Institutional decision making: empowering of health system and economic transformation.

Organized medicine (OM) is an institution built to defend the American health care system of the 20th century. The institutional structures that it employed, however, operated mechanically and independently of its practitioner base, which drew from physician and nonphysician health professions. This article suggests that OM's institutional structures were founded and defended by a "logic of confidence," which initially served as a buffer against external socioeconomic pressures. The institutional structures of OM came to be treated systemically as rules (e.g.,"Trust me, I'm a doctor" and "The doctor knows best"), biasing and guiding organizational decision making and activities. Such rules were inculcated through professional education and clinical practice and were promulgated to the public by OM's practitioner and consumer base. OM so effectively promoted its rules that they were installed as powerful myths in the American psyche. So powerful were these myths that even OM was prevented from updating its identity to match its changing socioeconomic context. Instead, OM compartmentalized and sequestered its operational components from the public and from one another, effectively decoupling its identity from its activities and its context. In this manner, OM maintained an outmoded status quo when confronted by changing socioeconomic circumstances. The author explains how OM's failure to adapt has impelled the strongest representatives of all health professions to resist top-down decoupling in favor of bottom-up identity maturation, applying a new "logic of appropriateness." The logic of appropriateness is offered as a framework to guard against biased decision making and to ensure that institutional and individual identity, context, and decision making are coordinated and relevant. A new, public health-led, American health system is described in which the family physician and family nurse practitioner co-lead primary care practice and in which professional psychology has a vital role at every level.