Conversation

I'm trying to look out for structural/organizational lessons that go beyond the basics like avoiding large gatherings, higher decentralization etc. One that struck me is the perils of specialization in healthcare that leads to 1 contact turning into dozens or more.
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When I was growing up, if I fell ill, I'd go see our one family doctor in his clinic (he was also a family friend). Number of contacts 1-2 (if a nurse was involved). Maybe 3 if an X-ray or blood draw was needed.
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Now, in the US, even the simplest doctor visit involves 3-4 contact points. The case of the lawyer in NY illustrates this: for a moderately complex healthcare need, you're likely to encounter half a dozen people at *each* escalation as you're passed around and upwards.
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One effect of this is that information is lost along the "patient's journey" and if you aren't well enough to advocate for yourself OR have a family member do it for you, you'll be moved along from station to station in an assembly line process that can *never* see you as a whole
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I don't mean loosey-goosey "seeing" as in recognized as a human with dignity. I mean literally no medical professional will ever see the whole jigsaw puzzle of your condition together and be able to put it together properly. It's an assembly line approach to testing/diagnosis.
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It works for normal "cases" that the "seeing like a state" hospital is equipped to actually see. Legible conditions with sufficient statistical heat signatures to have shaped the process design. For exceptions, there is no escalation to Dr. House's team. You just get mishandled.
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Mishandling as in: the correct diagnosis/intervention is delayed or never happens, and if you die, you might be filed away with an incorrect case history/understanding.
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In general, this is a problem that was well recognized by the business process re-engineering crowd in the early 90s, who recognized the epistemic value of a human tracking a "case" through a system rather than a series of actions in functional silos connected by automated links
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The problem is, no effective organizational alternatives were ever discovered and popularized. The BPR movement kinda fizzled out and got absorbed into general efficiency/cost-down drives that have a different intent.
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Pandemic responses radically increase the costs of epistemic miscalibration and procedural blindness. Especially in non-ergodic situations. By the time the glitch is noticed and acted upon, it's kinda too late. NY lawyer case:
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I don't have an answer, just flagging the problem. You cannot really run large-scale triage operations in a highly specialized service situation, in emergency mode, and not have such tradeoffs. Assigning a skilled Dr. House level patient advocate to each patient won't scale.
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You need some way to hybridize the cost and operational efficiencies of regular triage and assembly line style functional silo specialization breakdown (a flow or job shop in OR terms) with the greater epistemic coherence and non-blindness of case-flow models.
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Only model I've seen work is a scattering of talented domain-specific systems thinkers with high situation awareness monitoring the flow and picking up on anomalies early. Air traffic control basically. ATC for healthcare, but at a higher skill/knowledge level than triage nurses.
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Still doesn't solve the peculiar path costs here, where each step of handling/mishandling increases contagion risks. When this is over, modeling the "path risks" of a misrouted "case" will make a good PhD thesis in operations research for the right kind of thinker.
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Specific point on the materiality of "seeing like a state" theory applied to pandemics: microbes are *by definition* impossible to see without a microscope. It's literally an org battling microscopic realities that macro-humans present at best via confusing emergence.
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This feature is shared in other orgs that are oriented around microscopic realities. At Xerox it took me a long time to realize that the entire company was oriented around the micro-properties of toner, which isn't obviously the key element when you look at photocopier machines.
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Another example is silicon/microprocessor industry. Takes at least a year to wire your head around the sub-14-nm scale mental models of lithography.
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Seeing Like a State, Microscopy Edition. There's also Seeing Like a State, Telescopy edition, which I encountered during PhD work on NASA's interferometric telescopes program. Wrapping head around lightyears/thousands of kilometers as baselines. But I digress...
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