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Saturday, October 5, 2013

Knights, Knaves, and Pawns

I recently became aware of a series of articles published first in the social science literature (Knights,knaves or Pawns) and then adapted to the health care delivery realm (Are docs KKP?) which come under the rubric of people being noble (knights), essentially not to be trusted (knaves), or simply a function of their environments (pawns). There is both simplicity and power with this particular worldview because these labels line up with our personal perceptions relating to those around us. In our personal dealings, we quickly become aware that there are those who we can trust (knights), those who we will never trust (knaves) and those who we might trust in a certain contexts (pawns). In realms where know those who we deal with, we can use our judgement as to who we assign to specific categories. Unfortunately, many of our dealings are with individuals who we do not have sufficient information to judge. When this happens in the private realm, individuals have the latitude to make a broad range of  decisions, some of them good, many of them bad.

In his 1995 article in the Journal of Social Policy,  LeGrand addressed addressed issues that are important broadly for understanding the implications of social policy, especially the modern welfare state.
"To what extent are they a response to the perceived failures in the old systems? If they are a response to these failures, are they a good response? .....More specifically, I argue that both the quasi-market and legal changes in welfare systems are based on a particular view of human motivation and behaviour, and that this view is rather different from the assumptions concerning motivation that underlay older models of welfare systems. However, neither this ‘new’ view nor the ‘older’ assumptions are likely to provide an adequate account of the way in which people actually behave in welfare-relevant situations; hence welfare systems based solely on one or the other are likely to fail. What is needed are ‘robust’ welfare policies: ones that allow for the possibility of different kinds of human motivation and hence have the potential for more successful outcomes. This is a broad canvas. Inevitably in places the argument is speculative; equally inevitably it will involve both the caricaturing of distinguished thinkers’ arguments and the over-simplification of a complex reality."
This is politics in a nutshell. In order to gain political power to accomplish any goal, successful players must simplify, simplify, and simplify further. The cost of simplification is the loss of reflection, polarization, and a winner take all environment. This is unfortunate since understanding human nature is essential when defining social policy and there is nothing simple about human nature. Whether a particular social program meets its goals is completely dependent upon how people respond to the changing incentive structures and whether they act like knaves or knights will evolve over time as the norms of the population are changed by the changing social programs.

In the private realm, individuals and groups that make bad assessments regarding whether they are dealing with knights or knaves tend to do poorly over the long term. The rest of us can perhaps learn from their mistakes. In the public realm, politics pushes us toward "all in", one size fits all policies, driven often by slim political majorities. The time frames to assess success or failure often is beyond the ability of players to make key linkages. Success in the political realm may be defined by growth of programs and concentration of money and power. It rapidly gets very hard to figure out who are the knights and knaves.

LeGrand's work was applied to the medical realm, describing the evolving perspective of physicians (Are docs KKP).
"Le Grand’s work on post–World War II British social policy found that perceptions of human motivations gradually transformed, with the prevailing view of the typical British citizen morphing from knight into knave as the costs of maintaining an expensive welfare state increased. US perspectives on physicians have undergone a similar transformation with the increasing cost (both to taxpayers and to individual patients) of health care delivery. As physician behavior has been tied to these rising costs and increasing scrutiny has been applied to the quality of care delivered, policy discourse often reflects the perspective that physicians are an obstacle not an enabler to a functioning health care system. Rather than being counted on to exercise their professional ethic to address problems in health care delivery, physicians should be guided to do what is right with an increasing menu of incentive payments (ie, pay for performance or value-based purchasing) or strict regulations. Rather than being counted on to maintain their knowledge and expertise on their own accord, they are subject to periodic examinations to demonstrate continued proficiency. "
 We now appear to be in a world where physicians are no longer perceived to behave like knights. Some of this altered perception may be justified by less than honorable behavior of of knave like elements within the physician population. I would also venture that certain social programs implemented over the past 60 years have served to undermine physician professionalism, spawning gaming behavior in initially the few and more broadly over time.

We are not alone in being in a position of lost trust. What I find odd is when specific professionals lose the public trust, the response tends to be to recreate powerful regulatory structures within the realm of politics. What makes us believe that those who gravitate toward political  institutions are any more knightly or accountable? Can the problems associated with the complexities of human behavior by fixed best with political tools? I doubt it.

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