John this is such a wonderful example of the primary conflict in contemporary US healthcare. The dilema between the Mission and Margin. The tension is always present because right across healthcare the Margin has taken over so much of the operations of the healthcare machine. Patients are merely materials consumed and processed by the machine rather than human beings in pain and distress.
Now you and I both know that the actual humanity exemplified in your opening story is absolutely still in the core being of every single medical and care provider, but every single day we are asked to compromise our Mission at the feet of the Margin Idol. The machine becomes more and more built to sustain the Margin. Even the efforts to reduce administrative burden on clinicians is not fuelled with altruistic belief in the mission. It is wrapped in an expectation of greater productivity, lower costs and faster throughput.
Thank you for so thoughtfully describing your own insight and Eureka about your own part in this.
Yeah I get that and I suspect in my late 30’2 as an eager Sales leader with a young family and lots of ambitions, that was especially true. I stayed in healthcare because I still felt some of the Mission. However as I graduated into my 40’s, my son’s chronic conditions started to bed in and I started to see the cracks caused by the tension it really started to bother me. Changing my working focus from clinical systems to Revenue Cycle systems and developing the Interstitial Lung Disease that lead to my Double Lung Transplant three years, pushed me all the way back on the pendulum. From Nurse to survivor and advocate…Or opinionated loudmouth! Your mileage may vary ;-)
The hardest act in this story is not that you did nothing. It is that you stopped something already moving. The ambulance was appropriate, the transfer defensible, the workup done. By the ordinary grammar of emergency medicine the next step already had momentum, and you interrupted a medically legitimate trajectory because the meaning of the case had changed under it.
That is the kind of judgment that only shows up at the edge of treatment. It recognizes the moment the real question has quietly moved from where can we send this patient to where should this life be allowed to end. The clinical facts were all still true. They simply sat inside a different human frame, one that decided which of them now mattered.
That is also why the missing billing code feels so revealing. The system can count the scan, the call, the disposition. It has no way to see the moment when the most skilled medical act is to cancel the next medical act. What you gave that family was not less medicine. It was medicine that knew when to stop being motion and become witness.
This is the flip side of Peter Drucker's "If you can't measure it, you can't improve it." The corollary is that if it isn't objective data, AI has a difficult time "measuring" it.
Yes, and the corollary has a sharper edge than the soft data alone. Drucker's axiom is directional: what we can measure gets improved, accelerated, made more fluent, while what we cannot stays where it was. So over time AI does not simply fail to see the moment of stopping. By improving everything upstream of it, it keeps adding momentum to the very trajectory a clinician sometimes has to interrupt. The better the system becomes at motion, the more skill it takes to perform the one act that is the refusal of motion. Improvement aimed only at what counts quietly makes it harder to know when to stop counting.
John this is such a wonderful example of the primary conflict in contemporary US healthcare. The dilema between the Mission and Margin. The tension is always present because right across healthcare the Margin has taken over so much of the operations of the healthcare machine. Patients are merely materials consumed and processed by the machine rather than human beings in pain and distress.
Now you and I both know that the actual humanity exemplified in your opening story is absolutely still in the core being of every single medical and care provider, but every single day we are asked to compromise our Mission at the feet of the Margin Idol. The machine becomes more and more built to sustain the Margin. Even the efforts to reduce administrative burden on clinicians is not fuelled with altruistic belief in the mission. It is wrapped in an expectation of greater productivity, lower costs and faster throughput.
Thank you for so thoughtfully describing your own insight and Eureka about your own part in this.
I think Dan Pink's Drive spelled that out. The more hard data extrinsic motivators existed, the less satisfaction people had with their work.
Unfortunately, there are too many people in medicine for whom margin IS the mission.
Yeah I get that and I suspect in my late 30’2 as an eager Sales leader with a young family and lots of ambitions, that was especially true. I stayed in healthcare because I still felt some of the Mission. However as I graduated into my 40’s, my son’s chronic conditions started to bed in and I started to see the cracks caused by the tension it really started to bother me. Changing my working focus from clinical systems to Revenue Cycle systems and developing the Interstitial Lung Disease that lead to my Double Lung Transplant three years, pushed me all the way back on the pendulum. From Nurse to survivor and advocate…Or opinionated loudmouth! Your mileage may vary ;-)
The hardest act in this story is not that you did nothing. It is that you stopped something already moving. The ambulance was appropriate, the transfer defensible, the workup done. By the ordinary grammar of emergency medicine the next step already had momentum, and you interrupted a medically legitimate trajectory because the meaning of the case had changed under it.
That is the kind of judgment that only shows up at the edge of treatment. It recognizes the moment the real question has quietly moved from where can we send this patient to where should this life be allowed to end. The clinical facts were all still true. They simply sat inside a different human frame, one that decided which of them now mattered.
That is also why the missing billing code feels so revealing. The system can count the scan, the call, the disposition. It has no way to see the moment when the most skilled medical act is to cancel the next medical act. What you gave that family was not less medicine. It was medicine that knew when to stop being motion and become witness.
This is the flip side of Peter Drucker's "If you can't measure it, you can't improve it." The corollary is that if it isn't objective data, AI has a difficult time "measuring" it.
Yes, and the corollary has a sharper edge than the soft data alone. Drucker's axiom is directional: what we can measure gets improved, accelerated, made more fluent, while what we cannot stays where it was. So over time AI does not simply fail to see the moment of stopping. By improving everything upstream of it, it keeps adding momentum to the very trajectory a clinician sometimes has to interrupt. The better the system becomes at motion, the more skill it takes to perform the one act that is the refusal of motion. Improvement aimed only at what counts quietly makes it harder to know when to stop counting.
…like a CPT or EM code