The Problem of Scale

                 I was in the doctor’s lounge the other day waiting for a phone call when I happened to pay attention to the interview on the television. Charlie Rose was interviewing David Brooks, New York Times columnist, and he asked if Brooks could give an overarching theme to our political times. He said that in his view the last 35 years or so were characterized by an increasing degree of narcissism, but that he thought the country as a whole was moving back in a communitarian direction. Our political institutions, though, have ossified and still reflect excessive narcissism, which is being amplified by technology.

                As someone who came of age during the 1960’s, the times are similar: we are engaged in wars in distant places, the economy is in trouble in part because we refuse to pay the costs of those wars. There does seem to be one big difference: there is nothing equivalent to “The Establishment” that was the focus of so many protests in those years. Have you noticed the “Occupy Wall Street” movements are for or against “whatever?” 

                Immediately afterward, Charlie Rose interviewed a man named Dov Seidman.[i] I had not heard of him previously, but he is trained as a moral philosopher and, somewhat improbably, has started a company that seeks to help other companies find their moral compass. He characterized the last three decades as ones where our institutions had to “scale up” to compete in the global economy. In the process of scaling up, it was important to create business characterized by a “transactional” mode of operation. The example he used for this was how does a multinational company deal with beef? In the United States, beef is seen as a food crop, but rarely as a cow. In India, on the other hand, the cow is sacred and would never be viewed as “beef.” To make these international corporations work successfully, leadership had to avoid the values conflict inherent in these divergent views.

                His basic point, which is hardly new, is that such “valueless” transactions are not really sustainable, and easily lead to excesses such as Enron. He is finding a market for his business where he tries to find a moral basis for interactions, albeit one that is secular rather than religiously based. In such a business, individuals matter. They are not “fungible,[1]”[ii] meaning they are not interchangeable parts of the assembly line. Now he does not say that transactional businesses are immoral, nor does he say that explicitly moral values based businesses don’t commit immoral acts. He does insist, though, that people need a moral basis for their actions in order to feel “okay” about themselves.

                It occurred to me that perhaps this was also a source of the conflicts I have experienced in trying to articulate a vision of a new future, and a source of the conflict experienced by those who do not agree with my vision of a new future. The practice of medicine is, in my opinion, an explicitly moral contract. Patients trust me to put their interests first, and to give my best advice on courses of action. They expect me to not calibrate how much I put their interests first based upon how much they are paying for my time.  In other words, they explicitly reject a transactional basis for the exchange.  Have you ever had a patient ask you how much advice they could get for $100? 

                For at least 25 years, we have been “scaling up” medical institutions, such as hospitals, medical groups and insurance companies, and perhaps without recognizing it, these institutions have adopted a transactional philosophy—one where “providers” are fungible and everything is negotiable. At some level, those of us who view medicine as a moral enterprise find this approach offensive. How we respond with something other than disgust, though, is important. I would like to suggest that medical institutions are neither completely moral nor completely transactional. The trick is to create and maintain a dynamic equilibrium between the two points of view.

    

[i] http://www.charlierose.com/view/interview/8590/ 

[ii] Fungibility is the property of a good or a commodity whose individual units are capable of mutual substitution, such as crude oil, wheat, precious metals or currencies.  For example, if someone lends another person a $10 bill, it does not matter if they are given back the same $10 bill or a different one, since currency is fungible; if someone lends another person their car, however, they would not expect to be given back a different car, even of the same make and model, as cars are not fungible. Work is done by people, not FTE’s.  An FTE may be fungible, but people are not.

Written 28 November 2011, revised 4 May 2014.

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