Medicine Systems


I worked with someone (not a physician, but that doesn’t really matter here) whose title was “assistant director”. He and I quickly recognized that we worked well together: His head brimmed with big visions and ideas, whereas my head brimmed with plans as to how to make those ideas manifest in the actual world.

“He’s like a bunch of balloons,” I quipped to a colleague. “He’s got a ton of ideas—shiny, bright balloons—but he needs someone to hold all the ribbons to keep them from floating away.”

“Do you think medical school trains us to become managers or leaders?” my colleague asked. Someone several rungs up on the organizational chart had convened a supervisor training; one of the major points of discussion surrounded the differences between “managers” and “leaders”. One suggested generated a lot of wondrous “ooooh”ing: Managers ensure that the ship is running properly; leaders ensure that the ship is going the right direction.

“Managers,” I responded. “Particularly once you get to internship.” Interns are learning on the job how to diagnose and treat medical problems in actual human beings with all the complicating factors of life: Pregnancy, poverty, rare diseases, under- or over-involved family members, a health care system that can prioritize profits over patients.

“Really? I think medicine teaches us to become leaders. By the time we are attendings, we have to hold the entire context of a specific person in mind while ensuring that junior staff learn skills—the technical stuff in addition to the bedside manner stuff—that do not result in harm to patients.”

“Yeah, I agree with that,” I said after a pause. Only upon further reflection I was able to articulate that physicians are often “stuck” as managers because we are often too busy doing clinical work to exert influence and demonstrate leadership on the systems in which we work.

Sometimes it is the system that gets in the way of us doing all the things we want and should do.

Though I am more likely to be the person holding the balloons than the actual balloons, Big Thoughts still trickle through my mind:

  • What if the public mental health and substance use disorder systems worked from the assumption that people will get better and no longer need services? What if we built a system where people didn’t get stuck in it?
  • What if the ratio of “case management” to “treatment” was flipped in the public mental health and substance use disorder systems? What if people received effective treatment sooner? Would people then need as much “case management”?[1. To be clear, case management is important. The public systems are complicated and confusing. Case managers can help people navigate their way through and hopefully out.]
  • What if various skills—emotion regulation, distress tolerance, effective communication, relating to others, self-reflection—were automatically included in prenatal care and continued post-partum?
  • What if various skills—emotion regulation, distress tolerance, effective communication, relating to others, self-reflection—were included in school curricula for every grade?
  • What if designated leaders and managers of clinics, hospitals, and other health care entities included more clinicians (of all stripes) and people who receive services there? What if it were routine for health care entities and regulators—particularly Medicaid and Medicare—to solicit and implement ideas from clinicians and people who receive services?

I agree that systems—whether formal or not—need both managers and leaders. I also agree that the most effective managers and leaders do not rely upon their hierarchical positions to promote change and improvement; they instead cultivate and nurture interdependent relationships throughout the system. After all, in health care, our primary goal is (or at least should be) to help others.