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COVID-19 and the Failure of Top-Heavy Leadership

Our healthcare system cannot move forward with the model in place now. Hospitals and EMS lack the necessary mechanisms to be considered adaptive.1 This inability to adapt and optimize has never been more apparent than with the recent COVID-19 outbreak, which is ravaging hospitals and healthcare facilities.2 Among the many things that constitute a complex adaptive system, the bloated, top-heavy hierarchy typical of most hospitals is not on the list.3

The reason why top-heavy hierarchical models fail is that they cannot respond to changes fast enough to maintain equilibrium. For example, approximately half of all publicly traded companies are dead within 10 years.4

The explanation for why companies are so short-lived is that as they have success and become larger, they adopt a more top-heavy hierarchical structure. This makes responding to market changes take longer. Decisions made by higher executives take more time to trickle down to the individuals who in turn change their daily operations. As populations grow and systems serve more individuals, it becomes impossible to respond to market changes fast enough, and the system collapses—i.e., the company goes under.

Conversely, when systems utilize a fractal-like distribution of information among networks—fractals being infinitely complex, never-ending patterns that are self-similar across scales—it allows a system to grow by orders of magnitude in size without any major compromise in functional performance: Since fractals are considered to be scale-invariant, size no longer becomes a problem.5,6

With our exponentially growing population approaching eight billion globally, I believe hospitals must adopt a fractal-like distribution of information within their networks or else continue to be overwhelmed by new outbreaks. To accomplish this, we must appoint “complexity scientists”7 at the head of policy and healthcare administration, a role currently dominated by MBAs.

When you hand over the management of healthcare delivery to MBAs and other business professionals, the primary thing that matters can be whether the hospital makes a profit. All other defining features of optimization, such as quality of patient care, infection control, appropriate drug administration, etc., may receive secondary priority.

To give an anecdote that reinforces this: When I worked in cytogenetics at a major hospital, we had one month with slightly fewer samples than the previous year. The administration—all of them MBAs, naturally—told us that the invoice for that month was “a little light” and we needed to double-check our records and billing information.

The people who ran the hospital I worked at were literally upset because fewer people were dying from cancer.

When you focus only on profit, you cut corners wherever you can. You cut staffing to the point of decreased patient care;8 you buy fewer medical supplies to reduce supply chain costs9—a metric that has not served us well in the COVID-19 outbreak.

It is not just hospitals, either; literally every aspect of healthcare is “trimming the fat” and trying to maximize profit at the expense of patient care—sacrificing quality for quantity.10,11  

COVID-19 has been an assessment of how resilient and adaptive healthcare systems are and how good they are at their job. The American healthcare system is failing that assessment and being literally destroyed by it.


1. Trent R. What role does the science of complexity play in medicine? KevinMD, 2019 Aug 27,

2. Miles F, Upson C. NYC hospitals ‘overwhelmed’ by coronavirus patients, resident warns. Fox News, 2020 Mar 26,

3. West G. Scaling: The surprising mathematics of life and civilization. Santa Fe Institute, 2014 Oct 31,

4. The Lifespan and Number of U.S. Public Companies Is Shrinking. The IFOD, 2018 Aug 16,

5. Centre for Fractal Design and Consultancy. Fractals and Human Biology,

6. Wikipedia. Scale invariance,

7. Jogalekar A. Stephen Hawking’s advice for twenty-first century grads: Embrace complexity. Scientific American, 2013 Apr 23;

8. Quality Patient Care. By the numbers: Nurses are being understaffed by hospitals,

9. Guidehouse. Hospitals’ Supply Chain Savings Opportunity Jumps to $25.4 Billion a Year,

10. Sanders A, Tracy T. EMTs and paramedics scramble for supplies although de Blasio says FDNY has enough protective gear. New York Daily News,

11. Gabler E. Pharmacists at CVS, Rite Aid and Walgreen’s are struggling with understaffed and chaotic workplaces. Chicago Tribune, 2020 Feb 3,

Robert Trent is an active science and medicine communicator. He is currently a Doctor of Pharmacy candidate; his research interests include complexity science in pharmacokinetics. Prior to starting his doctorate, he worked in cytogenetics and as a technician in an emergency department, correctional facilities, and the mobile ICU.


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