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The Complexity of 21st Century Health Care

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Confronting Problems

We suspect the greatest mistakes many leaders (including ourselves) have made is to be dealing with a problem, dilemma, polarity or even mystery as if it is a puzzle.  One of us [JF] found that Medical Education tended to hone his puzzle skills (memorization, simple solutions, multiple-choice where there is clear right/wrong), He was then introduced into hospital learning, which also tends to focus on making every challenge a puzzle or at most a problem.  It was not rare to hear about “problem patients” the ones who didn’t just do what the doctor said they wanted them to do, for example.

There is something to human nature that wants to believe all the world is a puzzle that can be fixed and solved through effort alone.  Stepping back when treating people’s health challenges like a puzzle is not easy to do and, in fact, Fee-for-service encourages us to keep thinking people are a puzzle, just need one more expensive procedure and all will be well!!  Or that expensive medicine.  That will “fix you”.   So, the mechanistic, industrial-era mind-set of trying to see humans as machines contributes a great deal to this excessive effort to turn more complicated and complex challenges into puzzles.

A Faux-Problem Focus

Problem-based learning became a big fad during the 1990’s.  Describe the problems the patient is having and focus on helping him/her solve their problems…that was a good start.  Problem-based notes would keep us focused on problems that the patient brings to our attention.  Doctors and health care administrators were making everything into a “problem”—the diseases, the lab results, the patients. This was quite a challenge. The physician would be forced to ask: “How do I and why do I have to solve all their problems?   Oh yeah, I’m supposed to be an Individual HERO who goes out and solves all my patient’s problems for them….again….” Yet, in many cases, the “problems” were actually puzzles and might even be resolved only with the assistance of other members of the health care team. This focus also didn’t change the relationship between physician and patient. The physician was still in charge.

We would suggest that the real challenge is to keep the problems where they are—in the hands of our patient. The job of the physician is to help be a Sherpa guide for the patient. They must do the climbing themselves. The physician is to help their patient learn to solve his/her own problems. This, of course, produces a dilemma.  Am I, as the physician, really helping if I don’t “fix” the problem for my patients?  The reward systems are in place to reward me for “fixing” people’s problems. Do I defy this reward system—and why do I defy it?

I [JF] have shifted my perspective. I began to see myself as needing to practice dilemma-based care. It is vitally important to assure that there are two primary stakeholders in the room—the doctor and the patient. Both have equally important views. This means shifting away from “the doctor is always right” which was how I was trained to think and act.

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