Push Decisions to the Edge
This last Saturday, I stopped for a bagel. I went to the bagel chain named after a relatively smart guy. I ordered an everything bagel with chive cream cheese, my favorite! I asked if they had chai, and the clerk said, “All we have is coffee.” I looked up at the wall, and from the list there, I ordered an iced mocha. I’ve been doing the low-carb thing and wanted a treat - Saturday is my cheat day. The clerk replied again, “All we have is coffee.” I pointed to the wall, with a confused dog look on my face, and he told me that “corporate made them put the sign up even though they can’t make any of those fancy drinks and won’t let them take it down.” I could tell by the lilt of irritation in his voice he had to answer this question way too many times a day.
Having worked retail for a decade, I groaned inwardly. This happens when people don’t have the autonomy to do their jobs and are not trusted to make good decisions based on a clear corporate vision. If I were asked to write a vision for them based on my recent experience, it would be, “We want to torture our employees by treating them like children and by encouraging customers to ask them questions that make us look foolish. We want our customers to have the same choices at every store regardless of our ability to deliver.” I searched high and low on their website and couldn’t find a vision statement. Shocking! It doesn’t take a genius to figure out how to fix this, but it does take some autonomy, clear corporate vision, and some trust or perhaps some canny outlaws.
Are Rules and Incentives Killing Health Care?
Do you believe your doctor puts your health ahead of profits? Does the red tape of health care affect the quality of your care? These questions and more are addressed in a book by Barry Schwartz and Kenneth Sharpe called Practical Wisdom. They say that professions like medicine should be a calling, not something you do to make money. Doctors need income, and considering the cost of medical school and malpractice insurance, it needs to be substantial. However, money should be a side benefit for practicing medicine, not the primary motivation.
Practical Wisdom is a concept from Aristotle, “In matters concerning action and questions of what is beneficial, the agent must consider on each different occasion what the situation demands, just as in medicine as in navigation.” Rules get in the way of this kind of thinking. Doctors need to be able to make decisions about how to treat individual patients based on the whole picture of the patient, not through the rules of the insurance companies or hospitals. Incentives can also impede care; doctors are offered incentives to do too much - fees for services or for doing too little via productivity bonuses.
Doctors are under tremendous pressure. Many are expected to spend 15 minutes or less with a patient and solve whatever issue they are having and not make any mistakes. In this system, it’s very hard to push back against the rules to do what you think is right. Many doctors do push back. When they do, it can threaten their jobs and careers. This is a problem because doctors have fewer and fewer opportunities to learn about practical wisdom as they rely more on rules and incentives to guide how they care for patients.
A region’s culture of care is determined mainly by its biggest local hospital. It turns out that the way a doctor is compensated affects things like the quality and cost of care you receive and plays a part in determining the culture of care. At the Mayo Clinic in Minnesota, doctors are all salaried and receive no individual fees, the Mayo Clinic is one of the best hospitals in the world, and the region it’s in has some of the lowest costs for health care in the country as well as Medicare costs in the bottom 15% of the country. Central to the culture of care at the Mayo Clinic is the “cultural philosophy of doing the best for the patient.” In contrast to the Mayo, we have Doctors Hospital in McAllen, TX. The doctors all have a stake in the hospital and receive a cut of the profits from every procedure, test and office visit. They are all paid on a fee basis. The region around McAllen has the highest Medicare costs in the country and the people who live there are no healthier. It’s essentially a culture of money, where it’s part of the culture to over-treat and order more tests. Research on intrinsic motivation tells us that the closer money is to a task, the more likely it will interfere with it. This one thing, how we compensate physicians, would go a long way towards fixing our healthcare system.
There is a story in the book about a patient complaining of dizziness. He had seen his doctor and many specialists; months later, no one could figure out what was wrong with him. Finally, he was sent to a special diagnostic clinic at Stanford where for the first time, a doctor asked him what was going on in his life and asked him to describe his dizziness. It turns out that the man had recently lost his wife and his dizziness was a psychological problem, not a physical one. After a few months of therapy, he was back to normal. All this cost and turmoil because his primary care physician didn’t know his patient or bother to gather basic information.
Practical wisdom can be applied to any profession, not just medicine. We see the erosion of autonomy and purpose across many walks of life where rules and incentives interfere with us doing what we know is right. The older I get, the more obvious it is that we live in a world that’s not black and white but in many subtle shades of gray. “Having the know-how to do right by others makes us happy; it gives us the know-how to do right by ourselves.”
Practical Wisdom and Why Education is Doomed!
Our children are being systematically turned into automatons that pass tests. That is, if their teachers think they can pass the test. Otherwise, they’re discarded, and teachers are trained not to spend time with kids they don’t think will pass. I received an advance copy of Barry Schwartz’s and Kenneth Sharpe’s Practical Wisdom just before Christmas, and it’s been making me crazy! You can watch the TED video now. The book is coming out this month.
The words, ‘I’M AS MAD AS HELL, AND I’M NOT GOING TO TAKE THIS ANYMORE! from Howard Beale in the 1976 movie Network don’t come close to expressing my outrage. Schwartz talks about how standardized test scores and teaching affect our students. Low-performing schools in New York and other states are forced to teach all of their courses via standardized teaching materials that leave no room for teachers to be creative and help with individual student needs. The much-needed ability for teachers to think on their feet and create solutions as they go is actively being discouraged in most public school systems. Courses are scripted word by word!
Worse, starting in 2003, publishers like McGraw-Hill have trainers and consultants that interrupt lessons and chastise teachers in front of students for not following scripts. In Texas, a consultant hired to raise test scores came in and told the faculty of Beck Elementary School and handed out green, yellow and red highlighters. The consultant said, “Take out your classes’ latest benchmark scores, and divide your students into three groups. Color the “safe cases,” or kids who will pass, green. Now, here’s the most important part: Identify the kids who are “suitable cases for treatment.” Those are the ones who can pass with a little extra help. Color them yellow. Then, color the kids who have no chance of passing this year and the kids that don’t count, the “hopeless cases” - Red. You should focus your attention on the yellow kids. They’ll give you the biggest return on your investment.”
No child left behind my ass! More like every child doomed to mediocrity. Who’s bright idea was it to let the people selling the materials make the tests and evaluate their usage and outcomes? I was in tears as I read this. It’s why I’m sitting here writing now. I had to blow off some steam. This reads like a bad movie to me. The 1990 movie Pump up the Volume had a plot like this, but the principal was expelling the poor performers, not ignoring them.
I graduated from high school in 1982, and there were good teachers and bad ones, better and worse schools, but education was more accessible. Certainly, there was lots of room for improvement. I hated my grade school experiences. It was a special kind of hell. That’s what it’s like for someone who doesn’t fit neatly into square holes, but I did receive an education. Since I don’t have kids and haven’t been in classrooms much, I had no idea what was happening in them. Some of my friends homeschool their kids. Now I know why! It’s hard to believe that things have worsened since I was in school.
If we continue to judge the success of education on numbers alone, we will continue to doom future generations and, inevitably, our entire country to mediocrity at best. Numbers can and will be gamed to the advantage of the few and the detriment of the many.
Barry Schwartz: The real crisis? We stopped being wise
The author of Practical Wisdom’s TED talk
