Building Healthcare Worth Inheriting

Every human being, in every country, in every century, eventually becomes a patient. Healthcare is the one institution none of us escapes.  Yet despite the common denominators of the human condition, it has been built disparately across the globe. A mother in Barcelona, Spain and a mother in Winterville, North Carolina are not the same in language, or wealth, or circumstance, but in the moment a physician walks toward them with news about their child they are exactly the same, two human beings hoping to be told their world is not about to change. The encounter at the center of all of healthcare, a frightened person and someone who might help them, is the same everywhere on earth.

And almost everywhere on earth, the system built around that encounter fails the people inside it. Not always, and not entirely, but reliably enough that the failure has become the background condition of the work. The forms differ by country. The wealthy nations fail through complexity and cost. The poorer ones fail through scarcity and access. But underneath the local variations the failures rhyme, because they are not failures of any one nation's politics. They are failures of something more fundamental, and more human, that shows up wherever people try to organize care at scale. I have spent a career trying to understand what that something is. This book is what I have come to believe after a long time looking.

I should tell you where I have stood, not to claim authority but to explain the shape of what I can and cannot see. I trained as a physician and I have sat in the exam room with patients for decades, which is the first vantage point and in some ways the only one that ultimately matters. I have stood at the bedside and delivered news no one wanted, and I have been on the other side of it too, the family member in the hallway waiting to be told. I have run large parts of major health systems, sat in the executive suite where the strategy is set, and in the boardroom where the strategy is judged. I have been at the table where capital decides which ideas live and which do not. I have helped build technology meant to change how care is delivered, and I have watched some of it work and more of it fail.

I tell you this for one reason, and it is not the reason a list of roles usually implies. Having sat in that many seats did not leave me feeling that I understood healthcare. It left me with the opposite, a steadily deepening humility about how little any single seat in this system can see. Each vantage point is certain of itself. The clinician is certain the problem is the administration. The executive is certain the problem is the clinicians' resistance to change. The investor is certain the problem is the absence of good business models. The technologist is certain the problem is the absence of good tools. Each of them is partly right, and each of them is looking at the whole structure through the narrow window of their own position, and almost no one is positioned to see how the windows connect. The strange gift of having moved among so many of those seats is not mastery. It is the humbling knowledge of how partial every view of this system is, including my own, and of how often I have been confidently wrong from inside one seat about a thing that looked entirely different from another.

That is what set me searching, because once you have seen the system from enough sides you start to notice that the failures share a root juxtaposed against the moments of hope created through caring for another individual. What goes wrong, again and again, is not a shortage of intelligence. The people in healthcare are brilliant. It is not a shortage of money, though the money is distributed curiously. It is not a shortage of technology, which arrives faster than the system can absorb it. And it is not, despite how easy it would be to believe, a shortage of good intentions. I have met very few people in this work who did not come to it wanting to help. The failures happen anyway, in the presence of intelligence and capital and technology and devotion, which means none of those, by itself or even together, is the missing what.

What is missing is harder to name, and for a long time I could not name it, because the working language of American healthcare does not contain a good word for it. We have precise words for cost and quality and access and outcomes. We have no single word for the disciplined practical wisdom that knows how to hold all of those at once with a view toward a distant future not just today, that sees the whole structure clearly before it acts, that can tell the difference between the bold move and the reckless one, and that has the judgment to know when the conditions are ready and when they are not. 

A word about what this book is and is not. It is not a policy proposal (though the changes needed will require regulatory support), and it is not a set of instructions.. I am suspicious of anyone who has seen as much of this system as I have and still claims to hold the answers, because the first thing the full view teaches is humility about answers. This book is something more modest and, I hope, more useful. It is a way of seeing. It is an argument that the rarest and most decisive asset in healthcare is the quality of judgment that knows how to use everything else, and that the failures we keep mistaking for problems of money or technology or will are very often, underneath, failures of vision. I will make that argument across ten convictions, each one a claim I have come to hold strongly enough to build a firm and a life around. 

Healthcare is global, and human, and broken in ways that are more alike across the world than we usually admit. There are few industries that rely on the human spirit so deeply and despite the many flaws, it represents the power of that spirit to heal each other. I do not think the answer is more intelligence, or more money, or more technology, though we may need all three at times. I think the answer is a kind of wisdom rooted in compassion, innovation, and a conviction to build for the long-haul when it’s easier to focus on last week’s results. Our story of the future of healthcare starts in a small town in Catalonia that has been teaching how to build at scale in its stone square for over two hundred years.

Let me take you there.