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Oaks from Acorns — Farming Lessons Learned Do Fit Healthcare


This post first appeared in brief form as a comment to’s Commentary Newsletter for December 29, 2009, Can Medicine Learn From Agriculture?, The Misguided Journey of One Health Care Writer, by Richard A. Epstein, a libertarian law professor at the University of Chicago and New York University and a Senior Fellow at The Hoover Institution in Palo Alto.  The Forbes Commentary Newsletter by Professor Epstein was itself a response to a December 14, 2009 New Yorker article by Atul Gawande, a practicing surgeon and Harvard professor.

Gawande’s article offered a systemic change heuristic taken from US agricultural_extension agents and applied to healthcare from the bottom up based on change agents working on a US-wide regional basis from the middle out.  It’s a classic piece on social change agents in the organizational and knowledge development domain of action_learning.

Reading the Forbes Newsletter by Professor Epstein, and also reading the letters to the editor in The New Yorker for January 4, 2010 by doctors and medical school staff, there’s a remarkable unity across the libertarian thought, medical professors, and commenting doctors.  In particular, the commentators all completely ignored the specific ideas actually in the article.

The doctors said that hospitals would kill anything that reduced demand for hospital services because hospitals need the revenue.  Equally unexceptionally, Professor Epstein offered a libertarian dissection of the patchwork of subsidies, constraints, and market schemes concocted by government to benefit politically powerful agricultural states.  This was all very accurate and entertaining, but all beside the point.

Gawande presented a lesson learned from a vehicle that introduced change in a properly cautious group—hands-on farmers.  Farmers lose their whole operation if they try farming methods that fail.  Albeit in slow motion, farming is a high-consequence industry, akin to aviation or medicine regarding risk effects on practitioners and intended beneficiaries alike.  And so farmers, just like pilots and surgeons, keep an eye on what they see their peers doing for lessons learned and actions that work.  This approximates the scrutiny applied in the workplace silos occupied by doctors and medical schools.  Lawyers including Professor Epstein might call it stare_decisis, but it’s the practice of caution even in Latin.  They look around, and they stick to their comfort zones.  In that sense, farmers, doctors, pilots, and lawyers act alike—they share a social preference for observation and caution.

Gawande simply connected the dots across the shared social behavior in the farming and medical communities.  He saw that change had to flow from direct observation and adoption by significantly independent and risk-exposed actors.  He noted that an intentional local change agent can find a local early adopter who is willing to apply new practices.  Retail firms and venture capitalist have been looking for early adopters in their respective markets for years.  In the closely self-observing immediate social network of farming peers, if the early adopters had notably better years than their neighbors, the baseline members moved with all deliberate speed to adopt the successful innovations suggested by agricultural extension  agents.

That sounds remarkably like the analogous convergence on successful ideas in theoretically atomized competitive markets, if we can get around the issue of the need for markets in the aggregate to internalize the negative-externality of individual actions and actors (a topic for another day).  In effect, Gawande merely pointed out that an intentional social change process is a valuable tool to improve output and reduce cost in high risk scenarios where participant risk is directly personal, and where community or regional benefit depends on wide-spread adoption.

Early adopters in the medical world certainly do exist (Cheshire-Med formerly KeeneVision2020, ClevelandClinic, MayoClinic, others).  However, the medical community at large needs locally and regionally respected change agents to be introduced and maintained in order to ignite and sustain positive practitioner and patient change.  Through such agents, the medical community can observe and adopt effective systemic changes for experience-based progress payments, more collaborative practice, and lessons learned as enabled by public policy resources aimed at more informed healthcare demand, more effective provider collaboration, and improved payment and tort systems.

Steps to internalize the negative effects of highly specialized and fragmented practices and medications are not unknown.  Change agents modeled on agricultural extension services can help the medical and patient communities become more systemically effective.

For example, by adopting coherent price and results transparency across all practitioners and institutions, including hospitals, practices, drug firms, and medical equipment manufacturers; by enabling medication collaboration and network oversight by pharmacies incentivized toward lower costs for effective courses of care not lowest unit cost per pill; by pushing real patient responsibility through periodic risk assessments and healthy behavior credits for maintaining wellness; and by engaging employers, workers, and transfer payment agencies in making disintermediated payments through shared efficient mechanisms coupled with tort reform, US regions and states can improve health results, reduce health costs and social and labor overhead, enable decreased absenteeism and presenteeism, enjoy increased labor productivity from increasingly healthy workers, and advance regional and global competitiveness.

Not bad for a healthcare article derided as grounded in lessons learned from agriculture.

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