March 14, 2025
Dear Interested Readers,
Radical Versus Rational Change
Donald Trump roared into office claiming that he had a mandate for radical changes in government structure and policy that his supporters believed would “make America great again.” He alleged government employees ignored or participated in fraud and abuse that the chainsaw of Elon Musk could fix. He postulated that our allies and opponents were “ripping us off” in international alliances and agreements like NATO, the WHO, and the Paris Climate Accords, but mostly he felt we were disadvantaged in international trade. New efforts at isolation were his answer to what was preventing American prosperity. After scapegoating illeagal aliens and anyone with “liberal progressive thoughts” (all Democrats, supporters of DEI initiatives, or those concerned about global warming), the treatment he prescribed was withdrawal from our leadership of the “free world” and the institution of crippling tariffs against our friends and foes.
He convinced many voters that efforts to improve diversity, equity, and inclusion, or the rights of the LGBTQ+ population were disadvantageous to them and their children while opportunities were being lavished on undeserving, less ethical, and less talented “others.” He and his running mate postulated that inflation, housing shortages, and factitious and fictional rising crime rates were the product of the ultra-liberal policies of the Biden-Harris administration. As a side issue, transgendered women in athletics were an ominous threat to the health and self-esteem of those “assigned female” at birth. He sold many voters on his ability to block the flow of fentanyl and illeagal immigration while he would simultaneously end the war in Ukraine on “day one” and in short order would institute a swift and just peace in Gaza.
Promising more than can be delivered, is not unusual in politics. What sets the president apart from all others who ever held the office is not his inability to deliver on campaign promises, it is his ruthless disregard for the lives of innocent people, his lack of conformity to norms, his need for revenge for past grievances, his seeming lack of knowledge of history, a lack of understanding of complex systems, and his willingness to destroy trust by making everything transactional. I fear that the long-term consequence of his unbridled ineptitude and lack of awareness of the consequences of his ignorance (He seems not to know what he doesn’t know–The Dunning-Kruger effect.) will be damage done to our nation and the world that will take multiple decades to repair once we are finally rid of him whenever that might be.
What galls me as much as what he says and does are his apologists who whitewash his every blunder with the assertion that he knows what he is doing–just wait and see. I get into self-loathing when I know that what my biases want me to do is to randomly go up to everyone I think who was conned into voting for him and ask what they think of the price of eggs now or how long do they think his little period of “adjustment” (a euphemism for a recession and big losses in your 401K) will be before all the wonderful things he promised back in October will begin to happen. I want to ask them how this moment seems different than the multiple times one of his businesses went into bankruptcy or when he last cheated some honest contractors servicing one of his hotels by refusing to pay them. What leads these Trump loyalists to think that a convicted felon and sex offender who has never shown loyalty to anyone unless coupled with fealty to him would care about their wellbeing?
I know it has only been fifty days of chaos, and maybe the fire will burn itself out, but I fear his greatest strength is his ability to run through multiple stop signs while convincing supporters that progress is being made. Some of my disgust was well articulated by Tyler Pager in an article published on Wednesday in the New York Times entitled “Trump Promised Americans Booming Wealth. Now He’s Changing His Tune.” I resonated with the first few paragraphs:
As a presidential candidate, Donald J. Trump promised an economic “boom like no other.”
But eight weeks into his presidency, Mr. Trump is refusing to rule out a recession — a striking change in tone and message for a man who rode widespread economic dissatisfaction to the White House by promising to “make America affordable again.”
His comments come as the stock market is tumbling — the S&P 500 fell 2.7 percent Monday after falling 3.1 percent last week — and business leaders are spooked about the uncertainty over his tariffs. Even some Republicans, who fear retribution if they cross Mr. Trump, have started to raise concerns about his levies.
The moment captures a fundamental challenge for Mr. Trump, a showman who makes absolute and sweeping promises that inevitably run into the reality of governing.
The economy Mr. Trump inherited was by many standards in solid shape, with low unemployment, moderate growth and an inflation rate that, while still higher than what the Federal Reserve wants, had declined substantially. But the uncertainty that his policies have injected into the outlook is a jarring contrast with the picture Mr. Trump painted on the campaign trail.
Trump promised to be an emotional triumph for those Hilary Clinton had unfortunately and perhaps maliciously labeled as a “basket of deplorables.” Perhaps what we are witnessing is Trump’s ability to harness the FOMO, chronic poverty, self-respect limiting dependence on federal subsidies, and deep despair leading to the anger of that marginalized population, harnessed for the benefit of those who have too much, but for whom too much will never be enough.
For a more insightful and perhaps compassionate understanding of those who voted for Trump against their best interests click on the last link and read the New York Times review of Arlie Russell Hochchild’s recent book STOLEN PRIDE: Loss, Shame, and the Rise of the Right. Even better, read the book. I love the writing of this 85-year-old civil rights activist turned Berkley sociology professor. In the book review, we read:
In “Stolen Pride,” Hochschild updates the core of her previous book, what she calls her subjects’ “deep story” — the emotional narrative that they use to explain their lives. In this story, Hochschild explains, white, blue-collar conservatives feel that they had been waiting in line for the American dream only to have Democratic constituencies — educated women and minorities, for example — cut ahead of them. In “Stolen Pride,” Hochschild elaborates that those voters saw Barack Obama as a bully helping the line-cutters advance. Trump then emerged as the “good bully” who was strong enough to fight back.
Hochschild argues that Trump swindled the people…by tapping into their frustrations as Democratic urban areas became more prosperous. Their losses created “a sense of plausibility” that things … and finally, their pride — had been taken from them. The president’s rhetoric, she writes, tilted their “emotional needle from ‘loss’ to ‘stolen,’” and wove their indignation “into a master narrative.”
The election is in the rear-view mirror. Uncertainty with no idea when it will end is what we see through the windshield. In recent weeks I have said that Trump’s radical behavior has revealed to me that he is a “conservative in name only,” and simultaneously, to my surprise, I have realized that I have some “true conservative” attitudes and opinions. This week I discovered that I share some common ground with a classical conservative, Edmund Burke, a political philosopher of the seventeen hundreds that you might remember from college. My realization that I had some of Burke’s philosophical DNA came as I was reviewing a book by Charles Handy. You may remember from my December 20, 2024 post that Handy is a departed hero of mine. Handy wrote that Burke believed we owed something to past generations, to our generation, and to future generations. I asked ChatGPT to comment:
What did Edmund Burke say that we owed to the past, the present, and the future?
ChatGPT said:
Edmund Burke, in his reflections on society and government, articulated a vision of social and political order that emphasized a deep, intergenerational responsibility. He argued that society is a partnership not just among the living but also between “those who are living, those who are dead, and those who are to be born.”
Our Debt to the Past
Burke believed that we owe reverence and preservation to the past. He saw traditions, customs, and institutions as the accumulated wisdom of previous generations, which should not be discarded lightly. He was skeptical of radical change and emphasized the need to respect the historical foundations that shaped a stable society. This is evident in his opposition to the French Revolution, which he saw as recklessly overturning inherited wisdom in favor of abstract principles.
Our Responsibility to the Present
In the present, Burke advocated for stewardship and prudence. He believed that current generations have a duty to maintain and improve institutions while exercising careful judgment in governance and reform. Change, in his view, should be gradual and evolutionary, not abrupt or revolutionary. He valued practical wisdom over theoretical ideals, arguing that policies should be guided by experience rather than abstract ideology.
Our Duty to the Future
To the future, Burke insisted we owe protection and continuity. He saw society as a trust handed down through generations, and the present generation has a duty to pass it on intact, or even improved, for those yet to come. This means safeguarding institutions, moral values, and social order to ensure that future generations inherit a stable and functional society.
In sum, Burke’s philosophy emphasizes a moral and social contract across time, where each generation is a custodian rather than a mere occupant of society. His ideas continue to influence conservative and traditionalist thought, particularly regarding the role of history, gradual reform, and the dangers of radical upheaval.
Would you like a deeper exploration of how Burke’s ideas compare to modern political philosophy?
I did not accept that offer, but I didn’t see anything in President Trump’s first fifty days that echoed Burke’s concept of the responsibilities of conservatism. Thinking about Handy reminded me of how in my role as a board chair, and later as a CEO, I had been influenced by Handy’s discussion of two ideas which also could be presented as conservative concepts if one is thinking about what conservatism has stood for over in the past. So I asked:
Could you discuss the subjects of federalism and subsidiarity as presented by Charles Handy?
ChatGPT said:
Charles Handy, a well-known business thinker, discussed federalism and subsidiarity primarily in the context of organizational design and management. His ideas were influenced by broader political and economic concepts but were applied to how businesses and institutions should structure themselves for efficiency, autonomy, and empowerment.
Federalism in Handy’s Thought
Handy viewed federalism as a principle for organizing businesses and institutions in a way that balances central control with local autonomy. He borrowed from the political concept of federalism, where power is shared between a central authority and regional entities, to propose a model for organizations that allows different units to operate independently while being part of a larger system.
In his book The Age of Unreason, Handy argued that organizations should avoid excessive centralization and instead function as federations where:
- The central authority provides a unifying vision, values, and coordination.
- Individual business units or teams have the freedom to manage their own affairs within broad strategic guidelines.
- Power is distributed rather than concentrated at the top, fostering innovation and responsiveness.
This model contrasts with traditional hierarchical organizations, where decision-making is centralized and often rigid.
Subsidiarity in Handy’s Thought
The principle of subsidiarity, as applied by Handy, means that decisions should be made at the lowest possible level where competence exists. It emphasizes empowerment and decentralization, ensuring that responsibility is pushed down to the smallest, most local unit capable of handling it effectively.
Key aspects of subsidiarity in Handy’s approach include:
- Delegation of decision-making: Higher levels of management should not interfere with tasks that can be effectively handled at lower levels.
- Trust in employees and teams: People closest to the work should have the authority to make decisions about how it is done.
- Avoiding unnecessary bureaucracy: Organizations should not impose control from the top when local units are capable of self-management.
Application to Organizations
Handy’s concepts of federalism and subsidiarity align with modern management practices that promote agility, autonomy, and decentralized leadership. Many contemporary organizations, especially large multinational companies, operate using a federal structure where regional divisions have autonomy while adhering to shared corporate values and goals. Similarly, subsidiarity encourages employee empowerment, lean management, and customer-focused decision-making.
Broader Implications
Beyond business, Handy’s ideas also apply to governance, education, and nonprofit sectors. His work resonates with discussions on democratic governance, decentralization in government, and community-driven decision-making.
Handy’s Age of Unreason was published in 1989. Sometime in the early 90s, a colleague of mine who was a diligent student of business literature gave me a Harvard Business Review article by Handy which reviewed federalism and subsidiarity as he had discussed in the book. It was not long before I read the book because so much of what Handy said about federalism and subsidiarity directly applied to how I saw our organization. We became complex in the late 70s and early 80s as we opened multiple sites. Each site had its unique service area and demographics and needed some ability and different resources to address the local concerns of the populations they served. We became more complex in the mid-80s when HCHP expanded by forming affiliations with several suburban medical groups that were united as an IPA. In the early 90s, HCHP acquired Rhode Island Group Health Association (RIGHA), and in 1995 the complexity was further increased as Harvard Community Health Plan and Pilgrim Health Care merged to create Harvard Pilgrim Health Care. Each of these changes challenged the principles of federalism and subsidiarity.
As a leader in the Health Centers Division, the legacy of the original HCHP, I was constantly arguing for greater local independence even as I realized that certain functions like the automated medical record, quality initiatives, marketing, early DEI efforts (Yes there were diversity initiatives in the mid-nineties), some contracting, and government relations needed to be managed at the “federal” level. I was also aware of the constant natural efforts of corporate leaders ( the “suits”) to usurp what belonged locally. There was a constant tension that created a space for innovation between those who were centrally responsible for our business functions and financial survival and the clinicians in the local ”practices” who considered how care was delivered as their domain. In my mind, we have those same tensions now between Trump and his executive branch and the agencies of the government charged with critical responsibilities the importance of which the president doesn’t understand or care much about. Too much “centralization” feels authoritarian, and too much local freedom can undermine collective efficiencies. As CEO, I was constantly aware of and trying to manage this tension which was why I was attracted to Dr. Ebert’s pronunciation of 1965:
The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.
Robert Ebert, M.D., 1965
I knew that the optimal operating system would need to honor subsidiarity and that any system of healthcare finance would come up against the reality of federalism.
Memories of my past concerns about federalism and subsidiarity were fresh in my mind when I went to the post office on Wednesday. The latest copy of the New England Journal of Medicine was in my box along with this week’s New Yorker. As is my habit, I was reading the cover of the NEJM while standing in front of my mailbox. I was delighted when I saw a very interesting and timely article written by Marisha Burden, M.D., M.B.A., and Liselotte Dyrbye, M.D., M.H.P.E., entitled, Evidence-Based Work Design — Bridging the Divide. The title suggested to me that perhaps the issues of the “divide” touched on federalism and subsidiarity. As I read the article I realized that there were also observations that could apply to the radical disruption that we are experiencing in the thoughtless, bias-driven, self-interest-oriented destruction of federal agencies that are designed to give Trump and Musk a resistance-free pathway to greater control of our government, The first paragraph sets the stage:
U.S. health care is at a critical juncture. The shift of physician practices to employment models, coupled with the growing corporatization of health care, has contributed to organizational decision making that often prioritizes short-term financial gains at the expense of patient care. This environment runs counter to the values of health care workers (HCWs) and fuels widespread workforce problems, including high rates of HCW burnout and moral injury and erosion of safety culture, and has contributed to the impetus for recent HCW unionization efforts. Many of these challenges stem from modifiable work structures, processes, and environments that originate from organizational decisions and are therefore preventable.
“Administrative harm” — defined as adverse consequences of administrative decisions within health care that affect work structure, processes, and programs — is pervasive and often overlooked.
“Administrative harm” is a term that could be applied as appropriately to vulnerabilities experienced by healthcare professionals in a for-profit healthcare organization as to the plight of employees of our government in the Department of Education and in U.S.A.I.D. who are under attack from Elon Musk’s work with D.O.G.E.
I like the new acronym, HCW, at least new to me, that stands for healthcare workers. I also like that the article links HCW burnout and moral injury to the downstream impact of administrative harm. They continue:
Though the term is relatively new, the concept is not: research and analyses suggest that administrative harm has long contributed to the substantial challenges faced by HCWs as well as to problems with patient safety and the quality of care. Financial and productivity considerations frequently dominate decision making within health care, particularly when it comes to decisions about work design, including team structures, and resource allocation. This focus may be attributable both to a lack of evidence-based practices for optimizing work design and to organizations’ short-term financial imperatives, though it may actually cost them more in the long run. Financially driven decisions in this area contribute to a growing divide between frontline HCWs and organizational leaders, perpetuating mistrust and misalignment within organizations.
The authors suggest a “new approach” utilizing evidence-based practice to bridge the divide.
In clinical medicine, evidence-based practices inform decision making, as clinicians apply lessons from the best available research alongside their clinical expertise. But despite the direct effect of organizations’ administrative decisions on job demands and resources, as well as subsequent organizational outcomes — such as patient safety, health care quality, workforce retention and well-being, and operational and financial outcomes — there’s no equivalent evidence-based approach on the administrative front. Although heavy workloads are associated with worse patient outcomes as well as HCW burnout, there is no clear consensus on what constitutes an optimal workload.
The biggest divide in the old Harvard Community Health Plan, which cost one CEO his job, was the issue of “work expectations.” Practice structure and work expectations are more complicated now when the workforce shortages complicate deciding about the optimal structure of teams and which providers are best for what activities and what volume is reasonable to require from different medical professionals. I think “administrative harm” is active in the work of Musk and Trump as they try to blow up government agencies to empower Trump’s authoritarian ambitions.
Similarly, there’s no established optimal team structure to provide guidance in answering questions such as when to utilize a physician, an advanced practice clinician, or a team comprising both — questions that are becoming critical in the current health care environment. These knowledge gaps lead to challenging debates between financial and clinical leaders. Even more concerning is that decisions stemming from these discussions can inadvertently but directly contribute to harm, hence the urgent need for an evidence-based strategy…
These same tensions attracted me to approach the questions of organization design from a patient-centered, quality-oriented, clinician-preserving and empowering perspective. It was these issues of optimal clinical design and supporting finance that encouraged my attention to “best practices,” outcomes data, and management systems like Lean. The authors advocate approaching the problem like a scientific exploration free of biases that relate to finance. Musk and Trump are burdened by biases against government agencies and authoritarian aspirations that make it impossible to imagine improved function in government agencies as the outcome of their rampage.
To guide effective broadscale change, work design should build on the rigorous, adaptive methods from fields such as implementation science, systems science, quality improvement, and design thinking and incorporate insights from occupational health. Developing and implementing evidence-based work design approaches will require a multipronged strategy that acknowledges the complexity of the health care environment and the dynamic interconnections among HCWs, patients, administrators, culture, resources, policy, reimbursement, and finances.
To build momentum toward evidence-based work design, an innovative research agenda is needed. Much of the current relevant work involves observational studies, but though these have value, changing organizational behavior requires even more robust studies…
After expanding their ideas about what we should be doing now they look forward to the benefits and possible pitfalls that will be introduced by the integration of AI into practice.
Evidence-based work design will become even more critical as artificial intelligence (AI) tools become more pervasive in health care. These emerging technologies may help boost clinical efficiency by means of virtual scribes, assisted clinical decision making, and AI-generated or AI-facilitated documentation, but the benefits will come with trade-offs. Safety concerns and high implementation costs are significant challenges…understanding optimal implementation strategies and rigorously evaluating whether the technologies are driving the desired effect will be critical to ensuring sustainability as these tools are rapidly deployed across health systems.
Predictive analytics and machine-learning algorithms are poised to challenge the status quo of work design by enabling a shift from a simplistic, short-term focus on financial returns to a more proactive, data-driven approach to determining work structure and resource allocation.
They end with a hopeful outlook:
Evidence-based work design could be the solution that drives better organizational decision making, contributes to cultivating a thriving workforce and improving patient outcomes, and helps ensure long-term organizational success. Organizations that embrace this paradigm shift may truly achieve health care’s quadruple aim: to improve population health, enhance patients’ experience, reduce costs, and improve the work life of HCWs.
I like their reference to the “quadruple aim” which is an oft-suggested expansion of the triple aim to include the concerns of HCWs. I agree that an evidence-based approach to solving the problems of care delivery is the only way healthcare should seek to go forward. It would be nice if the administrators who control the system could see its wisdom. As unlikely as that possibility seems, it is much more likely than Musk and Trump recognizing that yes, the government’s functions should be improved, but it should be an evidence-driven process. We live in very challenging times.
It’s Sugaring Season!
Today’s header was lifted from the most recent video published by my neighbor, Peter Bloch. The ten-minute presentation is entitled “Maple Sugaring At Twin Lake Village.” There is a lot of information in that title. Over the years, the lake on which I live has had a few names based on its form which was created by the melting glaciers about 12,000 years ago. There is a large peninsula that is a combination of esker and drumlin that almost perfectly divides the lake into two lobes or halves.
I call our lake “Little Lake Sunapee .” “Big Lake Sunapee” is a half mile to the west. Some have called it Little Sunapee Lake. In the past, it was called “Spectacle Pond” since the two sides look like a pair of glasses if the peninsula is a nose. In the late 1800s, the lake was called “Twin Lakes.” That was when a large resort complex was built on the east side. Twin Lake Village is still in operation after at least 130 years of continuous operation. I often ask people how it came to be that they now live in New London. A frequent answer is, “My family came to Twin Lake Village when I was a child. I came to love the area during those vacations, so I retired here.”
If you watch the video you will learn a lot about how real maple syrup is made. You will also get a great picture of Twin Lake Village and the area. Perhaps, you might come some summer and enjoy the “village” and the maple syrup it produces.
In previous years, I have pointed out that the maple sugaring season depends on the transition between winter and spring. The sap rises when the nights are below freezing and the days warm up into the high thirties or forties. This season is off to a late start this year because until recently we were very cold both day and night. This week it was warm enough for me to take my first bike ride of the season. I rode right past Twin Lake Village going out and coming back.
We enjoy the sugaring season by going to the “sugar shack” of a couple who are close friends. They send out an email notice on the days when they “boil.” Guests are invited to come early to gather buckets of sap. I usually arrive late and find a comfortable place in a rocking chair near the fire and the pans for evaporation. The air is maple syrup flavored and there are plenty of goodies to eat and libations to enjoy.
If you get a chance to visit a sugar shack somewhere near you, don’t miss out. This weekend is “Maple Sugar Weekend in New Hampshire} and you are invited. Click here to learn more!
Be well,
Gene
