Insights January 2012

The Ghost of Healthcare Despair

Hugh MacLeod


Recently, I moved into a new office. One wall of the office was devoted to a huge map of Canada showing various healthcare systems, agencies, institutes and organizations with the title “The Canadian Healthcare System” written across the top in authoritative script. It was printed in the early 1990’s and so was naturally quite out of date. Some of the institutions it depicted were gone; many new ones were not represented.

As maps go, it was finely drafted but as I looked it over, I felt a growing dislike for it. The problem was not that some of the information was out of date. No, it was the very concept of the map that was somehow out of date. Don’t get me wrong. I like maps. I love looking at healthcare system information displayed in interesting ways. I especially love it when graphics help us see hidden trends and patterns.

So what was the message of this particular map hanging in this particular office? I think the map, in addition to telling the viewer the names and locations of a bunch of healthcare facilities, was communicating a problematic message; our “system” is essentially an aggregate of isolated institutions.

I decided the old map had to go. I got up and took it down. The map had clearly been up for a while - the paint behind the map was a different shade. The alternate colored square looked a bit like the outline of a doorway. Letting my mind spin out a daydream, I imagined where the doorway might lead. Would it open into a new way of looking at the healthcare system? If it did, what would I see? Would I be able to look past my pre-conceptions to see it afresh?

As I saw the doorway in my daydream, it was sporting a new sign that said ‘This way to the balcony of personal reflection’. That sounded intriguing. The doorway had no handle so I gave it a push and it swung open to reveal a simple staircase, leading upward at a steep angle. Peering up the staircase, I could see that it reached a landing and turned out of sight. The stairwell was dimly lit but I was hesitant to walk up.

As I stood there trying to make up my mind about whether I should explore further, I noticed a plaque on the wall. It was a quote from one of my heroes, Tommy Douglas. It read, in his direct, folksy style: “Courage, my friends; it is not too late to build a better world”. I decided to check out this balcony.

As I reached the first landing, I was suddenly confronted by an ugly and intimidating spectral figure. I froze, as it roared at me:

Halt! I am the Ghost of the Healthcare Despair. Look upon me and despair for I am fashioned out of all the timidity, cynicism and defeatism that crowds around your heart.

I am not one to be easily intimidated, but I have to say, this ghost had my number. With every word, I could feel myself being weighed down and becoming increasingly anxious. It was as if its very words evoked weakness and indecision in me. Eventually, I found my voice and shot back.

What are you doing in my daydream?

The Ghost thundered on as if it hadn’t even heard me at all.

I am bound to siloed halls, stairs and ladders by weight of all decisions that have been made in the way they were made because someone did not have the courage to look, think and say the truth that was available to them at the time. Thus is the public good damned. Only those who are brave enough to see for themselves, think for themselves and speak for themselves will find the strength to push past me.

The Ghost fell silent, glaring at me. Clearly, it was my turn to speak now but I wasn’t quite sure what to say. I studied it for a bit. The body, the face looked vaguely familiar, and I suddenly realized it looked a bit like me; it looked how I might if cynicism and despair really had taken possession of my heart. It was my version of Oscar Wilde’s The Picture of Dorian Gray. As I continued to stare at it, I noticed that its robe was made of documents – reports and briefing notes – that seemed to shift around, falling off and sinking into the floor, like stones into black water, only to be replaced by new documents that emerged to replace the pieces that had fallen off. It was as though a great shabby, heavy blanket of words was weighing it down. As if this weren’t enough, the ghost was also tethered to the wall by hundreds of strings of linked paper clips.

Following my gaze, the ghost spoke again, in a sneering tone.

Do you like my robes? They are a testament to my many victories! Each of these documents contains a moment of genuine insight and consensus in the healthcare system when a problem was well defined and a practical, innovative strategy was clearly articulated…but then, it was never acted upon! Ha, ha ha! I have quite a wardrobe. Each document represents hours of volunteer and paid hours of hard work, often by the best and brightest. Each document contains someone’s hope that they could make a difference. Nowhere am I more powerful than when the right idea is offered by the right people at the right time and yet, it becomes a study or report, and it dies somewhere in these halls, ending up adorning me in splendid fashion.

Sometimes, it is simply more useful to be angry than frightened and this ghost, was starting to get me riled. I shot back.

That doesn’t always happen! There are many fine people working very hard together to improve the healthcare system and we are making great progress.

The ghost replied more forcefully.

Idealists! You waste your time. You should study Saint Machiavelli who wrote:

It must be remembered that there is nothing more difficult to plan, more doubtful of success nor more dangerous to manage than the creation of a new system. For the initiator is the enemy of all who profit by the preservation of the old institution and merely lukewarm defenders in those who would gain by the new one.

Do you really think you can have any impact on the way things are? Healthcare delivery is chugging along guided by vested professional interests, political realities, disconnected personal ambitions, economic forces and a host of other factors that make up the real world.

Then it came to me:

Ghost! I do recognize you. I have seen you before, in myself and my colleagues. You are a great nuisance. You keep us quiet when we should ask questions. You keep us talking when we should listen. Worst of all, you keep us from acknowledging what is right in front of our noses and doing something about it.

At that, the ghost vanished but so did the next flight of stairs. I could hear its laughter echoing. Uncertain as to what to do, I gingerly put my foot forward and realized the stairs were actually still there.

I climbed the steep stairs, spiraling up ever higher, until I finally reached the balcony. Below me was spread the entire healthcare system. From here I could see all its components. I could see the degree to which it is a system and the degree to which it is not. I could see the strengths and I could see the problems. I could see pockets of brilliance. I could see the providers, working in their manifold tasks and I could see the patients and their families.

Healthcare is made up of interconnecting circles of complex activity; however, we are conditioned to see dots on a map, and think in straight lines of a road. But what we see depends on what we are prepared to see. Gandhi said it best…”We stand within a circle whose circumference is bounded by our fears. The circle is our comfort zone. If we stay there, we become complacent.”

There are no ghosts, except the ones we create in our minds and fear as if they were real.

About the Author(s)

Hugh MacLeod is Chief Executive Officer of the Canadian Patient Safety Institute.


Sal Causi wrote:

Posted 2012/12/18 at 02:41 PM EST

One of the best essays that I have read on the state of our Healthcare System. The Essay captures both the essence of the challenges to changing the Healthcare and the fear of those changes.


Douglas Maynard wrote:

Posted 2013/10/01 at 11:09 AM EDT

This should be turned into a theatrical monologue to be performed at healthcare conference across Canada! :)

Excellent article!


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