Take Two: EP438: Is It Mission and/or Margin? With John Lee, MD

How to Stay Mission-Driven When the System Is Working Against You

A third of healthcare waste is someone else's profit. That profit buys a lot of influence — and it's one reason why doing the right thing for patients can get your face smashed against the wall inside a large healthcare organization. That's the real world Dr. John Lee is talking about in this episode, and his question is the one most mission-driven clinicians and operators eventually ask: now what?

In this Take Two episode, Stacey Richter revisits her conversation with John Lee, MD — emergency physician, informaticist, and Chief Medical Information Officer — about how to maintain a sense of mission and avoid demoralization when you're working inside a system whose incentives are stacked against the very outcomes you're trying to achieve.

WHAT YOU'LL LEARN ✅ What cognitive dissonance looks like inside healthcare organizations — including the real-world example of a heart failure program that was shut down because it was too successful at reducing hospital admissions

✅ Why the system hasn't gamed most clinicians — it's gamed them: how RVU-driven comp models and hierarchical structures push good people into behavior they would never choose in a different environment

✅ Why the RaDonda Vaught case — a nurse criminally prosecuted after self-reporting a fatal medication error — illustrates exactly what happens when a system punishes transparency instead of using near-misses to prevent future harm

✅ Dr. Lee's boulder-and-pebbles framework: why one person cannot fix the dysfunction, but enough people removing enough pebbles will eventually start that boulder rocking

✅ Three practical strategies for working incrementally within a broken system: celebrate small wins, build technology and processes that support colleagues, and find like-minded people to serve as your sounding board and support network

WHY THIS MATTERS The cognitive dissonance that builds up when mission and margin are out of alignment doesn't just demoralize clinicians — it drives them out of the profession or into a kind of learned helplessness. Stacey frames it plainly: you are what you won't do for money. But for the people inside large institutions who are not suffering from that dissonance, the question isn't philosophical — it's operational. This episode is a practical field guide for anyone who wants to keep moving the ball forward without waiting for wholesale systemic change that may not arrive anytime soon.

=== LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/Take2-EP438

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09:23 What are the systems that start to bear down on individuals within the healthcare system?

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15:44 How can alignment still be achieved in the face of cognitive dissonance?

17:12 EP431 with Kenny Cole, MD.

20:43 Why does it take more than one person to solve the dysfunction in the healthcare system?

23:01 What are some little changes that can help change the cognitive dissonance in healthcare?

24:57 Why is a hierarchical healthcare structure not necessarily beneficial?

27:12 The RaDonda Vaught story.

34:30 "Be happy in the small things."