Managing the Myths of Health Care

1. Health Care Isn't a System, But a Fragmented Collection of Treatments.

Calling something a system does not make it a system where it needs to deliver.

Fragmented interventions. What we commonly refer to as "health care" is, in reality, a disjointed collection of treatments for diseases, rather than a cohesive, naturally linked system focused on holistic health. This field predominantly favors cure over care, acute diseases over chronic ones, and the treatment of existing conditions over prevention and health promotion.

Misplaced focus. The system's attention is heavily skewed towards reactive interventions. For instance, research disproportionately funds the investigation of cures rather than the underlying causes of illnesses. This inherent bias means that while individual treatments may be astonishingly effective, the overall "system" struggles to integrate these efforts into a unified approach to well-being.

Lack of natural linkages. Unlike a healthy cow, where all organs function harmoniously, health care often lacks seamless coordination between its parts. Physicians, nurses, community care, and administrators frequently operate in silos, leading to "intermittent and disjointed interventions" that fail to address health systemically, hindering the simultaneous delivery of quantity, quality, and equality.

2. The "Failing" Health Care System is Actually Succeeding Expensively.

In other words, where it focuses its attention, health care is suffering from success more than from failure.

Success, not failure. Despite widespread complaints globally, health care, particularly in developed nations, has achieved remarkable successes in treating diseases, significantly extending lifespans. The perception of "failure" often arises not from a lack of medical efficacy, but from the escalating costs associated with these impressive advancements.

Costly advancements. Medicine has excelled at developing expensive, life-saving treatments. The dilemma is that while individuals are rarely willing to forgo these advancements when their lives are at stake, societies collectively resist paying the rising price tag. This creates a fundamental tension: we demand more, but want to pay less.

Rationing is inevitable. The idea that demand for health services is insatiable is a myth; people don't eagerly line up for unnecessary procedures. The true challenge lies in meeting reasonable demand with services that are in short supply due to collective reluctance to fund them adequately. This leads to pervasive, often unacknowledged, rationing, where choices about care are made implicitly, rather than through transparent, collective decisions.

3. Heroic Leadership Undermines, Rather Than Fixes, Health Care.

True leadership is management practiced well.

Leadership obsession. The contemporary fascination with "heroic leadership," particularly in business and increasingly in health care, is counterproductive. It elevates leaders to a superior, detached status, implying they must "drive" or "empower" others, even though professionals often inherently know their purpose and tasks.

Detached "macroleading." This heroic model fosters "macroleading"—a disengagement where authority figures make decisions from a distance, disconnected from operational realities and their consequences. This artificial separation between leading and managing results in organizations that are "over-led and undermanaged," where strategic "formulation" is divorced from practical "implementation."

Communityship over heroism. Effective leadership, especially in professional fields like health care, should facilitate "communityship"—a collective sense of purpose and belonging that binds the organization through culture and engagement. Great organizations are robust communities of human beings, not generic "human resources." Success is a collective endeavor, requiring managers who are engaged, respectful, and see colleagues as partners, not subordinates.

4. Administrative Engineering Often Disrupts More Than It Improves.

What too many of them do is: Measure like mad. Reorganize constantly. Drive change from the "top," for the sake of "empowerment" at the bottom.

"Fixes" that break. Administrative "experts"—analysts, consultants, and reengineers—frequently impose simplistic, top-down solutions like continuous reorganization and obsessive measurement. These "fixes" often cause significant disruption to the actual delivery of health care, leading to more dysfunction than genuine improvement.

Fads and fallacies. Health care is susceptible to managerial fads and jargon, such as "managed care" or "re-engineering," which promise quick fixes but often lack substance. These approaches oversimplify the complex, often contradictory objectives of health institutions, leading to failures or, worse, successful implementation that ultimately degrades the quality of care. Examples include:

• Re-engineering: Simplifies processes, speeds them up, marginalizes doctors.
• Reorganization: Shuffles people on paper, disrupts operations, often adds layers.
• "Pretend markets": Create artificial competition, increase administrative costs.
• Mergers: Often power grabs, increase costs, negatively impact morale.

The myth of scale. The pervasive belief in "economies of scale" often leads to the creation of larger, more impersonal institutions, sacrificing human scale and personalized services. While some specialized procedures benefit from size, many health care services require local, human-centered delivery. This administrative drive for bigness often layers management, further detaching decision-making from the front lines where quality care is delivered.

5. Over-Categorization and Measurement Degrade Quality of Care.

Only by measuring and holding every system participant accountable for results will the performance of the health care system ever be significantly improved.

Calculation's pitfalls. The axiom "what is not measured can't be managed" drives an excessive reliance on categorization, commodification, and calculation in health care. While these tools simplify administration and payment, they often compromise the quality of services by forcing complex human conditions into rigid, standardized boxes.

Beyond the categories. Categorization proves inadequate when illnesses fall beyond established classifications (e.g., chronic or mental health conditions), across multiple categories (complex co-morbidities), or necessitate going beneath the categories to treat the unique individual. Reducing people to "diseased organs" or "patients" overlooks the holistic nature of health and the imperative for personalized care. Dr. Warwick's success with cystic fibrosis patients exemplifies going "beneath the categories."

The soft underbelly of data. "Hard data" is frequently limited in scope, overly aggregated, arrives too late, and can be unreliable or biased. An obsessive focus on measurable "efficiency" often devolves into mere "economy"—cutting tangible costs at the expense of intangible benefits like quality of care or social well-being. True effectiveness demands informed judgment, not just numbers, and acknowledging that many crucial aspects of health care are immeasurable.

6. Excessive Competition Harms; True Progress Lies in Cooperation.

What the field of health care desperately needs is not more or other kinds of competition so much as a great deal more coordination, cooperation, and collaboration.

Competition's high cost. The American embrace of competition in health care has resulted in the world's highest costs alongside mediocre outcomes. While some competition can prevent complacency, an excessive market-driven approach leads to massive administrative expenses, fragmented services, and a focus on profit over patient well-being.

"Right kind" of competition? Proponents advocate for "value-based competition" centered on specific diseases or treatments, favoring specialized, larger practices. However, this often neglects the need for local, integrated care for complex or multi-faceted conditions, and the importance of community. It also risks stifling innovation by fostering a "race to the bottom" or encouraging monopolies. Examples of harm include:

• High administrative costs due to multiple competing payers.
• Focus on profit over patient needs, leading to unethical practices.
• Suppression of research findings between competing scientists.

Cooperation is key. Health care already suffers from excessive internal competition—professionals vying for resources, institutions battling for budgets. This "individualization" undermines the collective effort essential for effective care. Instead of celebrating competition, the field urgently needs to foster genuine coordination, cooperation, and collaboration among all stakeholders, recognizing that collective well-being depends on shared effort, not just individual gain.

7. Health Care is a Calling, Not a Business to Be Run for Profit.

At its best, it is a calling.

A dangerous myth. The pervasive myth that all institutions, including health care, should be managed "more like businesses" is fundamentally flawed. Much of modern corporate management, with its emphasis on "human resources," detached leadership, and rigid strategic planning, is dysfunctional even for business, and proves catastrophic when applied to health care.

Business practices harm. Applying business models to health care can create perverse incentives, transforming patients into "profit centers" and driving care decisions by revenue maximization rather than genuine need. This leads to practices such as:

• Over-billing and aggressive marketing.
• "Cherry-picking" profitable cases while neglecting complex ones.
• Prioritizing "patient experience" amenities over clinical quality.
• Eroding trust and increasing overall costs.

Altruism and dedication. Most health care professionals are driven by a profound sense of accomplishment and a desire to serve, not by financial incentives or shareholder value. Treating them as "human resources" to be "empowered" or managed by corporate metrics undermines their intrinsic motivation and the very "soul" of medicine. Health care is a calling that thrives on altruism, dedication, and a primary focus on the patient's needs, as exemplified by the Mayo Clinic.

8. Beyond Public vs. Private: The Crucial Role of the Plural Sector.

Welcome to the Plural Sector for the Sake of Quality and Engagement.

False dichotomy. The long-standing debate over whether health care should be controlled by the public or private sector is a narrow, dogmatic divide. Neither extreme offers a complete solution; government controls can be "crude," and market forces "crass." Both are necessary, but neither should dominate, especially for professional health care services.

The overlooked "third sector." The vast majority of hospitals in countries like the U.S. and Canada are neither government-owned nor private for-profit; they belong to the "plural sector" (also known as civil society or non-profit). These institutions, often founded by communities or religious orders, are implicitly owned by their members or by no one, embodying the concept of "the commons." This sector includes:

• Voluntary hospitals and trusts.
• Cooperatives (e.g., physician-owned, user-owned).
• Non-governmental organizations (NGOs) like Doctors Without Borders.
• Research laboratories (e.g., those that discovered penicillin, insulin, Salk vaccine).

Quality and engagement. Plural sector organizations foster engagement and "communityship" because they are deeply embedded in local communities and driven by a shared sense of calling. Research consistently shows that non-profit health care facilities often outperform for-profit ones in terms of access, quality, and cost-effectiveness. Recognizing and supporting this sector, alongside appropriate roles for public regulation and private supply, is essential for a balanced and effective health care system.

9. Management Must Be Distributed and Deeply Engaged, Not Detached.

Not only should management be everywhere, but it can also include everyone.

Beyond the "top." The traditional view of management as a detached function "on top" of an organization is a distorting metaphor. Effective management in health care must be distributed throughout the organization, with managerial activities performed by whoever possesses the necessary knowledge and perspective, whether they are designated managers or not.

Engaging the ground. This means bringing administration closer to operations. Professionals on the ground, who understand the nuances of care, must be more deeply involved in administrative decisions, accepting responsibility for their consequences. Conversely, managers must abandon their "pedestals" and engage directly with the realities of clinical work, fostering open communication and collaboration.

Co-management and human connection. Health care management requires a "two-faced" approach: aggressive advocacy outward (for resources) and open reconciliation inward (among internal stakeholders). This often necessitates co-management, where different individuals balance these roles. Ultimately, effective health care management is a practice rooted in context, requiring visceral understanding, not just cerebral knowledge, and a dedication to continuous, holistic care over episodic cures.

10. Strategy Emerges from Learning on the Ground, Not Top-Down Planning.

Strategies don’t appear immaculately conceived, certainly not from some metaphoric top.

Planning is an oxymoron. The notion of "strategic planning" as a formal, top-down process is a myth. Strategies, especially in complex professional organizations like hospitals, cannot be simply "formulated" and then "implemented." Instead, they emerge gradually through a process of flexible learning, trial-and-error, and adaptation to what works on the ground.

Venturing from the base. In health care, strategies are often highly distributed and fragmented, arising from "ventures" championed by clinical professionals or small teams. These "intrapreneurs" develop new treatments or alter existing facilities, leading to significant innovations. Examples include:

• Pioneering of day surgeries by clinicians.
• Dr. John Snow's discovery of cholera's water-borne cause.
• A retired police officer's survey leading to reduced wait times.

Open-source strategizing. This "let a thousand flowers bloom" approach requires administrative support to recognize, promote, and propagate successful initiatives across the entire field. It's about "open source strategizing," where concerned and committed individuals, regardless of their formal position, can contribute to improving health care practice, much like the collaborative development of Wikipedia.

11. Organize for Collaboration, Communityship, and Human Scale.

Health care needs no one on top. Managers, doctors, floor cleaners, and others all have useful jobs to perform. Everyone should be respected for what he or she contributes, not for the titles they hold.

Beyond formal structures. Traditional organizational thinking, rooted in the "machine organization" model, emphasizes formal structure, hierarchy, and control. While some structure is necessary, health care's hyperspecializations and divisions create excessive "separations" (silos, slabs, curtains) that impede the essential communication and collaboration needed for effective care.

Fostering communityship. The solution is not more control, but a shift towards "communityship"—a deep sense of engagement, commitment, and loyalty among all associated with the organization. This means fostering an atmosphere of trust, appreciating health care as a calling, and promoting human-scale structures where people can connect personally, rather than being alienated by large, impersonal systems.

Culture for collaboration. A robust organizational culture, akin to a "soul," is the foundation of communityship and collaboration. It draws people in, energizes them collectively, and encourages them to see themselves as members of a noble institution, rather than mere "agents" or "human resources." This culture, built on mutual respect and shared purpose, allows collaboration to transcend competition and status hierarchies, leading to better quality of service.

12. Reframe Health Care as a Harmonious, Integrated System.

A system of health care, like a cow, should comprise autonomous parts that function as a harmonious whole.

The "cow" metaphor. Health care, currently a fragmented collection of parts, must strive to function like a healthy cow: an integrated system where specialized components work together harmoniously. This requires moving beyond the current "gaps" in communication, coordination, cooperation, and collaboration that plague the field.

Downloading the whole. Achieving a systems perspective means broadening the knowledge and understanding of health care into every part, especially the users themselves. Individuals are the "fractals" of the system, responsible for their own health promotion, prevention, and often self-treatment. Empowering individuals with tailored, accessible information is crucial, as is recognizing and integrating all effective practices, including those currently marginalized. This includes:

• Promoting a holistic systems perspective.
• Empowering individuals as primary health managers.
• Integrating all effective health practices (e.g., dentistry, "alternative" therapies).
• Developing "health navigators" to guide individuals through complex care.

Cooperative autonomy. The ultimate goal is "cooperative autonomy," where individuals, institutions, and regions maintain their distinct identities and strengths while functioning within a single, interconnected system. This requires balancing the roles of public regulation, private supply, and the plural sector, fostering partnerships that prioritize quality and engagement. By fixing health care through integration and collaboration, it can serve as a model for addressing other complex global challenges.

Last updated: August 18, 2025