I am reading a really interesting book entitled Team of Teams written by (naturally) a team, which includes retired United States Army General Stanley McChrystal. McChrystal, you may recall, was the commander of U.S. and coalition forces in Afghanistan before he got sacked for comments he and his staff made to a reporter for Rolling Stone. Prior to taking command, he served as the head of U.S. Special Forces in Iraq during the Sunni insurgency, and this book is about how he and his deputies restructured that “Task Force” to meet the unprecedented challenge they faced.
Early in the book, he discusses the rise of “efficiency” as an organizing principle for industry and, by extension, other forms of human endeavor. He tells the story of Frederick W. Taylor who, late in the 19th century, introduced the idea of organizing activities in a factory so that the workers could produce “more, faster, with less.” Taylor also popularized the means of doing so by standardizing processes to reduce wasted time and effort and by optimizing each element of production. He was, one could say, the Lean production maven of his day. Here's the passage from McChrystal's book that really caught my attention, describing Taylor's experience in a factory in 1874:
Taylor became fascinated by the contrast between the scientific precision of the machines in the shop and the remarkably unscientific processes that connected the humans to those beautiful contraptions. Although the industrial revolution has ushered in a new era of technology, the management structures that held everything in place had not changed since the days of artisans, small shops, and guilds: knowledge was largely rule of thumb, acquired through tips and tricks that would trickle down to aspiring craftsmen over the course of a long apprenticeship.
That transformation from artisanal workshop to organized enterprise, and from “tips and tricks” learned through apprenticeship to standardized work that can be specified and taught, sounds to me exactly like what medicine is going through today. In fact, the changes in medical practice that have been advocated as the pathway to better, less expensive care have been described using the very same language.
McChrystal's book goes on to document how the “efficient” model of military organization had to be reconsidered and redesigned to successfully confront and defeat an enemy operating in an unprecedented, technology-enabled, networked way. In doing so, it is a cautionary tale about the utility of the factory model in a changing world.
I think we should be similarly cautious about the slavish devotion to efficiency, standardization and optimization in our own complex, rapidly changing, technology-enabled, networked world of medicine.
What do you think?
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.