Photo: NYCArthur (Flickr)
The story goes that a New Yorker (Arthur Rubinstein, in some versions) is approached in the street near Carnegie Hall, and asked, "Excuse me sir, how do I get to Carnegie Hall?" He replies, "Practice, practice, practice."
There's another version of that story that I once saw in an ad (I can't remember for what). The question was the same but the answer was: "Well, I wouldn't start from here."
As I read Anu Gawande's article in The New Yorker about health care reform, titled Getting There From Here, it was this second version of the Carnegie Hall story that I remembered. Gawande's argues that pragmatic reform of the health care system built around the mess we have is preferable to any of the start-from-scratch proposals on the table (single payer or free market).
No-one can accuse him of having a rose-tinted perspective as he summarizes: "Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it...There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have."
Gawande bases his argument on the idea of path dependence. Shouldn't I already know about path dependence? I don't know. Anyway, it describes how decisions today are influenced and limited by decisions made in the past, even though past circumstances may no longer be relevant or optimum. Witness the QWERTY keyboard still going strong today even though it was designed originally to slow people down so they wouldn't jam the typebars on their typewriters.
In path-dependent processes, early events play a critical role in the market outcome. Take America's transportation system. Early decisions to base it on gasoline-powered automobiles (as well as a few well-timed interventions by the auto makers) have created an entire infrastructure that make it very difficult to do things differently.
What path dependence tells us it that, when people have devoted a lot of time and resources into a particular way of doing things and they have become efficient organizing themselves around a system, it can be really difficult and counterproductive to try and start from scratch. Applied to health care that means building on our flawed current system. Applied to business that means choosing business model evolution over reinvention (except when your industry is hit by a massive asteroid).
Such thinking doesn't need to lesson our ambition. We all can strive to get to our own Carnegie Hall. But we need to get try and get there from where we are now instead of where we might wish we were.
Tuesday, February 3, 2009
Photo: NYCArthur (Flickr)