The Millennium Prize Problems of Management
Welcome to the end of the first month of DEEP SOCKS. In the previous three chapters, we examined the managerial society’s formation, history, and uncertain future. We have discussed its fault lines and zones of conflict and attrition. We have also envisioned several futures for the succession of the managerial society. This week, we are posing three major problems for management to solve.
We are calling them The Millennium Prize Problems of Management—solving them will grant sure fame and glory, and it will preserve and extend the managerial society’s order for some great length of time by resolving a primary and highly visible contradiction.
The first problem we outlined was the problem of meatwar, the war on the ground, and its metastasis, when compared to the orderly and well-managed process of infowar.
Today, we come with the second, the problem of medicine in modern society, and its uncanny ability to produce an apparent social illness, and offer the beginnings of a potential solution.
The Major Threats to World Health
Iatrogenic disease is a very specific and storied problem. Literally, the name means doctor-created disease. Yet the problem is only exemplified by iatrogenesis in medicine, it is far more systemic and far reaching. But let's look at this abstract quickly, and typo aside, it's an odd thought to see in PubMed.
"Most of the literature establishes that modern medicine is one of the major threats to the world health."
That's right.
Most of the literature establishes that modern medicine is one of the major threats to the world health.
What the hell has happened?
The current model of health
Modern medicine proceeds from a particular point of view about health. Health is considered to be the objective absence of disease. Medical practice is the objective and scientific process of identifying and eliminating disease, counterbalanced against a patient's standing in a hypothetical lawsuit that is emerging at all times. In less litigious countries, this can be considered as the patient's current level of suffering and its mitigation by medicine.
The successes we attribute to modern medicine
Life expectancy increases
Expansion of mental illness
Birth control
Reduction in early childhood deaths
Reduction in childbirth mortality
Elimination of many endemic diseases
Mass availability of fentanyl
Extending acting careers via plastic surgery
Elimination of many STIs
Effective therapies for chronic illnesses including HIV-AIDS, diabetes, some autoimmune disorders
Anesthetic and antiseptic surgery
So, it's not all bad! Some of it is quite incredibly bad.
Healthcare is a highly managed and highly professionalized field—why does it fuck up so much?
Doctors are human. Malpractice is common and most attributable to human error and sloppiness in care. Doctors are under immense stress and pressure, and have immense loads of managerial work in addition to the taxing and thankless (but well-remunerated) work of being a physician.
Doctors are now managers of the Medical Stack. They do not simply treat illness, nor do they promote health, instead they are the supervisor and director of the activities of a number of professionals with drastically different educational levels, aims, and responsibilities. The ultimate goal of the physician in a modern clinical setting is to coordinate a positive health outcome, i.e. the elimination of illness.
Medicine has taken a great deal of unearned credit. The expansion of life expectancy and reduction of childhood and infant mortality are not attributable to modern medicine per se—rather to improvements in urban planning, food safety, reduction of toil, reduction of background social violence, and mass vaccination programs, which are apart from modern medical practice as we know it today. This has given doctors an extra leg to stand on, letting them shuffle genuine miracles into their mixed bag of accomplishments.
The Medical Stack
The conception of health as the objective elimination of disease turns the practice of medicine into a series of risk mitigation and processual steps. This balloons overhead and costs. This creates a situation where a doctor is properly conceived of as the manager of any number of ad hoc 'care teams' processing patients while simultaneously securing funding for almost every discrete step in the process from insurance companies. This is what we are calling the Medical Stack.
Remember, doctors went to school and were in training for about a decade, spending about a million dollars on this process if they were unlucky. And the end result is that they are now managing a care team. They must pay for their own insurance, which is a tremendous cost.
Their best bet to recoup the loss is to abandon the pretense of medicine as a profession of caring, and work hard to cash in on whatever the fuck medical suppliers are asking them to say, do, or endorse. What if you're an MD-PhD? Well, the upper ends of research and practice are combined with the insane problems of academic publishing. Do you want to mix the responsibilities of physician's duties with the supervening duty of 'publish or perish?'
So yes, doctors and medical professionals are trapped in a nightmarish system. They are beginning to resign in appreciable numbers, following the fun times of covid. Let's illustrate exactly the org-chart fuckery of a simple medical problem, had by a patient with means and insurance, treated at a clinic attached to a hospital by a conscientious and thorough doctor.
I have a neck pain
It really hurts, and ibuprofen isn't helping, changing the pillow isn't helping. This pain requires a doctor. Let's count the medical stack as we go through the process of a highly managed and professionalized environment.
To gain admission to a clinic or hospital for that kind of problem, you would want to make an appointment. There is a class of medical personnel whose chief specialty is interfacing with a bespoke appointment scheduler, they often also handle payment and processing of insurance forms. That's one person (1), plus one (1) corporation whose specialty is providing hospitals and clinics with their software.
They funnel you to a series of nurses whose main job is simply checking vitals and creating a preliminary form for the doctor to examine, confirming you are the height and weight that you appear to be, which a doctor could likely eyeball within a reasonable range, excepting the supermorbidly obese. This is done mostly to reduce liability in prescribing medication inaccurately, and to double check you aren't having an immediate cardiac or respiratory crisis. This level of care is necessary, based on the statistics of iatrogenic disease.
At my last checkup, this took a total of two (2) people. To print out the records of course implies there is an office manager of some sort. This brings our total of people directly involved in this service to 5. I have so far only had my pulse, temperature, and blood pressure checked.
First meeting with the doctor
Now, to wait, since this process is disjointed with the actual progress of care by the doctor. Once I see the doctor, we have a simple and perfunctory examination. The complaint is heard, and a basic physical examination is performed. It is often uncomfortable and rough, but it is apparently in the nature of medicine to make a patient into an object for examination. This is so far normal, and now there are at least 6 people involved in care, 2 in admin roles, and a major corporation who provided the essential software dedicated to the medical practice of recordkeeping.
The doctor is either able then and there to diagnose the pain, or you must now go through tests. Let's say you go through tests, the doctor wants to be sure you're just sleeping wrong or something. He calls a nurse, likely one of the ones who was taking your vitals previously.
To test thoroughly for this mysterious illness, the doctor must check for infection, muscle strain, bone injury, and a foreign mass causing the pain, I would need to see a minimum of a phlebotomist, radiological technician, and an ultrasound technician. Now, we are at 9 people, one major corporation, and a bunch of medical equipment. None of them are competent nor legally authorized to interpret the report they have generated for the doctor. Depending on the level of your pain and the size and location of the clinic you may need an orderly for transport, and possibly a nurse who is essentially being a tour guide at this stage. That brings us up to 11, maximum.
Remember, our mental model is a clinic attached to a hospital which is competent to perform most kinds of tests and examinations. Should you not be so lucky to visit such a clinic, it is quite possible you would have to make appointments outside the clinic to get these tests done. It would take a while! And at that point, you're looking at a geometric increase in personnel involved.
Second meeting with the doctor
Returning to the mental model, we are, within 3-4 hours, seeing the doctor again. If you are lucky and it's just a muscle spasm and your insurance company is ready to eat shit, the doctor will likely give you a conservative approach to treatment at first. This means the with the euphoric and addictive medicines available, to reduce his liability and insurance bills, and the medicines and treatments with the lowest risk profile. Here (based on personal experience) it would likely be a course of B vitamins, an anti-inflammatory, and light muscle relaxers with no drowsiness as a side-effect. To a certain extent, this is responsible and good, though relief may not be in sight just yet.
To obtain your medication, you will need at minimum the involvement of the pharmacist, if they're in the clinic at all. Perhaps your doctor has a nurse get you your prescriptions and there is no need to worry about the pharmacist personally. You are now at 12 people involved. The doctor's prescription pad, if you are in a developed country, is likely regulated by the national government since it is quite easy for a doctor to prescribe happy pills, which are a legal no-no. You are now at approximately 12 people, 1 corporation providing software, several providing equipment, 1 federal police agency--and we have not yet involved payment servicing through the insurance company, or any follow-ups.
This is not an uncommon or particularly onerous medical experience, and it's one where the outcome is straightforward, predictable, and routine. You have a problem, tests for possible causes are performed after a consult, and you are in the custody of medical professionals the whole time. You have been pushed through the Medical Stack. At every stage you are being moved on an assembly line with custody of your health being assured, but never in a manner that is particularly reassuring. This is taken care of only in the vaguest sense possible, often by people with minimal legal qualification and responsibility toward you, and your doctor's primary focus is treatment of symptoms followed by treatment of underlying cause, in the most time-efficient manner possible. You are not the only patient that day of course, and you have lost yours, being pushed through a Fordist assembly line.
The issue might be clear by now
Yes, the clinic is a processual, bureaucratic nightmare. Even if it works effectively, it is inhumane in an objective sense—you are treated like meat for a wide majority of the time. Even if this is done in your best interests, and the care is performed to a high standard, it is hard to say that the typical experience of navigating a clinic isn’t fundamentally alien and broken.
This, you may argue, is the natural end state of objective and responsible care. It is highly objectifying, and chains of custody must be maintained. This is true—in the framework of objective and responsible care, doctors must be highly trained, and a growing army of administrative and secondary medical professionals must exist. In fact, in order to provide an objective and responsible standard of care done by highly professionalized agents, not only is supply of doctors limited (by w ay of expensive, long, harrowing training and certification processes), but supply of administrators and secondary medical professionals to compensate must inflate.
What if we simply had more doctors? More prescription pads and people ready to use them? This then is a problem that can be solved by reprovisioning medical caregivers. Maybe triage clinics where you interact with nurse practitioners for aches and pains. That would be a simple enough solution—and it’s one being tried quite often in fact, with little reduction in the general awfulness of medicine. This goes far beyond the simple problem of supply and demand. We must ask, why is the supply limited? Why must doctors be trained to a point of excellence through expensive, long and harrowing training?
Because the medical conception of health requires the practice of highly scientific medicine. This is laudable as a goal! But it is the concept itself that creates the need to professionalize doctors. A need to professionalize doctors is also functionally the same as a need for medicine to operate as a highly profitable cartel where doctors can, in exchange for a significant portion of their life, receive status, moral benefit, cool scrubs, sweet medical gear, and significant salaries. The cart is before the horse. The conception of medicine as the objective elimination of disease, diagnosed using objective markers and observation produces a perverted incentive to create doctors who can do this, but are disinterested in the patient.
Banality of the saintly doctor
Morality laundering is an interesting and underexplored concept. Simply put, most physicians are in it for the money, the power, or the sex. They're right there for the taking. Many doctors, an appreciable minority, have had sexual contact with their patients. The money is obvious--and the rise of the chronic, incurable illness as the primary malady afflicting the population has lead to a bottomless trough of money for the unethical doctor to line up at. And there's no power like the power over life and death, sickness and health that really gets a sociopath's deadened nerves dancing.
But there are, in fact, saintly doctors. Very talented, compassionate and caring professionals who entered into medicine and stayed in medicine. How else would we have Médecins Sans Frontières without this sort of doctor? Many of us have had compassionate doctors.
This is an odd case where their apparent morality and decency are taken to be the primary traits of the medical field. It simply takes a limited experience with bad care to have lifelong side effects or simply a distrust and distaste for doctors. The good apple is keeping people bobbing in a tub full of rotten ones. In fact, there is a bifurcation between those who have had limited or mostly positive experiences with medicine and those who have had extensive or negative experiences with medicine.
The secondary effects of bad care
Bad care comes in many forms. Pill mill doctors. Doctors who collaborate with patients in obvious self-diagnosis. Overprescription of pain medication in general. Collaborating with delusional behaviors, such as Munchausen's. Extreme waits for competent physicians. Doctors who refuse to listen to their patients when it is essential that they do. Molestation. Disregard for the patient's comfort. Adverse drug reactions. Surgical mishaps. Botched medical procedures. Inflating costs of procedures. The many different forms of negligent malpractice that can occur when you ignore or disregard a patient. Pushing drugs as an agent of a pharmaceutical corporation. Everything Doctor House does. The list goes on and on.
Not only do these increase administrative and liability burdens for doctors to bear, they also create a class of people who are simply unwilling to participate in the healthcare system without a dire emergency, thus worsening costs and outcomes.
These people come to exist in an oppositional, anti-expertise mode, where they have seen the outcomes of managerial society, and while they may not understand it, they may just blame 'doctors' or 'that doctor' or 'that hospital' or 'insurance companies,' they certainly see that modern medicine is dysfunctional in the extreme. They have no relationship and are unreachable by even well-meaning, scientific, or well-practiced public health interventions.
The covid rebound against the medical profession
Obviously the past 3 years have certainly not seen any well-meaning, scientific, or well-practiced public health interventions. Millions are sick and dead, the vaccine did not have any of its promised or definitionally implied effects. It made many people quite ill. It killed a good number of people. These are controversial yet objective and clear facts.
Why are they controversial? Because in order to successfully narrativize an ad hoc, global managerial response to an emergent challenge, the first and greatest of its kind in a generation, the narrative had to be simple and intelligible.
Doctors = good, trustworthy, reliable. They sacrifice for you. Look at their face marks from their masks. Look at how tired they are. Watch a TikTok video of nurses dancing. Aren't they just the best?
Naturally, people who oppose this idiotic formula are not safe and in fact harmful to the body politic and must be segregated and kept away. The underlying assumption about the elimination of disease as health must be kept safe. There is no narrative compatible with the current highly managed, highly professionalized, highly coordinated Medical Stack that is about anything other than doctors doing their jobs downright heroically.
Iatrogenic social illness
The obvious lie to many that doctors are simply good and heroic people working hard creates a hard fork in reality. There are those who accept, and those who do not accept. It is impossible to manage a large group of people who are fundamentally not capable of agreement about the nature of the problem in front of them.
As the practice of medicine often creates malady through negligence, inattention, or stupidity at some critical point in care for an individual, so the aggregate effect of this can erode trust in the institution of medicine. Covid created parallel realities. But these were not, in spite of politicized media stating so, politically bifurcated realities. The split in reality grows out of the practice of medicine and the experience of patients. Republicans don't distrust doctors. Trump got the vaccine, he took the Regeneron, he got better! Many patients distrust doctors. Many people distrust doctors. Covid and the creation of parallel realities along lines of attitude toward medicine is symptomatic not of an epistemic crisis, or of a crisis of polarization, but of the dysfunction in medicine.
The Second Millennium Prize Problem of Management
The solution to any of these millennium prize problems will drastically increase the life expectancy of the managerial society. The solution to all three would certainly put us on the road to a more humane millennial kingdom of the manager.
Successfully solving the problem of iatrogenic illness, in its social and individual form, can potentially be accomplished by reconceiving the core concept of health. This could potentially effect a demanagerialization of medicine. From the highly abstracted point of view of managerial society, the trick would be in recognizing its own harms, and then letting go.
This solution cannot untangle the entire policy thicket though. But it is an attempt nonetheless worth undergoing. What if the conception of health was instead refocused on the adaptability of the patient, grounded in an intersubjective communication between doctor and patient? In less jargon--what if you weren't just a piece of meat to a physician? And what if medicine wasn't a series of procedures to process you through a health generating institutional machine? If doctors came to believe that medicine was something else than what it is now, it would have profound impacts on the practice of medicine, and over time its administrative structure.
That mission was set out most clearly by a French physician, Georges Canguilhem, in his 1943 book, The Normal and the Pathological. Canguilhem rejected the idea that there were normal or abnormal states of health. He saw health not as something defined statistically or mechanistically. Rather, he saw health as the ability to adapt to one's environment. Health is not a fixed entity. It varies for every individual, depending on their circumstances. Health is defined not by the doctor, but by the person, according to his or her functional needs. The role of the doctor is to help the individual adapt to their unique prevailing conditions. This should be the meaning of “personalized medicine”.
The beauty of Canguilhem's definition of health—of normality—is that it includes the animate and inanimate environment, as well as the physical, mental, and social dimensions of human life. It puts the individual patient, not the doctor, in a position of self-determining authority to define his or her health needs. The doctor becomes a partner in delivering those needs.
—The Lancet, March 2009