Sick Care is a Wicked Problem

by Arlen Meyers

Sick Care is a Wicked Problem

Sick care is a wicked problem. By that, I don’t mean just scary.

A wicked problem is a social or cultural problem that is difficult or impossible to solve for as many as four reasons: incomplete or contradictory knowledge, the number of people and opinions involved, the large economic burden, and the interconnected nature of these problems with other problems.

Horst Rittel, one of the first to formalize a theory of wicked problems, cites ten characteristics of these complicated social issues:

  1. Wicked problems have no definitive formulation. The problem of poverty in Texas is grossly similar but discretely different from poverty in Nairobi, so no practical characteristics describe “poverty.”
  2. It’s hard, maybe impossible, to measure or claim success with wicked problems because they bleed into one another, unlike the boundaries of traditional design problems that can be articulated or defined.
  3. Solutions to wicked problems can be only good or bad, not true or false. There is no idealized end state to arrive at, and so approaches to wicked problems should be tractable ways to improve a situation rather than solve it.
  4. There is no template to follow when tackling a wicked problem, although history may provide a guide. Teams that approach wicked problems must literally make things up as they go along.
  5. There is always more than one explanation for a wicked problem, with the appropriateness of the explanation depending greatly on the individual perspective of the designer.
  6. Every wicked problem is a symptom of another problem. The interconnected quality of socio-economic political systems illustrates how, for example, a change in education will cause new behavior in nutrition.
  7. No mitigation strategy for a wicked problem has a definitive scientific test because humans invented wicked problems and science exists to understand natural phenomena.
  8. Offering a “solution” to a wicked problem frequently is a “one shot” design effort because a significant intervention changes the design space enough to minimize the ability for trial and error.
  9. Every wicked problem is unique.
  10. Designers attempting to address a wicked problem must be fully responsible for their actions.

Examples of sick care wicked problems include:

THE NEXUS OF HOMELESSNESS, HOUSING AND HEALTH

  1. For the homeless, no amount of health care can substitute stable housing.

ALZHEIMER’S DISEASE

  1. Alzheimer’s: the 6th leading cause of death in the US & will affect 50M people by 2030.

CHILDHOOD OBESITY

  1. If all 12.7 million US obese children become obese adults,the societal costs may exceed $1.1 trillion.
  2. IMPROVING HEALTHCARE QUALITY: NARROWING THE CHASM BETWEEN THE CARE WE EXPECT AND THE CARE WE RECEIVE
  3. If medical error was a disease, it would rank as the 3rd leading cause of death in the US. A stat from @bmj_latest.

HEALTH LITERACY, INSURANCE AND DECISION MAKING: REDUCING THE COST OF HEALTHCARE DELIVERY THROUGH IMPROVED HEALTH LITERACY

  1. Healthcare costs have risen 120% since 2000, & are expected to rise +80% to $5.5 trillion by 2024.

CHRONIC PAIN MANAGEMENT

  1. 46 Americans die each day from opioid overdoses.

AGING

  1. By 2050, the number of Americans 65+ will multiply from 46 million today to 88 million.

MENTAL HEALTH MANAGEMENT

  1. Global cost of mental disease is expected to grow to $6 trillion in 2030 from $2.5 trillion in 2010

REDUCING THE ADMINISTRATIVE BURDEN

  1. Admin costs currently represent 18% of US health care spending, leaving less than 73% of spending for clinical care.

TOXIC STRESS AND ADVERSE CHILDHOOD EVENTS (ACES)

  1. 4 or more ACEs shortens your life by 20 years.

Recently, some models have evolved trying to address sick care as a wicked problem.Facing the wicked sick care problem will require us to rethink the problem and how we solve or attempt to mitigate it:

  1. Change how we think about integrating ecosystems
  2. Give up trying to solve an insolvable problem but rather try to mitigate or optimize to a certain achievable level
  3. Rethink thick and thin engagement, dissemination and implementation
  4. Create trust in and between communities when confidence in expertise is deterioration
  5. Accept the fact that sick care cannot be fixed from inside
  6. Practice open innovation
  7. Identify resources that support active participation
  8. Create metrics that measure inputs, processes, outputs and outcomes that make a difference.
  9. Build a community of sick care stakeholders that understand how to communicate and impact policy much like other not for profit and science policy initiatives
  10. Understand your audience and listen to them

Top down command and control techniques no longer work in a world of people who are unwilling to spend a lot of time on something, lack trust in institutions and authority, have infinite access to information and simply want to be treated like adults. Wicked indeed.

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Arlen MyersArlen Meyers, MD, MBA is the President and CEO of the Society of Physician Entrepreneurs at www.sopenet.org

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