“Who’s wearing the yellow hat? Always find the person with the yellow hat.”

Years ago, this was advice I received from a mentor seeking to educate me on problem-solving for thorny public policy issues. At first I was puzzled, thinking the instruction might be a colourful nod to east coast fishing fashion. But, after some explaining, I came to learn that “Who’s wearing the yellow hat?” really meant “Who’s in charge?” and the phrase was a reference to the supposed hierarchy of construction sites where the source of authority on a project might wear a yellow helmet to stand out.

In other words, I was told that if I wanted to improve the performance of a complicated public sector system (or any system, for that matter), I needed to start by figuring out who is making the decisions and then aligning incentives with the intended chain of command. The location of power mattered. It mattered for planning, it mattered for resourcing, it mattered for execution and it mattered for outcomes.

Having long viewed public policy through this lens, it seems clear to me that nowhere is this maxim more true than in healthcare. However, and very encouragingly, nowhere is there more ink being spilled on the need to optimize power dynamics than in the journals and conference agendas of our healthcare influencers. 

Whether it is the recent leadership of a McGill-based clinician in highlighting the importance of patient-centeredness in cardiovascular care, or the similarly new contributions of University of British Columbia and University of Toronto researchers in establishing patient-centered guidelines for depression care, notions of hierarchy in healthcare are being positively disrupted across Canadian healthcare systems. An old guard armed with white lab coats, clipboards and messy handwriting is embracing visions of a more empowered patient who is further fortified by health monitoring smart watches and peer support groups. In an era where a patient can choose to download any one of 350,000 health-based apps, or when artificial intelligence chatbots are seen to offer quality and empathetic responses to patient questions, healthcare is becoming participatory to the point of democratic.

The even better news is that democratic healthcare works. A 2021 study on the relationship between health literacy, patient activation and health outcomes in breast cancer patients, for example, concluded that patients “who are able to actively participate in managing their health and health care are more likely to have higher HRQoL [health-related quality of life].” Similarly, an earlier research project examining both the quality and cost implications of better patient engagement in primary care concluded that higher levels of patient activation were associated with “better clinical indicators, more healthy behaviors, and greater use of women's preventive screening tests — as well as with lower costs.” Controlling for age, sex, number of chronic conditions and income, the project authors found that as patient activation increased so too did the likelihood of cancer screening being obtained, avoided hospitalization or emergency department visits and the patient’s good cholesterol being in a normal range.

Critically, this shift toward democratized healthcare doesn’t just run on attitudinal adjustment. It is also driven by technological change, creating a virtuous race-to-the-top of patient-centricity in which clinicians are trying to leapfrog computer geeks, chatbots are trying to outsmart clipboards and patients feel literate enough to demand more and more from all of the above. It is no longer fantastical to assume that the sprint to meet escalating patient expectations by bringing care to patients or by personalizing medicine will result in grand therapeutic breakthroughs like transcontinental remote robot surgeries or cancer causing cells that turn into cancer fighting cells. Moreover, it is increasingly easy for patients and caregivers to find a myriad tech-enabled engagement tools in the upstream administrative corners of healthcare. Something as straightforward as automated patient rescheduling is lowering patient wait times and reducing no-show appointments. Likewise, the use of large language models in clinical trial patient recruitment  is helping patients access novel treatments faster. 

In macro policy terms this means that as the universe of healthcare expands, its gravitational structure is also altered. We have moved from a unipolar world, where physicians and hospitals dominated power structures to a multipolar world in which physicians and hospitals are still integral for the performance of healthcare, but now operate alongside a host of other well-resourced actors and venues, including allied health professionals, caregivers and patients; outpatient centres; and our own homes. Just as astoundingly, each of the now critical system actors seems to have avoided the trap of thinking that these evolutions of power are zero-sum – that is, necessarily threatening to one group, just because it is beneficial to another.

So at a time when we could choose to lament the rise of polarization in certain segments of society, at least some features of healthcare give us reason to trumpet the converse. The old guard and the avant-garde have linked arms, and are willing to open the circle to others. Perhaps this spirit of togetherness is born of health human resource challenges or fiscal constraints. Maybe, in public healthcare systems such as Canada’s, cooperation comes from the capacity for increased transparency, including heightened scrutiny and accountability. Wherever it comes from, it is a good thing, which ought to be celebrated and cultivated. In a space where expertise, empiricism and existential events constantly collide, we should never be distracted by ego trips. We should be a legion of leaders, a community of partners.

Therefore, my old mentor might have got things slightly wrong. Power does matter. But maybe there can be more than one yellow hat. 

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