Upstream Learning & Downstream Dysfunction: How to Train Leaders for a New Future

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“The arrogance of success is to think that what you did yesterday is sufficient for tomorrow.” – William Pollard

In health care right now, lots of people are talking about innovation as a generic way to describe the new holy grail to some of medicine’s biggest problems. Of course this line of logic might lead some to think medicine is in some state of “innovation-deficiency,”¬† a condition for which innovation replacement therapy is the clear and sole treatment. While this obviously isn’t always true, introducing new technologies and processes, if done the right way, can certainly help minimize waste, control cost, improve efficiency, and introduce equity into existing public systems.

So if medicine needs to up its innovation game, as many are suggesting, who’s it going to turn to? Where is the pipeline of leaders to fill the holy grail and how do you turn on the faucet of new and better ideas?

I’ve been thinking a lot about these questions over the past few weeks as I start my Fall semester at Harvard’s TH Chan School of Public Health. And no that wasn’t a name drop. It was a point of reference drop, to help place the problem I am about to describe, into context.

For the past 3 weeks I’ve been taking a pretty stand out course on quality improvement¬† taught by the incomparable Maureen Bisognano and her enviable squad of colleagues and friends. For a bit of background, Maureen is the President Emerita of the Institute for Healthcare Improvement, basically a healthcare innovation incubator based in Boston, and her friends include people like Don Berwick, Atul Gawande, Brent James, Ellen Goodman, and Derek Feeley, to name a few of the powerful speakers who inspired us. For 3 weeks, we reviewed international examples of ways to radically redesign the US healthcare system.

And then, I had fall registration.

Excited to push the boundaries of existing systems, I was eager to take classes across the University, and like Maureen showed us, find examples from other industries, sectors, and disciplines that could be applied to the great challenges facing medicine and build solutions that translate across public systems and private incentive structures. But to my surprise, that inter-sectional, open learning, not only wasn’t a requirement, but was incredibly difficult to find. And if it is hard to find at places branded on leadership, I worry it may be symptomatic of a larger issue.

Which got me thinking, just how are we going to train this next level of leaders when the educational pipeline through medicine looks remarkably similar to what was suggested in the landmark Flexnor Report in 1910, that established a system of medical education, that with few exceptions, continues today.

Courses continue to be divided by discipline, learners are isolated to their field of study, and for those who select to learn outside that box, they do so singularly, as a function of personal interest or a non-degree program rather than systematic integration of agents and ideas. Then is it any wonder why our systems remained silo’ed with divergent (and sometimes antagonistic) incentive structures despite overlapping public interests?

Don Berwick is often quoted as saying, “Every system is perfectly designed to get the results it gets.” In medicine, as we move upstream in our interventions for disease, to target root causes rather than downstream effects, we must do the same thing for the education pipeline. We have to challenge ourselves to teach future leaders how to think, reason, and execute rather than prescriptively guiding them, formally and informally, to reproduce the same system, with the same challenges we already have.

It has been more than 100 years since the last massive shift in professional medical education, perhaps parting with apprenticed dysfunction and practicing principled disruption is a good start.