Let It Be Or Not To Be

Had a great discussion earlier this day. After my adventures with sepsis, my attention has once more been drawn to healthcare innovations. As one of humanity’s great endeavors the healthcare industry attracts the good and the bad. More than a decade ago I had spent about a year preparing for the chief architect role for a large governmental healthcare program in Turkey, introducing eHealth and much much more. Timing was disadvantageous as the company I worked with hadn’t been able to grasp the shift towards softwarization and, while gravitating towards bankruptcy, had started flirting with other large IT companies, to eventually be acquired by one whose once visionary founder nowadays spirals down to the level of “old man yells at cloud” by advocating for AI-fueled surveillance to police the citizenry, in, again, a misinterpretation of whatever he seems to appreciate in Japanese culture. Anyway, even though a fruitless attempt, and only preparatory, the work had still been illuminating and inspiring concerning the potential to enable and facilitate today’s and tomorrow’s care systems. So, a seed was planted there already. Having been sucked into the healthcare system for roughly four months, empathy went in overdrive. It’s a strange sort of organization where many people appear to be so much involved with firefighting they can only divide and direct their attention to problems which are either of an immediate tactical nature or a top priority strategic one.

Maybe people suffer from victimized heroism, like veterans who have been fighting the good fight, but are gradually succumbing to the many emotional scars or even open wounds left over from the many battles fought. Like in such situations appears to be the norm, this can only be solved by working longer and harder. Which is becoming increasingly impossible due to growing labour shortages and a tsunami of new medical research and insights so large no one can encompass and digest it anymore. It is easy to find visionary articles about the medics of ten, fifteen years in the future. Generalists skilled in meta-methodologies with certain sub-specialties, being aided by artificial intelligence processing massive amounts of sensory data. But that same vision can be found in articles dating back ten years earlier, and even in some of twenty years ago. It is a future, a horizon, not a border, that moves along with time and is always ten, fifteen years away. Not that it is unrealistic, but organizations just never seem to get to the stage to make a real fundamental shift. Unless some whole new initiative tries to set something up from the ground up or the forces of creative destruction enforce a reincarnation, but then it often turns out that the growing potential of this future isn’t as probable or plausible as thought as the whole market hasn’t moved along with it and has gotten stuck in a proven but growingly outdated way of working. Yet, in the past, at hospitals, internists were the ones that were generalists. Specialist generalists, even more so than general practitioners. But even they appear to be swept away in the rapid progress of advances in medical science that is shaping people more towards acting as a generalist specialist than a specialist generalist. ?

My discussion partner was not unfamiliar with these paradoxicalities. With the influx of managers in healthcare, especially those skilled in six sigma, it seems like things have gotten worse. Many managers are trained in methods which are finance-oriented, and six sigma is meant for factory halls, not people-oriented workflows. As a counterreaction many in healthcare appear to increasingly brace themselves within the way of working as they used to do. A rather familist guild-like quasi-feudalism for the medics, oriented around reputed authority, which may appear odd for me with my IT background, but which is a natural organization form that works quite well. Nursing and supporting staff appear to have adopted a somewhat military regime, as that seems to work well for them. But instead of managers being change agents and grand communicators; to ease cross-silo cooperation they have adopted finances as a neutral reference frame, which it is not. I am not sure if this is typically Dutch, but the gap has filled with new-agey circus acts or marketing blah such as inspiration sessions. But no operational change. Nothing substantial has changed in the way of working. It is still ‘same old, same old’. And as a patient that nearly died from sepsis, I expect something more than trail and error and serial quizzing. Mind you, medics are smart, empathic and I will forever be grateful for what they’ve meant in treating my illness. But I am also Dutch and that means I am expected to be direct on the verge of rudeness. So, despite the fact that healers are so important for humanity they have an archetype of their own, I do think there are some much needed improvements that can help ease their work, while increasing efficiency and effectiveness. So, that is where the healthcare innovations I’m working on fit in but the talks this week and the discussion earlier today touch repeatedly on the soft side of working. Cultures, hegemony, attitudes, expectations, etcetera. And rightfully so. With organizations that are governmental, or collective, it is particularly painful to witness the effects of dehumanizing automation, where governance principles have been translated to operational instructions and have caught many such organisations in a web of rules which forces them and fellow citizens into a behaviorist straitjacket. Forcing, instead of facilitating the discretionary role of civil servants, letting them follow their code of conduct we trust they have been delegated to act upon.

And we know so much better. Of course, in the past managerial hypes have had a destructive effect when blindly trying to implement some new ideology, usually disregarding any existing dynamics. But there is a lot of difference when dealing with a causally closed or a causally open system, or organizational model. A causally closed system is like a machine, that produces the same result with a high level of reliability. Accountants will probably appreciate that. A causally open system is like a piece of farmland, which doesn’t produce plant life but brings it forth. Like Heidegger’s idea of ‘techne’, in the sense of ‘poiesis’ or ‘revealing’. Both approaches work, but don’t force people into a machine-like way of working. Leave them be but support them. Guide, mentor, nudge, support, do all the soft things without growing soft. Goals are nice in a shooting contest, hitting the bullseye, but such rather geometric analogies are actually a rarity. Nature prefers attractors. Let actions get pulled towards an objective, don’t push it. Pulling focuses, pushing disperses. And don’t try to score a goal at a game of chess. Attractors embody reflexivity, multi-directional and circular relationships where cause and effect move back and forth as if a conversation, and actually affect each other during the process. Feedback loops. And that was what we realized all too well during the discussion earlier today. People tend to overdo things. Overdoing and then stepping back too fast. That gets us to Masanobu Fukuoka, Japan’s farmer sage whose agricultural methods inspired many. He showed a way of working that in Taoist thought is called ‘wu wei’, doing non-doing. Instead of working hard to force his bit of farmland to produce food, he arranged the situation in such a way to make the farmland bring food forth. It is not stepping back and doing nothing but instead of overdoing he made things happen. Like his clay seed balls, small balls of with seeds for the desired crops mixed in with humus or compost, next season’s harvest in potentia, which are spread over the farmland fields to let the field itself regulate the optimal distribution. It wasn’t just the crops, he added clover to the clay balls that would form a groundcover that crowded out weeds and fixed nitrogen to enrich the soil. By spring he’d flood the fields for a short while, to let rice grow, as he had found out rice actually grew better and stronger in damp, not soaked, soil. He harvested as much or more than his neighboring farmers, who all were using industrial methods, with all the chemical additions that come along with trying to force nature into a machine-like way of working. There is something to it. Before encountering Masanobu Fukuoka, for me ‘wu wei’ meant a somewhat passive distancing that was accompanied by an equanimous state of mind, but it is more than just that. It is trust. It is result-focused. It is like the minor key, where the harmonic ratio of the major key is inverted and creates a lasting tension that is absent from the major key which tends towards closure. We need a more ‘blue note’ style of management, stop optimizing things so much out of fear, distrust or sheer anal fixation. Let things happen. That opens up a sense of creativity that fosters serendipity. Overdoing in name of management is not the answer. It should focus on the ‘unanswered question’. And that should help avoiding using excuses as a reason and help uplift healthcare out of the current mode of working. However much good is done, we can do better.