A Factory or a Forest?

Science and industrialization share a deep historical and intellectual connection. In many ways, they are a pair of “ways of seeing” that emerged and coevolved between the 17th and 19th century. The laws of thermodynamics and steam power co-developed, the discovery, explanation, and control of electromagnetism was the prime driver of how factories came to be organized with the “science of management” developed by Frederick Taylor and Henry Ford. It is thus entirely unsurprising that as medicine took the scientific turn in the 20th century, it looked towards industrialization to organize its delivery. If medicine views the body as a machine, then healthcare delivers it from its equivalent of a factory or a store. In fact, over the last hundred years, the culture and metaphors of industry have so thoroughly permeated healthcare that the “medical-industrial complex” is naturally and effortlessly called the healthcare industry.

As a part of this penetration, healthcare has wholesale adopted best-practices from industry. Methodologies of quality improvement such as Six Sigma, Plan-Do-Study-Act (PDSA), and LEAN have been imported from the automobile and airline industries. Techniques of reputation management, patient (customer) engagement, and satisfaction have been imported from retail. Dashboard metrics documenting enshrined key performance indicators that assess physician productivity, efficiency, quality, and (relative) value are omnipresent and impossible to ignore. There has been a proliferation of administrators, consultants, and executives dedicated to serve as custodians, evangelists, and enforcers of these metrics. Top of mind (and priority) for any healthcare entity at any scale are initiatives aimed to improve these metrics. Resource consuming pilots abound – many of them revolve around the electronic health record – with the intention to improve patient satisfaction scores, decrease door-to-doctor times, eliminate thirty day readmission, optimize billing and coding,  minimize risk-liability, and decrease diagnostic “fallouts.”

Despite these initiatives, healthcare costs have continued to spiral, whereas patient and physician satisfaction, as gleaned by behavior and surveys, continues to crater. Physicians are unhappy, burnt-out, and leaving medicine in droves, while patients are increasingly voicing their displeasure on surveys and seeking refuge in alternative and concierge practices. Possibly, the reason for this discordance is because we deliver healthcare like we sell, build, or repair artifacts. We have transformed the practice of medicine into a technique, the practitioner into a technician. Patients are referred and through-putted assembly line-like from department to department, appointment to appointment, and specialist to specialist. Radiology for imaging studies, the laboratory for biomarker testing, primary care to discuss the results in 15 minute slots, and the specialists for treatment recommendations. Often reduced to a disease, a biomarker, or the result of an imaging study they are simultaneously the customers, the consumers, and the products of healthcare. Physicians, on the other hand, attending to the computer, honed-in on their organs of specialization, and beleaguered by metric enforcers are the technicians moving the product through the assembly line or salespeople satisfying customers with drugs and tests.

However, human bodies are not engineered machines. Patients are not products, nor are they really customers or consumers and cannot be satisfied as such. A more apropos metaphor is one of a mostly unmapped ecosystem (future essay)  – self organizing, homeostatic, thermodynamically open, and messy – but with feelings, a rich interiority, and agency. Physicians on the other hand, are scientifically minded and technical, but are neither scientists nor technicians. Delivering healthcare is not equivalent to selling an artifact or repairing a machine. Illness, healing, and sickness are messy, brimming with uncertainty, nonlinear, and often painful. It is rife with suffering. The practice of medicine entails trial and error, judgment, compassion, and difficult conversations. These cannot easily be standardized and streamlined. Even in the current regime of evidence based, technologically driven medicine, a more appropriate metaphor for a physician is one of a steward or a guide engaged in the practice of medicine.

Metaphors are double-edged tools of cognition, simultaneously enlightening and blinding. For the past half-century, machines and factories have been the dominant metaphors in medicine and healthcare. However, if the body is more akin to a forest than a machine, then it would be advantageous to consider the practices and philosophy of modern ecosystem management (future essay). Moving beyond simplified, overly reductive and restrictive metrics to create systems that facilitate resilience (future essay), engender relationships, and are attuned to uncertainty.