Jonathan Swift
Jonathan Swift
Healthcare in the United States is in the midst of a massive wave of consolidation. For example, fifty years ago, virtually all non-academic, non-government U.S. physicians had an ownership interest in their practices. Today, approximately 70% of U.S. physicians are employed by hospitals or other corporate entities. Likewise, mergers and acquisitions have landed more than 70% of hospitals and 90% of hospital beds in multi-hospital health systems. As such, health care organizations have increased in size and their complexity has multiplied. For example, between 1975 and 2010, the number of U.S. physicians roughly doubled, but the number of healthcare administrators—employees of medical practices, hospitals, and health systems who do not directly care for patients—increased about thirty-six times. These sea changes have produced vigorous and ongoing debates over the effects of consolidation on quality and costs of care, but there are deeper issues at stake that cannot be adequately understood through healthcare statistics alone. Is consolidation, on balance, a good thing? What are its effects on patients and those who care for them? Where can we turn for a deeper understanding of the effects of changing size on healthcare organizations?

Jonathan Swift’s Gulliver’s Travels offers one of the most penetrating and sustained explorations of the idea that size really matters. Published in 1726 after Swift’s political ambitions had largely foundered, during a period in which he was serving in a kind of exile in the land of his birth as Dean of St. Patrick’s Cathedral in Dublin, the novel was inspired in part by the success of Daniel Defoe’s 1719 Robinson Crusoe. Both novels present tales of shipwreck and castaway but differ in other key respects. Defoe presents a largely hopeful account of the resilience, creativity, and dedication of a single person, suggesting that human beings can not only survive but also thrive in isolation. By contrast, Swift offers a portrait of a man who is always transformed by the social circumstances in which he finds himself, implying that human beings are largely defined by the society of which we are part. One of the most dramatic changes in social context Gulliver experiences during his voyages to strange lands concerns size—in the Land of Lilliput, the inhabitants are one-twelfth the height of Gulliver, while in the Land of Brobdingnag, Gulliver is one-twelfth the height of the natives.

Among the miniscule Lilliputians, Gulliver’s relatively immense size transforms his sense of his own identity. At first, he is seen as a great threat and shackled, and the inhabitants never completely get over their fear of him. Eventually convincing them that he intends them no injury, he is given the run of the land, on the condition that he avoid harming anyone. He soon becomes a favorite of the royals, although it is clear that he is prized above all for utilitarian reasons. The king persuades him to subdue a rival people, the Blefuscudians, by stealing their fleet. However, Gulliver refuses to make vassals of them, provoking royal displeasure. Soon thereafter, when he extinguishes a potentially disastrous conflagration by urinating on it, he is charged with treason. Convicted and sentenced to be blinded—a punishment that would largely deprive him of the ability to act independently yet preserve his immense potential as a power tool—he escapes the island. In a land of miniaturized human beings, where the king inspires awe because he is taller by the breadth of Gulliver’s fingernail than others in his court, otherwise ordinary Gulliver stands out as a Colossus.

In Brobdingnag, the tables are turned, and tiny Gulliver is regarded as little more than a curiosity. The farmer who finds him first gives him to his daughter as a pet, but then realizes that he can exhibit him for money. Soon sick of being shown as a freak, Gulliver is purchased by the queen of the land, who arranges for a special tiny house to be built for him. He is the butt of numerous indignities, including an attack by wasps and a near-death experience at the hands of a monkey who carries him to the rooftop. Just as in Lilliput Gulliver’s relative size meant that even the most trivial and routine aspects of his daily life, such as feeding and excretions, were transformed into matters of great moment, so among giants, everything about Gulliver seems trivial, mean, and subject to ridicule. How could such a small creature, the Brobdingnagians ask, possibly amount to anything worthy of more than trifling consideration? Such insults to Gulliver’s human dignity are compounded when he discusses history and politics with the king, who concludes that Europeans are “the most pernicious race of little odious vermin that nature ever suffered to crawl upon the surface of the earth.” In Swift’s account, seemingly defining human traits such as reason and virtue amount to very little indeed in the face of mere miniaturization and magnification.

In the spirit of Swift, consider the effect of size on health care organizations, from medical practices to multi-hospital health systems. On the one hand, increasing size can offer some readily apparent advantages. For example, larger organizations can take advantage of economies of scale in purchasing, marketing, and overheads. Medical supplies, equipment, and drugs often cost less per unit when purchased in large quantities. A larger organization can afford to mount larger and more sophisticated marketing campaigns, taking advantage of a wider range of media. Governance, documentation, billing, and information technology are among the overhead costs that may be relatively reduced as an organization grows. Moreover, larger organizations typically wield greater bargaining power, offer a greater variety of resources (such as different medical specialties and diagnostic and treatment options), exert greater influence in a healthcare market, and provide greater compensation to their executive staff, based at least in part on the rationale that they are overseeing a larger organization and therefore doing more work.

I do not think anyone would contest that we need some large healthcare organizations. A solo-practice physician cannot offer the same around-the-clock care as a group of physicians staffing different shifts. Likewise, a family physician cannot offer the same level of subspecialty expertise as a multi-specialty group practice that includes specialists in fields such as neurology, cardiology, and gastroenterology. Moreover, as a medical practice grows in size, it is able to reduce duplication and per-physician administrative costs such as record keeping, coding, and billing, a consideration that also applies to hospitals. A small hospital of a few dozen beds or less cannot afford to offer the same diagnostic and therapeutic equipment and services, including PET/MRI scanners, robotic surgery devices, and highly advanced service lines such as cutting-edge neurosurgery and cancer care, as can a hospital of hundreds of beds. Some also argue that larger healthcare organizations can also improve quality of care and reduce costs, although this is hotly debated. If bigger is not necessarily better, it does at least open up multiple opportunities for enhancement.

Yet there are also numerous downsides to consolidation, one of which is the inevitable rise of bureaucracy, or “the rule of desks.” In a small organization, everyone can know everyone else, and many decisions can be made on the basis of personal relationships, based on respect and trust. As organizations grow, not everyone can know everyone else, and decisions must be made on the basis of impersonal factors, such as job descriptions, organization charts, and policy and procedure manuals. In an industry such as manufacturing, this might not pose a problem, but medicine is founded on relationships between individual patients and physicians. As bureaucratization progresses, organizations such as medical practices and hospitals tend to become more and more rigid and less and less creative. People are hired, promoted, and fired less on the basis of the personal relationships they build than on whether they do what those above them on the organization chart expect. Everything must be done according to the chain of command, and if someone steps outside that chain, even though their idea is first rate, they are likely to be reprimanded.

“Just as Gulliver soon longs to be treated as a human being, so no physician wants to be treated as little more than a member of the class of internists, pediatricians, or surgeons.”

In Lilliput and Brobdingnag, the royals do not really care about Gulliver as a person. Instead, their interest in him is based on what he can be made to do—in the land of the small, to function as a weapon of war, and in the land of giants, as a sort of parlor trick. His functions are fixed according to the advantages of his relative size, and if he were the same size as the inhabitants, they might take no interest in him at all. Gulliver becomes nothing more than a member of a size-based class, and any other European would be treated in the same way, as a tool of war or amusement. It is no wonder that Gulliver does not wish to linger in either land, where genuine companionship is rendered essentially impossible. Just as Gulliver soon longs to be treated as a human being, so no physician wants to be treated as little more than a member of the class of internists, pediatricians, or surgeons. Every physician wants to be seen as making distinctive contributions, but a heavily bureaucratized organization finds it difficult or impossible to treat the occupants of the boxes on its organization chart as anything else. What matters most is not the initiative of physicians but whether they are obeying the rules and performing their jobs as prescribed.

Physicians in a small-group practice or a single hospital may function day to day by putting relationships first. They are likely to know their patients and colleagues as individual human beings, with distinctive personalities, life stories, and aptitudes and interests. Such relationships help to get things done, precisely because people know and trust one another. By contrast, as organizations grow, they begin functioning more and more like inhabitants of what sociologist Max Weber called an “iron cage.” To those working within it, the organization feels less and less like a network of personal relationships—a community—and more and more like a machine. What seems most real in a small organization is often people and interpersonal relationships, but what seems most real in a bureaucracy is the design and operation of the machine, in comparison to which personnel such as physicians are often made to feel like interchangeable cogs. For people whose professional identity is bound up with caring for individual human beings, this machine-like—even prison-like—environment can prove profoundly disheartening and even positively disabling. Gulliver quickly grows weary of being treated as a mere tool.

Of course, the pernicious effects of consolidation are not confined to physician practices or hospitals. They are also readily apparent in other industries, where just as growing hospitals and health systems can begin to think of themselves as businesses whose service line happens to be healthcare, so other industries can think of themselves in terms of little more than market share, profits, and market capitalization, gradually devoting less and less attention to the quality of the products and services they were originally founded to provide. In other words, money can become such an overarching consideration that some businesses will forsake quality, reputation, and trust in order to make more of it. As Plato wrote 2,500 years ago, when this happens, a physician ceases to be a physician, a craftsman ceases to be a craftsman, and a politician ceases to be a politician, as all three are transformed into little more than money makers. Such metamorphoses are especially common when finance seems to rule the economy, business school graduates are presumed to be ready to lead in any field, and companies are bought and sold, located and relocated, and staffed and downsized based strictly on financial considerations.

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It is just at this point, when our pride gets the better of us, that we are most vulnerable. Medical practices, hospitals, and health systems exist not to expand their markets, to boost their profits, or to fatten the wallets of their executives. They exist to care for patients, and even though remaining small may run counter to every instinct of the contemporary business school graduate, there are many things in healthcare that tend to be better done at a smaller scale. First and foremost is caring. Just as Gulliver can find no intimacy with the Lilliputians, and the Brobdingnagians can find no intimacy with him, so a large and necessarily bureaucratic healthcare organization cannot care for its employees or the people for whom its employees care. Why? Because it does not operate at their scale. It is simply too big to operate on personal relationships because it is too big to see individual human beings. And any organization that cannot operate on personal relationships, with a steady focus on individual human beings, cannot, by its very nature, foster the human excellences on which good medicine depends.

*Richard Gunderman is Chancellor’s Professor of Radiology, Pediatrics, Medical Education, Philosophy, Liberal Arts, Philanthropy, and Medical Humanities and Health Studies at Indiana University. He is also John A Campbell Professor of Radiology and in 2019-21 serves as Bicentennial Professor. He received his AB Summa Cum Laude from Wabash College; MD and PhD (Committee on Social Thought) with honors from the University of Chicago; and MPH from Indiana University.