In 1974, a remarkable man sent a remarkable letter to his political leadership. He included frank and incisive criticisms of the current state of affairs of the great country of which he was a citizen.
People asked him – what is the use of one man speaking up to a massive, continent-spanning superpower?
This brilliant author, Alexander Solzhenitsyn, a Nobel Prize winner in Literature, passed away just ten years ago this August. The country which he criticized, the Soviet Union, vanished nearly three decades before his death. Such is the power and the proof of being right.
From his perspective, many of the ghastly forces dragging down his beloved Russia had come from European Communism and the West. He referred to them as such.
Here, in the West, we can see more clearly how they fit into the taxonomy of bad ideas and can name them. Much of what he sees in burdensome in the USSR comes under what we know as Scientific Management and Taylorism; and the irrepressible urge to modernize everything by increasing its scale, centralizing its administration, and pursuing standards which have the effect of exalting mediocrity. This is a common curse and a detriment in many areas, but in none so imminent in the “healthcare industry” in America
What follows is a sampling from Aleksandr Solzhenitsyn, Letter to the Soviet Leaders. 1974. IT can be read online in its original form at https://soviethistory.msu.edu/1973-2/the-dissident-movement/the-dissident-movement-texts/conservative-dissent/
In my reading the letter, I see it speaking not only to the Soviet leadership of 1974, but the leaders of “reform” in American Medicine who have stagnated its excellence and constrained its progress. Those who would unify everything under Best Practices, would effect the same miseries on medicine that the Soviet leadership effected upon the work and lives of its citizens. Please understand that this is not a reprint of his work, but an abstraction of his ideas through phrases, ideas that are helpful to understanding the very frustrating time of American medicine today in 2018. Ellipsis and rewording are not marked. To see the inspirational document by Solzhenitsyn, please see the wonderful letter put online by Michigan State University.
The murky whirlwind of progressive ideology has swept in on us over the last few decades, and has tormented and ravaged our souls quite enough …
And all this has so “suddenly” come tumbling out into American medicine. A new crisis! But in every instant for the last twenty years, the crisis of the moment. How fond our medical leadership were in ridiculing those retrogrades: physicians who called upon us to cherish, appreciate and have pity on our past, who called upon us to save the old days of the small local clinics and solo practitioners, not to abandon clinics for enormous hospital-factories and massive warehouse clinics, not to crowd care into cities, not to clamber on top of one another in multistory medical delivery anthills. How they laughed, how they tormented those reactionaries! They hounded the men who said that it was perfectly feasible for a colossus like America, with all its many local habits, peculiarities and folk traditions, each to find its own particular path; and that it could not be that the entirety of the country should follow a single, homogenized, absolutely identical pattern of care, one-size-fits-all.
No, we had to be dragged along the path of bigger-is-better, new-is-worthy, embrace of the Corporate Retail machine gods in medicine toward the close of the twentieth century Any village graybeard in America had understood from time immemorial and could have explained to the progressive commentators ages ago, had the reformers and MBA’s and commentators ever found the time in that dizzy fever of theirs to consult him: that a dozen worms can’t go on and on gnawing the same apple forever, that if the earth is a finite object, then its expanses and resources are finite also, and the endless, infinite progress dinned into our heads by the dreamers of the Brave New Medical World cannot be accomplished on it. No, we had to shuffle on and on behind other people, without knowing what lay ahead of us. Pretty soon, we’ll hear the scouts calling to one another: We’ve blundered into a blind alley, we’ll have to turn back. All that “endless progress” turned out to be an insane, ill-considered, furious dash into a blind alley. A civilization greedy for “perpetual progress” in the “healthcare industry” has now choked and is on its last legs.
But what about us? Us, with our unwieldiness and our inertia, with our flinching and inability to change even a single letter, a single syllable, of this idea that “bigger is better” and “the MBA’s will show us the way?” Economically and physically we are perfectly capable of saving ourselves. But there is a roadblock on the path to our salvation-the sole progressive world view. if we renounce industrial development, who is going to enforce, create, organize the police the work of American Medicine? What, leave it all to the patient and doctor themselves? My God – who will keep them from practicing medicine just the way they feel like?
But you chiefs are already being called “revisionists” anyway, whatever you may do in the future. So wouldn’t it be better for you university leadership of the medical industry and the medical societies and boards to do your duty soberly, responsibly and firmly, and give up the dead letter for the sake of a living people who are utterly dependent on your power and your decisions? And you must do it without delay. Why dawdle if we shall have to snap out of it sometime anyway? Why repeat what others have done and loop the agonizing loop right to the end, when we are not too far into it to turn back? If the man at the head of the column cries, “I have lost my way,” do we absolutely have to plow right on to the spot where he realized his mistake and only there -turn back? Why not turn and start on the right course from wherever we happen to be?
As it is, we have followed the myth of technology too long and too faithfully. Medicine is – and has always been – one and the same with advancement and innovation. We doctors are no charlatans practicing a dubious superstition. But now, our myth of technology is perverted. It means the dominance of the “medical industry leadership”, which has supposed to have been so “original” in calling down various monstrous doctrines-on the clinician, on the local practitioner-so why, then, have we been so dolefully unoriginal in understanding the advancement of the business of medicine, and why have we so unthinkingly, so blindly, copied the methods of Corporate Retail business?
One might have thought that, with the burgeoning central planning of which we are so proud in every aspect of civilization, we of all people had the chance not to spoil the country’s natural beauty, not to create antihuman, multimillion concentrations of people.
We have squandered our resources foolishly, not only in medicine but in many other areas without so much as a backward glance, sapped our soil, contaminated belts of wasteland around our industrial centers-but for the moment, at least, far more still remains untainted by us, which we haven’t had time to touch. So let us come to our senses in time, let us change our course! This great principle of sustainability has particular meaning in the process of the practice of medicine.
This Ideology that fell to us by inheritance is not only decrepit and hopelessly antiquated now. Francis Peabody had roundly damned it in JAMA in 1927; even during its best decades it was totally mistaken in its predictions and view of the future and was never a matter of the “scientific progress of medicine.”
The Taylorist principles of running business like a factory floor is over 150 years old now, nearly as ancient as the sad old intellectual failure of the 19thcentury, Marxism. There are scarcely any true advocates of Marxism after a century and a half of failure. And Taylorism has been inflicted, again and again, in American medicine, only to be beaten back – also after a century and a half of failure.
What keeps the corporate/industrial/academic authoritarian model still breathing? Only the cupidity of some, the blindness of others and a craving for faith on the part of still others can serve to explain this grim jest of the twentieth century: how can such a discredited and bankrupt doctrine still have so many followers in healthcare! We who have had a taste of it are only pretending to respect it. We loathe it, we dread it.
People say, yes, but the old medicine was authoritative around the person or role of the doctor. However, in those days an important condition was fulfilled: that doctor in authority was constantly required to possess a strong moral foundation. But as the business and retail model crept in, once this moral principle was perverted and weakened, the authority of the physician, despite the apparent external successes of the medical industry, gradually went into a decline and eventually perished.
As fidelity to truth disappears, and propaganda takes its place, trust evaporates. Decisions are made from persuasion and coercion, not from character and decency.
It is not leadership itself that is intolerable, but the ideological lies that are daily foisted upon us. Not so much oversight as arbitrariness and illegality, the sheer illegality of having a cluster of overlords in each political or insurance or quality or other hive; each province and each sphere, often ignorant and brutal, whose will alone decides all things. Issuance of a valid order should not mean that objective rules are unnecessary or that they exist only on paper, or that they should not reflect the notions and will of the population.
What have you to fear? Is the idea really so terrible? Are you really so unsure of yourselves? You will still have power, a separate, strong and exclusive guiding and regulating ability-but let the physicians and patients breathe, let them think and develop! If you belong to the people heart and soul, there can be nothing to hold you back!
After all, does the human heart not still feel the need to atone for the past?