Why Do We Accept Mediocrity in Healthcare?

By Gerrit Van Wyk

Medicine is a social science, and politics is nothing else but medicine on a large scale”, Rudolf Virchow.

Dr. Harry Rakowski, a physician and commentator, published an article titled Why do we accept mediocrity in health care? in the National Post on October 9, 2023. In it, he goes through a list of reasons why healthcare in Canada is considered mediocre, and notes the frustration it causes healthcare professionals. He correctly points out the short-termism of governments, which is a brake on progress, and then suggests we need to tell our governments we won’t put up with this anymore. The comment section contains the usual mix of opinions and beliefs, and blaming of one’s least favorite political party.

The problem is we all know there is a problem, and we know a lot about the problem, but are kneecapped by the fact the problem and its possible solution plays out within the context of a very complex social world which we ignore, fail to talk about, and make no effort to understand. If we continue that path, we’ll have to put up with the mediocrity.

Let’s look at some of that complexity by naming some of the things, which, like Lord Voldemort in the Harry Potter books, cannot be named. These things play out unconsciously in the shadows, and bringing them to light causes consternation and fear for losing status, power, etc., but is necessary.

No political party is interested in solving healthcare, their only interest is in Band-Aid solutions with preppy slogans contributing to policy platforms for the next election. The purpose of politics is to get and stay in power, not solving anything. Politicians don’t have the ability to come up with plans themselves, hence, they rely on anyone with a fancy suit and color presentation who can secure an audience with the party leader, as the next miracle maker with a simplistic solution. Healthcare workers are few and spread over many ridings, hence are politically irrelevant.

Citizens can get the attention of politicians in swing ridings if they organize around something like the closure of an emergency room in their community, lobby effectively, and find the ear of media, looking for their next story, if it can trigger enough emotion. For publications on the right side of the incumbent party, it becomes a clarion of support, and to those on the wrong side, an opportunity for criticism. The purpose of the press is not solving problems, it’s about attracting eyeballs, advertising, career paths, awards, and the usual box of tricks in social games. Most of the electorate is spread out, hence are unable to organize in a meaningful way, hence, as Smith and De Mesquito argued, other than serving the purpose to vote, they are politically irrelevant and their votes have little impact.

Healthcare in Canada is managed by large bureaucracies, organized mechanically in rigid hierarchies. Their purpose is not finding solutions, but, as Parkinson, Greiner, and others pointed out, to grow and outlast the incumbent party, while keeping things the way they are. The TV series Yes Minister, demonstrated that dynamic very well as comedy, or perhaps satire.

Solutions don’t come from famous universities and richly endowed departments. As Schmidt showed, the purpose of academics is becoming experts locked up in silos without windows, and replicating graduate students like them. Their jobs are not to solve healthcare’s problems in a meaningful way.

The healthcare procedures we still use, in general, emerged towards the end of the 18th and beginning of the 19th Centuries. Under the influence of medical schools on the Continent, and later North America, medical practice became lucrative with high social status, hence physicians have more incentive to keep things the way they are, than change them. Additionally, social scientists started attacked that privilege towards the 1980’s, with a loss of some of it, hence physicians were incentivized to defend the Alamo while the wagons circle. Concurrently, nurses, pharmacists, etc., more recently started moving up the pecking order; what goes down is balance by what goes up, hence subconsciously they benefit and don’t want change either.

Human society is structured along hierarchies of social status, which provide access to economic, social, and cultural resources, and through them self-esteem and social power. Most people aspire to climb up the greased pole, while, for social reasons, others slide down. Jackall’s research showed how that plays out in bureaucracies, which is the default in medicine. Hence, what holds us back is what we do to each other as part of the social game.

To summarize, the reasons for the mediocrity we experience, are many, they are interlinked and interrelated, and what drives them under the hood is human social behavior. It also means we can’t turn it around into excellence via some single grand plan or solution, we must accept that complexity and work with it, rather than against it.

Small groups of like-minded people, by cooperating, can trial ideas at a local level, observe the outcome, adjust, and learn together towards a collective goal. At that level, the complexity of social interaction doesn’t disappear, but it becomes more manageable. Fact is, no single grand plan can fix healthcare, but many small, local interventions can, some of which may ripple out on a larger scale, and we don’t know ahead of time which ones they are. The biggest single resource they need is not money, but guidance and mentoring to understand the complexity that created the mediocrity to begin with. There are a few people trained and qualified to do so, but the social complexity I’m referring to also suggests others with Armani suits and Gucci shoes creating an air of confidence make a better impression, and are therefore more likely to be signed up to lead us to mediocrity instead.

We all contribute to healthcare’s mediocrity, and it is up to us all to take ownership of and change that. There are many reasons why few will take up that offer, but, as George Bernard Shaw said, “reasonable people adapt to the world and unreasonable ones try to alter it, human progress depends on the unreasonable ones”. We can continue to be reasonable, and mediocre, or choose to be unreasonable, name the things that cannot be said, and change things; each of us have choices to make.

As Cassius said in Shakespeare’s Julius Caesar, ‘the fault, dear Brutus, is not in our stars, but in ourselves, that we are underlings’. There are the things we say we do, and below the waterline the things we actually do, and, if we don’t want to be mediocre, we must hold our breaths, put our faces in the water, and look at what goes on below.