Turf Wars and Healthcare’s “Rare Orchid” Problem

In healthcare, we often refer to ‘turf’ wars; we turf a patient off a service or out of the ED; department chairs defend their turf from other clinical services or departments, and practice groups and health systems defend their turf from their competitors across town.

But in reality, these are increasingly turd wars: with the same pride as a toilet training toddler, each department chair, or practice network, or hospital system produces a little turd — dank and brown, but theirs and theirs alone — which they proceed to hang onto for dear life, and defend beyond its true value, often to the severe detriment of society and the communities of which they are a part.

These turds only have value to their creators, and the energy put into turd defense can severely disrupt progress; since everyone is so invested in their turds, it makes it very difficult to collaborate or align around a collective priority, like improving the health status of the community.

This gives rise to the ‘rare orchid’ problem.

Imagine finding a rare orchid among the weeds of your organizations back yard. But when asked to contribute their turds to a collective, enterprise-level effort to fertilize and nurture it, healthcare silos more often choose to protect their assets rather than contributing to the collaborative opportunity. Many a rare orchid has died as a result of this phenomenon.

Over the last few decades, the profession of medicine has been buffeted by many forces of change, none so powerfully as the competition for its economic and social capital. Physicians have been largely destabilized and rendered vulnerable to those with less selfless and less generous agendas: a commercial community unimpeded by the cultural and academic mores that have been the historical underpinnings of the medical profession.

What Dr. Arnold Relman, former Editor-in-Chief of the New England Journal of Medicine called the ‘medical- industrial complex” took advantage of doctor’s vulnerability by increasing unpredictability in fee schedules, offloading administrative responsibilities and costs to patients and the physician community and disintermediating the traditional doctor-patient relationship.

Physicians tried to fight the battle, but the rules of engagement of the free market were largely foreign to their professional culture. The effort ended up driving more of a wedge into the professional community; physicians organized around specialty identities and entering a zero- sum game, with primary care and specialist physicians bickering over how dollars are divided among themselves while payers doled them out like parents deciding if they earned their allowance.

This fragmentation, pitting physician-against-physician, only served to weaken the profession even more — with the patients losing trust as physicians were distracted and reduced in their capacity to share the work of worry about their health.

Healthcare has always tended to organize around specialty or role-based professional identities and these historical boundaries between disciplines, and cultural mores within each discipline, are also impediments to true collaboration.

Collaboration is not a native discipline to healthcare. Even when everyone is at the table (or facing the patient for that matter), collaboration often is no more real that the parallel play of toddlers. It is the connections between the players that are missing and increasingly required, to deliver effective health care.

Collaboration is a mutually beneficial relationship between individuals or organizations who work toward common goals by sharing responsibility, authority and accountability for achieving results: it’s the idea of “we”.

Who are “we” in healthcare? In our current condition, each specialty or organizational silo is its own “we”, an independent operating system with its own tendencies towards boundary defense. They may interact with others or even acknowledge interdependencies, but fundamentally few (specialties, practice groups, hospital networks, payers) are able to subsume their identity to metamorphose into single entity of which they all are a part: a system of care with a common goal to improve the quality of health of individuals and communities..

It is not easy to manage collaboration in healthcare; emotional investments are significant. In everyone’s mind, his or her turd has the potential to become a rare orchid.

Collaboration requires understanding and supporting system-level priorities, acquiring new competencies and relinquishing individual priorities to free up energy and resources to support what is increasingly the ‘last mile’ barrier to achievement of any ambitious goals for 21st century healthcare.

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