Competition in the Health Care Professions: A Distant Mirror?

I’ve written at length about sociologist Andrew Abbott’s 1988 book, The System of Professions (Chicago, 1998), and his very astute analysis about how the information professions—all of them, ranging from librarians to MBA consultants—compete with each other, obstruct competing groups when they reach for more power, and so on. He describes what professionals do as offering a “treatment,” which requires special training and knowledge, and the exercise of independent judgment. When a particular group wants to gain the upper hand, moving into an emerging market, for example, they practice “treatment substitution.” Essentially they are saying “I know a lot too, and my strategy is a better one.”

Since we all work together in the information professions, the actual dynamics of treatment substitution can be obscured by good vibrations, collaborative spirit and so on—or at least, we can hope so. However, oftentimes the easiest way to perceive the current of competition in our own field of expertise is to look to other fields and see what is happening there.  With respect to treatment substitution, there is no better example than the medical professions, and Andrew Abbott devoted many pages of his book to the medical fields along with the information professions.

Well, unsurprisingly, the Affordable Care Act (ACA) is stirring up controversy and also creating opportunity. When opportunities abound, professional competition can heat up fast. And next comes treatment substitution!

Nurse Practitioners: Exercising New Muscle

On March 24, 2013, the San Francisco Chronicle reported on the current struggle of nurse practitioners to exercise more independent judgment in health care delivery. NPs already can diagnose acute and chronic illness, are trained in pharmacology and health care ethics, and they have become essential partners in care. They are regulated at the state level, and so what they can actually do varies by region. Chronicle Reporter Shannon Pettypiece describes the overall status of their struggle, which increasingly is playing out in the courts.

Physicians have always seen themselves as the “captain of the ship,” and they and their associations vigorously guard their primacy in the practice of medicine. Yet at the same time, there is a shortage of 13,000 doctors right now, and this shortage is forecast to grow to 130,000 in the coming years. Nurse practitioners argue that they could fill a crucial gap, if they are afforded the privileges needed to diagnose and treat patients. This is particularly true in rural regions.

Closer to Home: Opportunity from Atomization

In the information professions, there has been splintering of major concepts and established roles–you could even say atomization of “skill sets,” as the digital era unfolds. MIS managers, consultants, CIOs, information specialists and librarians all compete to offer the best information “treatments,” but new technology and ideas about social interaction are rewriting the rules. Treatments on offer include digital curation, digital publishing, preservation, digital conversations, reference consultations, and more. As digital convergence pushes us all closer together, we face more moments when we must choose to collaborate or compete.

In the journals marketplace, the emergence of SPARC and new strategies to promote open access scholarship are swiftly changing our expectations and assumptions about the future of information management and delivery. At the same time, technical skills can be learned readily by just about any enterprising person with a dream. These enterprising people can create apps and other tools that become “must-have” functionalities on our smartphones.

In other words:  competition, and treatment substitution, are alive and well in the information professions. We even have litigation over publishing markets and journal pricing, although our version seems a lot less personal than physicians’ assertion that they simply “know more” than nurses.

“A Finch Sang in Berkeley Square….”

I don’t think we have a single issue that defines current competition among the various information handling professions; rather we have a great many, and they are diverse. But for the moment, with the release of the “Finch Report” in the United Kingdom and its mandate to build “Gold Open Access” models to make research available to all, I’d say open access is a illuminating issue that defines what competition looks like. At what point does a publisher need the library, or for that matter, at what point does the library actually “become” the publisher? Or further: at what point do authors become the “agents of change” in an all-new style of writers’ guild, given that technology makes this possible, right now?

These and many other questions will not be answered soon, although the nature of competition may reveal some of the strategies that many of us will surely test. Meanwhile, while we continue to work together, we continue to hone our skill at monitoring the digital environment we work in, and the new opportunities that arise to extend our reach.

Hari Seldon Lives: Revenge of the Original ‘Psychohistorians’

The February 23rd, 2013 issue of The Economist a brief but provocative article on the rapid development of massive data analysis by means of social media, and the potential to develop much better models to discover patterns of predictability—in other word, Isaac Asimov’s concept of psychohistory, as conceived in his Foundation novels.

Sci-Fi junkies nearly to a person would rank Asimov’s Foundation trilogy as one of the seminal works of science fiction. With a flair for “space opera” on a galactic level, Asimov sculpts a story in which science meets social sciences, and the resulting “Seldon Plan” would enable “psychohistory”—the forecast of society’s ups and downs—to steer humanity through and beyond a collapse of galactic civilization. In the course of the story he fleshes out the idea of the “scientist as hero,” later popularized by Kim Stanley Robinson in his Mars trilogy. This brand of hero essentially saves us from ourselves—whether the crisis at hand is a collapse in galactic civilization, or a mere well-organized expansion of human beings to Mars.

Well, if The Economist has captured an emerging scientific process, and if what is past is prologue, we may soon get a version of psychohistory in real time, although it might be a tad more primitive than Hari Seldon’s Plan.

The Economist profiles a number of projects underway that use Big Data to predict social outcomes, ranging from using cell phone records to chart “where” we are at any given time, to using epidemiology to forecast future vectors.

Politics—and we could some serious, big-time help in that arena—is the next frontier for the data crunchers. Boleslaw Szymanski of the Rennsselaer Polytechnic Institute is analyzing the role of “catalytic minorities,” which are groups of only about ten percent of a given population, but can suddenly swing public opinion in their direction.

The authors go on to speculate whether ultimately it might be possible to develop a theory of Society, much in the same manner that physicists are exploring a theory of everything.”  Now we are truly getting in Seldon territory, as our correspondent at The Economist call it. But modeling something as complex as society will not be easy. Our correspondent says:  “Small errors can quickly snowball to produce wildly different outcomes.”

In the Foundation series, the little glitch in the Seldon Plan appears in the form of an individual who has the extrasensory ability to influence peoples’ actions and minds—known as The Mule. He tipped the Seldon Plan off course, driving the story forward into unknown territory. The heroic psychohistorians labor to control for The Mule’s impact on their complex, formula-driven plan for humanity.  In the end (Whew!) they pull it off, and galactic civilization does not fall into a long dark age.

I think research along these lines is quite worthwhile, and in light of the 2012 election season, I can’t help wondering if we are seeing some baby steps in the direction that the Hari Seldons of the future might dare to tread. In the meantime, I’m left with the real-world record of social scientists in the here and now, and how they must “control” for every known factor as they set up models. Perhaps a theory of society is possible to some degree, but it would better overall if we would just behave as told to keep the models.  Somehow I think we will as recalcitrant as ever, to the dismay and disappointment of our current posse of scientific heroes….

Computers In Libraries Column: Key Players in the E-Book Marketplace


From my column, “Duking it Out in the E-Book’s Wild West Marketplace,” in Computers in Libraries, January/February 2013, p. 17:

The e-book is a new medium, but it follows many other breakthrough products with histories of disruption, adoption, market acceptance, and the forging of new business relationships. Perennials such as CD-Roms, DVDs and iPods come to mind, as each of these new technologies triggered important changes in commerce and entertainment. The disruption was real and has caused serious distress for publishers, but there is no getting around the fact that we are in a new era now. Publishers have gained expertise in digital media and are engaged in intensive experimentation. They are taking big risks with e-books and trying new innovative pricing models. And they are playing a tough game to protect revenue.

Chronicle of Higher Ed Reports on Electronic Course Reserves Kerfuffle

In the Chronicle of Higher Education:

“Publishers and Library Groups Spar in Appeal to Ruling on Electronic Course Reserves”

This case is heading for appeal. The following quote expresses one the publishers’ key arguments:

In their brief, filed on Monday, the publishers argue that, if the lower court’s ruling stands, it will have implications that go far beyond Georgia State’s practices. The publishers play up the idea that e-reserves amount to course packs or anthologies of reading material. Judge Evans’s decision “invites universities nationwide to accelerate the migration of course-pack creation from paper to electronic format” and to sidestep legal permission to use copyrighted content, the brief states.

And this from the intrepid Association of Research Libraries:

…Brandon Butler, director of public-policy initiatives for the Association of Research Libraries, took issue with the argument that e-reserves put publishers at great risk.

“I’m baffled that the publishers continue to claim that course reserves pose some kind of existential threat to their business,” he told The Chronicle via e-mail. “It was established at trial that GSU’s practices are in the mainstream, so libraries are basically already doing what the publishers claim will put them out of business, and yet Oxford University Press reported $1-billion in sales last year, $180-million in profits. Is that what a publisher on the verge of collapse looks like?”

Let’s hope the principal of “Fair Use” continues to prevail.

Metrics and Management: New Book, New Implications

The Org: The Underlying Logic of the Office, by Ray Fisman and Tim Sullivan (Twelve, 2013), was featured today on first page of the New York Times Business Day section. The article starts out by comparing British Petroleum’s record as a government enterprise, and then later as private corporation. (Pop quiz: what are the two biggest disasters BP created, and when did they occur?).  This alone is intriguing and suggests the book is a good read, but the following quotes really caught my attention:

“The more we reward those things we can measure, and not reward the things we care about but don’t measure, the more we will distort behavior.”  -Burton Weisbrod, Northwestern University.

“If what gets measured is what gets managed, then what gets managed is what gets done.,”  –-Fisman and Sullivan

–With the implication that what is not managed not only will not get done, but may go wrong in unforeseen ways (Deep Water, anyone?).

These insights apply to bibliometrics as well as to management, particularly when it comes to measuring the quality and impact of library services that are not (sufficiently) measured.

My December Column in Computers in Libraries: “Making Our Own Futures.”

Computers in Libraries magazine usually devotes its December issues to trend-spotting and future-casting. In that end of year spirit, I take a look at “additive manufacturing” (aka 3D printing), “Zoomable user interfaces (ZUIs), “Unsourcing” (I love that use of irony), and widely distributed Print on Demand.  Have a look at the December issue of CIL.

In Search of the Next Value Proposition


An excerpt from my column in Computers in Libraries, November 2012, of the same title:

Although it is pretty easy to find colleagues who will express fatigue or frustration about the constant need for libraries to prove their value proposition, there is also an upside to the exercise of crafting a message that justifies our mission. The catch is that however good your crafted message may be, forget about finishing the dog-and-pony show once and for all. Information professionals live on the front lines of disruptive technology, and are subject to the forces of digital convergence, which are forever pushing knowledge workers closer together and challenging them to rethink what they do. The sheer cascade of new technologies throughout the workplace, the entertainment sphere, and society in general requires constant review of our top goals, how we frame them to our users, and what “deliverables” we rely upon to build an evidence-based record of our relevance. And then there is the future: we must search not only for this year’s value proposition, but also for next year, and for the year after that. Mind you, we’ve come up with some real winners over time; even so, the big payoff of creating winning “meme” essentially amounts to extending its lifespan from 12 months to 24.