• In an Era of Epidemics, Time for Some New Rules

    Larry McEvoy Dec 05, 2016

    Larry McEvoy“I love being a doctor, but I hate coming to work.”

    It may have been a lone physician who said that, but the deflating sense of a profession lost pervades the clinician psyche these days. We are living in an age of epidemics—opioids, obesity, physician and nurse burnout. We have other epidemics, too, in a manner of speaking: painful electronic health record installs, hyperproliferative regulation, a swirl of mergers and acquisitions (depending on how you count them, over 110 in 2015, breaking the record set in 2014, and on pace for more this year).

    Health care has gotten bigger, more sophisticated, more technologically capable—and apparently more dispiriting, more disconnecting. Its very inertia has rendered masses of categorized people (patients, families, clinical personnel, nonclinical partners) weary, disempowered—and unhealthy.

    We live in a metric-driven, pay-for-performance world—where the metrics are abundant, cost is still high, performance still variable. Good things are going on, of course, and talented, committed people are working on these issues every day. But we’re wearing out. It’s increasingly clear what we’re supposed to do, but continually bewildering how we’ll get there before we run out of energy. The goals are good, even great, but you have to wonder about our collective physiology, which might best be described as chronic adrenergy.

    Each of us is small—what to do in all this sprawling bigness? Where do we start? How do we create a sector, an industry, a profession, a vocation, an experience in which individual volition, trust, and fulfillment increase in conjunction with systemic value, adaptation, innovation, consistency, and reliability? The mere question is enough to trigger cortical vertigo. It’s all gotten so complicated that people are revving up, then tiring out, and then going numb.

    Around such appropriate and necessary goals, the approach we’ve used to design the environment in which we all live and work has grown pretty mechanical: Scale + productivity grids + clinical policies and protocols + trained best practices = something better, somehow, some way, yet not fast enough (but actually = long surveys + long waits for data + harried clinicians). All this mechanical complicatedness isn’t working.

    Perhaps complicatedness isn’t what we’re supposed to be doing. Perhaps all this mechanical thinking is the moribund remnant of an era of assembly lines and mass production that is less applicable to modern-day healthcare challenges. These require a neural net of thought and action, the design of which allows us to knit together the big and small, the practical and meaningful.

    Striving for an Adaptive System

    More and more people are beginning to understand that health care should work less like a machine and more like a complex adaptive system—a honeybee hive, an ecosystem, or the human body itself. As Dinesh Sharma, a vice president at SAP, wrote in a recent Forbes blog post, “A connected company is a complex, adaptive system that functions more like an organism than a machine.” 

    Sharma drops this pearl that every harried clinician will recognize in a physiological context and as an antidote to a harried day: “Natural interactions that remove unnecessary aspects from our daily work lives allow us to seize the full promise of hyperconnectivity.” Dee Hock, the founder of Visa, put it this way: "Simple, clear purpose and principles give rise to complex, intelligent behavior. Complex rules and regulations give rise to simple, stupid behavior.” 

    Complex adaptive systems embody both the daunting challenge of reordering our thinking and the inviting possibility of a more elegant function arising from a return to simplicity. Such systems, it turns out, are self-organizing (no, that is not an oxymoron): Their identity, properties, and effects emerge from the micro-interactions within them and, consequently, from the character of those micro-interactions, repeated again and again and again. 

    In other words, establishing collaboration in an organization requires establishing collaboration at the person-to-person level. For starters, scalpel throwing is out. Using first names and expressing gratitude is in. Simple enough. What ultimately emerges, what pops up even though it isn’t expressly designed, is a culture that innovates, for example, or begins spontaneously self-modulating through coaching and feedback within the field of collaborative individuals who begin creating unintended but adaptive outcomes.  Bee-flower, bee-flower, bee-flower, bee-bee, bee-bee, bees-bees: honey.

    Amid all these epidemics, all this bigness that makes us potentially so small, the idea of thinking in terms of a complex adaptive system means we get to think about simple rules—rules that might recharge fundamental interactions in the field of health care in a way that attracts increasing “collisions” between “particles” (i.e., meaningful interactions between patients and clinicians, and within and across teams and disciplines, in a way that drives emergent, macro value—all those gigantic, elusive outcomes we seek). If the interactions between physicians, physicians and patients, staff and families, etc., are designed around what is essential and attractive to the participants, the need for “engagement” goes away, and the capacity for these interactions to imbue the entire organization with a constructive approach goes up. So what’s attractive to doctors and patients? Motivation. Learning. Connection. Impact. Influence.

    Achieving Elegant Function

    Perhaps the evolution of health care is more like embryology—getting the fundamental unit and process right and then multiplying again and again, establishing a consistent identity of how cells act and interact  that streams into billions of cells, then tissue, and finally organ systems, resulting in the elegant function of an entire organism. Maybe bottom-up and side to side are necessary ways to design, build, test, and adapt essential complements to the signals that come at us from the top down and outside in. 

    In complex adaptation, our role as leaders becomes about weaving context out of chaos, facilitating interaction and accelerated learning, and aggregating that context, interaction, and learning into a positive counter-epidemic that can grow by restoring our energy rather than degrading it. “I love being a doctor, and I love how the way we work makes so many things happen.” Possible? Yes. Easy? No. But not complicated.

    Larry McEvoy, MD, FACEP, is co-founder and chief of strategy and innovation at PracticingExcllence.com.