Who's Lookin' Out for the System?

Sofia Ramirez

Welcome back, everyone. If you're new here, or catching up, this podcast dives into the transformational changes needed to fix—well, frankly, our entire health system. Last two episodes we considered the importance of a shared vision, a vision of health for all that the lowest cost.

David Caldwell

Yeah. And I just want to take a second upfront to remind everyone that we’re an AI-hosted podcast. We’re here thanks to Dr. Chad Swanson—he’s, well, the mastermind behind this all. Chad’s an emergency room doctor, and he started this project because he wanted to fill in the gaps—stuff he wishes he’d known during training or early in his career. Kind of his way of—of giving back, right? Like sharing all the insights that could help educate folks at every level.

Sofia Ramirez

Exactly. And for anyone wondering, part of his vision, honestly, is for this to be a hub—a place to connect, to learn, and to help propel the changes we so desperately need. We're not just discussing ideas; we're building toward that critical mass—or tipping point, you could say—that’ll drive real systemic transformation.

David Caldwell

Here's the thing. I know sometimes we, uh, might sound a little harsh—or even negative—on the system, right? But Sofia, I mean, how often do we talk about this?

Sofia Ramirez

All the time. And I want to be crystal clear about this from the start. We’re critical of the system, absolutely. But the people working inside it?

David Caldwell

Yeah. Some of the smartest, most compassionate people I've ever met.

Sofia Ramirez

Exactly. The doctors, nurses, educators, administrators—everyone, really—they're doing the work, day in and day out, within a system they never asked for, but, unfortunately, inherited.

David Caldwell

Totally. And that's why we want to dig deep into how this system functions—and how we can make it better, together. So, let’s jump into where we’re going today.

David Caldwell

Alright, so as we dig into how this system works, Sofia, you’ve been pointing out how the different players within the health system often have their own agendas. Can you break that down a little? Like, who’s advocating for what and where do those priorities overlap—or clash?

Sofia Ramirez

Sure. Let’s start with, say, pediatricians. Their focus is often on the sick child sitting in front of them. They’re managing a million things—patients, treatment plans, parents, insurance complexities—all while trying to run a busy practice.

David Caldwell

Right, like, they’re stuck in this hyper-focused, day-to-day grind.

Sofia Ramirez

Exactly. Now think about hospital administrators. They’re worried about the bottom line—making sure the hospital can pay its bills, stay open, and attract patients who—let’s be honest—can pay.

David Caldwell

Yikes. That’s, uh, a little depressing, isn’t it?

Sofia Ramirez

It is. But it’s the reality. Then there are politicians, who are often more focused on getting reelected than making the deep, systemic changes we need. They’re thinking in election cycles, not decades.

David Caldwell

So, short-term fixes instead of real solutions?

Sofia Ramirez

Unfortunately, yeah. And public health managers—good intentions, for sure—but they’re under constant pressure to implement the latest projects or chase funding, often without enough time to evaluate what actually works.

David Caldwell

Okay, but what about surgeons? They seem kind of like rock stars in this system, right?

Sofia Ramirez

Good question. Surgeons tend to focus on episodes of care. The more patients they see, the more they operate, and, well, the more they’re reimbursed. Volume often drives their incentives.

David Caldwell

And then there’s, like, the food and pharmaceutical industries. I’m guessing their priorities aren’t... altruistic?

Sofia Ramirez

Not usually. For the food industry, it’s about profits. And for pharmaceuticals, yes, research and development matter, but patents often outweigh public health needs. They invest in drugs that make money, not necessarily the ones that save the most lives.

David Caldwell

Okay... so with all these players doing their own thing, who’s actually looking out for the big picture? The system itself?

Sofia Ramirez

That’s the question, isn’t it?

David Caldwell

So, Sofia, when we talk about the big picture, like you mentioned earlier, how does systems thinking come into play? I mean, how is it different from just tackling problems one by one?

Sofia Ramirez

That’s a great starting point. Think of it this way: for years, especially in the late 1800s and 1900s, we looked at healthcare through this very mechanistic lens—almost like it was a machine. Every part had its role, and if one part broke, you just repaired it and moved on.

David Caldwell

Yeah, like patching a flat tire or replacing a broken gear.

Sofia Ramirez

Exactly. But our health system isn’t a machine. It’s more like what we’d call a complex adaptive system. It’s made up of people, organizations, and policies, all interacting in ways that are constantly changing based on political shifts, epidemics, even innovation in technology or policy. It’s messy. And dynamic.

David Caldwell

Kind of like human beings, right? Messy and unpredictable. Got it.

Sofia Ramirez

Right. And this is where systems thinking comes in. It’s more than just a theory—it’s a way of understanding and approaching these massive, interconnected challenges. It focuses on the relationships, on the feedback loops that drive how things change over time. This is a big deal. This has even been called the "Century of the System."

David Caldwell

Wait, wait—feedback loops? You gotta explain that one for me.

Sofia Ramirez

Okay, so think about when COVID hit. Hospitals were overwhelmed, resources were scarce, and policies had to adapt—sometimes daily. That’s an example of what systems thinking calls a feedback loop. The pressure from one part of the system forces changes in another, which then feeds back into the original issue.

David Caldwell

Oh, like when hospitals ran out of beds, and then governments scrambled to build temporary ones—and that created more need for staff that didn’t exist?

Sofia Ramirez

Precisely. And there are two kinds of feedback loops: reinforcing, which amplify changes, and balancing, which stabilize things. Both exist in constant tension within the system.

David Caldwell

Okay, so these loops are like the push and pull forces keeping the whole thing from either flying apart or stagnating?

Sofia Ramirez

Exactly. Another key idea is that within these systems, interventions have ripple effects. A change in one part might lead to unexpected outcomes elsewhere, often for better or worse.

David Caldwell

So, it’s like that old saying—what is it? The flap of a butterfly’s wings in Brazil causes a hurricane in Texas?

Sofia Ramirez

That’s the idea, but on a healthcare scale. We have to think holistically. Problems like access or health disparities can’t just be ‘fixed’ in isolation. The entire system adapts—often in unpredictable ways.

David Caldwell

Whoa, so there are no easy fixes, huh?

David Caldwell

Alright, Sofia, we’ve been unpacking systems thinking and its importance in healthcare, but let me ask you this—how does it all tie into this bold concept you mentioned earlier, "The Century of the System"? Where does that idea come from?

Sofia Ramirez

It’s from Atul Gawande’s 2014 Reith Lectures. He introduced this idea that the 20th century was defined by the development of medicine—think vaccines, antibiotics, surgical advances—the big breakthroughs. But now, in the 21st century, he argues the focus has shifted. It’s no longer just about the individual advances; it’s about how the system as a whole delivers care.

David Caldwell

So, we’re... less about making shiny new tools and more about figuring out how to use them together?

Sofia Ramirez

Exactly. Gawande calls it the “Century of the System” because, well, even the best tools—robotic surgeries, advanced drugs—they mean nothing if you don’t have a functional system to deliver them to everyone who needs them.

David Caldwell

Okay, but like, isn’t that what the healthcare system is already doing? Delivering care?

Sofia Ramirez

In theory, yes. But in practice, not quite. Take something as simple as handwashing in hospitals. Decades after we’ve known it prevents infection, compliance rates are still far from perfect. The problem isn’t knowledge; it’s systems that don’t prioritize or support consistent practice.

David Caldwell

Wait—something as basic as washing your hands still isn’t locked down?

Sofia Ramirez

Right, and that’s exactly the point. The issue isn’t individual failure; it’s the system. If you don’t have policies, reminders, or even enough soap dispensers in place, you’re not setting people up for success.

David Caldwell

Okay, that kind of sounds like a workplace problem. Like if everyone’s running around but no one’s managing the workflow.

Sofia Ramirez

It’s similar. A well-designed system creates environments where good outcomes are the default. Think checklists in surgery, for instance—that wasn't standard until relatively recently, yet it cut complications dramatically. That’s systems thinking in action.

David Caldwell

And this works because it changes the process, not just the people?

Sofia Ramirez

Exactly. It’s not about blaming individuals—doctors, nurses—it’s about creating an ecosystem where delivering high-quality, reliable care isn’t a struggle. The system makes it easier to do the right thing.

David Caldwell

Okay, but how do you even start redesigning something this massive?

Sofia Ramirez

That’s the billion-dollar question. Gawande suggests learning from other industries—aviation, manufacturing—where systems thinking has become the norm. They focus on standardization, coordination, and constant feedback to improve outcomes.

David Caldwell

And in healthcare, we’re not there yet because we’re still, what, working in silos?

Sofia Ramirez

Exactly. Breaking down those silos is crucial. But we also have to understand the system’s complexity—how every change in one part creates ripple effects throughout the whole network. And it's not just the healthcare system. This is a whole-society challenge.

David Caldwell

And that, I’m guessing, brings us to complex adaptive systems?

David Caldwell

Sofia, you mentioned complex adaptive systems just as we wrapped up earlier, and I’ve been thinking—it sounds pretty abstract. What does that actually look like in healthcare, on a day-to-day basis?

Sofia Ramirez

Fair point. So, think about healthcare as this living, breathing entity. You’ve got patients, hospitals, insurance companies, policymakers—all interacting in ways we sometimes can’t predict. A complex adaptive system is, well, complex because it’s made up of all these interconnected parts that adapt based on the circumstances.

David Caldwell

So, like one of those massive ant colonies you see in nature documentaries? Everyone’s doing their own thing, but together, it... works? Or doesn’t?

Sofia Ramirez

Exactly. And here’s why it matters. In a traditional healthcare setup, we’ve been super focused on individual fixes. A clinic runs out of vaccines? Ship more. A hospital’s too busy? Expand it. But with a complex adaptive systems lens, we stop just reacting and start asking bigger questions. Like, why do certain clinics always run out of supplies? Or, why are hospitals consistently overwhelmed during flu season?

David Caldwell

Ah, so instead of plugging leaks in the pipe, you’re asking, why does the pipe keep breaking in the first place?

Sofia Ramirez

Exactly. And one practical example is how we handle something like hospital readmissions. Traditionally, the solution has been to focus on improving hospital discharge processes. But if we view it through a systems lens, we realize it’s also about what happens after a patient leaves. Do they have access to follow-up care? Stable housing? Healthy food?

David Caldwell

Oh, wow. So, it’s not just about the hospital—it’s about the entire ecosystem around the patient?

Sofia Ramirez

Right. And that’s where things get even more interesting. Because when you zoom out, you might find those readmissions aren’t just a medical issue—they’re tied to social policies or even local economies.

David Caldwell

So, healthcare isn’t this bubble—it’s more like... the tip of the iceberg?

Sofia Ramirez

Absolutely. And when we treat it like an isolated system, we keep missing the underlying causes. But shifting to this broader perspective? It changes how we see solutions. Like in the UK, where they’re experimenting with prescribing things like gym memberships or housing assistance instead of just more medications.

David Caldwell

Wait, wait, wait. Doctors can prescribe a house? That’s... wild.

Sofia Ramirez

It sounds wild, but the idea is simple: address the root cause, not just the symptoms. If someone’s asthma is worse because of moldy housing, what’s more effective? Another inhaler or fixing their living conditions?

David Caldwell

And I’m guessing fixing the house is cheaper in the long run, too?

Sofia Ramirez

Exactly. And that’s why this perspective is so powerful. It’s not just an interesting theory—it has real, practical applications that could revolutionize how we deliver care and improve outcomes.

David Caldwell

So, it seems like tackling root causes goes far beyond individual actions. Is that where this idea of a 'systems steward' comes in? What does that even mean—more of a mindset, or an actual role?

Sofia Ramirez

Great question. It’s definitely more of a mindset. Systems stewardship is about taking ownership of the larger picture—even if your official role doesn’t require it. It means understanding how your decisions and actions contribute to the greater whole, instead of just focusing on your immediate task or responsibility.

David Caldwell

Okay, but considering how crazy things are—I mean, you’ve got overloaded hospitals, burnt-out staff, and all these competing demands—who’s got time for that kind of big-picture thinking?

Sofia Ramirez

Fair point. The truth is, few people are incentivized to think beyond their immediate sphere. A nurse is focused on her shift. An administrator is consumed with budgets. But this is exactly our problem—by staying locked into our silos, we lose sight of how interconnected everything is. And frankly, the system keeps perpetuating behaviors that reinforce this fragmented view.

David Caldwell

Right, so everyone’s just trying to survive in their little corner of the system?

Sofia Ramirez

Exactly. But survival isn’t enough anymore. If we want to fix this, we need people across all levels—clinicians, leaders, even patients—to adopt this broader perspective. To ask not just, “How does this impact me?” but, “How does this impact the system?”

David Caldwell

Alright, but let’s get practical. If I'm, say, a primary care doctor, what does systems stewardship even look like for me? Like, day-to-day?

Sofia Ramirez

It could be as simple as questioning the usual. For example, instead of just managing patients individually, you might start noticing patterns—like, are several patients struggling with food insecurity? That insight could lead to working with local organizations to improve access to healthy food. Essentially, you’re thinking about solutions that go beyond the walls of your clinic.

David Caldwell

Got it. So it’s like zooming out and asking why the same problems keep showing up in the first place?

Sofia Ramirez

Exactly. And systems stewards also bridge gaps. They don’t just identify problems—they connect the dots. Think about it: If everyone plays their part without collaboration, the system stagnates. But when people start asking those bigger questions, it rewires the system for long-term growth and change. The Ripple Foundation, the Robert Wood Johnson Foundation, and many other organizations and people are advocating for this type of role and change.

David Caldwell

Hmm, sounds inspiring in theory. But how do you even begin to shift that mindset in an entire system where most people aren’t trained to think this way?

Sofia Ramirez

It starts with awareness. People need to see the system before they can steward it. That means creating space—in training, in policy discussions, even in daily routines—for conversations about the bigger picture. Without that, we’re just running on autopilot.

David Caldwell

Okay, but autopilot’s comfy, isn’t it?

Sofia Ramirez

It is. Until you crash.

Sofia Ramirez

But here’s the thing about autopilot—it’s exactly how systems stagnate. That’s why systems stewardship is so crucial. This podcast isn’t just about pointing out flaws in the healthcare system—because let’s be real, we could analyze problems forever. It’s about inspiring, connecting, and supporting people who want to break out of that autopilot mode and say, “Let’s actually change this.”

David Caldwell

Right. You talk about those “high-leverage points” all the time, and I gotta say, I love that idea. Like, finding the one thing that can tilt the whole system.

Sofia Ramirez

Exactly. And these aren’t just tweaks at the edges; it’s about targeting those areas that can lead to revolutionary changes. Think about how medicine transformed in the late 1800s. Back then, we had no real hospitals, no scientific understanding of disease, surgeries were—you know—downright terrifying.

David Caldwell

Yeah, just imagining how far we’ve come is, honestly, mind-blowing.

Sofia Ramirez

It really is. But what’s exciting is that kind of transformation is possible again. This time, though, instead of groundbreaking discoveries in biology or surgery, it’s about re-imagining how we deliver healthcare as a system. How do we make it equitable, sustainable, and, frankly, humane? And how we transforming institutions, even society.

David Caldwell

And we can do this, right? I mean, you sound so hopeful when you talk about this stuff, even when it feels overwhelming.

Sofia Ramirez

We can. It’s going to take vision, coordination, and a lot of resilience, but we can. And ultimately, it’s going to come down to the stewards—the people listening to this podcast, the ones on the frontlines, the leaders willing to push the boundaries—that’s who will drive this change.

David Caldwell

And that’s the key, huh? It’s not some single hero who swoops in and fixes the whole thing—it’s all of us, working together, building momentum.

Sofia Ramirez

Exactly right. The health system doesn’t change one person at a time; systems change when people come together, rally around those high-leverage points, and keep pushing until the change sticks.

David Caldwell

Well, on that note, I think it’s safe to say we’ve covered a lot today.

Sofia Ramirez

We have. And as always, thank you to everyone listening. It’s been such a pleasure diving into all of this with you.

David Caldwell

Absolutely. And hey, remember—whether you’re a doctor, a nurse, a policymaker, or just someone wondering what you can do—we’re all in this together. This is about building something better for everyone. We’ll see you next time on "It’s Time."