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The Complexity of 21st Century Health Care

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Point B may not be achievable or only achievable with inevitable and rapid return to point A. We’ve lost track of how many deviations from our initial planning we have had to make, now there are multiple people involved in the planning process who may not agree on the right course to take. Multi-perspective, multi-pathway problems are no longer problems, they are dilemmas. They must be approached in dilemma-resolving ways—collaboratively, exploring pros and cons, moving out of right/wrong and into better/worse dichotomies.

It is quite common for the emergence of dilemmas to create discomfort with those facing the dilemma. It is also quite common not to recognize when we have moved beyond problems into the realm of dilemmas. We try to force the dilemma back into being a problem. One approach is to remove people from the decision process who don’t agree with our interpretation. One can also remove steps and determine “we don’t need to follow all these steps. This person needs to leave the hospital—so I am writing the discharge order and expect him or her to be gone when I come by tomorrow.”

In hockey, this is often called a “power play.” Intentional limitations are placed that create a different context for action. In this medical instance the doctor is taking on a higher power role and ordering other members of the team to comply with his game-plan. Ridicule might be used to reduce the voices of those who don’t agree with the doctor. Threats of consequences for not following the doctor’s discharge order may limit resistance—thus allowing the doctor to feel he or she has “solved the problem of discharging this patient.”

Converting a dilemma into a problem comes at a price and can lead to unexpected behaviors on the part of other players or participants in the decision-making process. For example, a senior nurse has seen this doctor inappropriately discharge patients. The doctor shows up minutes to hours later in the ED. The patient gets re-admitted. The senior nurse is tired of over-working his nursing staff by having to go through the intricate discharge and re-admission process.

He worries that his nurses license may be at risk. An administrator may be upset at the rising re-admission rate that is leading to fines by Medicare. So, he waits until the doctor has gone home and tells his staff not to discharge the patient. He calls an administrator to get cover, knowing the doctor will be upset the next day. The doctor may face consequences and surely the relationship between the doctor and the senior nurse may be impacted by events. The doctor might be labelled a disruptive doctor or a problem doctor. She may find fewer consultations coming her way. An inability to engage in dilemma resolution can have far-reaching consequences for those involved in the dilemma and the organizations that are unable to distinguish between problems and dilemmas and engage the team in finding collective solutions and the best pathway forward together.

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