Cars, Medicine and Businesses: A Crash Course in the Dangers of Specialization. Entry 14 - 2008.

As regular readers of this blog already know, here at HHCF we examine the interconnectedness among an array of workforce characteristics, corporate policies and practices, and outcomes. These factors all affect each other—absence policies affect health care costs, compensation policies affect prevention rates, management practices affect turnover, and so on. Whether we are talking about the “whole patient” or the “whole workforce,” it is literally impossible to optimize wellbeing one system at a time without considering its context within other systems.

In medicine, almost everyone has heard of examples like the following:
My friend’s grandmother has multiple health conditions and receives advice and treatment from a variety of providers; the list includes a psychologist (minor depression), an endocrinologist (diabetes), a cardiologist (high blood pressure and heart arrhythmia) and a pulmonologist (chronic lung disease). Each provider provides his own recommendations and medications, but no single provider tracks everything. Over time the combination of treatments has accumulated, she feels lousy, and sleeps much of the time. Because one cannot separate the effects of the problems from the effects of the medications, there is no easy way to discern which affects her quality of life the most. Further, one can only suspect that the uncoordinated treatment and multiple medications contributed to her subsequent fall and broken hip.

It is quite possible that each specialist in this case is providing appropriate treatment for each individual condition. Further, the medical system does not pay doctors (or pays very little) to coordinate care and talk to the patient and family. So, Grandma could conceivably receive well-designed, compartmentalized treatments that—when combined—actually compromise her overall wellbeing. Things that look OK in isolation may look quite different in a broader context.

Specialization evolved for a reason.
One can claim that much of the advancements in medical science have come from specialization in research, drugs, techniques, and skills. And economists argue that specialization and trade are the root sources of overall economic progress. Why do specialized professions develop? Because no one person can be an expert at everything. In manufacturing, the industrial revolution resulted from one person being responsible for one part. Individuals can probably not each assemble an entire car in a day. But a group of people each adding one part to a car can produce many. Because of specialization, all of the contributors could be made better off by sharing the aggregate results of their specializations. However, the key is coordination of the specialized contribution.

So, expertise surely has its place. But more and more often I see evidence of specialization and compartmentalization leading to inefficiency, close-mindedness and excess cost. And while medicine provides many examples of problematic over-specialization, it also predominates in business.

In business we behave the same way, except the patient is the company.
I speak at a variety of conferences, including some for wellness professionals, nurses, doctors, human-resource professionals, safety and risk professionals, benefits managers, labor-management personnel, compensation designers, performance and business managers. Each group has its own national society, national and regional conferences, publications, websites, specialized terminology, and world view. Each has its own system of defining value and best-practice, a refined focus on internal excellence.

So, not surprisingly, when I share our evidence about how everything connects, inevitably someone in the group reacts,

“That’s really interesting, but it’s not part of my job.”

Health professionals explain that they are not involved in hiring or training, compensation managers insist that health status is beyond their control, safety managers clarify that they do not set absence policy, and wellness advocates maintain that their domain is health behavior, regardless of work environment. Like a cardiologist who suggests you “go see someone else about that rash,” when faced with the possibility that the problem (and solution) will require coordination beyond defined boundaries, each professional organization points down the hall toward a different door.

It is not only understandable, it is completely reasonable that we stay in our respective boxes. As business professionals, we are rarely recognized for or given incentives to maximize the wellbeing of the company as a whole, only our piece of it. If you are a lung specialist, help the patient breathe. If you are a benefits manager, design a good health plan. Another doctor will fix the broken foot. Another department will deal with training. It is human nature to protect our own turf, deal with what we know, and maximize our own importance.

But then, if every problem gets put in a distinct container, can there be interconnected solutions? If no one sees the full situation, does any single action have a chance to achieve the best collective result?

Having no place
Ironically, the evidence supporting interconnectedness also has trouble finding a home. Journals are so specialized that their reviewers get uncomfortable when factors outside the usual domain get introduced (“this is a pharmacy journal, not a policy journal”). As an example, one fascinating theory of how work and health connect is Job Strain Theory. It was developed by a researcher named Karasek who demonstrated that people in jobs that had high levels of demand (lots of work to do, must work quickly) combined with low decision-latitude (I have little control over how to do my tasks) had much higher rates of both physical (heart problems) and mental health conditions (depression) (1). Interestingly, high job-demands combined with high decision-latitude had no such effect. Essentially, hard work didn’t contribute to illness, but hard work in a setting where people had minimal control placed people at risk.

His work continued to show that jobs with low demand and low control (called passive work) have a carry-over effect on employees becoming less engaged in all aspects of their lives outside work than people who had active jobs (2). Essentially, it suggests that how we design jobs bleeds over into how people behave in the community at large. Thus, his ideas spanned work environment, policy, psychology, disease, and society.

This theory and others like it often become orphans in the world of specialized journals. Karasek’s original work was published in an obscure journal called Administrative Science Quarterly in 1979 (1). The carry-over work, 25 years later was released in the Bulletin of Science, Technology & Society (2). And his other references appear here and there in business and health journals. But mostly they fit neither the mainstream health literature, nor the mainstream management literature, so integrated ideas of this sort tend to fall between the cracks, relevant to many but owned by none.

Whole company, whole person
It seems that in becoming specialized, we have neglected what must have been the original reason for becoming experts; to do the best we can to help a person or company reach its potential. It almost seems like we have divided a car into pieces, asking one expert to be responsible for each part when no one is actually looking to see that the whole car is safe, operational, and headed in the right direction. If the expert running the gas pedal insists his job is more important than—and unrelated to—the expert in charge of brakes, eventually we’re headed for a crash.

Corporate departments as specialties
You may not think of your company’s departments as specialists, but consider how well each department coordinates with others. Is their primary concern to determine which activity best serves the company and the workforce, regardless of where funds must be allotted? Are all employees rewarded for contributing to the collective good of the organization? Do department heads integrate their data with others to see if policies in one area are affecting another?

More specifically, if someone in department A learned something new that was important to department B, how likely would they be to cooperate and collaborate for the good of the company? Or would each insist the other is “not their job?”

What if our real job is simply to learn as much as we can about and act in ways that best serve the overall health and future potential of the patient or company we are serving? In that case, wouldn’t we all blur the boundaries of the boxes we have constructed around our expertise?

In managing health, there is no substitute for a generalist who understands the many dimensions of a patient’s life, health, treatments, worries, and preferences. But it would also help if the various specialists who touch each patient were in communication---or at least aware—of what each other had advised.

In business, perhaps we need better structures and rewards for interdepartmental collaboration, data sharing, and collective problem solving. At minimum, it would help if everyone understood they are on the same team with the same overall purpose. By staying in our “places” we not only miss opportunities to optimize wellbeing, but like doctors prescribing harmful combinations of medicine, we may actually be making things worse.

Why this matters
Isolated expertise, while useful, is no match for a general, collective understanding of the connections among systems. When we insist our own domains are more valuable unto themselves than as one component of an overall solution, the more likely it is that we are actually making the situation worse.
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References
(1) Karasek, R. A. (1979). Job demands, job decision latitude, and mental strain: Implications for job redesign. Administrative Science Quarterly, 24, 285-307.

(2) Karasek, R.A. (2004). Job socialization: the carry-over effects of work on political and leisure activities. Bulletin of Science, Technology & Society, 24(4), 284-304.