An Ethics of Complexity

As a long-time member of the military medical community, this article caught my eye: “1 in 5 Army hospital leaders suspended in 2 years: What’s behind the discipline?”

The reasons for these suspensions are known only at the highest level of command, and I suspect that there they will remain. But such a circumstance is significant, and we must ask for the reasons, to determine if they are relevant to all of us in the healthcare profession, and not just to our military medical leaders.

In my decades-long experience with dozens of hospital commanders I have found that they are professionals of the highest integrity, dedication, and ability. They achieved their roles after years of challenging jobs, most certainly in the trying times since 9/11. They have ample leadership experience before being selected as hospital commanders, and the scrutiny and accountability they faced to get there is testimony to their abilities. It doesn’t take much of a slip to put one out of the running for hospital command.

But this level of scrutiny has become magnified in our age of technology and instant communications. Within large organizations vast amounts of information flow up and down the chain of command at the speed of light through fiber optic cables. Data is tracked, analyzed, and reported, requirements are created, and information is sought, gathered, pushed, scrutinized, speculated on, and multiplied. One effect is to have leaders constantly under surveillance, not from any mal intent, but from the pressures to succeed and avoid failure. When formerly errors might have been overlooked, found late, or simply not seen as errors, they now can be seen instantly and broadcast far and wide. If “to err is human,” there is diminishing room to be human.

In a small example–a few years ago I became the physician representative for my hospital’s implementation of an organization-wide initiative. The program was sound in concept, useful in practice, and beneficial to medical staff and patients alike.

The problem came as we watched the organization inch its way toward implementation. Nobody objected to the concept and it’s utility. Leaders and staff were simply too preoccupied with other demands. I as well did not pursue all the potential uses of the system simply because I already had my hands, and mind, fully occupied with everything else I had to know to practice medicine and use the existing computer systems.

I realized that if I, who am sought out as someone who can work through the complexities of technology, is at his limits in what he can attend to, then the organization is unlikely to get much more from either its busy leaders, or from physicians who have less patience or facility with the demands of technology.

I doubt that anyone can escape this phenomenon, for the complexity and scrutiny exist at any level, albeit in varying forms. We cannot afford to ignore it or simply acquiesce, for if the best among us fall, then the rest of are less likely to even try.

This steadily increasing complexity contrasts with a passage I recently re-read in Richard Swenson’s book, Letters to a Young Doctor: “There is no more beautiful sight in the world than that of a kindly, efficient doctor engaged in the examination of the body of a fellow human being.”

I wonder if such a passage makes sense to many people today. But what struck me is that part of the beauty was a simplicity unencumbered by the distractions of modernity. We decry “technology” but can’t separate ourselves from it. It’s not the technology itself from which we wish to be liberated, but the complexity that it brings.

What we need, then, is an “ethics of complexity” within the healthcare profession. This would measure the modern trends and pressures on and within healthcare by their tendency to create complexity, and thereby overburden and distract both healthcare professional and patient from the pure and ultimate goal of establishing a lasting therapeutic relationship, or covenant, as described by William May. The goal, then, of organizations, leaders, staff, and even patients, would be to identify complexity when it arises, and modify systems to mitigate it. I only hope that this one additional consideration doesn’t just add to the problem of managing healthcare.

An “ethics of complexity” would be grounded in the idea that mankind, in all his abilities to create and adapt, still has a limit…and that to push this limit is to begin to sacrifice something critical to our humanity. For those physicians who still sense the beauty of the doctor-patient relationship, such a recognition is overdue.

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