Let me begin with a charmingly absurd tale: there’s a town with a massive hole right in the middle of it. People fall into this hole, cars tumble into it, causing a great deal of harm and imposing huge costs on the local healthcare system. Naturally, the city council gathers to solve the problem. One suggests parking the ambulances next to the hole, so we can whisk the injured directly to the hospital. Another says, “Why bother driving? Let’s move the hospital next to the hole!” Then someone, in a moment of unhinged brilliance, declares they’ll fill the hole where it stands—and dig a new one right next to the hospital.
We laugh at this sort of ‘management by patchwork’ because it reveals a common temptation: tinkering with the symptoms while ignoring the fundamental cause. In this case, that cause is the hole itself. And yet, in the world of organizations—and particularly in healthcare—we often fail to recognize that the biggest barriers to thoughtful reform are lurking deep in our cultural bedrock. The ‘hole’ is not always physical. Often, it’s a set of values or assumptions, considered so untouchable that we do everything to accommodate it rather than challenge its purpose.
Consider Les Invasions Barbares (The Barbarian Invasions), a film that vividly captures the tension between public and private healthcare in Quebec. The middle-aged protagonist lies gravely ill in a crowded public hospital; his successful son arrives from Texas, prepared to whisk him away for top-of-the-line, private American treatment—yet the father refuses. Why? Because the public system isn’t merely a set of services but a source of cultural pride and collective identity. To this patient, leaving the public system would be almost unthinkable, even at the cost of comfort or possibly better outcomes. It’s a telling example of how powerful culture can be, even when it may seem illogical from a purely utilitarian point of view.
Now, let’s add another classic anecdote to the mix: the Five Monkeys Experiment. Imagine a group of five monkeys, a ladder, and a banana perched at the top. Whenever one monkey climbs toward the banana, the others are blasted with ice-cold water. In short order, the group learns: no one touches the ladder, or everyone suffers. Then the experimenters replace the original monkeys one at a time, until none of the monkeys left have ever felt the icy blast. Yet they all prevent anyone from climbing, following a norm they no longer understand. This is how culture can work: practices and beliefs, once introduced for a reason, become so ingrained that people forget the reason. The prohibition endures regardless.
In healthcare—or any organizational system—it’s not enough to point and laugh at absurd decisions or put a positive spin on superficial fixes. We need the courage to question deeply held, sometimes sacred, assumptions. After all, we can’t manage what we don’t understand, and we certainly can’t mend what we refuse to see.
The ‘hole’—whether it’s public healthcare in Quebec or cherished language laws—often reflects deeply rooted values. Over time, the context changes, the hole expands or shifts, and we find ourselves grappling with the question: Is this hole worth keeping? Sometimes we should. Culture can be a powerful source of identity and purpose. Other times, we need to patch it and move on. Balancing respect for cultural convictions with the pressing need for innovation requires leadership willing to dig deeper, ask uncomfortable questions, and weigh the true costs and benefits of our cherished traditions.
The next time you’re tempted to scoff at “those fools who keep that ridiculous hole,” remember: the absurd often reflects a deeper human need. If we want to move forward in our hospitals or our communities, we must learn to recognize when a hole has outlived its purpose. Otherwise, we’ll be stuck digging new holes in new places—rather than figuring out how to fill the one we’re already in.
A Hole in Our Thinking: Culture and the Perils of Organizational Myopia
Let me begin with a charmingly absurd tale: there’s a town with a massive hole right in the middle of it. People tumble into this hole—cars, too—causing a great deal of harm and imposing huge costs on the local healthcare system. Naturally, the city council gathers to solve the problem. One suggests parking ambulances next to the hole so they can whisk the injured straight to the hospital. Another says, “Why bother driving? Let’s move the hospital next to the hole!” Then someone else, in a burst of questionable brilliance, proposes filling the hole where it stands—and digging a new one right beside the hospital.
We laugh at this sort of “management by patchwork” because it exposes a common temptation: we tinker with the obvious symptoms while ignoring the deeper cause. In this case, the cause is the hole itself. And yet in real organizations—and especially in healthcare—we often do much the same. We focus on mitigating damage rather than asking the fundamental question: Should this hole even exist?
Holes in Healthcare Culture
Consider Les Invasions Barbares (The Barbarian Invasions), a film that vividly illustrates Quebec’s tension between public and private healthcare. A middle-aged protagonist lies gravely ill in an overcrowded public hospital; his successful son arrives from Texas, prepared to whisk him away for top-of-the-line private American treatment. Yet the father refuses. Why? Because to him, the public system isn’t just a network of services—it’s a source of cultural pride and collective identity. Leaving the public system would be nearly unthinkable, even if it might mean greater comfort or better outcomes.
In Quebec—and in countless other places—healthcare policies and practices can become woven into our sense of who we are. This sense of identity, while often unifying, can also keep us from asking difficult questions about how well our cherished systems serve us. We end up defending the “hole” instead of asking if it should still exist.
The Five Monkeys Experiment
A second story brings this point home. Imagine a cage of five monkeys, a ladder, and a banana perched at the top. Each time a monkey climbs the ladder to reach the banana, the others at the bottom are blasted with ice-cold water. Soon, they learn: no one approaches the ladder, or everyone suffers. Then, one by one, the experimenters replace the original monkeys until none of them has ever experienced that arctic spray. Yet the prohibition remains. The group continues preventing any newcomer from climbing, even though the original reason—avoid getting soaked—no longer applies to them.
This is how culture can work: a practice introduced for a valid reason endures long after that reason is forgotten. The prohibition remains because “that’s the way we’ve always done it.”
From Noble Act to Chronic Challenges: The Canada Health Act
While anecdotes about monkeys and banana ladders may sound far-fetched, similar dynamics play out in real policy. Look at the Canada Health Act. Introduced in 1984, it was designed to guarantee universal access to hospital and physician services—an admirable achievement in an era when acute, urgent care was the dominant concern. But here we are, decades later, facing an aging population saddled with chronic conditions like dementia, diabetes, and cancer—problems that require long-term, integrated care rather than the hospital-centric, doctor-focused framework the Act enshrined.
Yet attempts to adapt or expand the Act to today’s chronic-care realities often spark fierce resistance. Why? Because the Canada Health Act has evolved into something of a sacred text—much like those monkeys clinging to the “no one climbs the ladder” norm. The original impetus was laudable, but the surrounding culture has made it untouchable, even as the healthcare landscape changes dramatically.
In other words, what was once crucial for ensuring fair access to basic medical services can now also hinder broader reforms in home care, mental health, and long-term chronic disease management. The Act remains culturally and politically “off-limits” for significant revisions—an example of how a once-vital principle can become a proverbial “hole” no one dares to fill.
Now this is an opinion piece, so here comes the opinion: I believe that Canada Health Act does more harm than good in 2025. “What’s that? you ask? Let me reiterate and remove the nuance from the rhetoric: “I believe that in 2025 Canada Health Act kills more people than it saves”.
Culture vs. Practical Constraints
Culture is, by definition, a powerful anchor. It provides meaning, unity, and a sense of shared purpose. But sometimes that anchor weighs us down. When we treat it as untouchable—even if it drags us away from viable alternatives—then the culture stops serving us, and we start serving it.
At the same time, not all holes persist purely out of cultural devotion. They can be propped up by practical constraints: political pressures, budgetary limitations, entrenched interest groups, or bureaucratic inertia. The challenge is figuring out which holes are grounded in legitimate convictions worth preserving—and which have simply outlived their usefulness.
Toward Deeper Questions—and Real Solutions
Tinkering with band-aid solutions, like parking ambulances next to the hole, might relieve a few symptoms in the short term but won’t address the bigger issue: the assumptions embedded in our organizations and systems. We need the courage to challenge those assumptions—no matter how sacred or longstanding. After all, we can’t manage what we don’t understand, and we certainly can’t mend what we refuse to see.
If you suspect your own town—or your own organization—has one of these “holes,” here are a few bold steps to consider:
- Conduct a ‘Cultural Audit.’
- Identify unspoken rules and rituals driving day-to-day decisions. Are they still relevant, or have they become empty habits?
- Invite Critical Voices.
Encourage fresh perspectives. Sometimes a newcomer’s naive question—“Why do we keep doing this?”—reveals cultural blind spots seasoned insiders fail to see.
- Balance Innovation with Identity.
Recognize the positive role culture plays, but also adapt to shifting realities. Not every tradition needs to be jettisoned, but neither should every relic be preserved.
- Start Incrementally.
Filling the hole overnight might be too jarring. Pilot smaller changes and see how they resonate before scaling up.
Filling the Hole—or Building Around It
Every hole has a story. Sometimes, that story remains vital. Other times, it merely traps us in outdated habits. Ultimately, refusing to fill in a problematic hole forces us to dig new ones—wasting time and resources that could be better spent on genuine, transformative solutions.
The next time you’re tempted to scoff at “those fools who keep that ridiculous hole,” pause. Behind every deeply ingrained rule or revered policy lies a deeper human need—a belief, an identity, a sense of purpose. We owe it to ourselves, and to the people who rely on our systems, to understand that need before deciding how best to respond. That’s how we move forward with our eyes open, rather than our heads stuck in the sand—or the hole.