This Guest Post was kindly authored by Allan Kornberg, MD MBA, Senior Vice President of National Initiative for Children's Healthcare Quality. His biographical sketch can be found at the end of his post.
The July 8, 2009 Wall Street Journal noted the passing of Robert S. McNamara (former Ford CEO, Secretary of Defense, and President of the World Bank) with From McNamara to Obama an opinion piece by Bret Stephens who comments on the dangers of too much rationalism - or more aptly - on the dangers of hubris. Not an insignificant pitfall for health care leaders to consider.
McNamara was celebrated as a well read, cerebral man, who was one of JFK's 'best and brightest.' That phrase, coined as the title of David Halberstam's 1972 book about the Kennedy era brain trust, today carries more than a small amount of irony. Earlier this year, this blog commented on the nature of health care leadership teams in Is the Brightest Leadership Team Necessarily the Best Team?. Mr. Stephens however drilled down on Mr. McNamara alone who, in his words:
"...symbolized the idea that one could manage and control events, in an intelligent, rational way. Taking on a guerrilla war was like buying a sick foreign company; you brought your systems to it."
McNamara's downfall, and that of President Kennedy's successor (Lyndon Johnson) as well, was the Vietnam War. "Blind rationalism" or "knowing" the right answer or the right way to do things without necessarily testing incrementally and learning from testing, led to a war that did not end well for America. McNamara subsequently took the World Bank helm, arguably as penance for the death and destruction and failure in Vietnam in part at his hand, and brought the same decision making approach that relied on massive data, detailed five year plans, and a problem solving approach that didn't regularly seek alternative options. The result was more nuanced than that of the Vietnam War. But in the end, McNamara's 13 years of World Bank leadership and the associated massive lending spree which triggered a Third World debt crisis, may have catalyzed Africa's decent into chaos by provided funds for corruption on a large scale in many developing countries.
Stephens makes the point that rationalism isn't the same as reason (and certainly not the same as common sense). Or as, in my words, good judgment. He goes on to quote William Easterly in The White Man's Burden:
"A Planner thinks he already knows the answers; he thinks of poverty as a technical engineering problem that his answers will solve. A Searcher admits he doesn't know the answers in advance; he believes that poverty is a complicated tangle of political, social, historical, institutional, and technological factors. A Searcher hopes to find answers to individual problems only by trial and error experimentation. A Planner believes outsiders know enough to impose solutions."
Stephens then compares McNamara to President Obama and raises concern that the current administration's approach to banking, autos, climate change, and health care may run the same risks that McNamara and the rest of Kennedy's 'best and the brightest' by - as our British friends would say - 'being too smart by half.'
Regardless of where health care leaders fall on the political spectrum, thinking as a Searcher can be of great value. Absent a genuine time sensitive emergency (which for the combat officer may be incoming missiles and for the physician a critical major trauma patient) in which case decisive action is necessary, an incremental, empirical, learning approach has value. In quality improvement we learn and teach that, whether it's Deming on the manufacturing floor or Berwick in the hospital, rapid cycle, 'plan-do-study-act,' there is great value to iterative approaches to improvement. Incremental learning at each step yields the best solutions, foundations for sustainability, and potential for dissemination.
Whether one is running a country, a health system, or a clinic, an approach that involves accepting that we may not know the answers in advance, and that incorporates a willingness to err and learn as we go, deserves to be respected.
Health care leaders....go forth and be Searchers.
Allan Kornberg, MD MBA is a pediatrician with 25 years of clinical and executive experience. Dr. Kornberg practiced in both a primary care office that he co-founded and as chief of emergency medicine at a children's hospital. He has held executive positions with hospitals and health plans in New York, Georgia, and Massachusetts including as CEO of Network Health, a Medicaid managed care plan serving Massachusetts. He is currently senior vice-president of the National Initiative for Children's Healthcare Quality.
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