One of the things that the maelstrom of controversy over healthcare reform has underscored, yet again, is that there are no easy buttons in health care. Many scholars and pundits have weighed in on this issue with the pros and cons of why we should or should not change how we finance and deliver health care in this country. I won’t be adding to that discussion. I will, however, pose a different question: Can we tame wicked problems in health care?
Real world preventive medicine and public health problems are vexing--complex, complicated, and messy. Rittel and Webber (1973, p.160), wrote on planning, and first dubbed these “wicked problems.” Drinka and Clark (2000, p. 37) wrote about “tame versus wicked problems.” Tame problems can be defined and while not easy, can be solved. Wicked problems are difficult to define and not easily resolved—and sometimes can never be truly solved due to layers of issues, such as we see in health care. Rittel and Weber (1973) described ten key features of wicked problems.
- “There is no definitive formulation of a wicked problem” (Rittel and Weber, 1973, p. 161).
- “Wicked problems have no stopping rule” (Rittel and Weber, 1973, p. 162).
- “Solutions to wicked problems are not true-or-false, but good-or-bad” (Rittel and Weber, 1973, p. 162).
- “There is no immediate and no ultimate test of a solution to wicked problem” (Rittel and Weber, 1973, p. 163).
- “Every solution to a wicked problem is a “one-shot operation;” because there is no opportunity to learn by trial-and-error, every attempt counts significantly” (Rittel and Weber, 1973, p. 163).
- “Wicked problems do not have an enumerable (or an exhaustively describable) set of potential solutions, nor is there a well-described set of permissible operations that may be incorporated into the plan” (Rittel and Weber, 1973, p. 164).
- “Every wicked problem is essentially unique” (Rittel and Weber, 1973, p. 164).
- “Every wicked problem can be considered to be a symptom of another problem” (Rittel and Weber, 1973, p. 165).
- “The existence of a discrepancy representing a wicked problem can be explained in numerous ways. The choice of explanation determines the nature of the problem’s resolution” (Rittel and Weber, 1973, p. 166).
- “The planner has no right to be wrong” (Rittel and Weber, 1973, p. 166).
Most health care problems fall along the continuum of tame to wicked, with many levels of messiness along the way (Buchbinder, 2009). Conklin (2008) speaks of fragmentation as a result of vexing, wicked problems interacting with social complexity. By having only one discipline examines an issue; problems can actually be exacerbated, rather than ameliorated. When different factions stare at their pieces of the puzzle, and don’t attempt to see the perspectives of others, problems are addressed in a piecemeal, not a holistic manner.
What is needed now in health care is a new vision of this wicked problem. Wicked problems cannot be solved by one person or one discipline. We need to take off our disciplinary hats and approach these issues with interdisciplinary and transdisciplinary teams. Confused about the terminology? Here’s a brief overview:
“If you want to be alone in your silo, working only with like researchers, you are a unidisciplinarian. If you like working with other disciplines to address an issue, but don’t feel the need to learn new constructs and theories, then you will probably be happy in a multidisciplinary team. If you are interested in learning more about other disciplines and are willing to take a risk and cross boundaries of potentially conflicting theories and constructs, you might enjoy working on an interdisciplinary team. If you want to build new theories, products, sciences and ways of knowing the world and the problems to be solved, then you may also enjoy working on a transdisciplinary team.” (Buchbinder, 2009a p. 5)
In health care, there is blood in the water with wicked problems. Passion. Angst. Fear. Guilt. It's--emotional--plus all the logical, practical concerns of how will we do this. When we allow our primitive emotional brain to drive the discussions, we cannot expect to arrive at a good solution to a wicked problem. People become impassioned, speak for the "patient," have trouble separating themselves from the emotion. In some instances, fear tactics are being used to whip voters into frenzies on both sides of the health care reform issue. When we are in a fight/flight/fear mode, we cannot think in a logical manner (Buchbinder, 2009b).
It is time for everyone to take a deep breath, step away from the emotional frenzy and think about what our goals are for this country. Do we want to have one of the worst infant mortality rates in the world (MacDorman & Mathews, 2008)? Do we want to have an obesity epidemic, and concomitant sequelae (CDC, 2009)? Do we want our older women to live in poverty and worry about paying for health care (OWL, 2009)? Do we want health care disparities (OMHD, 2009)? Do we want to continue to have health professional shortage areas and medically underserved areas and populations (HRSA, 2009)? I would like to think that in a country that prides itself on equality and justice for all that we would not want the current state of health care to continue.
It is time for a transdisciplinary approach to this wicked problem, one that includes patients, and that creates a new vision of what health care can look like in this country. It is time to tame this wicked problem.
Sharon B. Buchbinder, RN, PhD
Professor & Chair
Department of Health Science
Sharon Buchbinder is an Adjunct Professor of Nursing at Stevenson University in the Graduate and Professional School , and former chair of the Association of University Programs in Health Administration (AUPHA). She is also the author of two books from Jones & Bartlett: Introduction to Health Care Management and Career Opportunities in Health Care Management.
Here are some references if you are interested in this topic.
Buchbinder, Sharon B. (2009a, October). AJPM Special Supplement Explores: Interdisciplinarity and the Science of Team Science. Association of Integrative Studies Newsletter. 31:(3) 5-8.
Buchbinder, Sharon B. (2009b, July 29). Emotional Intelligence and Leadership (Blog). Available at: http://portfolio.jblearning.com/health/2009/7/29/emotional-intelligence-and-leadership.html
Centers for Disease Control and Prevention (CDC). (2009, August 19). U.S. Obesity Trends: 1985-2008. Retrieved September 4, 2009
Office of Minority Health and Health Disparities (OMHD). (2009, March 17). Eliminating racial and ethnic health disparities. Retrieved September 4, 2009
Conklin, J. (2008). Wicked problems and social complexity. Retrieved August 15, 2009
Drinka, T.J.K., & Clark, P.G. (2000). Health care teamwork: Interdisciplinary practice and teaching. Westport: CT: Auburn House.
Health Resources and Services Administration (HRSA). (2009, April 20). Shortage designation: HPSAs, MUAs & MUPs. Retrieved on September 9, 2009
MacDorman, M.F., & Mathews, T.J. (2008, October) Recent trends in infant mortality in the United States. NCHS Data Brief No. 9, Hyattsville (MD): National Center for Health Statistics. Retrieved on September 4, 2009 from http://www.cdc.gov/nchs/data/databriefs/db09.pdf
Older Women’s League (OWL). (2009). Older women and poverty. Retrieved September 4, 2009 fromhttp://www.owl-national.org/Issues_Fact_Sheets.html
Rittel, H. & Webber, M. (1973). Dilemmas in a general theory of planning. Policy Sciences, 4: 155-169. In N. Cross (ed) (1984). Developments in Design Methodology (pp. 135-144) J. Chichester: Wiley & Sons. Retrieved September 4, 2009