"Why clinicians hold the key to fixing health care's complexity problem"

I once wrote a post with the title, "A jumbo jet is complicated, but mayonnaise is complex..." with the point that there is an important difference between complicated and complex.  Mary Uhl-Bien and Michael Arena came up with the concept in one of their articles ("Complexity leadership: Enabling people and organizations for adaptability"), stating, "… a jumbo jet is complicated but mayonnaise is complex. When you add parts to a jumbo jet they make a bigger entity but the original components do not change–a wheel is still a wheel, a window is a window, and steel always remains steel. When you mix the ingredients in mayonnaise (eggs, oil, lemon juice), however, the ingredients are fundamentally changed, and you can never get the original elements back. In complexity terms, the system is not decomposable back to its original parts…"

As Alex Di Miceli explains in a blog post on Medium ("Complex or complicated?"), complex systems are emergent, meaning that the whole is always greater than the sum of its parts.  Like the mayonnaise, you can't break complex systems down into their individual components easily and figure out how they work together.  Complicated systems are not emergent, so you can break these systems down into their individual components rather easily and see how they fit and interact together.  He writes further:

"A car engine is complicated, traffic is complex."

"Building a skyscraper is complicated. The functioning of cities is complex."

"Coding software is complicated. Launching a software startup is complex."

The differences between complex and complicated is similar to the difference between Newtonian physics and quantum physics (see my post, "Like clockwork?" for more on this point).   Classical physics, often called Newtonian physics is based upon Sir Isaac Newton's three universal laws of motion and emphasizes the linear, cause-and-effect nature of the world around us.  To every action there is an equal and opposite counteraction.  Output is proportional to input.  The overall system is a sum of its individual component parts.  Under this paradigm, we should be able to both predict and understand exactly what happens in a system by breaking it down into its individual components.  The laws of the universe should work like clockwork.  Quantum physics, however, is completely different.  Rather than the machine-like, clockwork universe of Newton, we appreciate that the world is quite complex (rather than complicated).  It is non-linear and emergent.  We could never fully understand or appreciate how exactly a system works just by understanding its individual components.

Alejandro Quiroga and Thomas Lee recently wrote an article for NEJM Catalyst, "Why clinicians hold the key to fixing health care's complexity problem".  They suggest (and I tend to agree with them on this point) that clinicians are ideally suited to a world of complexity, because that is exactly what they deal with on a daily basis.  They write, "The decision-making processes honed by clinicians in medical school and residency, which emphasize teamwork, hypothesis-testing, and rapid adaptation, are better suited to complex problems than the processes typically taught in business and health administration programs, and organizations can benefit from harnessing their clinicians' skills to address complex operational problems."

Drs. Quiroga and Lee also suggest that the current state of U.S. health care is a paradox, in that "systems are managed as single, predictable machines, even though they frequently face complex, unpredictable problems."  Hospitals and health systems employ a vast army (their exact word) of physicians and nurses who are used to working in a non-linear quantum universe!  And yet, over the last couple of decades health care organizations have created operating systems based upon the business and/or manufacturing industry, with a focus on Lean/Six Sigma, the Toyota Production System, standardization, dashboards, checklists, huddles, etc.  While these changes have made our operating systems better, they have fallen short of the results observed outside of health care.  A major reason for these lower-than-expected results are that they work well in a complicated world, but they don't work as well in a complex one, like health care.

They suggest that physicians and nurses are trained to lead in the complex world of health care.  They write, "If clinicians want a more agile system, then they have to engage with how it works, not just how it feels.  That means stepping into strategy, governance, and operational design with the same adaptive, emergent mindset they use at the bedside.  Administrators must allow clinicians to step into those realms, and move from controlling to enabling, from predicting to learning, and from perfect plans to rapid, iterative pilots."

It's a great article written by two very well-respected leaders in health care.  Dr. Quiroga is currently the President and CEO of Children's Mercy in Kansas City, while Dr. Lee is the Chief Medical Officer at Press Gainey Associates, Inc.  They end their article by recommending that leaders at every level (even non-clinician leaders) can start by:

1. Creating adaptive space for experimentation, in addition to standard operational systems

2. Learning to pivot and paying attention to emergence

3. Flattening hierarchy to increase information flow, ensuring leaders have access to the information being learned on the front line

4. Nurturing social capital as core infrastructure

5. Leading with curiosity and humility, knowing that without a doubt, we don't know it all.

Erase or embrace?

I came across (special thanks to my boss for sharing it with me) another great blog post by Korn Ferry CEO Gary Burnison, "Erase or Embrace?"  Burnison talked about one of his favorite college professors, who happened to teach geology.  When I first started reading the post, I had to ask myself, "What in the world does geology have to do with leadership?"  Well, stay tuned.

As it turns out, this particular professor used to write out very long and detailed notes on the chalkboard during his lectures.  I know that chalkboards are a thing of the past, but that's how college professors used to deliver their lectures!  Anyway, Burnison's geology professor would fill up the chalkboard with notes, and as he did so, his clothes, hands, face, and mouth would get covered in chalk dust.  Burnison said, "Every time he said the words metamorphic rock or tectonic shifts, a sea of white dust showered the first row of students."

When the chalkboard became completely filled with notes, the professor would grab the chalk eraser and erase all the old notes and then start completely over with new notes.  Now, for those of us who are old enough to remember chalkboards, we will know that erasing chalkboards never completely eliminated the old writing.  No matter how much swiping you would do with the eraser, the old writing always showed through, making it nearly impossible to decipher the writing that came afterwards.  

Burnison suggests that as leaders, we deal with the same issue - "operating at the intersection of past and present" as he calls it.  He then asks a rhetorical question, "So, is it time to erase - or embrace?  The answer is yes!"

In other words, we should both embrace the past and look to the future.  It's not so much as an "either/or" but a "both/and" answer.  As Burnison writes, "We need to erase what's holding us back so we can embrace what moves us forward.  It's like the dichotomy we find in the old saying - the same boiling water that hardens the egg softens the potato."

In our turbulent and chaotic world, organizations (and their leaders) must continually adapt.  Flexibility and agility is absolutely essential.  Burnison suggests, "As leaders we need to ask ourselves: Are we keepers of the past, ambassadors of the present, or emissaries of the future?  Are we simply historians of what was - or heralds of what will be?"  The answer is that we need to be all of it.  We can't be stuck in the past, but we also can't ignore it either.  We have to be ready for the future, but we can't lose sight of how we got here in the first place.  As I've said before, the need for change doesn't have to be an indictment on the past.

Once again...the math horror show

A couple of months ago, I posted about some disturbing statistics about how the current generation of high school students are struggling with mathematics (see "U.S. high school reading and math scores at an all-time low").  According to a 2024 statistics released by the Nation's Report Card, a branch of the National Center for Education Statistics (NCES) and the Department of Education,  twenty-two percent of 12th graders performed at or above what is defined as a proficient level in mathematics.  The Wall Street Journal published an article with an accompanying editorial that same week (September 9, 2025) entitled "Another K-12 Education Disaster" and wrote that "nearly half [of high school seniors] can't do rudimentary math."  I ended my post by stating, "What is clear to me (and not political) is that whatever we've been doing in the last decade or so just isn't working.  Education is too important an issue - we don't just need to get a "passing grade" with our education system (and we aren't), we should be trying to get straight A's!"

I recently read yet further confirmatory evidence of just how widespread this problem has become.  Again, the Wall Street Journal recently published an article entitled "A math horror show at UC San Diego" on November 25, 2025 that reported "At one of California's top universities, many freshmen are unable to do middle-school math."  UCSD is one of our nation's top public universities, ranking sixth in the annual U.S. News and World Report rankings.  And yet, they found that one in eight freshmen have math skills that fall below the high-school level - a 30-fold increase since 2020!  More concerning, one in twelve freshmen have math skills that fall below middle-school levels.  And yet, the average high-school math GPA for entering freshmen taking a middle-school remedial math course was an A minus.

In a follow-up editorial ("The college students who can't do elementary math"), the Wall Street Journal defined rudimentary high-school math skills as "geometry, algebra, and algebra 2."  In addition, they expanded on the scope of the problem, stating that "Students who had been placed in a remedial high-school math class in 2023 had roughly fifth-grade-level [math] abilities.  Only 39% could correctly round the number 374,518 to the nearest hundred - a third-grade skill."

There's a lot here to unpack.  I am sure that UCSD is not alone in their experience here.  The editors at the Wall Street Journal have some theories that I do not fully agree with (rampant grade inflation in high school, the fact that the University of California system stopped requiring standardized testing for enrollment, lower standards to increase the diversity of the student body, etc), but I do agree with their conclusion that "The sum of all this is a tragedy of the education commons."  The impact on the deteriorating skills in mathematics (as well as other subjects) remains to be seen, but I for one am deeply concerned about our future.  Given the direction that society is moving, skills in the STEM courses are going to be more important than ever.  And it seems that we are jeopardizing our future.

"Remember to look up at the stars..."

The late Stephen Hawking was arguably one of the greatest minds in at least our lifetime, if not in history in general.  He passed away in 2018 after living 50 years with motor neuron disease, which is also known as amyotrophic lateral sclerosis (ALS) and Lou Gehrig's Disease.  During a 2010 ABC News television interview with Diane Sawyer, Hawking offered the following advice to his three children, Lucy, Robert, and Tim:

"Here are the most important pieces of advice that I've passed on to my children. One, remember to look up at the stars and not down at your feet. Two, never give up work. Work gives you meaning and purpose and life is empty without it. Three, if you are lucky enough to find love, remember it is rare and don't throw it away."

It's great advice for leadership and life, so I want to dive a little deeper in what I think he meant.  

"Remember to look up at the stars and not down at your feet"

The first piece of advice is both literal and metaphorical.  Hawking is telling us to always have a sense of wonder and curiosity about the world around us.  Only through our imagination and our curiosity can we understand the proverbial "big picture" and solve some of life's most difficult challenges.  As leaders, we should never stop questioning about whether or not there is a better way to do something.  There usually is a better way.  

Hawking suffered through severe physical limitations throughout his life.  He eventually would lose the ability to breathe on his own, and he was only able to communicate through a speech-generating device that he eventually would operate with only a single cheek muscle.  And yet, he continued to make important discoveries in his field that would challenge how all of us think about the world and our place in it.  Most of us are fortunate enough that we will never experience these physical limitations.  We should not let the day-to-day frustrations consume our lives, but rather we should always look forward and continue to challenge ourselves to grow and develop.  

"Never give up work"

The second piece of advice is more literal, but it is equally as important.  Hawking suggests that we should always have a goal in life, an intellectual pursuit that gives us a sense of purpose.  Our wellbeing is critically dependent on our sense of purpose.  Without it, we are lost.  For Hawking, his life's work in theoretical physics and cosmology was his passion.  It wasn't just a job or a career for him.  His passion for his field was his reason for being.  

I talked about the Harvard Business Review article, "How the Busiest People Find Joy" by Leslie A. Perlow, Sari Mentser, and Salvatore J. Affinito in my post "Finding Joy" from earlier this year.  They began the article by stating, "Research suggests that to have a satisfying life, you need to regularly feel three things: achievement (recognition or a sense of accomplishment), meaningfulness (a connection to something bigger than yourself), and joy (happiness or positive emotion) in the moment."  Our work should give us all three.

"If you are lucky enough to find love, remember it is rare and don't throw it away"

Hawking's third piece of advice is fairly self-explanatory.  Love is an uncommon gift that we should not take for granted.  Ever.  Once you find true love, never let it go.

We shall never forget...

"We shall never forget" is a common, powerful refrain used every December 7th, which is known throughout America as National Pearl Harbor Remembrance Day.  Yesterday, we honored the over 2,400 Americans killed in the surprise Japanese attack in 1941, a date then President Franklin D. Roosevelt called "a date which will live in infamy," ensuring the sacrifice, bravery, and lessons of that day are remembered to inspire future generations and uphold peace.  

Yes, now that 84 years have passed, Japan and the United States of America are friends.  There are those that would suggest that we should not continue to live in the past.  There are those among us who would suggest by referring to December 7, 1941, we are in some way anti-Japanese or even worse, racist.  They are wrong.  We should always honor our soldiers, airmen, sailors, and marines for their service to our country.  Life as they knew it changed forever after December 7, 1941.  And for some, their very lives ended on December 7, 1941.  We can honor their sacrifice without being anti-Japan.

We honor and cherish those who gave their lives in the service of their country every year on National Pearl Harbor Remembrance Day.  But we also remember, on that day of all days, an entire generation who likely saved our world from ultimate destruction.  We too remember their sacrifice.

President George H.W. Bush, who was himself a member of that "greatest generation" and who served as a Naval aviator during World War II, gave a speech at the USS Arizona Memorial on the fiftieth anniversary of Pearl Harbor on this day in 1991.  I encourage all of you to watch it - it is very moving.  He ended his remarks by looking out over the water, his voice cracking as he fought back his emotions:

Look at the water here, clear and quiet, bidding us to sum up and remember. One day, in what now seems another lifetime, it wrapped its arms around the finest sons any nation could ever have, and it carried them to a better world. May God bless them. And may God bless America, the most wondrous land on Earth.

Let us remember.  Never forget...

It's an island thing!

It's definitely winter here in the Midwest!  Our family recently took a trip to Grand Cayman Island and missed the post-Thanksgiving snowstorm.  It's always great to be able to relax and recuperate, and we definitely enjoyed the time away.  I will fully admit that even though there is about 12 inches of snow on the ground today and the temperature here is about 75 degrees cooler than where we just were this past week, it's good to be back home.

While we were at the beach, we were visited several times by a small group of feral chickens (including one very proud and very noisy rooster - who ever said that roosters only crow at dawn??).  If you've never spent time on a tropical island, the chickens would be a fairly unwelcome surprise.  However, just about every tropical island that we've been to (including the island of Guam where we were stationed as a family during my time in the Navy) has feral chickens!  As I said to one of our kids this week, "It's an island thing!"  Apparently the feral chicken population has grown so large in Hawaii that the local government has started taking measures to control the population (see The Atlantic article, "Hawaii's feral chickens are out of control").

There is something unsettling about having a chicken walk up to you while you are trying to relax on the beach.  While I consider myself a lover of animals, I could do without the feral chickens on my beach vacation.  They are a nuisance.  But that got me thinking more.  Nothing is perfect.  We learn to appreciate things when we take the good with the bad, the positive with the negative.  When we lived in Guam, I think we started to take for granted the fact that we were completely surrounded by the ocean and could go to the beach whenever we wanted.  It was only when we headed back to the Midwest and spent time in the cold that we really and truly appreciated all the great things about living on a tropical island.

With all things, you learn to take the good with the bad.  Sometimes you have to experience the bad in order to appreciate the good things in life.  And sometimes, you just need to tolerate the feral chickens, because "It's an island thing!"

Future Shock

I've been wanting to read Future Shock by Alvin Toffler for several years.  It's an older book (it was first published in 1970), so I wasn't sure it would be as relevant today as it was when it was first released.  After I kept reading or hearing references to the book, I finally decided a few months ago to check it out at the library and read it.  The book was an interesting read, even if at times a bit of a struggle.  Many of Toffler's predictions were off (not too surprisingly),  but some were spot on.  The book itself hasn't aged particularly well.  For example, Toffler focuses on men in the workforce, and he even talks at one point about how wives make friends with their husbands' co-workers' wives and how this could pose a problem when the man gets promoted and his colleagues are now his direct reports.  However, some of Toffler's main points still resonate and are useful to some of the problems confronting society today.

Toffler first coined the term "future shock" in an article "The future as a way of life" in Horizon magazine in 1965.  The term is used in this context "to describe the shattering stress and disorientation that we induce in individuals by subjecting them to too much change in too short a time."  That change can be technological, cultural, or social in nature.  At the time he wrote the book, the world was changing rapidly, at least in Toffler's opinion.  Whereas previous generations had experienced gradual transformation over time, the newer generations growing up in modern society were facing constant, rapid shifts in everything from family life to work to values.

For example, Toffler describes a concept that he calls the 800th lifetime.  All of human history can be divided into lifetimes, each lasting approximately 62 years (the average lifespan at the time he wrote the book).  If you start "human history" from the very beginning of Homo sapiens, we humans have been around for nearly 50,000 years, which equates to about 800 lifetimes.  Of these 800 lifetimes, about 650 lifetimes were spent in caves.  We have, in fact, only been communicating with future lifetimes during the last 70 lifetimes, following the invention of writing.  We've had the benefit of mass communication following the invention of the printing press for the last six lifetimes.  Toffler goes on to write, "Only during the last four has it been possible to measure time with any precision.  Only in the last two has anyone anywhere used an electric motor.  And the overwhelming majority of all the material goods we use in daily life today have been developed within the present, the 800th, lifetime."

Toffler suggests then that one of the main drivers of "future shock" is the rapid pace of societal change that has occurred in just the last few lifetimes.  Other scientists have expressed a similar sentiment.  Carl Sagan once dedicated part of an episode in his popular television series of 1980, Cosmos to a concept he called the cosmic calendar.  Sagan maps the entire 13.7 billion year life of our universe (give or take a few million years!) on to a single calendar year.  The so-called "Big Bang" takes place just around midnight on January 1st.  Earth is formed around September 14, while prokaryotes first appear around September 21.  Dinosaurs roamed the Earth around December 25, while our own modern times coincides with just before midnight on December 31!  In other words, when viewed on the timescale of the entire universe, our society has made remarkable progress in a very, very short period of time!

It's hard to keep up with change when it occurs at such a rapid pace.  However, Toffler would also suggest that the pace of change is accelerating, and that makes sense if you consider his 800th lifetimes concept of Sagan's cosmic calendar.  Toffler writes, ""How do we know that change is accelerating?  There is, after all, no absolute way to measure change."  Instead, he asks us to consider another analogy.  He writes, "When a fifty-year-old father tells his fifteen-year-old son that he will have to wait two years before he can have a car of his own, that interval of 730 days represents a mere 4 percent of the father's lifetime to date.  It represents over 13 percent of the boy's lifetime."

Toffler cautions that the pace of change will force all of us to adapt, but not everyone will be successful in doing so.  He quotes Lawrence Suhm, a sociologist who was at the University of Wisconsin: "We are going through a period as traumatic as the evolution of man's predecessors from sea creatures to land creatures...Those who can adapt will; those who can't will either go on surviving somehow at a lower level of development or will perish - washed up on the shores."

Overall, I was glad that I read the book.  I plan to return to Toffler's themes discussed in Future Shock in a future post.