Health care is a calling that resides in the personal proficiency of professionals, beyond the technical efficiency of systems. Accordingly, we cannot manage it like a business, through control by top-down reorganizing, technocratic measuring, and the like. This Commentary offers a sequence of five postulates to reorganize our heads instead, beginning with the assertion that health care suffers from success, and ending with a plea for communityship beyond leadership.

Here are five postulates from the article:

Postulate 1:  We may talk incessantly about its failures, but health care, in fact, suffers from success.

Postulate 2: The incessant reorganizing of health care mostly distracts rather than improves the practices of the professionals.

Postulate 3:  Performance measurements are not suited to controlling professional services. It may be easy enough to measure the efficiency of producing automobiles on an assembly line. But how about measuring the proficiency of treating patients in a psychiatric clinic?

Postulate 4: Coming down the administrative hierarchy, the fixes fail at the great divide in health care, where they meet the Professional Assembly which they seek to manage like a Programmed Machine.

Postulate 5:  For the sake of the necessary collaboration, effective organizations in health care will have to foster communityship, beyond leadership.

You can read the full article in BMJ Leader – an international, peer-reviewed, online-only journal focusing on leadership in health and care.

Here is a tale of three infections. This is local fiction; is it global fact?

She had been especially careful, always wearing a mask and keeping her distance as advised. She trained her children to do the same. (Why, then, was the government that insisted on this now sending children back to school without these protections?)

Then it happened, but not through the children. On a Sunday, she relaxed in her back yard, with no-one around, except a neighbor at a safe distance. The aroma drifted in from his barbecue, but there was no recognized harm in that.  He knew he was infected, but he, too, did everything right. Almost a week into his quarantine, why not a little barbequing in his own back yard?

When he coughed, the droplets fell nearby, as he knew they would. What he didn’t know was that they were accompanied by aerosols, tiny particles of the virus that didn’t fall: they could travel farther in the air. (But why should he have known that, when it took scientists at the World Health Organization several months to acknowledge it.) Across the lawn that day, she became infected, initially without symptoms (a state in which the infection could be passed on; that, again, took the WHO several months to acknowledge).

The next day she went to work downtown. She and others had long complained about the air in the ventilating system of their building, but as in so many such buildings, including schools, this was never corrected. So while going about her normal business, mask off when alone, she was breathing aerosols into that air. Days later, several people in the building “mysteriously” became infected.

But that’s not the way another guy got infected. At lunchtime, she walked to the bank, quickly, because the smog was particularly foul. She took side streets to avoid people, so as not to bother putting on her mask until she got to the bank. But she did continue to breathe, after all, sending aerosols into the polluted air.

Why should the pollution have mattered? In March, a report by a team of Italian scientists had put some potentially important handwriting on the wall: the viruses can attach to aerosols and particles of pollution in the air, possibly enabling them to travel greater distances. This finding was sporadically reported and widely ignored, despite mounting evidence since March that pollution, frequently in the form of smoke, was present at a number of prominent outbreaks (for example, in and around hog plants that smoked ham and in the American Embassy in Riyadh after a barbeque party). Pollution! Smoke! To minds fixated on opening up economies, this must have sounded like Trump’s bleach.

He was taking a walk elsewhere downtown, blanketed by the same smog. Again, being alone, he saw no need to wear a mask. These were, after all, designed to protect others, not himself. Besides, what risk was he taking in a deserted park?

Little did he realize that the risk was in the pollution, for several reasons. First, some of the aerosols that she breathed into the side streets were on their way to the park, hitched to particles of pollution in the air. Second, on a clear day, these aerosols would have been rendered inactive by the ultraviolet rays of the sun. But not on this day: the smog was blocking the sun. Third, while it might have taken a greater density of aerosols to infect most people, his immune system had been compromised by having grown up in the polluted air of the city.

Thus, it was not long before he came down with COVID-19, again without ever knowing why. And once that virus got into his lungs, also weakened by years in that air, he was unable to fight it off. Soon he was fighting for his life in the ICU of the local hospital.

Need he have ended up there if the local and global authorities had seen past their distancing, into the polluted air?
_____________________________________________
I post this, not to worry you more about the coronavirus, but to worry you about those authorities—in medicine, administration, even op ed pages—who have blocked unorthodox explanations for this pandemic, much as smog blocks the rays of the sun. A way forward, with the full story evidenced and referenced, can be accessed on Pollution and Pandemic. While dealing with the pandemic, we face an unprecedented window of opportunity to deal with climate change.

© Henry Mintzberg 2020, posted on the fifth anniversary of this blog. No rights reserved, under a Creative Commons Attribution-NonCommercial 4.0 International License. Feel free to forward, circulate, quote and post this blog and the associated link. For more questioning of the correctness, please see Managing the Myths of Health Care and other books listed on the mintzberg.org home page.

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Ce blogue est une adaptation de deux extraits de mon nouvel ouvrage Managing the Myths of Health Care.

Le patient est la « personne la plus sous-utilisée du domaine de la santé ». Cette personne, c’est vous et moi. Nous ne sommes pas des joueurs occasionnels en ce qui concerne notre santé, peu importe notre état de passivité lorsque nous nous retrouvons devant un médecin.

La plupart du temps, nous ne sommes même pas devant un médecin, voire des patients. Nous devons assumer personnellement la responsabilité de notre propre santé, y compris en matière de prévention de la maladie. La plupart du temps, d’ailleurs, nous sommes les « premiers répondants ». Nous sentons qu’il y a quelque chose qui cloche et nous allons consulter un professionnel ou encore nous nous occupons nous-mêmes du problème. (Vous avez mis un pansement dernièrement?) Et pas que pour nous. Nous pouvons être les premiers répondants pour nos enfants, parfois même pour nos parents âgés. Il convient donc de bien s’informer.

Savons-nous bien nous informer? Il existe tout un éventail de renseignements en matière de soins de santé. À quelle part de ces renseignements importants avons-nous accès? Est-il exagéré d’avancer 10 %?

À l’épicerie, je trouve des œufs, certains étiquetés « Oméga 3 », d’autres « bio ». Lesquels sont préférables? J’ai toujours l’intention de consulter Internet en rentrant, mais j’oublie tout le temps de le faire. À quoi bon? La réponse changera probablement rapidement de toute façon. Ce n’est toutefois pas la fiabilité des renseignements qui me préoccupe, mais plutôt l’interprétation qui en est faite pour mon usage personnel.

Bon, alors comment puis-je bien m’informer pour ma propre survie? N’importe comment. Si je n’avais pas écouté la radio une certaine journée l’an dernier, je n’aurais pas su que je n’avais plus besoin de me forcer à boire huit verres d’eau par jour. En revanche, cette année, si je n’avais pas écouté mes amis qui travaillent dans le domaine médical, je n’aurais pas consulté un naturopathe et découvert qu’il me fallait après tout boire toute cette eau pour traiter un problème de santé. Est-ce là la façon de m’informer sur ma propre santé : une émission de radio, le journal télévisé, une consultation, un article envoyé par un ami et, de façon plus systématique, toutes ces publicités qui m’indiquent quel analgésique avaler?

Seulement, j’ai un avantage : je suis instruit et j’ai le temps de lire. De plus, j’ai des amis médecins que je peux consulter au besoin. Et maintenant, grâce à Internet, je peux trouver toutes sortes de renseignements à mal interpréter. Particulièrement, toutefois, je suis dépassé par tous ces renseignements disponibles et je ne sais trop quoi en faire. J’ai besoin d’AIDE!

UN NAVIGATEUR DE LA SANTÉ À LA RESCOUSSE

Les omnipraticiens, même les plus attentifs, sont des personnes occupées qui doivent diagnostiquer, traiter ou recommander et conseiller, et ce, généralement alors que leur salle d’attente est bondée de personnes anxieuses. Nous, ces personnes qui attendent, avons besoin d’un peu plus.

Permettez-moi donc de proposer le rôle de navigateur de la santé. N’allez pas le confondre avec celui de l’infirmière praticienne qui vient du domaine de la santé, au soutien des médecins. Il convient de noter que la santé englobe davantage que ce que font principalement les médecins, y compris la promotion de la santé (particulièrement le régime alimentaire), la prévention de plusieurs maladies et le traitement de celles que la médecine traite peu (comme le syndrome du côlon irritable et plusieurs maladies auto-immunes). D’autres services comme l’acupuncture, la naturopathie et l’homéopathie traitent certaines de ces maladies, et selon moi parfois de façon exceptionnelle, mais sont marginalisés par le corps médical qui agit de temps à autre en double aveugle.

Un navigateur de la santé, professionnellement formé, fournirait des renseignements et des conseils à vous et moi, ces personnes derrière les patients, au cœur de la collectivité, au-delà des populations des épidémiologistes. Le navigateur de la santé pourrait :

• Apprendre à nous connaître, en tant que personne, mais également au sein de la collectivité, en commençant par un premier entretien complet couvrant tous les volets de notre santé (à l’instar de la pratique homéopathique), et garderait ces renseignements à jour.
• Se tenir au fait des questions de santé de façon générale, ainsi que des sites fiables qui fournissent des renseignements et des services disponibles dans la collectivité.
• Fournir à chacun de nous les renseignements nécessaires et des conseils pour tenter de rester en santé.
• En cas de maladie, nous orienter dans le dédale des diagnostics, des traitements et surtout sur le chemin de la guérison.

Le diagramme qui suit montre les cinq volets essentiels de la santé – le maintien de la santé, le dépistage de la maladie, le diagnostic de la maladie, le traitement de la maladie et le recouvrement de la santé – autour de deux cercles concentriques. Le cercle extérieur est le Cercle professionnel alors que le cercle intérieur représente la Sphère personnelle. Le navigateur de la santé évoluerait en périphérie de ce cercle, comme l’indique le diagramme, à l’intérieur du Cercle professionnel, mais à proximité de la Sphère personnelle.

VOIR LES PARTIES AUTOUR DU TOUT
 

Devrions-nous laisser le sort de notre santé à l’anarchie du marché de l’information de même que dans les limites de la pratique médicale? Ou devrions-nous trouver comment prendre personnellement soin de notre propre santé?

© Henry Mintzberg, 2017, à partir d’extraits de Managing the Myths of Health Care.

Traduction par Nathalie Tremblay

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Medicine has made profound advances in treating many diseases, but in its great strength lies its debilitating weakness.

Organizing for Professional Work 

To understand this, consider how professional work tends to be organized. Much of it is rather standardized, carried out by highly-trained people with a good deal of individual autonomy—at least from their colleagues, if not from the professional associations that set their standards. Just as the musicians of a symphony orchestra play in harmony while each plays to the notes written for his or her instrument, so too can a surgeon and anesthetist spend hours in an operating room without exchanging a single word. By virtue of their training, each knows exactly what to expect of the other.

Accordingly, much of modern medicine does not solve problems in an open-ended way so much as categorize patients’ conditions in a restricted way. Each is slotted into an established category of disease—a process known as diagnosis—to which an established, ideally evidence-based treatment—referred to as a set of protocols—can be applied.

This standardization is not, however, absolute: it takes the form of tailored customization. (See our article Customizing Customization.) The predetermined standards—those protocols—are tailored to the condition in question. The patient presents with a pain in the chest; the diagnosis indicates a blocked artery; a particular stent is installed in a particular place; and an administrative box is ticked so that a standard payment can be made.

Misfits 

The great strength of modern medicine lies in the fits that work. The patient enters the hospital with a diseased heart and leaves soon after with a repaired one. But where the fit fails can be found modern medicine’s debilitating weakness. Fits fail, more often than generally realized, beyond the categories, across the categories, and beneath the categories.

Beyond the categories lie those illnesses that fit into no predetermined category of disease. The patient may not be treated at all—indeed, sometimes dismissed as a hypochondriac—or forced into an inadequate, if convenient, category. Think about IBS (Irritable Bowel Syndrome), a label for ignorance, or some auto-immune conditions.

Across the categories fall those patients with multiple conditions that fit several disease categories concurrently. If these can be treated sequentially, the professional model of organizing is preserved. He or she is sent from one specialist to another. But where the conditions interact in more complex ways, as in many geriatric cases, more open-ended, collaborative problem-solving can be required. (The chief of geriatrics in a Montreal hospital, big on teamwork, used to say that a physiotherapist was their best diagnostician.) While geriatric departments may be encouraged to engage in such collaboration, much of the rest of medicine, where multiple diseases implicate different departments, each grinding in its own mill, does not. How often do we hear from frustrated patients: “Why can’t they just speak with each other, instead of passing around these little notes while I am being asked to describe my condition again and again?” 

Beneath the categories lies a misfit that is no less common, or significant, than the other two. The fit is correct, but insufficient for effective treatment. Here medicine has to get past the “patient”, to the person.

Dr. Atul Gawande, in a New Yorker article entitled “The Bell Curve” (6 December 2004), reported on his observation of a renowned cystic fibrosis physician. He wrote the protocols that others used, yet had much better results. Meeting a young woman, and seeing a reduced measure of lung-function, he asked if she was taking her treatments. She said that she was. But he probed further, to discover that she had a new boyfriend and a new job that were getting in the way of taking those treatments. Together they figured out how she could alter her schedule.

Here, then, lay the good doctor’s secret: he treated the person and not just the patient, by delving beneath the medical context, to her personal situation.

Management and Medicine Alike

Of course, too much contemporary administration hardly encourages this kind of probing. If the administration of that doctor’s hospital was managing in the modern way, it may have questioned why he was spending so much time with this one patient. True she might live longer, but how to measure that in a budgeting system focussed on current expenditures?

Before any physician jumps on this point with great glee, he or she would do well to recognize that the management weakness here is not fundamentally different from that of medicine. Both suffer from an excessive tendency to categorize, commodify, and calculate—indeed, much like the rest of modern society. (See my TWOG on pat and playful puzzles.) Are managers who claim that “If you can’t measure it, you can’t manage it” any more sensible than physicians who claim that “If it’s not evidence-based, it’s not proper medicine”? Subscribing to either canon would close down both management and medicine.

Evidence-guided medicine is fine, as is evidence-guided management. That good doctor used the evidence presented to him. But he probed beneath it, to that woman’s experience. Within and across the categories called medicine and management, physicians and administrators alike would do well to get past their common debilitating weakness, to engage collaboratively for better health care.

© Henry Mintzberg 2018, drawing from my book, Managing the Myths of Health Care

This blog is for your ears.

CBC radio recently broadcast an interview with me about my book Managing the Myths of Health Care. Michael Enright, who has been hosting the popular “Sunday Edition” for years, and I have always resonated well in earlier interviews, but never this well—at least judging by the tweets and emails that came in. Needless to say, this has many controversial comments, but I always maintain that my most outrageous ones are usually the truest.

Given the reaction in Canada, why not post the interview for people elsewhere. (It’s not especially about Canadian health care.) So here it is, not as a transcription, but as the audio version itself. Moreover, instead of putting up my own tweets, we have selected them from the reactions of the listeners—tweets and emails, to and by the CBC, and to myself.

Here is the link to the full audio interview. Hearing the easy bantering between Michael and myself may encourage you to listen to all of it.
Otherwise, this takes you to the CBC summary of the interview, including quotes from it. But I warn you: much is lost in the transcription!

Find the book here on Amazon. 

____________________

Welcome to Nina Hermes, who joins me in preparing and posting these TWOGs. And thank you to Tanya Sardana who has been doing so.

Follow this TWOG on Twitter @mintzberg141, or receive the blogs directly in your inbox by subscribing here. To help disseminate these blogs, we also have a Facebook page and a LinkedIn page.

This blog is adapted from two passages of my new book Managing the Myths of Health Care.

The patient is the “single most underused person in health care”. This means you and me. We are not casual players when it comes to our health, no matter how passive we may be in front of our doctors.

Much of the time, we are not even in front of them, or even patients. We have to take primary responsibility for the care of much of our own health, including the prevention of diseases. Moreover, we are often the “first responders.” We feel something coming on and get ourselves to a professional, or else just deal with some problem ourselves. (Have you put on a bandage lately?)  And not just for ourselves. We can be the first responders for our children, sometimes even for our elderly parents. So we better be well informed.

How well are we informed? There is a vast array of health care information out there: how much of what we need to know actually gets to us? Is 10% a gross exaggeration?

I go into the supermarket and see eggs, Omega 3 and Organic. Which is better? I always mean to check on the Internet when I get home, but I always forget. What’s the use? The answer will probably change soon anyway. But it’s not the reliability of the information that bothers me so much as the rendering of it for my personal use.

So how do I get informed for my very survival?  Haphazardly. Had I not had the radio on a particular day last year, I would not have heard that I no longer need to force eight glasses of water down my throat every day. But this year, had I listened to my medical friends and not gone to see a naturopath, I would not have found out that, for a particular condition I have, I had better drink all that water after all. Is this any way to get informed about my health—a radio program here, TV news there, a consultation, an article sent by a friend, and most systematically of all, ads telling me what pain killer to swallow?

And I’m advantaged: well educated, with time to read. Plus I have physician friends I can call about these things. And now, thanks to the Internet, I can find all kinds of information to misinterpret. Mostly, however, I am overwhelmed by the information available, and underwhelmed by what of it I get. I need HELP!!!

Health Navigator to the rescue

General practitioners, even the most responsive ones, are busy people. They have to diagnose, treat or refer, and advise—usually with a waiting room full of anxious people. We, the people out there, need something more.

So let me suggest the role of health navigator. Don't confuse this with nurse practitioner, who comes from the perspective of medicine, as a supplement to physicians. It should be noted that there's a lot more to health care than what physicians mostly do, including the promotion of health (especially diet), the prevention of many illnesses, and the treatment of those that medicine has yet to address (such as IBS and many auto-immune conditions).  Other services, such as acupuncture, naturopathy, and homeopathy, do treat some of these conditions—in my experience, at times remarkably well—yet get marginalized by a medical establishment that can be doubly blind.

A health navigator, professionally trained, would provide information and advice to you and me, the persons beneath the patients—in our communities, beneath the epidemiologists’ populations. The health navigator would:

• Get to know us, as individuals and in our community, beginning with an extensive first interview about all aspects of our health (as homeopaths do), and continuing to maintain that understanding.
• Remain abreast of health care information in general, as well as of the reliable sites that provide it, and of the services that are available in our community.
• Provide us with whatever of that information each of us needs, alongside advice to help maintain our health.
• In the event of illness, guide us through the intricacies of diagnosis, treatment, and especially recovery.

The diagram below shows the five key aspects of health care—maintaining health, detecting illness, diagnosing disease, treating disease, and recovering health—around two concentric circles. The outer one is labelled the Professional Ring while the inner one, closer to ourselves, is labelled the Personal Sphere. The health navigator would work all around he circle—as shown in the diagram, in the Professional Ring but close to the Personal Sphere.

Seeing the Parts around the Whole

Must we leave the fate of our health to the haphazardness of the information marketplace as well as to the limitations of medical practice? Or shall we find our proper place in the care of our own health?

© Henry Mintzberg 2017 with passages from Managing the Myths of Health Care.

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Managing the Myths of Health Care

BERRETT-KOHLER  AMAZON UK  AMAZON

From the back cover:

“Health care is not failing but succeeding, expensively, and we don’t want to pay for it. So the administrations, public and private alike, intervene to cut costs, and herein lies the failure.”

In this sure-to-be-controversial book, leading management thinker Henry Mintzberg turns his attention to reframing the management and organization of health care.

The problem is not management per se but a form of remote-control management detached from the operations yet determined to control them. It reorganizes relentlessly, measures like mad, promotes a heroic form of leadership, favors competition where the need is for cooperation, and pretends that the calling of health care should be managed like a business.

“Management in health care should be about dedicated and continuous care more than interventionist and episodic cures.”

The professional form of organizing is the source of health care’s great strength as well as its debilitating weakness. In its administration, as in its operations, it categorizes whatever it can to apply standardized practices whose results can be measured. When the categories fit, this works wonderfully well. The physician diagnoses appendicitis and operates; some administrator ticks the appropriate box and pays. But what happens when the fit fails—when patients fall outside the categories or across several categories or need to be treated as people beneath the categories, or when the managers and professionals pass each other like ships in the night?

To cope with all this, Mintzberg says that we need to reorganize our heads instead of our institutions. He discusses how we can think differently about systems and strategies, sectors and scale, measurement and management, leadership and organization, competition and collaboration.

“Market control of health care is crass, state control is crude, professional control is closed. We need all three—in their place.”

The overall message of Mintzberg’s masterful analysis is that care, cure, control, and community have to work together, within health-care institutions and across them, to deliver quantity, quality, and equality simultaneously.

Some other excerpts:

In management no less than medicine, scalpels usually work better than axes.

Narrowness pervades health care, from professionals on the ground who can’t see past their specialities, to managers in the offices who can’t see past their institutions, analysts in governments and insurance companies who can’t see past their numbers, and economists in the air who can’t see past their dogma.

Reorganizing is the expected disjointed intervention for a health care “system” built on disjointed interventions.

While the ill act as a concerted force for spending more locally, the healthy act as a general lobby for spending less nationally. This makes the field of health care sick.

There are no management problems in health care, separate from medical problems, nursing problems, or prevention problems. There are only health care problems.

Because economics begins before medicine ends, the technocrats of health care have too often trumped the professionals.

In the name of competition, health care suffers from individualism: every patient, provider, and institution for themselves.

The field of health care may be appropriately supplied by businesses, but in the delivery of its most basic services, it is not a business at all, nor should it be run like one. At its best, it is a calling.

I can think of no field that is more global in its professional practices yet more parochial in its administrative ones than health care.

Certainly we have to measure what we can; we just cannot allow ourselves to be mesmerized by measurement—as we so often are.

Physicians who like to belittle hierarchies of authority are often slaves to their own hierarchies of status.

Who can possibly be against evidence in medicine? Me, for one, when it is used as a club to beat up on experience.

The essential problem in health care may lie in forcing detached administrative solutions on to practices that require informed and nuanced judgments.

It can be taken as almost an axiom of professional work that dysfunctional practices cannot be fixed by tighter administration. The problems have to be addressed within the work itself.

Strategy making in the field of health care tends to be about venturing more than visioning, and personal and collective learning more than institutional planning.

When we promote leadership, we demote everyone else. How about plain old management?

Instead of people pointing the finger at each other, they should be pointing their fingers together at the procedures and structures that set them apart.

Health care doesn’t need more measuring and reorganizing so much as better cultures of collaboration that open up the pathways of communication.

A systems perspective requires a focus on the person in the community, beyond a patient in a population.

There’s a massive amount of health care information out there, some of which I need to know. How much of that part am I actually getting? Is 10 percent a gross exaggeration? And how do I get even that? Haphazardly!

To find the systems perspective in health care, look first in the mirror: we are as close as we are going to get. That is because you and I are significantly responsible for promoting our own health, preventing our potential illnesses, and even treating many of our own diseases.

The invisible hand that is supposed to serve everyone by serving ourselves turns out to be a visible underhand in much of health care when it serves some users at the expense of others.

See full Table of Contents

© Henry Mintzberg 2017

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You probably know people who have had some sort of cancer. You also know many more who will be getting these diseases—you just don’t know who they are. So when you “Run for Cancer”, the money likely goes for those people who have the disease, to find a cure, rather than to the investigation of cause, so that many more people needn’t get the disease in the first place. We certainly need to celebrate concern for the ill, but shouldn’t we show equivalent concern for the healthy, so that they don’t get ill? Is not an ounce of prevention worth a pound of cure?

Part of the problem lies with medicine itself. It is mostly about treating diseases, and since physicians do so much of the research, that’s where the bulk of the funding goes. I asked a surgeon active in breast cancer research about the proportion of funding that went to finding cause. She estimated it to be 1%. (Some physicians even refer to as “prevention” stopping Stage 1 breast cancer from advancing to Stage 2. That’s like claiming that the cause of Stage 2 cancer Is Stage 1 cancer.) True there are diseases such as Alzheimer’s that do better, but how many others are like breast cancer?

And let’s not get started on pharmaceuticals, except to note that there is no money to be made from people who are well, or at least usually a lot less money from one-shot vaccines to keep them well. So developing medications gets most of the big bucks, and siphons off a great deal of the creative talent that could be looking for causes. All around, our health care needs to be better focused on the care of health.

John Robbins has written a wonderful allegory about a cliff that people kept falling over. There thus developed a highly sophisticated effort to treat the injured, involving physicians, ambulances, and hospitals with the latest technological wizardly. Efforts were even undertaken to develop drugs to cure the injuries of the fallen. When some people suggested building a fence atop the cliff, they were ignored, or else dismissed: what did they know about health care?¹

Dr Jonas Salk didn’t buy any of this. He never cured any child of polio. Instead he ensured that no child ever had to be cured. His laboratory developed a vaccine that eradicated the disease. We need more money and talent dedicated to stopping diseases, including studying the toxic effects of what we inhale, ingest, and absorb. And by the way, Dr Salk refused to patent his vaccine, with the comment that “Who owns my polio vaccine? The people. Could you patent the sun?” He could have made a great deal of money by ensuring at the outset that only the children of rich parents could get the vaccine. Instead children all over the world became protected rather quickly.

Researching cause can be quite different from researching cure. It is often more like detective work, where samples of one can be perfectly appropriate. After all, find the cause in someone and you may be on your way to finding the cause in everyone.

A 2003 poll by Hospital Doctor named Dr John Snow the greatest physician ever. Partly he earned that with a sample of 2. When an outbreak of cholera exploded in London’s Soho District in 1854, believing that the disease was water-born, even though the physicians who mattered were convinced it was air-born, he plotted the locations of the recent victims on a map. They clustered around one well, all except two, who lived miles away. Like a good detective, Dr Snow visited the home of one of them. A relative told him that she liked the water of that well and had someone fetch it for her. Her niece also liked that water, he was told, and she died too. And where did she live? There was sample Number 2. Finally Dr Snow’s colleagues listened to him. (Sewage seeping into the well—i.e., toxin—was later found to be the cause of the outbreak.). The handle of the well was removed—that was the cure! (for this well at least)—and the epidemic ended.

Some years ago, I heard about an astonishingly high incidence of certain cancers among children in Alexandria. So for this TWOG I went on the internet and found one related article, in the Journal of the Egypt Public Health Association, 2002, under the title “Patterns in the incidence of pediatric cancer in Alexandria, Egypt, from 1972 to 2001.” The article concluded that “The trends in some cancer types suggest the need of a closer examination of the underlying factors and environmental contaminants leading to the disease in children.” Yes indeed, and what a perfect place to research cause. But who is to do that: where is the constituency for cause?² In other words, where are the Dr Snow’s when we need them now?

If you have lost a cherished member of your family to a dreaded disease, I can well understand your wish to help find a cure for it.  But cannot this emotion also be directed into helping avoid the suffering of others? So please, the next time you run for a disease, or fund a research chair, or just donate a few pennies for health care, consider cause. Invest in health.

© Henry Mintzberg 2016. HM is the Founding Director of the International Masters for Health Leadership (imhl.org) and author of the forthcoming Managing the Myths of Health Care (Berrett-Koehler, 2017). Follow this TWOG on Twitter @mintzberg141, or receive the blogs directly in your inbox by subscribing here. To help disseminate these blogs, we now also have a Facebook page and a LinkedIn.

Great debates continue as to who should manage hospitals and other health care institutions. For example, should the head be a physician? a nurse? a professional manager? The physicians know cure, the nurses know care, the professional managers know control. But who knows all three? Is there thus good reason to reject all these candidates? I reject the question itself.

Professional managers so called, namely people who believe they are qualified to manage everything because they sat still in an MBA or MHA classroom for a couple of years, have been the target of several TWOGs here. Being educated in the abstractions of administration prepares no one for the cauldrons of practice.

Management, unlike medicine, uses little science: hence it is not a profession. Or to put this another way, because illnesses in organizations, and prescriptions for their treatment, have hardly been specified with any reliability, management has to be practiced as a craft, rooted in experience, and an art, dependent on insights. Visceral understanding counts for a lot more than cerebral knowledge.

Well then, if not professional managers, how about physicians? Surely they have the visceral understanding of the operations, plus the status to be heard. Moreover, are hospitals not fundamentally about medicine? Yes to all of the above questions. But there is a lot more to managing health care than knowing medicine. In fact, there are reasons to believe that the practice of medicine is antithetical to the practice of management.

Physicians are trained mostly to act alone, individually and decisively. Every time one sees a patient, an explicit decision is made, even if that is to do nothing. Decision making in management is not only more ambiguous, but also more collaborative. A cartoon appeared some years ago showing several surgeons around an anesthetized patient, over the caption: “Who opens?” In management, that is a serious question! Add to this the facts that medicine tends to be interventionist, mostly about episodic cures, rather than continuous care; that it usually focuses on parts, not wholes; and that it strives to be scientific and evidence-based, and you have to worry about physicians running hospitals.

This leaves the nurses. Their practice is often more visceral, more engaging, and arguably closer to concern about the whole patient. Moreover, their jobs are ones of continuous care more than intermittent cure, plus they are inclined to engage in more teamwork. So some nurses at least should be rather more suited to managing hospitals.

Sure―but how to get the doctors to accept management by the nurses?

So the conclusion appears to be evident: no-one can possibly manage a hospital! Running even a complicated corporation must seem like child’s play compared with managing a general hospital: the strident doctors, the beleaguered nurses, the sick patients, the worried families, the demanding funders, the posturing politicians, the escalating costs, the accelerating technologies―all embedded in cases of life and death.

Yet people do manage hospitals and other health care institutions, sometimes with rather astonishing effectiveness. So beyond the evident answer to our question is the obvious answer: People, not categories, have to manage health care institutions. I have encountered physicians who were renowned as heads of hospitals. (One of Montreal’s most respected hospital directors was an obstetrician with an MBA.) Likewise have I seen some awfully impressive nurses managing hospitals―and imagine how many more there would be if given the chance.

My own preference is for people who have worked in the operations before moving into the management, whether that be in nursing, medicine, physiotherapy, or social work, etc. In fact, the wider the net is cast, the greater the chances of success.

That is not to conclude that training in management is irrelevant, only that it should follow experience on the job, and build on it. That is what we have been doing at McGill since 2006, with great success and delight, in our International Masters for Health Leadership (mcgill.ca/imhl), for people from all aspects of health care all over the world.

Now for the ultimate bit of administrative engineering

In a recent TWOG on managing the care of health, I discussed a number of dysfunctional forms of administrative engineering—mergers, measures, reorganizations, etc.—that are meant to fix health care where it is not broken. Some weeks ago I underwent a bypass operation in a Montreal hospital that had been administratively engineered in a particular way.

Our hospitals in Canada are mostly non-owned―they are independent trusts. But that has not necessarily stopped the provincial governments that provide most of their funding from treating them like government departments.

Last year in Quebec, the prime minister and his minister of health, both physicians, solved the problem of who should manage hospitals by deciding that no one should. They eliminated the positions of director general—head of the hospital--and indeed of most of the health care institutions in Quebec. In effect, they fired them all, and combined all these institutions into regional agglomerations, each with its own single président-directeur général (the French term for CEO).¹

This is not Alice in Wonderland. In the teaching hospital where I was treated, with its 637 beds, there is no longer anyone in charge. The former directeur général was kicked upstairs—transformed into a PDG―to manage the whole agglomeration. This comprised nine (yes 9) separate institutions, across acute, community, rehabilitative, palliative, and geriatric care, etc. Think of all the money our government has saved. Think too of all the chaos that is to come.²

So I have a terrific idea. Do we really need all those government ministers? Health, Justice, Culture, Finance, Education, Agriculture, Mines, and eighteen or so more. Why don’t we just agglomerate them all, and have the prime minister run the whole works himself. Think of how much more money we could save.

© Henry Mintzberg 2016. Partly drawn from my forthcoming book Managing the Myths of Health Care.

Follow me on Twitter @Mintzberg141. You can also receive the blog directly in your inbox by subscribing to mintzberg.org/blog.

This is the third in a set of three TWOGS based on a book I am completing called Managing the Myths of Health Care. The first TWOG introduced two myths: that health care is a “system” and that it is failing. In fact it is succeeding, astonishingly (at least where it chooses to focus its attention, namely on the treatment of acute diseases rather than chronic conditions). It’s just that this is expensive, and we don’t want to pay for it. So we intervene with all kinds of administrative fixes, that were the subject of the second TWOG: measures, markets, and mergers, heroic leadership, relentless reorganizing, and making health care more like a business. Arguably, these are the causes of the perceived failures. In this TWOG I discuss some basic ways to reframe certain key practices of health care, to render it more like a system.

Clearly we need administrative engineering to keep the lid on the costs of health care. But that does not mean, to quote from a flamboyant article in the Harvard Business Review, that hospitals need to be seen as “focused factories”, doctors as “industry players”, and patients as “customers” and consumers” who carry out “one-stop shopping” for their services.

Beyond being a patient, I am a person. Beyond being part of some population, we are members of communities. Practiced properly, health care is not a business at all, but a calling. Can anyone possibly believe that most physicians, nurses, and other professionals would work as conscientiously as they do, in the face of so much pressure and frustration, in order to maximize the  “value” of some shareholders they never met?

There is thus a compelling need to proceed differently in health care, with scalpels instead of axes, out of the administrative offices and into the operating rooms, of all kinds. What looks good on paper can wreak havoc in practice because administrative prescriptions are often simple and reality is often complex. So ways have to be found to combine the efforts of dedicated professionals with those of engaged managers.

In the final section of my book Managing the Myths of Health Care, I discuss reframing across various key aspects of health care. Those concerning managing and organizing are discussed here. We do not have the space to get into three others: Reframing Scale—to make the default position human scale rather than economic scale; Reframing Ownership—to recognize the key role that common ownership has to play in this field beside public and private ownership; and Reframing Strategy—as venturing, not planning (which is touched upon here). I may discuss these in later TWOGs.

Reframing Management: as distributed beyond the “top”

Most everywhere, an essential problem in health care lies in forcing detached administrative solutions on to practices that require informed and nuanced judgments. In a 1994 article on health care reform, Donald Berwick put it: “Only those who deliver care can, in the end, change care…. The outsider can judge care; but only the insider can improve it.” Clinicians should, therefore, “stop feeling battered” by the reforms and begin to do something about the problems. Bear in mind that it was clinicians who developed day surgeries: one of the great advances of health care in recent times, that both cut costs and improved qualities dramatically.

In fact, eliminating the word “outsider”, as well as the vocabulary of “top” and “middle”, would also help, by challenging the artificial gaps between levels of administrative authority as well as those of professional status. Everyone who works in this field contributes and therefore deserves the full respect of everyone else, so long as they return that respect.

There are three ways to close the artificial gaps between administration and operations: One is to bring “down” this “top” by wooing those people concerned with administration―managers, administrative engineers, government officials, and so on―off their hierarchical pedestals and into more direct contact with the operations. A second is to bring the base “up” by involving the providers of the services in the administrative practices (without necessarily having to become managers). But most important may be eliminating the formal levels between administrations and operations—for example by favoring smaller institutions and regions in the first place.

Concerned and committed people in all kinds of unexpected places can improve the practice of health care, much as so many people are changing Wikipedia every day. (Think of this as open source strategizing.) A policeman in receipt of dialysis treatment helped reorganize the scheduling for everyone’s benefit. “Let a thousand flowers bloom” could thus be the motto for driving effective changes in health care.

Reframing Organization: as collaboration transcending competition

There is no doubt that we are all competitive beings, from which can spring good and bad. But we are also cooperative beings, from which can spring a lot more good, especially in health care, where we already have too much competition. In the name of that competition, health care suffers from individualization: every recipient, every provider, every institution for him, her, or itself. So enough of professionals grinding in their own mills, apart from managers who try to remote control them, let alone apart from each other who believe they can coordinate everything on automatic pilot. There are no management problems in this field, separate from medical problems or nursing problems or prevention problems, etc. There are only health care problems. 

Reframing the Practice of Managing: as caring before curing¹

Instead of leaders who don’t manage, health care needs managers who lead. Such managers are part and parcel of their institutional community; they do not sit “on top” of it.

In response to a newspaper commentary I published about heroic leadership, a retired manager of nursing wrote to me about her experiences with people “not skilled in understanding the work of front-line staff… [they] managed from a meeting, from their offices, or from their home computer”:

In health care today, the vertical monopoly structure is leaving the front-line point-of-care team questioning where is the support, where is the leadership, where is the inspiration, where are the coaches, who really cares? I do not believe there is a shortage of staff; there is a lack of retention of staff. The idealistic, intelligent, youth are not satisfied with mediocre leadership and turn to other professions to have their dreams fulfilled.²

Health care institutions—and businesses too these days—need something quite different: managing as convincing more than controlling, demonstrating more than directing, inspiring more than empowering, above all managers who engage themselves in order to engage others. Put differently, in health care managing itself should be about dedicated, continuous, holistic, and pre-emptive care more than interventionist, episodic, narrow, and radical cures.

How to get to this? Managers can start by purging their organizations of the corporate vocabulary—“CEO” and all the rest. On the ground, they can experience people beyond patients, providers beyond professionals, communities beyond populations. And by the same token, the providers can be reaching out sideways, to communicate with each other more effectively for the sake of continuous care.

As discussed in the TWOG of the week before last, a cow is a system: its parts function harmoniously. Why can’t health care work like that?

© Henry Mintzberg 2015, Have a look at our International Masters for Health Leadership (mcgill.ca/imhl), where mid-career people from all aspects of health care the world over get together for five 11 day modules to consider all this and much more.

Last week’s TWOG, the first in a series of three, discussed two myths of health care: #1 that it is a system, #2 which is failing, In fact this non-system is succeeding, brilliantly, at least in the treatment of diseases that are acute more than chronic.  The problem is that it is doing so expensively, and we don’t want to pay for it. So we try to fix it, in all kinds of dysfunctional ways, and herein lies the failure. This week’s TWOG looks at the most popular of these fixes—five more myths.

Myth #3: Health care can be fixed by measuring like mad.  Administrative engineering marches on: when in doubt, measure. As a senior official in the British health department replied when asked why they measure so much: “What else can we do when we don’t understand what’s going on?” (How about leaving your office to find out what‘s going on?) The fallacy here is the assumption that we can measure everything that matters. Another is that doctors can be incentivized like Pavlovian dogs.

Myth #4: Health care can be fixed by relentless reorganizing. This fix is popular because it’s so easy. Shuffle people around on pieces of paper, and off you go. The fallacy here lies in the assumption that hierarchy is organization: change who reports to whom and people magically coordinate with each other. Does all this reorganizing make a difference where managerial authority is so easily trumped by medical sovereignty? Actually it does: it drives all the providers to distraction. Patients beware!

Myth #5: Health care institutions can be fixed by making them bigger. There may be economies of scale in assembly lines, but the patients and providers of health care are not automobiles. We care about how we are treated. We prefer intimacy. Yet the problems of health care institutions are frequently dealt with by making them bigger–the institutions I mean, although usually the problems too. A corollary of this myth is that mergers are magical: combine one happy health care organization with another happy health care organization and together they will be blissful.  

Myth #6: Health care institutions, not to mention the whole non-system, can be fixed with more heroic leadership. Sure leadership matters, especially when it replaces a leadership that was worse. But how can some leader siting on “top” render more effective all those people working on the ground–unless, of course, he or she gets off that pedestal, to find out what’s happening on that ground. But that means forsaking heroic leadership for engaged management.

Myth #7: Health care can be fixed by making it more competitive. Health care? It already has too much competition, thank you, albeit among physicians fighting over beds and administrators fighting over budgets. How about a little more cooperation guys and gals, for the sake of the patients, who are, after all, people? As for market competition, I have three words: American health care.¹ And as for the related myth, that health care can be fixed by running it more like a business², I have three words for that too: American health care. Beware of caveat emptor when the seller knows a lot more than the buyer. That’s why the best of health care is a calling, not a business.

So what can we do?  For starters, we can recognize that the real failure of health care may well lie in these fixes: mergers, measures, and markets, leading, organizing, and businessing. Remember that if we always do as we always did, we will always get what we always got. Tune in next week to hear about doing differently.

© Henry Mintzberg 2015  HM is the Founding Director of the International Masters for Health Leadership (mcgill.ca/imhl), which brings  together people from all over this field and this world to get beyond such myths.

Follow me on Twitter @Mintzberg141. You can also receive the blog directly in your inbox by subscribing to mintzberg.org/blog.

Longer ago than I care to remember, I started a book called Managing the Myths of Health Care. This week I finished a draft of it suitable to submit for publication. So here, and for the next two weeks, are some excerpts from the book. This one is about two of the major myths.

Myth #1: that health care is a system.   Calling something a system does not make it a system where it matters, namely in the consolidated delivery of its services, on the ground. In health care, mostly we have a collection of disease cures, or at least treatments, often the more acute the better. Overall, we favor cure over care, acute diseases over chronic ones, and the treatment of diseases in particular over the prevention of them and the promotion of health in general.

It is certainty important to treat people who are ill, but it is also politically advantageous: they are an aggressive lobby, in the hospitals and governments, to spend as much as necessary to get them well. The many more people who will be getting these diseases, but don’t know it yet, hardly lobby at all in comparison. (That would take a systems perspective.). So we spend the lion’s share of our money treating diseases, whereas more on preventing them would actually increase our longevity!¹

Myth #2: this so-called system is failing.  If there is one general area of agreement in health care, it is that this “system” is failing, all over the world. Users and providers alike complain bitterly about their services.

At a party in Montreal a few years ago, I got into a conversation with a young radiologist who went on and on about how bad health care was in Quebec. “You did your residency in the United States,” I finally intervened: “How about that?” She threw her hands in the air: “Don’t get me started on the American system!” Some time later I was in Italy, with some people working in the field who were likewise putting down their health care. So how does Italy compare with other countries, I asked. Oh, they replied, in the latest ranking by the World Health Organization (2000), Italy ranked second best in the world. I guess second best is not good?

Quite the opposite. In most places in the developed world, the treatment of disease is succeeding―albeit expensively. And where health care does not focus, in preventing illness in the first place, there have still been improvements, for example in the promotion of better eating and more exercise. It is just that here the pace of improvement has been much slower, and the resources expended for this are shamefully low (this in the face of a perpetual battle with so many forces that promote poor eating and sedentary living).

On some of the broadest measures of health, such as life expectancy and infant mortality, performance in most countries has been steadily improving. For example, a World Health Report found that Chilean women in 1998 could expect to live to age 79 on average, 46 years longer than their predecessors of 1910. Indeed, they could even expect to live 25 years longer than women in 1910 whose countries had the 1998 Chilean level of income.² The report concluded that access “to new knowledge, drugs, and vaccines appears to have been substantially more important” than improvements in food intake and sanitation. Health care has its problems, to be sure, but it has been making remarkable progress—where it cares.

Imagine that you have chest pains and are offered the following choice. (1) Health care circa 1960: Your GP comes to your house, gets you straight into a hospital with attention from many sympathetic doctors and nurses, who eventually send you home to rest and hope for the best. Or (2) Health care now: No doctor will come to your house. You get yourself to an overcrowded emergency room, eventually to get to cardiac surgery, where a stent is installed—with perhaps no personal attention at all—so that you can be sent home the next day, in rather good shape.

The problem: We don’t want to pay for this success.  Let me repeat: In most places in the developed world, the treatment of disease is succeeding―albeit expensively. We just don’t want to pay for it. And herein lies the great problem in health care today: this field is suffering from success more than failure.

Medicine has been practically brilliant at developing expensive new treatments, and pharmaceutical companies have been particularly clever at getting away with pricing their innovations obscenely.³ Who among us is prepared to forego one of these needed to save our life?

Of course, as the costs of treatments go up, so too must the expenditures to cover them, whether in the form of taxes, insurance premiums, or personal payments. If we want more, we have to pay more. But in this age of consumptive greed, we want to pay less―or at least not that much more.

For the most part in the field of health care, we are not buying services so much as the possibility of needing services (i.e., insurance). Why, then, should I pay for you, who is sick, while I am healthy, and probably invincible at that? In other words, while the ill act as a concerted force for spending more individually, the healthy act as a general lobby for spending less collectively.

This is not a happy combination: it makes the field of health care sick. It encourages us to intervene in all kinds of dysfunctional ways, not directly and clinically, but indirectly and administratively. And that often drives clinicians literally to distraction. To cite two common examples, we reorganize them relentlessly and measure their behaviors obsessively.

Next week I wish to discuss a number of these popular ways not to fix health care, and the week after that, to propose a different way to think about dealing with this problem.

© Henry Mintzberg 2015