The Fifth Discipline was a business book phenomenon in the very early 1990s. Written by Peter Senge from MIT it launched a whole movement (that, unfortunately, turned into a buzzword) for organizations to aspire to become “learning organizations.”
The titled fifth discipline was, and is, the discipline of systems thinking and in my opinion we need it more than ever. We especially need it to properly position the heated debates and warring camps associated with “fixing our broken health care system,” or words to that effect.
The foundation of systems thinking is that we operate within systems possessing both detail and dynamic complexity. In other words, there are lots of parts and most are changing all the time.
Chapter Four in Senge’s book enumerates the eleven laws of the systems thinking. Here they are, with a bit of commentary about our health care system and attempts to fix it.
- Today’s problems come from yesterday’s solutions. In the WW II era, big businesses used company sponsored health insurance as a way to get around wage controls to capture and keep the best workers. Now the costs are onerous and harmful to our competitive position in the world market.
- The harder you push, the harder the system pushes back. A current proposal to deal with the shortage of general practitioners and family doctors is to cut the Medicare reimbursement to specialty docs, since they make the most money. Gee, do you think they might push back?
- Behavior grows better before it grows worse. Politicians will be tempted to enact some simple solutions to appease interest groups (hard to believe!) and costs might actually go down for a short period. However, if they don’t consider the larger system, they may not see the delay in feedback that will (later) add costs.
- The easy way out usually leads back in. Universal health care might seem like a humane response to the needs of the uninsured and underinsured and might appeal to a majority. However, if the system is not made more effective or efficient we will find that we cannot afford the humane solution.
- The cure can be worse than the disease. As we put policy and technology in place we have to ask how “the burden” is shifting and to whom.
- Faster is slower. My concern about health care reform is that it will get connected to an election cycle and our friends in Washington (after watching this thing go from bad to worse of decades) will rush legislation to show that they are doing something. Point solutions will slow the repair of the system.
- Cause and effect are not closely related in time and space. So, for example, let’s say that they legislate the wholesale switch to electronic medical records. Will they think through the long-term impact on costs, privacy and integration?
- Small changes can produce big results – but the areas of highest leverage are often the least obvious. If we focused on wellness we might not have the costs of dealing with sickness. Unfortunately, the system is not designed to make us healthy; it’s designed to fix us when we’re sick.
- You can have you cake and eat it too – but not at once. New information technologies may make the system more cost effective over time – but the upfront costs will be significant.
- Dividing an elephant in half does not produce two small elephants. The private healthcare system is not separate from the government (VA, Medicare) system. Trying to keep them apart is senseless.
- There is no blame. Give me a break! That’s all Congress knows how to do!
So, what if we resurrected a good idea from the very early 1990s and give it another shot? Which of the laws do you think we might use? Which are useless in this situation?