If Healthcare Was 'Game of Thrones': Healthcare Stakeholders as the Great Houses and Kingdoms of Westeros
Apologies to my fellow digital health devotees, but someone had to write this blog.
Like many of you, healthcare and Game of Thrones (GoT) are two of my great preoccupations. As I started re-engaging with some of my favorite GoT podcasts, I was struck by the parallels that seem to exist between what we are trying to do in healthcare to life in Westeros -- e.g., multiple stakeholders (the Seven Kingdoms and the Great Houses that rule them) with differing values and competing interests, but mostly committed to making healthcare (the realm) work better for patients (the people of Westeros).
So here is one fanboy’s take on who’s who and what healthcare might glean from the story arcs of the kingdoms, families and people we’ve come to know so well. Also, please consider this your GoT spoiler alert.
For starters, the premise and purpose of healthcare is (thankfully) less barbaric and more humane than the quest for the Iron Throne in Westeros. While competition in healthcare undoubtedly exists—and I’ve certainly known and counseled some Type As—none rise to the level of a Euron Greyjoy. In my experience, people working in healthcare tend to think and act more like Varys--for the good of the realm and its people. And of course, no group is more in line with this thinking than those who have dedicated their lives to patient care: providers.
Ned Stark, M.D.
Like providers, the Starks are, in many respects, the most noble of the Great Houses. They are one of the oldest, most trusted and iconic families. They hold themselves to high standards of conduct, similar to how doctors and nurses are held to clinical and ethical standards. And, yes, winter (i.e., sickness and disease) is always coming; but a Stark-like approach has, at times, prevented them from reading the writing on the wall (e.g., Ned’s beheading, the Red Wedding, value-based care, etc).
However, Season 8 has seen the Starks and their allies in the North become more open to collaboration. Their begrudging acceptance of the Dragon Queen meant their continued survival when her dragons and army saved many Northerners from certain death. And thank goodness for Arya’s residency in Bravos with “Dr. H’ghar,” or the Dead would be halfway to King’s Landing by now.
The lesson from the Starks? Adhere to ethics and principles always, but continue to embrace collaboration, new technology and techniques from outside the silos of the North. And, keep working on that bedside manner; flashing an occasional smile and practicing sensitivity can do wonders in providing a better patient experience.
Dragons and digital health: The wonders of new technology
I think it was Maester Aemon who once said, “...Used for good, EHRs and dragons can be game changers. Used for bad or left to their own devices, many innocents will surely perish.” (Note: My tongue is firmly implanted in my cheek.)
Electronic health record platforms represent the most sweeping example of technology adoption in healthcare over the past decade. But depending on your perspective, the role of dragons is either compelling the Great Houses to bend the knee, or uniting the Seven Kingdoms and ushering in an unprecedented era of safety and prosperity across the realm.
As innovative as dragons, Valyrian steel and a fire-proof epidermis are, they are best when deployed as part of a solution to a real threat to our health. For example, in provable outcomes, such as fire killing wights or a surgically applied Valyrian steel dagger to the chest of the Night King. Technology in the service of ego and platinum-hair branding will enrich the few at the expense of the realm and its people.
(Aside: If the Iron Bank had any sense, it would offer the Three-Eyed-Raven successor, Bran, seed funding for a Children of the Forest development team to fix the storage and caching issues with v1 of the Weirwood-net.)
Health plans: Moon door or life-saving cavalry?
Though perhaps not as obvious, health plans seem to most resemble House Arryn and the people of the Vale. Yes, some of us have had experiences that lead us to see payers as aloof and (quite literally) above the concerns of the members they commit to serving, especially given the mountainous, often inaccessible terrain that patients can face when trying to understand or appeal a claim, or even get a simple question answered about coverage.
At times, health plan policies, customs and judgement can seem a bit out of touch with what a patient or population needs (just think of Lysa or Robin Arryn determining what your policy does and does not cover -- yikes!). And, there may even be occasions when one of us may feel as though we are being pushed through the Moon Door.
On the other hand, the Knights of the Vale have ridden to the rescue of other Great Houses on more than one occasion. They are extremely capable, have deep resources and, when properly led, can apply those resources to incredibly beneficial ends.
The lesson here: you can’t have enough Jon Arryns (i.e., respected leaders) to ensure the health and safety of the realm, but you must be careful about who you marry and be mindful of who you select as Master of Coin.
‘I Shall Wear No Crowns and Win No Glory… I Am the Watcher on the Wall’
The above quote is, in my humble opinion, some of the most elegant and purposeful writing by GoT author George R.R. Martin. And in our healthcare system, the role of the Night’s Watch is played by our brothers and sisters working for federal, state and local governments and NGOs throughout the realm.
At the federal level, the CDC, HHS, CMS, ONC, FDA and other agencies all play critical parts in protecting us from death and disease while providing a shield to those most in need. However, the men and women working to regulate and support our system of healthcare often go unrecognized — and that is a shame, as our regulators’ watch has no end and never will. What’s more, the work of government agencies is often misunderstood and widely mischaracterized.
Do they rely on the other kingdoms for support? Yes. Do they sometimes make mistakes? Of course — we all do. But they are far more likely to prevent the next pandemic, make sure we are covered for pre-existing conditions, and finance the next breakthrough in science and medicine. While many us have learned to appreciate the women and men who “take the black,” let’s all resolve to continue to support and voice our appreciation for these selfless individuals and the vital role they play in making healthcare work.
The Citadel and its Maesters: Protectors of science, “provers” of outcomes
This one was pretty obvious, but it merits inclusion as the healthcare system is going through a massive transformation — and now more than ever, we need data, science, standards and clinical guidelines to inform this change.
New technology, models of care delivery, and methods of financing require extensive research and due diligence to ensure the right frameworks are set up to achieve optimal, patient-centered results. Luckily, as a country, the U.S. is extremely fortunate to have many “Citadels” in the industry in the form of the NIH, universities, and academic medical centers, each filled to the brim with established and aspiring maesters. (See Samwell Tarley’s soon-to-be-published JAMA paper on a pain-free treatment for greyscale).,
Qyburn’s experiments in zombie medicine aside, the most innovative aspects of our healthcare system must re-commit to upholding the tradition of scientific method and proving medical outcomes, none of which would be possible without the existence of the organizations, academia and researchers dedicated to finding and preserving the answers.
Yes, pharma, you are the Lannisters — And that’s not a bad thing
Before all my life science pals start slinging arrows at me from their lofty perches high above the Sunset Sea, allow me to qualify the association between pharma and those with hair O’gold.
First off, who can deny the wealth you’ve created by mining the lands of drug discovery? And while that is a massive oversimplification of the R&D process, let’s just agree that pharma seems to always be able to pay its debts.
Next, take Tywin and Cersei out of the mix, and the Lannisters have no more a notorious reputation for less than virtuous deeds than most of the other Great Houses. And therein lies the opportunity for pharma moving forward: Will life sciences organizations channel their inner Tyrion and try to think their way to a better strategy (e.g., pricing changes and more efficient drug development), or allow his big sister and cohorts to run amok?
Then again, perhaps the most instructive example is Ser Jaime. With an opportunity for redemption at hand (pun intended), what will he do? Fall back into old habits, or complete his arc in the way we all hope?
Winter is here: Now what?
So what do you think, fellow GoT nerds and healthcare pros? Which characterizations would you quibble with, either kingdom and lesson-wise? Where does Dorne fit in? What about House Tyrell? Battle it out in the comments!
Here’s to a satisfying and — gulp — healthy series finale!