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Healthcare professionals are experts. Researchers, physicians, nurses, technologists, administrators and so many others succeed in improving the health and well-being, and frequently in saving the lives, of the people they serve to the extent that they bring expertise to their roles.
However, expertise does not function in isolation. It is part of complex economic and societal conditions that include public perceptions. These conditions and their relationship to expertise have evolved in important ways over the past 75 years. Understanding this evolution is critical to healthcare organizations’ continued ability to apply their expertise in a way that yields success both economically and in the mission of improving the health of communities.
Good news
Beginning in the post–World War II, post-industrial society, as the economy shifted from a focus on goods to a focus on services, intellectual expertise became a more valuable, and valued, part of society, giving rise to what has been popularly called the “knowledge economy.”
The organizations that provided services in post-industrialized society succeeded in large part by marshalling increasingly specialized forms of expertise. In his 1973 book The Coming of Post-Industrial Society, acclaimed sociologist Daniel Bell wrote, “If there is anything which…marks off the second half of the 20th century from the first half, it is the extension of the specialization of function from the economic to the intellectual realm.”
According to Bell, the importance of expertise to individual organizations and to society as a whole was intertwined. Bell wrote, “The husbanding of talent and the spread of educational and intellectual institutions will become a primary concern of the society; not only the best talents, but eventually the entire complex of prestige and status will be rooted in the intellectual and scientific communities.”
In the field of medicine and healthcare, the American people have benefitted greatly from this valuing of expertise, which has resulted in decades of elite advancements in medical treatments and scientific discoveries.
While the public has experienced the benefits of American healthcare expertise, so have healthcare organizations, including hospitals and health systems. Expertise is part of the value proposition of almost every provider organization in the country. For organizations perceived as having the highest levels of expertise, certain competitive advantages accrue, particularly when an organization is a destination for people experiencing the most challenging health conditions.
That is the good news about expertise. But, as is so often the case with good news, its opposite is not far behind.
Bad news
Coming hard on the heels of the emergence of expertise as a vital economic and societal force in the post-industrial society was a perhaps-inevitable backlash.
In his Pulitzer Prize–winning 1964 book Anti-Intellectualism in American Life, historian Richard Hofstadter wrote that anti-intellectualism was “older than our national identity,” but that “increasing prominence” escalated “the resentment from which the intellectual has suffered.” In the 1950s, Hofstadter wrote, “the term anti-intellectualism, only rarely heard before…took on the character of a national movement.”
This growing skepticism of intellectuals had subtle characteristics that are important to recognize, particularly in the context of Americans’ views about expertise in fields such as healthcare.
Hofstadter drew a distinction between the perception of intellectuals as experts versus intellectuals as ideologists. “[T]he intellectual as expert,” Hofstadter wrote, “must be accepted even when he is feared.” In other words, while intellectualism was questioned, expertise was still viewed as necessary because of the benefits it yields. On the other hand, Hofstadter wrote, “the intellectual as ideologist is an object of unqualified suspicion, resentment, and distrust…the ideologist is widely believed to have already destroyed a cherished American society.”
So, while an expert might have been called “the wild-eyed professor, the irresponsible brain truster, or the mad scientist,” as long as that expert did not assume “a profane role by mixing in public affairs,” he or she avoided the worst of public skepticism.
Until fairly recently, the experts that constitute America’s hospitals and health systems have not found this distinction between expert and ideologist too difficult to maintain. They have delivered the necessary, tangible and personal benefit of high-quality healthcare while not being perceived as doing so in service of any particular individual or organizational ideology.
A shift in perception
All that has changed in recent years.
Hofstadter wrote about the intrinsic tendency in our nation to elevate distrust into a kind of creed similar to class struggle in other societies. In recent years, that tendency has been weaponized by social media.
Certainly, social media, and the internet in general, has had some positive effects—connections within and among communities, rapid and broad dissemination of useful information. It has also had the effect of causing simmering suspicions to boil.
At the same time, for reasons too complex to go into here, an important shift took place in public perception of science generally and healthcare specifically. Whereas scientific and healthcare expertise at one time were not generally seen as being part of an ideology, now more people see these forms of expertise as part of an ideology that is threatening to American society. And, using the tools of social media, people holding this view have expressed it at increasing volume and to an increasingly receptive audience.
The growing momentum of this medicine-as-ideology view has brought this belief into the country’s government, resulting in actions including cancellation of grants to U.S. medical schools and hospitals, elimination of student loan programs affecting nearly half of medical students, termination or resignation of experts in disease prevention and control, and changes to vaccination policy.
Difficult decisions
Daniel Bell emphasized the relationship between expertise and economic benefit in post-industrial America. That relationship still exists, but in a very different form.
Whereas after World Wall II, expertise was something to be gathered, organized and mobilized by organizations seeking business success, today, expertise carries with it the potential for both business success and damage.
For healthcare organizations, the issue of expertise is more complex than for many other organizations.
For hospitals and health systems, consumer perception plays an important but only a partial role in economic well-being, while governments and insurance companies play an outsized role. Therefore, any decisions a healthcare organization makes about how it applies its expertise run a gauntlet of potential opposition from many quarters: from a public whose opinions on this issue are highly polarized and potentially situation-specific; from a government with the power to legislate and whose policies reflect its own changing opinions and ideologies; and from insurers focused on navigating the current divisive environment in a way that maximizes their margins.
Adding yet another layer of complexity, hospitals and health systems have mission considerations that may at times override economic considerations. In their policies and practices, hospitals cannot simply follow the path of economic least resistance by bowing to the latest opinions from their payers and other stakeholders. They have the duty of care, and as mission-based organizations, that duty always is the first concern in business and operational decisions.
Balancing what is best for patient care and community health with what is best for the organization’s economic health is a familiar challenge for hospital executives and boards. Today, performing that balancing act is more complex than ever, is more public than ever, is more emotionally charged than ever and has higher stakes than ever.
Navigating this new world of skepticism about expertise will require boards and C-suites to start not with the latest outcries, but with the deepest principles. What are the basic principles of the organization about its role in medicine, patient care and public health? How do those principles intersect with the most pressing controversies about health and healthcare in the public and governmental spheres? What are the potential consequences—economic, reputational, even legal—of organizational decisions that may follow principle but conflict with current perceptions? And most important, how will boards and C-suites actually make these decisions as the need arises?
Over the past 50 years, the advancements in healthcare have been nothing short of extraordinary. American cancer research into medical interventions, preventive measures and public education has fueled a 33% decrease in cancer deaths from 1991 to 2020. American research about risk factors, prevention and treatment of heart disease has helped bring about a 68% decrease in deaths from heart disease from 1969 to 2015.
Despite the extraordinary nature of these gains, the scientific opportunities going forward promise to be more remarkable than ever. Executing on those opportunities will require nothing less than the very highest level of expertise.
