1 Boring Old Man

I used the Iron Curtain as my example because of a personal experience. Not long after I left academia and went into practice, I decided that we needed a computerized billing system, and the ones available back then were for the big practices – not a four person office with a sole secretary. So I wrote one myself [IBM PC, DOS, dBase III+]. It got to be a hobby of sorts. It actually worked but it was way too slow. Shortly after we started using it, a company called Clipper introduced a way to compile dBase programs that made them run at what was then lightning speed. So my new hobby became compiling our little system.

This was in the days before the World Wide Web, but there was something called Compuserve. When I got home at night, I’d fire up my PC and log on to the Compuserve bulletin board for Clipper to see if anyone had answered my questions from the night before. At the time, I thought that the fact that I could do this was the most remarkable piece of technology that there would ever be. One night, there were posts from a Clipper representative in  Moscow. Amazing! I opened one, and realized that the guy was typing as fast as he could about something big happening there. Tanks were rolling down the streets. I was reading about it upstairs, and shortly thereafter, it was all over the television set downstairs pouring out of Russia on phones, fax machines, computers, [and the Internet, although we regular folks didn’t know it was there in 1989]. I guess I had thought the "Iron Curtain" was a wall, but it was really the blockade of communications going in both directions. When people know things and are able to talk about them, some amazing things happen. Now, a little more than twenty years later, we watch history on our computers, television sets, and iPhones [and get irritated when the cameras haven’t yet arrived on the scene].

But it takes more than communications. Even with something as remarkable as the Internet, somebody has to take all the facts and put them all together. People like me can whine endlessly about the corruption that has crept into our professions, and speculate about how the pharmaceutical and insurance industries have intruded into our academic and organizational institutions – but we don’t have the resources or the understanding to really answer the how/why questions. We have to rely on people who can see a bigger picture – people like Paul Thacker at POGO, or Ed Silverman at Pharmalot. Health Care Renewal is another one of those big picture sites that I began to follow for the occasional posts by Dr. Bernard Carroll about the sheenanigans in psychiatry, but the really big picture person on Health Care Renewal is Dr. Roy Poses. He talks frequently about something called "the anechoic effect." It just means that when something gets exposed, it doesn’t echo – the story gets lost, forgotten, and loses the power it really ought to have [often as a result of the interventions of the exposed]. I guess it’s the opposite of that saying journalists use about a story "having legs" for one that grows bigger by the hour [eg Representative Anthony Weiner’s 20 days in the spotlight]. So Dr. Poses uses Health Care Renewal to keep us focused on stories that didn’t get enough echos to grow any legs.

Summary

So, through her mutiple roles that allowed her to serve at several key nodes of networks of influence in health care, one person has been linked to multiple dysfunctional aspects of US health care that arguably have been responsible for our increasing costs, declining access, and poor quality.  Note that these multiple roles seem to have been logically and even ideologically inconsistent, suggesting that multiplying her roles within the  networks may have been more compelling to her than logical or ideological rationales for particular actions.

We have discussed before, the leadership of health care organizations has become incredibly interrelated, interlocked, and incestuous. It appears that top leaders of various health care organizations may be more familiar with and identify more with each other, and with other hired executives and managers, than with their organizations, their organizations’ missions, and their organizations’ professionals, staff, students, clients, and patients.  It now appears reasonable to characterize the relationships among health care leaders as embedded networks of influence. 

So to repeat- I strongly believe that there needs to be much more investigation, academic, journalistic, and perhaps legal, of the identity, nature, and culture of the leaders of health care, and their relationships. A few bloggers cannot do it all. Obviously, the anechoic effect mitigates against medical and health care academics looking into their own leaders. However, failing to understand who is leading our march to the brink of health care failure ought not to be something such academics would want on their conscience.

Finally, and obviously, health care organizations need leaders that uphold the core values of health care, and focus on and are accountable for the mission, not on secondary responsibilities that conflict with these values and their mission, and not on self-enrichment. Leaders ought to be rewarded reasonably, but not lavishly, for doing what ultimately improves patient care, or when applicable, good education and good research.

If we do not fix the severe problems affecting the leadership and governance of health care, and do not increase accountability, integrity and transparency of health care leadership and governance, we will be as much to blame as the leaders when the system collapses.