Sunday, March 05, 2017

Experts, anger, and the madness of crowds

We find ourselves in a most peculiar historical moment. Among other things--many other things--problems of health care policy, research, and clinical practice more and more resemble those of society at large. There's a general sense everywhere that, whatever the outfit, the Wrong Guy is in charge of it. Then like a snake eating its tail, we argue endlessly about the details.

It's enough to give one a migraine, bigly. Whether we're talking DC, the Oscars, or (OMG) yet another health care reorg: if only we could get rid of the Gang That Couldn't Shoot Straight. But replace [fill in the blank] ... with what?

Let's look at a couple of recent Anglo-American pieces--here and here--and try to understand this odd moment in time.

In a recent number of The Guardian, an editorialist links the recent Oscars fiasco to what we here at HCRenewal, along with many others have come to call managerialism. The reliance on, indeed the cult of well paid and generic consultancy over real expertise seems now to have metastasized throughout our society. Why should we be surprised if this blight turns out to've insinuated itself into every nook and cranny of our medical organizations?

The hallmarks are the same everywhere. Bigness.  The notion that generic managers know best. If you have a problem, do what you need to do. Bring in an outside hired-gun pseudo-expert and then keep your job. (Of course, occasionally the behavior is so laughably clumsy that some shmoe, like the accountant tweeting from the Academy Award wings, has to be thrown under the bus. So that their bosses can keep their jobs.)

The best bons mots in the Guardian piece: "[T]he kind of expertise worth paying for is almost always the least reassuring." So that, for example, in the case of Britain's National Health Service, "[i]t doesn’t take a consultant to understand, for example, that the NHS needs more money; but it takes a very special and expensive skill not to understand it."

And here we come to the meat of the matter. We all have to get through each and every day. So how do we offload the big decisions? Do we think (as so many AMA docs do) that decisions in health care should go back into the hands of Everyman Physician? (Our new HHS Secretary has been sounding a lot like that.)

Do we place our trust in the hands of the generic Experts? Our lead blogger at HCRenewal has, over many years, shown us how that usually works out.

Or do we place our trust in the hands of those with serious domain knowledge? Ah, but you see, these are the elites. And right now, if you're a knowledgeable person who gets that label, you're out of favor. They say the most non-reassuring things. Who're you gonna believe: me or your lying eyes? So much easier to trust the Big Man, Mr. Authority, or, if we're doing Group Think, generic Manager Man.

Why are we, both without and within Health Care, so gullible? Roger Cohen, in his Times piece, provides some guidance. Anger. Hard to believe that matters of culture and emotion can be so impactful. But Cohen makes the case. He notes that "the attempt to squeeze the last cent of profit out of any operation has also squeezed the last trace of sentiment out of what passes for human interaction. [Individuals] see that technology serves relentless efficiency, and somewhere in that efficiency life gets joyless and existence precarious."

"They note," he continues, "that good unions, retirement benefits, manufacturing jobs, overtime and health care get eliminated or curtailed in pursuit of that last cent. They observe how put-together types with attitude and little qualification can make a bundle buying and eviscerating solid companies that actually produce things or setting up consultancies that trade on connections at the money-influence margins of politics. They know that if something goes wrong with the rigged system the losses will get 'socialized.'"

EMR, anyone?

In any case what's interesting is that this kind of anger can lead to vesting faith equally in a Bernie or a Donald. Masses of people are tempted to go for simplistic solutions. Polarization is inevitable. The crowd supports autocrats, narcissists and charismatics of left and the right,

Fortunately, as a part-way solution, Englightenment thinkers--the authors of the Constitution--created a creaky but resilient system that usually leads to a regression to the mean. Pull people back to the sensible center. That may well happen in health care. What's a lot more questionable is: what's going to happen about our cult of managerialism? It really is a ball and chain. In the Guardian, a secondary header fails to reassure: "In troubled times, the appearance of authority is worth far more than the content of advice."

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