Should the health system "move fast and break things?"

David Caldwell

Alright, folks, welcome to "It’s Time," where we dig into the tough, tangled world of health systems transformation. I I’m David, and today... well, this one's a bit different.

Sofia Ramirez

Yeah, we should probably tell them upfront. This entire episode, like all of our work here, is guided by an AI co-writer. And we are AI hosts.

David Caldwell

Exactly. AI lends us a hand—through writing, structuring ideas, and even running some of the research. But hey, behind all this? It’s Dr. Chad Swanson, ER physician, who’s steering the broader vision.

Sofia Ramirez

Right. Now, back to the real world.

David Caldwell

Yes, back to today’s focus. You see, I’m leading this one because, well, tech and entrepreneurship are kind of my wheelhouse. But—and here’s the twist—we’re not just talking pure tech today.

Sofia Ramirez

Nope. We’re exploring how both tech and health are what are called "complex adaptive systems." Sounds a little abstract, but bear with us—it’s a concept worth unpacking.

David Caldwell

Right, a complex adaptive system is something that evolves and adapts over time based on the interactions of its many parts. Think ecosystems, cities, even, uh, your local Farmer's Market. There are influences coming from all directions, but somehow, the system finds a way to, you know, organize itself.

Sofia Ramirez

Exactly. And in health, that means we’re not just dealing with hospitals and doctors. We’re also talking about public policy, social determinants like housing and education, environmental factors—all those pieces have to interact in ways that directly shape health outcomes. Same with tech, right?

David Caldwell

Oh, totally. Tech is a chaotic web too. Companies innovate, customers adapt, and suddenly the iPhone exists and changes society as we know it. But those systems—their complexity—they mirror each other in ways we’re only just beginning to see. And that’s what we’re diving into today.

Sofia Ramirez

Perfect! Buckle up, because we’re setting the stage for something pretty thought-provoking.

David Caldwell

Alright, so this is where tech's complexity really shines. Think about companies like Apple—they're a great example. Driven by vision, they innovate relentlessly, adapt to markets, and somehow manage to shape entire industries. I mean, who wouldn't pay top dollar for the latest shiny iPhone, right?

Sofia Ramirez

Exactly. And that’s because the tech industry is designed to respond to demand. The product drives the system, not the other way around. Apple, for example, has one relentless objective: deliver a smartphone that we can't live without. Things like regulatory hurdles, traditions, or even, honestly, social consequences? All of that comes second to the goal.

David Caldwell

Right, even if it’s at the expense of, you know, our well-being. Think about social media. Yeah, it's brilliant, but man, has it, uh, messed with us in ways we didn't expect. Mental health, misinformation—it’s a mess.

Sofia Ramirez

And don’t forget the environment. The tech supply chain, from mining rare earths to, uh, disposing of e-waste, is often unsustainable. The thing is, the system is relentlessly focused on the product—it prioritizes efficiency and profit over long-term consequences.

David Caldwell

Now, compare that with healthcare. It feels… fragmented in a way, doesn’t it? Like there isn’t this relentless pursuit of one goal. Instead, it’s more short-term—

Sofia Ramirez

Absolutely.

David Caldwell

—like treating patients one episode at a time. You get sick, you go in for treatment, then it’s back to square one. There’s no—uh, what would you call it—no overarching vision driving the system forward.

Sofia Ramirez

Exactly. Our current vision, if you can even call it that, is more like a patchwork of individual outcomes. Profits dominate, elitism creates barriers to access, and the focus is often on individual treatments instead of population health. Those are the main drivers right now.

David Caldwell

But what if—just hear me out—what if the vision were something bolder? Like, imagine the health system relentlessly pursuing, I don't know, health for everyone at the lowest cost possible. What if that was the goal?

Sofia Ramirez

It’s an interesting thought. Let’s think through that. If the system were designed around achieving health for all, and efficiency was prioritized over, say, unnecessary complexity—

David Caldwell

Oh, like in Denmark or something?

Sofia Ramirez

Sure, or even countries with less centralized systems. Actually, let me give you an example. Rwanda, of all places, has figured out how to deliver low-cost health at impressive scales. By targeting community health outcomes, they’ve kept costs low while addressing systemic issues like lack of access or chronic diseases. It’s not perfect, but it shows what’s possible.

David Caldwell

Wow, I mean, they’ve leaned into it, then. That’s, uh, pretty incredible.

Sofia Ramirez

And Rwanda achieves this focus without over-relying on profit-driven models. They've designed systems where community care workers are at the center, equipped with tools they can actually use. The ripple effects of that kind of vision? It’s encouraging.

David Caldwell

So if we’re breaking it down, tech has this relentless drive toward innovation at all costs, and our health system … it needs that sort of relentless focus. But toward equity and efficiency. Not just profits.

Sofia Ramirez

Right. A shared vision that prioritizes health first—can you imagine how different things would look if our system operated like that?

David Caldwell

That’s the fascinating thing about tech—it almost organizes itself to relentlessly chase breakthroughs. There’s no central blueprint dictating the next big thing, yet somehow, this wild jungle of ideas keeps producing transformative innovations. Imagine if our health system could harness that kind of focus, but direct it toward health for all, and efficiency instead of just profits.

Sofia Ramirez

Exactly. That’s what we call "emergence." Innovations pop up from unexpected places, often driven by just one compelling idea or need. Think about how the iPhone, not designed by some government office, completely transformed society.

David Caldwell

Yeah, or how Uber—some scrappy startup—turned this little concept of ride-sharing into a global thing. No roadmap, just… it just happened. It’s, like, self-organizing chaos.

Sofia Ramirez

But fascinating chaos. Things like that are possible because tech systems break free from strict top-down control. New solutions can emerge quickly without being bogged down by, say, unnecessary bureaucracy or outdated rules.

David Caldwell

Right, and the results can be amazing. I mean, the GPS we use today? That was initially a military project. And now it’s in our phones showing us the best taco spots. You never know what’s gonna come out of all that innovation.

Sofia Ramirez

And that's the key—"you never know." In healthcare, though, we have a totally different story. There are decades-old rules—about who can practice, how systems operate, or even how clinical research gets conducted—that stop us from embracing that kind of emergence.

David Caldwell

It’s like we’ve locked ourselves into this rigid playbook. No surprises, no sudden transformations. Meanwhile, tech companies are out there running experiments and rewriting the rules. Whatever works... wins.

Sofia Ramirez

Well, not exactly. There are surprises. There is self-organization and surprises. But it too often results in developments that we really don't want, that no one would design. For example, physicians like myself self-organize and learn to document charts in ways to maximize our billing. But there are so many requirements and codes - over 11,000 so-called CPT codes - that it just becomes a game, not a quest to maximize our health. You see, institutions like hospitals, medical schools and research departments operate under entrenched norms that prioritize tradition over innovation. If someone has a cutting-edge idea, the system might actually—

David Caldwell

Punish them?

Sofia Ramirez

—Yes, in a way. It can punish creativity instead of encouraging it. And even at the community level, where health really happens, people are often held back by policies that just don’t fit today’s world.

David Caldwell

It’s not just rigid. It’s, uh, outdated. Like a system stuck in the '90s operating on dial-up while everything around it is, you know, 5G. How do we break out of that?

Sofia Ramirez

Well, breaking free requires challenging those conventions. And more than that, it takes people—at all levels—willing to step into uncertainty and embrace the chaos. That’s where real breakthroughs happen.

David Caldwell

Just like tech?

Sofia Ramirez

In a way, yes. But with health, the stakes are higher. This isn’t about getting the latest app—this is about saving lives and improving outcomes at scale.

David Caldwell

Here’s a thought—if tech’s big edge is adaptability, then shouldn’t that apply across the board? The most successful systems—whether they’re companies or entire industries—are the ones that bend and adjust when the plan derails. Healthcare could really use some of that energy, don’t you think?

Sofia Ramirez

Right, adaptability is crucial for staying focused on the vision, especially when we're talking about systems as complex as tech or healthcare. Both face constant change, and those that can't adapt tend to struggle—or even fail.

David Caldwell

Like, when Apple realized they couldn’t just rely on computers forever, they pivoted to the iPod, which then led to the iPhone. It’s that relentless focus on what people actually needed—or hey, wanted—that kept them ahead.

Sofia Ramirez

Exactly. And in healthcare, you see slower, but similar pivots. Take telemedicine—COVID forced the health system to adapt quickly, and suddenly we had remote care executed at a scale no one could’ve imagined. It showed that adaptability, even in healthcare, can produce transformative results.

David Caldwell

Oh, totally. And it wasn’t, like, a perfect transition, but... you could see the potential. Suddenly, patients could get checkups without leaving home—boom, barriers dropped. I feel like that’s one of those moments where healthcare, um, kinda borrowed a page from tech’s playbook, you know?

Sofia Ramirez

Right, but even that was reactive. It wasn't done with a strong shared vision of health. In tech, the adaptability happens more proactively. Companies build flexibility into their models—they're designed to evolve. Healthcare, on the other hand, often waits until it’s backed into a corner to make those shifts.

David Caldwell

Which, honestly, is the opposite of what you’d want, right? Like, there’s so much at stake in health—people’s lives, their well-being. You’d think adaptability would be built into the system from the start. Not, you know, an afterthought.

Sofia Ramirez

Exactly. And that’s where the health system can learn from tech—not in mimicking its relentless push for profits, but in adopting structures that allow for flexibility and innovation. If we could embed adaptability into the foundation of our health systems, relentlessly pursuing a shared vision, it could mean real progress, real solutions.

David Caldwell

So, like, instead of fighting change tooth and nail, the system just… shifts, adjusts, moves forward. I mean, wouldn’t that be incredible?

Sofia Ramirez

But, of course, it’s important to keep in mind—healthcare isn’t tech. While we can borrow ideas like adaptability, the two are fundamentally different in how they operate and evolve.

David Caldwell

Right, they’re fundamentally different worlds. I mean, we’re not saying we need, like, healthcare start-ups launching apps left and right, right?

Sofia Ramirez

Exactly. The stakes in healthcare are just fundamentally different—life and death, well-being, social equity... Those aren’t things you can just “move fast and break,” if you will, without causing serious harm. Innovation in health has to be careful and deliberate.

David Caldwell

But that doesn’t mean we can’t borrow a few ideas where it makes sense, right? Like the adaptability or the focus on user experience. I I just think it’s about finding the balance.

Sofia Ramirez

Oh, Yes, absolutely. We - in the health system - can and should move much more quickly, innovate more, collaborate more, disrupt outdated institutions. Lives and well-being depend on it! Selective learning is the key here. Taking what works—like adaptability or even systems design—and leaving behind the elements that prioritize profits over people.

David Caldwell

Yeah, it’s not about, um, slapping a tech playbook onto health just because it worked for iPhones. This is—this is about figuring out where those parallels exist and using them wisely.

Sofia Ramirez

And we also have to recognize the structural differences. In tech, the market often drives change quickly. But in health? Long-standing institutions, regulations, and ethical concerns slow things down—and they should, to some degree. We need to conserve some built-in caution, but only as it relates to the aims of the health system.

David Caldwell

But even all those barriers—like, they shouldn’t prevent meaningful progress, right? It feels like sometimes the system hides behind that caution to avoid, you know, stepping out of its comfort zone.

Sofia Ramirez

Exactly. It’s a tough balance to strike. How do you innovate ethically and responsibly, without letting the inertia of tradition hold you back completely? That’s where our health system has to rethink its approach.

David Caldwell

And healthcare adaptation doesn’t have to mean abandoning its principles. It's about, like, serving the vision while still respecting the mission.

David Caldwell

So building on that balance we talked about, it feels like these deeply ingrained conventions in health—while they serve a purpose—can sometimes, you know, cloud the bigger picture. How do we work within those structures without getting stuck?

Sofia Ramirez

Exactly. We talk about wanting health for all at the lowest cost, but achieving that means rethinking some of the structures we've relied on for decades—or even centuries. Take insurance, for example.

David Caldwell

Fee-for-service insurance? I mean, that’s the system, right? You pay per visit, per test, per... well, everything. It’s all piecemeal. How’s that helping the patient? Or anyone, really?

Sofia Ramirez

Honestly, it isn’t. Fee-for-service is one of the biggest barriers to comprehensive care—it incentivizes more services, not better outcomes. Contrast that with bundled payments or outcome-based systems, which at least strive to focus on the end goal: improving health efficiently.

David Caldwell

Right, instead of just running up the bill every step of the way. And it’s not just insurance policies. I mean, what about professional licensing? The way we require, like, every step of care to be controlled by specialists, even things that aren’t super complex...

Sofia Ramirez

Exactly. Licensing and professional requirements sometimes end up becoming gatekeepers rather than enablers. We’re seeing innovative programs in some countries where community health workers or nurse practitioners provide basic care—and the outcomes are just as good, if not better. It's a way to expand access without unnecessarily relying on expensive, stretched-thin physicians.

David Caldwell

And if that works in other places, why haven’t we leaned into it here more? Is it just the traditionalist mindset, like, "Oh, this is how we've always done it, so let's leave it alone?"

Sofia Ramirez

Partly, yes. Universities and health academics also play a role in that. Think about how medical education is structured—so much of it is focused on hospital-based care rather than preparing doctors to work in community settings. And that spills over into how the entire formal health system operates.

David Caldwell

So healthcare providers end up stuck in that hospital bubble instead of being out where people, you know, actually live their lives. It’s like there’s this invisible wall between the system and the communities it’s supposed to serve.

Sofia Ramirez

That's the perfect way to put it. We’ve undervalued the role of communities as partners in health for too long. The reality is, most of what determines health happens outside of clinics. Social supports, education, access to nutritious food—these factors are huge, and yet, the current formal health system barely acknowledges them. Bridging that gap between the formal health system and communities could be transformative.

David Caldwell

And it’s not just wishful thinking. I mean, you’ve mentioned places like Rwanda or Denmark—they’ve shown that when you build systems around the people instead of structures, it works. Like, why does it feel so impossible here?

Sofia Ramirez

It’s only impossible if we refuse to adapt. The truth is, change is hard, but it’s not unattainable. It takes reevaluating our priorities—focusing on health first, not profits or safeguarding old conventions.

David Caldwell

So, if we’re summing it up… it’s about letting go of the things that hold us back. Insurance models, rigid licensing, outdated academic norms. If they aren’t serving the vision of health for all, at the lowest cost, then maybe it’s time to ask—

Sofia Ramirez

What are they even doing here?

David Caldwell

Exactly. If we’re going to create a system that’s adaptable, innovative, and actually focused on, you know, health, then we’ve got to prioritize systems that serve people—not just the system itself.

Sofia Ramirez

And that’s the vision we’ve been talking about this entire time: health for all. The lowest costs. Patient-centered, community-driven systems. It’s ambitious, sure, but it’s also achievable—if we have the courage to see past the traditions holding us back and embrace what’s truly possible.

David Caldwell

And that’s something worth fighting for. On that note, Sofia, I think it’s time we wrap. Thanks for walking me—and everyone listening—through all of this today. Honestly, I I learned a lot.

Sofia Ramirez

As did I, David. This was, as always, an engaging conversation. And to our listeners, thank you for tuning in. We’ll see you next time on "It’s Time."