The 10th Man (is not just for a Minyan)

In the movie “World War Z”, there is a part which takes place in Israel. The movie itself is about a zombie inducing virus which actually has meaning in the real world, especially considering the latest news about Ebola. In any case,the lead character, played by Brad Pitt, goes to Israel to find out how the Israelis knew about the virus earlier than anyone else and proceeded to build a protective wall around the entire country.

In one scene, Brad Pitt is speaking with a senior Israeli representative who explains the principle of the 10th man. The idea is as follows: if a piece of intelligence comes along which seems totally impossible, such that a specially selected group of 10 individuals all agree that it cannot be, it is nevertheless the responsibility of the 10th man to not only consider that the news is true, but also to fully Investigate it and even act on it. I personally enjoy the entire movie and I recommend it to others. But there is no question that this 10th man concept stayed with me well after the final credits..

Consensus is a very powerful thing. It is arguable that we are evolutionarily and genetically programmed to seek consensus in order to survive the challenges around us. Consensus is the foundation of a society that decides, as a whole, to follow a universal set of laws and customs. Those individuals who are outside of the consensus may even be considered lawbreakers and thus be jailed or expelled from the society.

But there is a danger in consensus. I think that most people in the world appreciate that absolute consensus can suppress individuality and personal freedoms. Seeking consensus can be used as a way to enforce a dictatorial government. People can definitely be turned against their friends and family, in order to stay part of the consensus.

As I have discussed in previous blogs, medical decisions can be based, far too often, on monetary considerations. Especially in a private system of care, there is a very strong push to maximize profits even at the expense of quality of care. When an individual doctor stands up and calls for a change in the priorities of such a medical institution, this doctor can quickly find him or herself  outside of the consensus. Imagine a doctor arguing that personal bonuses should be withheld and instead, the same money should be used to improve quality of care, whether by increased training or the purchase of new or better equipment, and the like. How many people would agree to forego their personal financial gain for the greater good? More so, how many of these people might even act in a hostile manner towards the doctor who insists on redirecting funds to better healthcare.

Let’s say, that the medical service in question is already providing a “good enough” service. Why would anyone argue that further funds should still be invested in improving this “good enough” service. That is why, you need the 10th man or woman.

I would argue that as a basic principle of proper management, at least with regards to health care, any committee that is deciding on purchasing and budgeting and investment, must have the equivalent of the “10th man” to challenge any and all assumptions. If a major part of funding is unanimously chosen to be directed towards a non-medical target, the 10th man should raise a hand and argue vehemently in opposition to this decision. The reality is that this 10th man may not succeed in swaying the other decision-makers. In fact, this 10th man may rarely be successful. But at the very least, the decision-makers must seriously consider what the 10th man has to say. And if it turns out that the opinion of the 10th man is never accepted, then this whole system is in fact a farce and is no more than a rubber stamp for whatever decisions are made.

Decision-makers, especially in medicine, must realize that their opinions are not absolutes and can easily be wrong. They must appoint at least one person, who they respect and who can make a solid argument, to be the challenger when the decision-makers act in a questionable fashion. This is not supposed to be about politics. This is not supposed to be about settling scores. This is supposed to be about a group of people who respect each other and appreciate that consensus is not always the best way to “rule”.

Caring for people should instill humility in those leaders that decide on the quantity and quality of the healthcare provided. But when ever personal profit is involved, it is far too easy to forget this critical responsibility. It is the purpose of the 10th man to remind everyone within and even outside of the organization, that the most has been done in order to find the proper balance between quality of care and sustainable business practice.

When the day comes that computers make many of the medical decisions that decide our health, perhaps there will no longer be a need for a 10th man. But for all I know, there will be a new  need for a 10th CPU.

Thanks for listening

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.
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