The effects of structures on decision-making policies in health care.

BACKGROUND There is plenty of evidence in the literature indicating how difficult it is to recognize, question and eventually change our current mental models of the structures and decision-making processes in health care. The citizens of western countries are offered more health care services than ever and report themselves to be somatically healthier than ever. Paradoxically, many health care systems claim to be in a state of crisis, for which the cure is believed to more services and more money. Growth is a major feature of modern medicine and most people assume that more medical care must lead to improved health and wellbeing. However, adding more resources and more health care may also have counterintuitive effects. OBJECTIVE This perspective describes common phenomena seen in our health care structures and searches for reports and results that may challenge some of the 'self-evident' solutions to these problems. RESULTS AND DISCUSSION Most organizations and systems learn poorly and it is difficult to recognize how we contribute to our own problems and crisis. Even if the evidence has been apparent for decades, it may simply be ignored or rejected when it is inconsistent with the underlying beliefs. Learning seems to be associated more with attitudes and mental models than with evidence. As we are part of the health care structure, we share responsibility for problems generated by the system. It is time for health care professionals to study and question the efficacy of our current paradigms and practices.