The above links will take you to the Center for the Health Professions site.

Centering on...Revisiting our Paradigm

It has been several decades since the culture re-discovered the word paradigm - we seemed to have used it to the point of exhaustion. Everything in the mid-eighties either defined or broke the paradigm. Eventually it became passé and fell from use in the more informed discussions on any matter. I would like to bring it back and use it to critique where we are in health care in the U.S. today.

Thomas Kuhn introduced us to the enormously powerful notions of paradigms in his classic work on the ways scientists use frameworks. The book gave us insight into how these mental devices both create understanding and limit the view, literally, of anyone using the framework.
Over the past sixty years since the Second World War, health care in America and the professionals who work within it have developed a powerful paradigm with special skills, vocabularies, privileges and ways of doing work. The paradigm produced many of the gains that have come from health care in the past ranging from basic biomedical knowledge to its applications from immunizations to surgery. Because it worked so well, it also produced economic gain and social prestige for the incumbents within the system.

One of the problems with paradigms, which have been as successful as health care in the U.S., is that we don't recognize when they are no longer working for us. Because they have performed so well in the past, when they start to fail, we do more of what we have done in the past, hoping for a better or different outcome. My proposition here is that our highly specialized, acute care-centric, in-patient delivered model of care - the one people fly from around the world to receive care from - no longer works as the dominating model for how health care should be delivered to the nation. It simply no longer matches with the population nor with the epidemiologic, technological, cultural or educational realities of the nation. But because we are so wedded to this model, because it has served us so well in the past, we will pump more and more resources into the process even as it delivers less and less. Today this health care paradigm may actually be inadequate to addressing the challenges of health care which leaves a large percentage of the population without regular service, uses more and more economic resources every year, is uneven, at best, in its standards of quality, and which causes thousands of avoidable deaths annually.

Yet, because of its effectiveness in the past and because the incumbents derive so much from its maintenance, we continue to offer it resources, like some primitive cult, hoping against hope that it will return to its effectiveness of old. To break such a hold, a powerful vision is needed; one that explains the irrationality of sustaining what we do and challenges us to create a new framework for doing our health care business.

Where should we look for the elements of the new paradigm? Innovators rarely look to the core of the existing system for all of the reasons discussed above. The best source for new insights in health care would be to look to those who have been most systematically excluded from its direction: the consumers. Here we have the untapped genius of what motivates them to comply with good heath advice, the value of health care innovation, the standards of service excellence and preferences for which investments will pay the greatest rewards for each segment of the health care market. From the perspective of the formal health care system we know very little about this set of preferences, but as the market and regulations around health care flex we are discovering that some portion of the population would like to receive some parts of their primary care at Target or Wal-Mart, travel to Costa Rica for a hip replacement, pay extra for email access to a trusted physician advisor, participate in a self-help group and fund access to an integrated health record. Whether we call them consumers, customers or the community, they hold the secrets to future success.

The second step in breaking out of paradigm blindness is giving up what is not important. To do that we need to know where we are going and what success would look like. Without that focus, everything is necessary and nothing is left behind. Health care is filled with all sorts of mandates, some imposed from the outside, but many others driven by the preferences of the professionals and institutions. The insight of the customers can begin this process by framing what must be changed. This will produce insights that are disturbing because they represent disquieting departures from the status quo. When this disease erupts, then the paradigm is about to change.

Once all of that which has been so carefully built is put asunder, it is time to look around and with the new partners of the customer, build a new vehicle to drive us to the desired goal. It doesn't matter if the goal is educating a team orientated professional, mastering quality goals, reducing costs by a fourth, managing health outcomes using only population interventions or returning health to individuals, none of these audacious ends can be achieved starting where we sit today. We know how to get to where we need to go, we know it in our minds and hearts and souls, but we will not get there with the baggage we carry about. Let it go and be successful.

For years I have used the poet Stephen Mitchell's retelling of the myth of Sisyphus to end creativity sessions. It seems appropriate to share it here.

"We tend to think of Sisyphus as a tragic hero, condemned
by the gods to shoulder his rock steadily up the mountain,
and again up the mountain.

The truth is that Sisyphus is in love with the rock. He
cherishes every roughness and every ounce of it. He talks
to it, sings to it. It has become the mysterious Other. He
even dreams of it as he sleepwalks upward. Life is
unimaginable without it, looming always above him like
a huge gray moon.

He doesn't realize that at any moment
he is permitted to step aside, let the rock hurtle to the bottom, and go home.

Tragedy is the inertial force of the mind."

Stephen Mitchell, Parables and Portraits

Let go of the rock, or the curriculum or the way you learned to lead, the expected role of the health professional, the paradigm that holds you back and breaks your back trying to sustain it. All you have to gain is a dream of a better way.

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