change reveals something about how the larger system should change.
In my book, I make the argument that increasing specialization has killed the traditional role of doctor, and while we still have people who are called “doctor” they no longer perform the roles they used to perform, and they are being forced into new roles that waste their time and increase expense while benefiting no one. I suggest that what’s needed is someone between the doctor and the patient — a patient advocate, who can play a role for us like a lawyer would play for us if we were accused of a crime.
Since this is also going to be among my suggestions for fixing our democracy, I here post the bulk of my argument, as it applies to the medical system.
Still, this is the 21st Century. We have a wealth of sociological studies that reveal how much individual effort can be distorted by group dynamics. (Consider the original Milgram experiments, back in the 1960s, where participants believed they were delivering almost lethal electric shocks to study subjects, and these participants did so feeling that those in charge of the study would accept responsibility. Workers in bureaucracies often demonstrate this same obedience to rules, even when the rules lead to unfortunate results for some particular individual. See: https://www.verywellmind.com/the-milgram-obedience-experiment-2795243 .) Every bureaucracy develops its own strange dynamics, which often limit the effectiveness of the people being managed, and occasionally cause outcomes that are the very opposite of what people in the system want.
Accepting and encouraging professional adversaries in the medical system will lead to better results for patients. This principle is already recognized regarding pregnancy, where it's become somewhat common for women to have someone with them who is trained to advocate for them (the traditional term for this is "doula"). I'm suggesting that something like this needs to be expanded to all patients, for all situations. Such a change would offer two benefits:
1.) Patients who know nothing about the medical system would have an objective professional who could explain the medical system to them.
2.) When a blind algorithm, enforced by the unthinking bureaucracy, would lead to a horrific outcome for a particular patient, there is someone who understands the bureaucracy and who therefore can go to war against it to pull from it a solution that better adapts to the unique circumstances of this particular patient.
Am I actually suggesting something new? One could argue that anyone in the U.S. can hire a lawyer and sue any medical establishment for malpractice, thus what I'm suggesting already exists. But that's not what I'm thinking of. Malpractice lawsuits are reactive; they happen after something bad has happened. I'm thinking of something much more proactive, something that helps shape the care a patient receives while they are in the hospital. Something a bit more like a defense attorney, filing motions to get the best treatment for the accused, but right there with the patient, in the hospital, just as a defense attorney would be with their client when in court.
What is the difference between a patient advocate and a doctor? Let's review the history. During the 1800s a doctor was someone who took absolute responsibility for the health of a family. At that time, a family doctor was practically part of the family. If someone was sick, you called the doctor and they came over to your house right away to see if they could help.
We have moved away from that model by two related factors:
1.) the growth of medical knowledge led to specialization among medical professionals
2.) a vast bureaucracy sprang up to organize the different specialists and to manage the money needed to pay for the complexity of the system
Consider the novel Tristram Shandy, written by Laurence Sterne and published in 1759. Sterne remarks that doctors are making such remarkable discoveries, at such an astonishing speed, that the sum total of all medical knowledge had doubled during the previous seven years. I'm not sure how he was measuring, but it is true things were moving quickly at that time and have continued to do so for the ensuing 260 years. By 1900 it was generally understood that the total amount of medical knowledge was exceeding what one person could memorize, even if they devoted their whole life to study; therefore, doctors were going to have to specialize. And as they specialized, they would lose sight of patients as whole people, and would come to see them as blobs of specialty parts: a heart, a liver, a nervous system.
The crucial point is that, from the perspective of the 1800s, we no longer have doctors. Most people make the assumption that the modern family General Practitioner is the same as what used to simply be called "doctor," but there are some important differences. In particular, a general practitioner will not give you advice if you get contradictory advice from two specialists.
An example: you are a middle-age male with some occasional chest discomfort. You go see your General Practitioner. They send you to a cardiologist. The cardiologist says your arteries are clogged and you'll have to go for triple bypass surgery. You are concerned and you'd like to know your options. Both your General Practitioner and the cardiologist suggest you get a second opinion. So you go and see a second cardiologist. This new cardiologist doesn't think your condition is so bad and that it can be managed with a stent and some medication; no surgery is necessary.
Who is right? And who can help you decide? If you ask the General Practitioner, your so-called doctor, they will demur and explain that they cannot advise against a cardiologist on a matter that is explicitly involving the heart.
You can seek a third opinion, a fourth, a fifth. You'll end up with a lot of opinions. And in the end it will be you who have to decide.
That’s what I find absolutely amazing regarding the modern medical system; on the most complex issues of life and death, we are thrown back on our own resources.
What is the difference between a patient advocate and a doctor? I'm imagining a patient advocate as a new role that combines attributes of a doula, a lawyer, and some old functions of a doctor.
There is one more trend to consider which influenced how I reached my conclusions.
In 1900, doctors spent close to 0% of their time on paperwork. They would quickly dictate some patient notes to a nurse, who would act as secretary. There was no bureaucracy managing payment systems, so there was no need to figure out which "codes" the bureaucracy was expecting for a given condition, or treatment, or test.
In the 1960s doctors were still only spending about 5% of their time on paperwork, though with the growth of private insurance and the introduction of Medicare and then Medicaid, the need for paperwork was growing. But fortunately, at this time, most insurance schemes covered 100% of costs without review, so there was no system of approval needed, no co-pays, no complex math about who had to cover what percentage of each different procedure.
In the early 1990s, the HMOs began to take over, and with it the concept of "managed care," which was a euphemism for insurance companies that could argue over a bill and refuse payment for some procedures. This meant doctors now had to justify everything they wanted to do. This was the inflection point that led to the explosion of bureaucracy. Even worse, most small hospitals didn't have the money to hire lawyers to fight the HMOs when they refused payment. The biggest medical systems, however, did have the money to hire such lawyers and win cases — awarding them even more money. This was the beginning of the era when the American medical system began to consolidate. Small, rural hospitals no longer generated enough revenue to survive.
At the current moment, most studies suggest doctors are spending almost 50% of their time on paperwork. When economists wonder, "Why has labor productivity in the U.S. stagnated for the last 50 years?" they should consider situations like this, in which the best-educated and most productive category of worker loses 50% of their time to paperwork. Among the many problems of the new system, it has amounted to a war against efficiency.
In recent years, the system has been moving to use nurse practitioners instead of doctors. For instance, a nurse practitioner anesthesiologist does everything that an anesthesiologist used to do, but the anesthesiologist continues to carry the legal burden and the insurance to protect them from lawsuits, while the nurse practitioner does all the labor. During surgery, a nurse practitioner anesthesiologist will keep the patient alive. In theory, they are under the authority of the actual anesthesiologist, but this is a legal fiction.
While this system can be applauded for separating the work from the legal burdens of the work, it means that a doctor spends 10 to 15 years learning a specialty, such as anesthesiology, and then immediately abandons it and becomes a manager who oversees nurse practitioners. It is entirely inefficient. For this reason, I view the current situation as transitional. But that raises the question, to what kind of system are we transitioning?
Start with the history, and then follow the trend. Where does it go? At some point doctors will spend 70% of their time on paperwork, then 80%, then 90%, then eventually all of their time. The system is clearly demanding someone who can fill this role, someone who can absorb the burden of the bureaucracy.
What does this mean? Why should the system generate such a curious and counterintuitive phenomenon? Why would anyone want doctors to spend almost all of their time on paperwork? At what point does the medical system actually help real human beings?
When I talk this over with friends who understand the medical system, some indulge in fantasy: they believe that one day the bureaucracy will magically disappear. They suggest that one day the U.S. will have a different payment mechanism, perhaps single-payer, or perhaps whatever Sweden does, or Canada, and all of our problems will be solved once we pass a particular law.
As I mentioned, I regard this as fantasy. It is true that if the U.S. adopts a simple payment mechanism, then the bureaucracy will shrink, insofar as it relates to payment. But it will continue to grow insofar as it relates to organizing an increasingly specialized system.
Therefore I take two trends to be irreversible.
1.) Medical knowledge will continue to expand; ergo, medical professionals will continue to specialize into ever-narrower domains of knowledge.
2.) The bureaucracy must continue to expand to help organize the complexity of a system that is made of a number of increasingly narrow specialties.
(I am somewhat influenced here by my long career in software development. A simple app can do one thing, do it well, and can be written in a day — and it can be excellent software that does a beautiful job with its one task. However, as a software system becomes more complex, a greater percentage of the system needs to be given over to the meta task of managing the system. In very large systems, one needs a system of systems. And as some of the systems I've worked on have been in the service of medical bureaucracies, the growth of the complexity of the software system gives me insight into the growth of the complexity of such bureaucracies.)
Is there any point having a doctor who spends 100% of their time on paperwork? Does it make sense that someone should spend ten years of their life pursuing advanced skills so they can save human life, only to then be told that they should never again examine a human? Doctors are, in some sense, the last craftspeople. One can no longer easily find a master woodworker to build an unusual house, nor can one easily find a master potter to create a set of mugs using an unusual mix of minerals. Even as advancing technology and increasing specialization have virtually eliminated the great crafts of old, so too the same trends are now devouring the remnants of the traditional general practitioners.