It's the System, Stupid
For the record, this phrase is a variation of James Carville's famous quote during the Clinton campaign, "It's the economy, stupid," which highlighted how voters' financial well-being determines elections. It's a call to recognize when we're focusing on peripheral issues while ignoring the elephant in the room.
I'm appropriating this phrase for healthcare because over my four decades in medicine and health services research, I've watched countless solutions target our dysfunctional healthcare system while avoiding the most obvious issue: the system itself. And by "system," I don't mean individual components like primary care practices or emergency rooms—I mean the entire interconnected structure. The whole ball of wax is the elephant in the room.
Several "movements" in Health Services Research have emerged to address healthcare's recognized problems of high cost, variable quality, limited access, and growing dissatisfaction among patients and staff:
The Outcomes Measurement movement (treating healthcare as an organism lacking a nervous system)
Total Quality Management movement (eliminating waste in specific care processes)
Evidence-based Medicine movement (only performing and paying for scientifically supported activities)
Population Health movement (addressing upstream prevention rather than downstream illness)
Shared Decision Making movement (engaging patients and families in informed choices)
Real-world Evidence movement (using electronic data and quasi-experimental designs to determine risk, efficacy, and cost)
Implementation Science movement (identifying solutions through mixed methods while deeply engaging patients)
Each approach legitimately identifies both a problem and a solution. But none—except perhaps Implementation Science—addresses the system holistically or tackles healthcare's emergent complexity. By "emergent complexity," I mean more than just having numerous parts (like an airplane) or uncountable components (like Earth's atmosphere). I'm referring to dynamic complexity where relationships constantly change, creating feedback loops and time delays that produce unintended outcomes. Each movement speaks to a truth, but each remains incomplete and has achieved limited success in addressing fundamental dysfunction.
One could blame this lack of success—evident in how these movements rise and fall in scientific and popular literature—on meager funding for health services research, which represents a tiny fraction of healthcare expenditures. Some might argue that with adequate resources, movements like outcomes research could have significantly improved cost, quality, and satisfaction.
I propose that while all these movements matter, they must be considered within the context of the system's full complexity—including payment structures, capacity, demand, information flows, epidemiology, and governance. We need a system change approach that goes beyond sentiment and matches the challenge. Specifically, we need an approach that engages stakeholders in healthcare processes and outcomes, operates from a shared causal framework to target promising leverage points, and enables decisions that stakeholders can truly own and advocate for, even if not perfectly optimal.
"Systems thinking" must be more than just an idea—it requires coherent methodology. Several approaches offer suitable foundations for complex systems improvement, including Theory of Constraints, Viable Systems Modeling, and System Dynamics. However, implementing these methods effectively requires overcoming significant hurdles: we need skilled practitioners who can engage diverse stakeholders, bridge content and methods, commit sufficient time and energy, and secure supportive leadership and resources.
Translating systems thinking from concept to measurable, sustainable change isn't easy. Currently, only a handful of people can support major initiatives in large health systems. This bottleneck must be addressed if we hope to avoid the "sizzle and fizzle" cycle that has characterized health services research history.
Let's not be stupid.
