Larry Merlo, formerly the President and Chief Executive Officer, CVS Caremark Corporation, took the courageous action of ending the sale of cigarettes in CVS stores.
AFP via Getty Images
While healthcare organizations claim to encourage open communication, few can identify individuals who actively speak out. The true measure of an institution’s commitment is not in honoring critics after they’ve been proven right, but in safeguarding them when their views are still contentious and unsettling.
Twelve years ago, I, along with Brian Powers and Christine Cassel, wrote an essay in the Journal of General Internal Medicine titled “The Power of Embedded Critics.” We argued that those best positioned to reform institutions are insiders who possess unique insights and influence. We believed there was a wealth of potential reformers within the profession, waiting to be utilized.
I maintain the validity of our argument, but I underestimated one aspect: the obstacle isn’t awareness but the cost of speaking out. Over the years, I’ve observed how few in the industry are willing to bear this cost and how effectively we penalize those who do.
Walzer’s connected critic
Michael Walzer’s concept of the connected critic, which we referenced, emphasizes that the most effective critic is not an outsider but someone slightly removed from their own society. Unlike the disconnected critic, who is easily dismissed, the connected critic uses the institution’s own moral language to highlight its failings, arguing not that the institution’s values are wrong, but that it is failing to live up to them.
Walzer’s example is the Hebrew prophet, such as Isaiah, who had access to power and critiqued the rituals of his own community, not an external enemy.
Peacetime leadership and wartime leadership
Traditional leadership focuses on maintaining stability and managing reputation and risk. In peaceful times, protecting the institution equates to serving it. However, when the institution’s own processes become more harmful than external threats, it signals a shift to wartime.
Peacetime leaders focus on optimization, while wartime leaders must focus on transformation. Loyalty during wartime involves protecting the institution’s mission, even from itself. This transition is seldom announced, and many continue using peacetime strategies for wartime issues, such as initiating listening tours or rebranding.
In wartime, internal reformers must challenge the establishment. Outsiders can critique but lack the insider’s standing, access, and knowledge. This insider silence is costly.
The American healthcare system gradually entered wartime, unnoticed by many. We accepted inefficiencies and rising costs, mislabeling preventable delays as scheduling and irrelevant documentation as compliance. Yet, we continue to deploy peacetime leaders to issue statements and form task forces, ignoring the internal threats.
The lineage is right in front of us
Much of the progress in modern American healthcare originated from embedded critics, often mislabeled as pioneers. Figures like Don Berwick have long challenged the status quo. Four notable examples illustrate this trend.
Avedis Donabedian is lauded as the father of quality measurement but was an outspoken critic who believed quality foundations were moral, not technical. He criticized physicians who blamed systems for their failings, asserting that system responsibility lies with medical professionals and leaders.
Howard Hiatt used his position at Harvard to investigate how often hospitals harmed patients. His findings backed the patient safety movement and later the report To Err Is Human. He scrutinized his own institution rather than pointing fingers elsewhere.
Barbara Starfield spent her career at Johns Hopkins arguing that a primary care-focused system would outperform one centered on specialists. Her publication on medical care-induced deaths was initially dismissed by a journal for being uninteresting.
Troyen Brennan, as chief medical officer of CVS Caremark, advocated for ending tobacco sales, directly critiquing his own company. With CEO Larry Merlo, CVS ceased tobacco sales, sacrificing an estimated $2 billion in annual revenue.
The power of self-indictment
External criticism is easy, but internal criticism carries weight and credibility due to its cost. Acknowledging a practice you benefit from removes easy dismissal, making self-indictment powerful yet rare. It’s uncomfortable and professionally costly, often discouraged by communications teams.
Richard Baron exemplified this by publicly admitting the American Board of Internal Medicine’s error and suspending contentious requirements. This straightforward apology is still referenced, unlike typical defenses issued by leaders in similar situations.
In my role with a Medicare Advantage plan, I’ve criticized industry practices like coding intensity and prior authorization. This self-critique is not virtuous but necessary for credibility.
Why institutions suppress the people they most need
Leaders often solicit criticism in theory but suppress embedded critics who challenge the presumption of complexity. Outsiders are easily dismissed for lacking understanding, but insiders, who know the workings intimately, face attacks on their motives instead.
Institutions rarely lack good intentions but fail because those who know the problems have reasons to stay silent.
Two people I don’t always agree with
Praising historical critics is easy, but contemporary ones face challenges. Anthony DiGiorgio, a neurosurgeon, critiques the 340B drug pricing program, while Anish Koka, a cardiologist, writes about conformity in his profession. Despite disagreements, their criticisms highlight what is often normalized.
Critics don’t need universal agreement but rather accuracy and courage.
Doctors have leverage they are not spending
Physicians, among the most secure professionals, are often silent. The issue is cultural, not contractual. They are trained to advocate for patients against external entities but not against their own organizations.
Some, like Helen Ouyang and Danielle Ofri, use their positions to critique their own systems through journalism and writing, demonstrating the potential impact of leveraging their positions.
Choosing not to use this leverage is not a hardship but a choice.
We honor our critics too late
Critics like Donabedian, Hiatt, Starfield, and Brennan are now celebrated, but they were not treated as such when active. They were often marginalized, their motives questioned, and their involvement reduced quietly over time.
Posthumous honors are easy, but promoting critics while they are active and their critiques are uncomfortable is more challenging. Institutions that only honor departed critics pair past admiration with present suppression, and younger members notice.
What I am asking for
Institutions claim to value truth, but the real test is whether they accept truth that brings consequences. The change needed is cultural. While healthcare criticism is abundant, it is often anonymous and without personal cost. What is needed is real-time recognition of connected critics, even when their critiques are uncomfortable.
Leaders can start by identifying who in their organization consistently challenges them and consider how they have supported or suppressed them.
To truly support dissent, institutions should promote and protect these individuals without requiring them to conform. They should be given a platform to voice their critiques and be involved in addressing the issues they highlight.
Leaders should also model self-indictment to normalize it for others. True institutional courage arises not from hiring brave individuals but from creating environments where they can thrive.
