In one of my earlier posts (I’m great….and by the way, you’re not—September 6, 2020), I related how understanding Organizational Culture is vital to understanding the arrogance and ignorance so often seen in the medical profession, especially during the COVID Disaster. Let me amplify a bit more upon that.
Although I was trained as a clinician, I had a shadow career. For twenty years I was heavily involved in Continuous Quality Improvement and had served as the physician leader of this program at a large tertiary care medical center. I was a firm believer in Statistical Quality Control. I had been convinced that “if you can’t measure it, you can’t manage it”. Because of our belief in the power of these methods, our efforts had a strong statistical focus. We rooted out variation and tried to encourage everybody to follow the “evidence-based medicine” approach to the problem. I became a Black Belt in Six Sigma and at meetings was armed with control charts and PowerPoint slides to illustrate our efforts. Our goal was to have enterprise-wide conformity to what we had deemed to be the proper enterprise-wide approach. We followed a modified Six Sigma approach to quality with a “DMAIC” wheel: Define-Measure-Assess-Improve-Control:
Then the process started over. I would pore over Control Charts looking for “special cause variation” and then try to find if it was due to one of the “Six M’s”: Method, Machinery, Material, Manpower, Measurement, Mother Nature—with modifications for healthcare.
And the thing was, IT WORKED VERY WELL….MOST OF THE TIME. We had spectacular successes in improving outcomes and satisfaction and cutting costs….most of the time. But when it didn’t work, the failures were utter and spectacular. As we were operating in a Level 3 Organizational Culture (“I’m great…and by the way, you’re not”) we usually just blamed the people involved.
My time at USC taught me that was wrong…it was the Organizational Culture that was at the root of the failure, but that was really only part of it. I needed another epiphany…..
It came while reading the November 2007 issue of Harvard Business Review. I came across this article by David Snowden and Mary Boone. You must read it yourself:
All too often, managers rely on common leadership approaches that work well in one set of circumstances but fall short in others. Why do these approaches fail even when logic indicates they should prevail? The answer lies in a fundamental assumption of organizational theory and practice: that a certain level of predictability and order exists in the world. This assumption, grounded in the Newtonian science that underlies scientific management, encourages simplifications that are useful in ordered circumstances. Circumstances change, however, and as they become more complex, the simplifications can fail. Good leadership is not a one-size-fits-all proposition.
Could this be a part of the puzzle I was missing? The more I read, the more excited I became. I always thought that “complex” was just another term for “really, really complicated”. I realized I needed to learn more about this, so I sought out David Snowden to spend more time with him learning about this fascinating topic.
Snowden and Boone had created The Cynefin Framework to make sense out of the various situations with which we are faced:
The ordered world, the world I assumed we always operated in, only contains the Simple and the Complicated domains. My linear, scientific method worked very well in those, but it fell apart in the unordered world, the domains of the Complex and Chaotic. A different set of assumptions and a different tool set were needed when operating in those domains.
So…how do we tell the difference? There are two main tools. One is the “Stacey Matrix”:
In the Simple domain, there is a high degree of certainty of results and agreement on the tools to use. At the other extreme, the Chaotic domain, there is little certainty and little agreement. In between is the “Gray Zone”, with no hard and fast boundaries between the Complicated and Complex.
Another way to differentiate the different domains is to use the relationship between cause and effect. In the Simple Domain, everybody can see the relationship. In the Complex, only experts may be able to see it. In the Chaotic Domain, there is no relationship between cause and effect. In the Complex Domain, that relationship is only apparent in retrospect. This leads to some non-intuitive conclusions regarding activity and practice. We hear so much about “Best Practice” in healthcare. Unfortunately, that really is only appropriate for the Simple Domain. In the Complicated Domain, multiple “Good Practices” are possible, based upon individual characteristics. In the Complex Domain, one needs to rely upon “Emergent Practices:
In the Complex Domain, the horizon of predictability is very short. Rather than formulating a huge universal “Fail-Safe” strategy, it is necessary to employ multiple “Safe-Fail” strategies! Find out what works, where, and amplify it. If it doesn’t work, or doesn’t work in that finely-grained situation, stop doing it and try something else. In a very real sense, this “isn’t rocket science….it is more like jazz improvisation.
Dave Snowden taught me the most important answer to questions in the Complex Domain:
It depends……
There is no hard and fast answer that can be based upon the pre-conceived assumptions of “experts”.
What happened in COVID? We were faced with a novel virus that had not affected humans before. We didn’t know where it came from, or those who did know didn’t tell us. We thought that mathematical modeling would help us and made our plans on models that turned out to be based on wildly faulty data. We tried to construct a huge Fail-Safe Strategy that would work everywhere. And we were incredibly wrong.
But we did have the knowledge that had been the mainstay of pandemic treatments for decades. The four pillars of treatment were: Contagion Control, Early Home Treatment, Late Stage Hospitalization and Vaccines:
This pandemic certainly fit the definition of the Complex Domain. There was little certainty of outcome and little agreement on a course of action. But there were data available. We were not in the Chaotic Domain where cause and effect had no relationship. Cause and effect still worked….it was just that it could only be seen after the fact. We needed to update our understanding based upon rapid re-assessment of the situation instead of formulating a plan and then putting it on auto-pilot.
Multiple physicians who were on the front lines treating patients during the frightening early stage of this disease reported their results with various treatments. These were the “multiple safe-fail experiments that are the way to operate in the Complex Domain. Reports from doctors like Zev Zelenko, George Fareed, Brian Tyson, Pierre Kory, Paul Marik, Peter McCullough and many others too numerous to mention were indeed out there for all to see.
What was the response of our Public Health Leadership? Did they understand that such multiple approaches needed to be done in order to most expeditiously find the correct course to follow? No, they did not! For reasons that are yet to be fully determined (but will be, for sure!) all of the positive approaches were demonized in order to do nothing except social distance, lock down “non-essential” businesses like churches, but keep open those “essential” businesses like liquor stores, sicken at home and await the coming salvation of the “vaccine”.
An inside look into the time course of these actions is available in multiple primary sources such as:
The man who claimed to “personify science” stated that the only evidence that should be accepted for safe and effective treatment was a “double blind placebo controlled clinical trial”. It seemed that even though people were dying, and some agents that had been in safe use for decades prevented death, more convincing evidence was needed! Huh? This may make sense to an academic epidemiologist analyzing the data at his or her desktop computer, but to a physician in the trenches, actually treating real patients, it was amazingly short sighted.
Yet when multiple credible reports of serious adverse reactions occurring with the mRNA pharmaceuticals come to light, they were not investigated at all. Remember, we were still operating in the COMPLEX DOMAIN! The jury is still out on much of this. The horizon of predictability on these agents is still extremely short and ignoring credible safety signals is something that has never been done before.
Those who put their trust in “peer-reviewed scientific publications” should look at the number of peer-reviewed publications dealing with COVID that have been recalled, regardless of the reasons. This is unprecedented. One also needs to look at this:
In this short video, an ecologist, Allan Savory, bemoans the fact that individuals come out of grad school only believing what is contained in peer-reviewed papers:
People talk glibly about science. What is science? People are coming out of the university with a master’s degree or a PhD, you take them into the field, they literally don’t believe anything unless it’s a peer reviewed paper…that’s the only thing they accept. And you say to them…Let’s observe, let’s think, let’s discuss. They don’t do it! Only when it is in a peer-reviewed paper or not. That’s their view of science. I think it’s pathetic! Gone into universities as bright young people…they come out of it brain dead! Not even knowing what science means. They think it means peer-reviewed papers, etc.. NO! That’s academia. And if a paper is peer-reviewed it means everybody thought the same, therefore they approved it. An unintended consequence is, when new knowledge emerges, new scientific insights, they can never ever be peer-reviewed. So we’re blocking all new advances in science that are big advances. If you look at the breakthroughs in sciences, almost always they don’t come from the center of that profession… they come from the fringe. The finest candlemakers in the world couldn’t even think of electric lights. They don’t come from within…they often come from outside the bricks. We’re going to kill ourselves because of stupidity.
He was far from the first person to make this observation. The recurrent Pumps and Pipes conference involving cardiovascular physicians, petroleum engineers and aerospace scientists is held annually in Houston:
Savory wasn’t talking about Public Health and COVID, but he certainly could have been. To come to grips with this deadly disease, did the public health elite harness the group genius of people from multiple backgrounds and perspectives in an objective and collegial way? Again, they did not. There was an enforced and rigid orthodoxy. Anybody who strayed was cancelled intellectually and professionally and personally vilified:
When the frontline physicians were eventually found to be right all along, was there an apology, a recognition of errors that could have been avoided? Not yet.
And how many people DID die because of their stupidity, arrogance and ignorance? What are we going to do about this to make sure it never happens again???
In my estimation it will take a wholesale review of the qualities we use to evaluate entry and advancement in the healthcare professions. Yes, excellence in the STEM subjects is necessary, but it is not sufficient. It will not counter the disasters that occurred with their response to COVID. We will continue to turn out “Hollow Professionals”, like the hollow ecologists described by Allan Savory. We will turn out “academics” but not “academic caregiving professionals”.
We could do so, so much more. Why don’t we? Why don’t we insist on educating true scientists who possess specialized knowledge but who also are courageous and ethical critical thinkers capable of, and committed to, moral reasoning and action. Medical school is too late. It must start early, at the latest in undergrad, but ideally in secondary or even middle school.
The best time to plant a tree was 20 years ago. The next best time is today. We need an academic institution that has the capability, vision and reach to begin the process…I know it is out there somewhere….
Basic assumptions used for making decisions always need to be checked and re-checked. We assumed that the healthcare bureaucrats, University Presidents and Administrators, and most doctors were motivated to save lives and keep people healthy. I think that was the basic mistake, not the organizational complexities you mention, and the domains (complex, chaotic, complicated, etc) you list. You raise the question: "And how many people DID die because of their stupidity, arrogance and ignorance?" Again, you're assuming they were stupid, arrogant, and ignorant. If, however, you assume that they were intelligent and knew exactly what they were doing, and the objective was not to save lives or keep people healthy, then all the pieces of the puzzle fall into place. Ignoring the safety signals was not poor practice, or a mistake. That's the kind of excuse we will be hearing more and more, especially from those who want Amnesty. Ignoring safety signals, denying early and appropriate treatments, giving untested "vaccines" with new technology to demographics who were not in danger from serious COVID-19 effects, are all actions that mesh with the objectives of harming and killing people rather than saving lives.
Initially, I believed mistakes were being made and data were being overlooked by the decision-makers. However, as more data poured in, and the decisions did not change, it became clear the objectives of the decision-makers were far more sinister than I believed initially. I did not come to this realization early; it took me about a year before I could accept it. For me, the most egregious behavior came from the University Presidents who mandated the shots for students of child-bearing age who had no need for such "vaccines".
What we all missed was the radical change in objectives of those who we entrusted with our lives and the lives of our loved ones. The tragedy is how few people have come to recognize this shift after three years of continuing disaster.
Do you see a problem on the horizon with the DEI czars in place at every institute of higher learning, including our medical schools, ferreting out the higher scoring kiddos who might not have the correct intersectionality to fit into the diversity mold that is desired at these schools? There are more and more medical schools tossing out the MCAT as an admission requisite. I fear this will lower the common denominator and produce mediocre scientists and physicians. And about morality: Can a society hell bent on killing children in the womb ever be moral or ethical? It pains me to think of it but I am 77 years old and probably will not live to see the full extent of the damage of what is happening in our society. I fear for my grandchildren, however, and this is why I will fight this decay until I die. For the children. Matthew 18:6
Basic assumptions used for making decisions always need to be checked and re-checked. We assumed that the healthcare bureaucrats, University Presidents and Administrators, and most doctors were motivated to save lives and keep people healthy. I think that was the basic mistake, not the organizational complexities you mention, and the domains (complex, chaotic, complicated, etc) you list. You raise the question: "And how many people DID die because of their stupidity, arrogance and ignorance?" Again, you're assuming they were stupid, arrogant, and ignorant. If, however, you assume that they were intelligent and knew exactly what they were doing, and the objective was not to save lives or keep people healthy, then all the pieces of the puzzle fall into place. Ignoring the safety signals was not poor practice, or a mistake. That's the kind of excuse we will be hearing more and more, especially from those who want Amnesty. Ignoring safety signals, denying early and appropriate treatments, giving untested "vaccines" with new technology to demographics who were not in danger from serious COVID-19 effects, are all actions that mesh with the objectives of harming and killing people rather than saving lives.
Initially, I believed mistakes were being made and data were being overlooked by the decision-makers. However, as more data poured in, and the decisions did not change, it became clear the objectives of the decision-makers were far more sinister than I believed initially. I did not come to this realization early; it took me about a year before I could accept it. For me, the most egregious behavior came from the University Presidents who mandated the shots for students of child-bearing age who had no need for such "vaccines".
What we all missed was the radical change in objectives of those who we entrusted with our lives and the lives of our loved ones. The tragedy is how few people have come to recognize this shift after three years of continuing disaster.
Do you see a problem on the horizon with the DEI czars in place at every institute of higher learning, including our medical schools, ferreting out the higher scoring kiddos who might not have the correct intersectionality to fit into the diversity mold that is desired at these schools? There are more and more medical schools tossing out the MCAT as an admission requisite. I fear this will lower the common denominator and produce mediocre scientists and physicians. And about morality: Can a society hell bent on killing children in the womb ever be moral or ethical? It pains me to think of it but I am 77 years old and probably will not live to see the full extent of the damage of what is happening in our society. I fear for my grandchildren, however, and this is why I will fight this decay until I die. For the children. Matthew 18:6