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Cathedral Thinking
Recently, I described how physicians who had practiced during WWII came together to create the healthcare system in my town that is still in place today. It also got me to thinking about the reform efforts I was involved in and why they failed. Although the circumstances varied, as did the details, I think there were three basic reasons for failure. First, at no time were all of the parties motivated by a notion that the status quo was no longer meeting the needs of either the providers or the patients and something better was needed. One side or the other, but not both, was motivated by economic distress. This meant one side was always looking at ways to gain short-term advantage. Second, we never really came to terms with the cultural differences between the way doctors think and the way hospital executives think. Third, all conversations rapidly broke down because everyone wanted to know the details of the plan before we were able to come to the table to negotiate the way toward our goals. The majority wanted to analyze and criticize a finished plan rather than hold the tension necessary to explore options. Now this is not peculiar to my town, my colleagues, or even health care. For instance, a lot of the political discussions around difficult issues, like financing healthcare or how to do a pandemic stimulus package, both the participants as well as the lobbyists and the commentariat want to know the details so they can criticize or object. This forces those who want to make progress to congress in secret, which may be the only way to move forward.[1] Of necessity, then, the focus is often on the short-term and “doable.” Roman Krznaric has recently written a cogent critique of what he calls short term thinking called The Good Ancestor.[2] Although his prescriptions are decidedly Malthusian, and not ones I think appealing, his emphasis on how “now” has come to mean progressively shorter intervals of time as a result of computers seems about right. As an example, when I was overseas during a deployment in 1982, letters home through the Army Post Office took a week each way, so my weekly letters were always responding to events at home from two weeks previously. When my daughter and her husband went to England in 2000, I subconsciously expected the same delay, but she used VoIP technology and we talked by phone more than we had when she was in Dallas. Now, of course, we could do videoconferencing in any number of ways. The author contends this and other forces has shortened the practical attention span of people. He emphasizes that humans have always had a capacity for long-term thinking, whether they used it or not, which put me in mind of Aesop’s fable about the grasshopper and the ant.[3] I think the author would say we are all grasshoppers now. As antidotes to short term thinking, he has six different ways of changing thinking. I want to focus on one: cathedral thinking. Now what I know about building cathedrals is from watching a PBS program devoted to the subject,[4] but a few things are evident. First, the originators of the cathedral building had to make a plan that defined the size of the building. (The shape (cruciform) and the orientation (east-west) were prescribed by tradition.) Second, they had to build on bedrock. Great effort at hand digging was often required to accomplish this, but everyone knew this step had to be done and done right if the building were to stand. Third, the load of the roof was going to be enormous, so the walls had to be straight and braced. One of the interesting facts is that even though the measuring tools consisted of plumb bobs and sextants, modern survey instruments show these building are rarely more than a couple of centimeters out of plumb over their span. Fourth, they knew these projects were going to take longer than one lifetime to complete, so there seems to have been an open approach to the future—future masons and builders were expected to adapt and solve the problems as they arose, not as the founders would have done. It is common to assume these people were motivated by their transcendent vision of honoring God, but daily concerns of empire building, power and prestige were also involved. As I researched the topic, I found a recent article on the building of the Cathedral of St. John the Divine in New York City, a building that is not anywhere near completion.[5] The author points out that the Episcopal Church was motivated in part to compete with the Roman Catholic St. Peter’s Cathedral, which was then the only other cathedral in the city. So, the projects were always a mix of secular and sacred concerns. What lessons does cathedral thinking have for health care systems? First, the transcendent goal has always been providing health care to the people. But what if the mission needs to be improving the health of the people? This question has profound implications for the design adopted. The second mission statement is larger and will require entirely new approaches, structures, and attitudes. Either way, meeting the mission requires people who serve the needs of other people. Yes, new technology will be part of how we accomplish this, but the service aspect and the relational aspect are bedrock principles. We have often forgotten that in our enthusiasm for the hot new (expensive) technology. Third, cathedrals are never really finished. Competition for the fanciest new facility is a kind of cathedral-building arms race, but, as European Gothic cathedrals show, unless the original mission is maintained, they become tourist attractions or fall down. There is also evidence that many cathedrals have been partially rebuilt when flaws in the original building were discovered, or new ideas were incorporated into the project. Of course, these massive buildings need constant maintenance to avoid collapse and, as the fire in Notre Dame cathedral in Paris demonstrates, even well-intentioned efforts to do maintenance can cause catastrophic damage. In the middle of the pandemic crisis, it is difficult to envision anything, but after the crisis passes my hope is for renewed enthusiasm for “cathedral thinking” as they set about trying to rebuild, renovate, and restore their cathedrals, and maybe even consider abandoning them and reusing the materials for a new project. If they can agree on bedrock principles and overall design, they must understand and accept the approach has to be open-ended. Can we sustain the tension between the short and the long-term perspectives? 10 January 2021 [1] The founders of The Jackson Clinic had their early meetings at the farm of one of them in the next county. [2] Krznaric, Roman. The Good Ancestor: A Radical Prescription for Long-Term Thinking. (New York: The Experiment, LLC, 2020.) [3] http://read.gov/aesop/052.html. Accessed 10 January 2021. [4] https://www.pbs.org/wgbh/nova/video/building-the-great-cathedrals/. [5] Kemper, Nicholas. Building a Cathedral. 29 April 2019. Accessed 10 January 2021 at https://theprepared.org/features/2019/4/28/building-a-cathedral. |
Further Reading
Answering Strategic Questions Answering strategic questions is hard work and also uncertain, but these are not reasons to avoid asking them. Concordat The pandemic is a time of disruption. Can it be chance to "push the reset button? Getting to Why Reduced government spending by definition means someone's income goes down. To mitigate those changes medical organizations need to get to "why." On Strategy A central question for healthcare organizations as they face the future is what is our goal? While taking care of patients might seem the obvious answer, it is the one that is usually not considered. Optimism or Hope "Hope is optimism with a plan." Population Health Population health is a phrase that disguises some hard realities as illustrated by two recent reports. System Failure Medicine has adopted the language of manufacturing with terms such as efficiency, reliability, and “lean processes.” An unintended consequence may be increased risk of system failure. |