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Chuck Anderson's avatar

I love these explainers, because it often "unlocks" other similar things I've seen to understand them in a new way.

For instance, I'm a nurse in the US and there is a similar hierarchy. As in finance, at some point the compensation and hierarchy becomes severed from the value or service it is trying to provide. I think about this all the time - if a doctor, for example, gives an order to draw blood or administer a medication but I am the one physically DOING it, why is the doctor paid so much more? And why does the CEO - who arguably actually does nothing? - make 1,000x that doctor? And the insurance exec 10x more than him? And why is the housekeeper, who is ABSOLUTELY ESSENTIAL for me to practice safely, paid 90% less?

It might be argued that it's for expertise, and yes - this is probably where it started, rewarding the longer years of study and effort - but this is no longer usually the case. Almost all medicine is algorithmic. A computer spits out a pathway or a plan based on given inputs. Those inputs come almost exclusively from nurses, techs, and medics. The nurse already knows what the doctor is going to order, and in fact changes or emphasizes different parts of her documentation to match what they know the doctor is looking for.

My theory is that Doctors (and CEOs) were actually paid this premium to accept responsibility for the outcomes under their care. They wouldn't always get it right, but the relationship was "small" enough that a patient could hear or accept that a doctor had attempted all they could, even if the outcome was poor. It would break it up into small enough units for meaningful accountability and meaningful process improvement. I think it was intended to be the same for CEOs and top finance guys - someone to blame if things go wrong, someone responsible for the training and actions of those working directly under them.

Now though, in healthcare as in finance, it all feels scrambled. Those higher up the chain have so much power that they are beyond accountability and can deflect the downside of their positions (responsibility) onto workers below them or "systems/protocols" above them. I often joke with my nursing students that we have to know every bit as much as the doctors do, and that we exist to be a moral crumple zone - to have our tiny mistakes or omissions in documentation magnified by huge teams of well paid lawyers so the doctor or CEO can avoid responsibility.

I don't know how to fix it, but yeah - it's a mess. Sorry I don't have more solutions to contribute, just more ways that this infects our interdependence and gets in the way of people doing the right thing.

Antje Lang's avatar

I went to one of these gala events for the first time a few weeks ago....it was very uncomfortable and I couldn't understand how everyone there didn't see it!! Thanks for the article

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