

Big Med (2012) - tptacek
http://www.newyorker.com/magazine/2012/08/13/big-med

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grownseed
Talking from a slightly different perspective - the public health sector (so
not the US) - I can also confirm that a number of the major problems in
healthcare stem from entrenched cultural values. Most healthcare staff I work
with or have met are really adverse to change. One must understand however
that it is not change itself that they usually dislike, it is everything that
comes with it.

Historically, healthcare, particularly the public kind, has proven to be
riddled with senseless bureaucracy, and trust me, I don't mean that lightly. A
simple change to a procedure will require filing forms upon forms, countless
layers of approval (often from people who have little to no relevance on the
matter), using completely antiquated systems, etc. The first step to
facilitating the acceptance of change is to cut the bullshit, to let people do
their jobs, but that too is made very hard.

When ills and death are at the core of your field, it's easy to see how people
will constantly look to assign or shift blame. Bureaucracy, in its own very
messed up way, attempts to fix this but instead ends up tripping over itself,
repeatedly and increasingly. Costs that should have been divided and spread
instead end up being multiplied and painfully reworked to match the different
sources of funding.

Another major pain point in the public health sector (at least in Canada)
which the OP indirectly touches on is the drastic lack of common business
skills among leaders. In fact, the hierarchy and the "power pyramid" are
completely and utterly devoid of any common business sense. Authority and
management positions are aquired purely on the basis of seniority and academic
fame (a whole story by itself...), but not a single drop of management skills
is ever required. It is not uncommon to see well networked researchers make it
to the top while having no social skills, no business experience and no
leadership skills, all the while directly or indirectly, and often
unknowingly, affecting hundreds of healthcare workers, and ultimately the
patients. Redundant effort (duplicated research, processes, etc.) is rampant,
entire departments can have several, unrelated heads, or conversely, exist in
near vacuum with nobody to be held accountable (again, worthy of a dedicated
story).

In this convoluted context, people will seek to bypass the rules or bend them
so far that the rules themselves stop making sense. People at the top will
often officially hold different supposedly full-time positions (!) to get
their salaries increased (because the current process, particularly with
recently-enforced unionization, no longer allows for individual raises, and
because funding is so fundamentally messed up). The "ground" staff will often
do whatever it takes to satisfy the rules, often in ways that don't satisfy
the original aim of the rules but that allow work to be pushed through. As an
example, I pointed out severe security issues in our organization ; the
response was to create a security council that would decide how to act on it.
The result was official (ISO) standards are now being implemented (more than a
year later) with people scratching their heads to find the most creative ways
to meet those standards, so swaths of new standard operating procedures are
being designed, which will themselves require validation, through validation
processes that do not yet exist. Meanwhile, nearly all the security issues I
identified back then are still well and truly alive, but the illusion (or
rather, public appearance) of security apparently matters more politically
than actual security.

The topics I have discussed here barely blow the dust off of the old
proverbial healthcare book. As much as I feel rewarded by my professional
position in a technical way (and there is obviously a lot to do), I can't help
but feel bitter about the state of the system as a whole, about people's
attitude towards healthcare on all sides of the equation. My personal efforts
and suggestions to improve public healthcare are often met with the perennial
"eh, what can you do?" that disillusioned, blasé healthcare workers have grown
accustomed to.

Should anybody out there want to hear or discuss some of my thoughts on how to
fix (public) healthcare, or is already actively working on it, please feel
free to contact me, I'm kinder than I may appear :)

