Medicine 2024

A Lost Art, A Lost Science

In 2010, I was honored to deliver the Wendell Hughes Memorial Lecture at the American Academy of Ophthalmology. I envisioned a bright future for my profession.  I am sorry to say, but I was sadly mistaken….

I had envisioned a giant leap forward.  Instead, the bottom of all of medicine and science fell out in 2020.  Let me explain:

In his 1967 Presidential Address to the American Academy of Ophthalmology, Dr. Hughes pointed out the paradox he saw in Medicine:

“During the past third of a century, the average length of life of the individual has been increased by almost twenty years.  But, in this age of forced early retirement, are the latter years of our life happy, or are they filled with uncertainty and fear of physical incapacity?”

I agreed with him in his assessment. In an attempt to explain how we had arrived at that situation, I stated in the lecture:

To understand what has happened, as well as the solution, we need to look outside of our past experience and outside of our profession.  In “The Empty Raincoat” published in the US under the title, “The Age of Paradox”, Charles Handy described the natural history of change in the utility paradigm as a sigmoid curve.

A prolific polymath, Charles Handy wore many hats in his life: marketing executive for a petroleum company, business school professor, author and philosopher. He had a close friendship with Warren Bennis, the “Father of Leadership Studies” and, in a sense, my own professional grandfather (Bennis mentored David Logan and David mentored me).  Bennis recuperated from a heart attack in the Handy apartment after being stricken in London.

In two remarkable books (The Age of Unreason, 1989 and The Age of Paradox, 1994) handy articulated his view of how to move ahead in the future.  In The Age of Unreason, he introduced the term “upside down thinking”.  Change required a new way of approaching problems, not just using the old ways “better”.  This outside-the-box approach was continued in The Age of Paradox in which he envisioned change as a series of sigmoid curves.  First in such a curve is a period of slow growth, followed by a rapid acceleration followed by a peak and fall.  The trick was to catch a new sigmoid curve before the old one started the decline.  Handy warned that depending upon the successes of the past was like “driving looking in the rear-view mirror”.

The need to jump to the next curve while the old one was still doing great was put together in this diagram by David Snowden.  He kindly allowed me to modify it for the 2010 Lecture:

Snowden used the successive sigmoid curves as manifestations of the types of problems in the different domains discussed in the Cynefin Framework . 

The problems can be differentiated by a number of means including the relationship of Cause and Effect.  In Simple Problems, everyone can see the relationship between Cause and Effect.  It is the domain of “Best Practice”.  When the problem is Complicated, experts can still see the relationship and can plot a reasonable plan of approach.  It is the domain of “Multiple Good Practices”.  However, in the Complex Domain, Cause and Effect are still operative, but they can only be seen after the problem is solved! 

Imagine the solution to a Sudoku Puzzle.  It can be challenging as you attempt to solve, but once it is solved, you can check the answer in seconds.  Snowden realized that problems in all of the domains continue, but the dominant management challenge of the day tended to move in a time-dependent fashion.  In 2010, Simple and Complicated Problems still existed, but the approach to solving them was well-known.  It was the Complex or Wicked Problems that took the effort.

Applying this to medicine, I saw the Flexner Report of 1910 as the introduction of Scientific Management to healthcare.  With the Control of Function in Scientific Management, huge advances in treatment of infectious diseases were possible.  By the 1990’s however, that Scientific Management was incapable of dealing with the explosive costs of medical care and application of the Toyota Production System was touted as the answer.  However, Steven Spear and Kent Bowen warned that confusing the tools with the philosophy of Toyota was doomed to failure. To deal with the next level--the level of Complex or Wicked Problems, a different approach was needed. 

Unfortunately, Medicine never completely made the jump from the Scientific Management curve to the Systems Thinking Curve, let alone to the Sense Making Curve I had envisioned.  Medicine was still stuck on the “Best Practice” mode of dealing with all problems, probably because it was just easier to deal with things this way.  This would have ominous implications in 2020.  The Randomized Controlled Trial, or RCT, was locked in as the ONLY way in which progress could be made.  This was predicated on all problems being, at the most, “merely complicated” in which experts could envision the way forward and test their hypotheses.  It was a linear approach to a dynamical system problem and completely ignored the unanticipated effects of the potential solution.

Nevertheless, in 2010, I was hopeful that enough people in medicine would see that we needed to expand our thinking.  I could not have been more wrong….

I didn’t appreciate that titanic forces were at work in the background, and had been for quite some time, that would create a perfect storm ten years later and make all of this moot.  Just a few months before I delivered the lecture, we had undergone a “fundamental transformation” as a nation.

In America’s Cultural Revolution, Chris Rufo has meticulously cataloged the undermining of the social fabric of the United States.  Little by little, the institutions of this country were changed until, while outwardly still standing, only a shove was needed to topple them.  Imagine those Handy Sigmoid Curves were bridge spans and the rivets holding them were gradually weakened, only to have everything collapse when placed under stress.  That stress would come with the Rise of COVID, the death of George Floyd and the intense hatred of Donald Trump by the leftist elite who had gained control of the institutions of society in the United States. Postmodernism triumphed over rationalism.  Ideology became everything, and truth failed to have any meaning. When truth is a relative concept so is the relationship of Cause and Effect.

 Medicine followed the path outlined in the Cynefin Framework:  The relationship between Cause and Effect could not be recognized by anybody, because there was no relationship anymore!  Those attempting to bring sanity back into our approach to the Great COVID Disaster were frustrated because no matter how logical and reasoned the approaches were, they were rejected out of hand as they did not fit the ideology of those in control.  We had entered the Chaotic Domain.

How to solve a problem in the Chaotic Domain?  In the Cynefin Framework, it demands decisive action from the outside to stop the unfolding disaster.  Will this be necessary?  Must the “fundamental transformation” of the fabric of society in our current Postmodern world be reversed? How can this be done?  How can we restore objective truth?  Chris Rufo has some ideas in America’s Cultural Revolution and everyone reading this should carefully listen to them.   But one thing is certain.  Society will need to step up as current medical leadership has no incentive to solve this problem…..