The Battle over Health Care - NY Times

One way we could all "save money" would be to stop putting oil into our cars. Of course, then we would have to deal with the "high cost" of replacing engines, the long waits at engine repair shops, etc. And we could have national programs to cut that cost down by 20% or so. So, we could save the $15/year we spend on oil, and replace it with $1,500 a year in engine replacement costs.

I am hoping that most people would see that the "money saving" scheme above is a terrible idea. What's remarkable is that, when we shift to health care for our bodies, everyone seems to be arguing about reducing the cost of engine replacement and what kind of insurance should pay for it. The idea of preventing the problem in the first place somehow got lost in the shuffle.

In a fascinating editorial today titled "The Battle over Health Care" the New York Times compares candidates platforms and seems something missing. The editors state:

WHAT’S MISSING

All of the plans, both Republican and Democratic, fail to provide a plausible solution to the problem that has driven health care reform to the fore as a political issue: the inexorably rising costs that drive up insurance rates and force employers to cut back on coverage or charge higher premiums. All of the plans acknowledge the need to restrain costs, but most of the remedies they offer are not likely to do much.

Electronic medical records to eliminate errors and increase efficiency, more preventive care to head off serious diseases, and better coordination of patients suffering multiple, chronic illnesses are all worthy proposals, but there is scant evidence they will reduce costs.

Well, I beg to differ. Adding oil costs way less than replacing engines. Preventing disease costs way less than "fixing" it. And yet, of every hundred dollars spent on "health care" in the US, less than $2 is spent on such prevention.

What it seems to me "is missing" is a serious discussion and investigation of exactly why and how we have, as a nation, become so blind to the obvious. And, why is this defect in our national perception resistant to any learning curve?

Since everything decays, including resistance to learning, something must actively be replenishing this social myth. Something like, say, today's NY Times editorial?

I don't want to spend today's column presenting evidence for the value of preventive care, except to note that your sense about oil in your car is correct. Maybe when I get done I'll add links to authoritative sources on preventive care. I've argued that before.

It is an astonishing fact that half of all increases in life expectancy in recorded history have occurred within this century and that most occurred in the first half of the century, before the introduction of modern drugs and vaccines. (Harvard University)

What I do want to do is look at the cultural and psychosocial factors that have created this blindness and that sustain it in the face of overwhelming contrary data.

Off hand, there are a number of contributing factors that spring to mind:

• Clinical health has far better marketing than public health
• Public Health is, effectively, clinically depressed
• Most players on the receiving end of the cash flow don't see the cash flow as a problem.
• Prevention is distant in space and time from the engine-failure event
• It's very hard to count events that would have happened but didn't
• It's very hard to "take credit" for successful preventive maintenance.
• Really good preventive maintenance staff tend to be fired, since "nothing ever breaks, so who needs them!"
• It's very hard for any politician to invest in efforts today that won't bear fruit until a decade from now, regardless how big the fruit is.

We can disentangle these factors somewhat more. Some of them are "perceptual" problems, where even good scientists lack good tools to see, let alone measure, what's called "distal causality" -- that is, causation far in time and space from events, or even harder, an absence of events.

THERE! DID YOU SEE THAT thing that just didn't happen! Just then!
LOOK! It didn't happen again!

Nope, we're not wired that way. Still, people can understand about putting oil in the car. What's different about health care?

A major factor here, generally not considered polite conversation, is a running battle well over a thousand years old between public health and the advocates of prevention on one side, and clinical health and the advocates of heroic acute repair on the other. Those receiving the money tend to argue that they are not biased by this cash flow, contrary to everything known about clinical trials and the insidious effects of bias on judgment. It certainly takes the punch out of arguing that the best "final state" to be desired, socially, would be the degrading of importance of hospitals and doctors or the elimination of both entirely to an era we'd all rather forget when people didn't know how to stay healthy.

I'm not saying that investing in public health would eliminate doctors, but it would certainly refocus them and you'd have to go well against human nature to expect them to be setting up as a national end-goal their own elimination as a respected and rewarded group. So, silence from the American Medical Association on this subject can hardly be viewed as an biased judgment call. And, to be fair, the AMA just elected a Dr. Ronald Davis, a preventive medicine specialist as president, so I suspect they know this change in focus is inevitable and are already reluctantly starting to prepare for it and shift focus to prevention and quality improvement and actually tracking "outcomes." At a recent talk at a Global Health Preparedness conference at the University of Michigan, Dr. Davis emphasized the links between public health and the AMA and his intent to build new bridges between the groups.

Amazingly, however, we don't hear the insurance industry advocating greater prevention efforts. I've inquired about this, and apparently they make money on transactions, not on keeping people healthy, so the corporate bias would be to want more transactions, if you get my drift. They aren't financially motivated to eliminate their source of revenue (broken engines.)

And public health mostly talks to itself, kicking the cat and muttering about how nobody loves them and there's just no point in talking, so have another drink and live with it. Their silence is actually probably due to a lack of funding for good media campaigns, as a result of the last 100 years being kicked across the schoolyard by the AMA and the insurance industry and other beneficiaries of the cash flow. I don't think "clinically depressed" is too strong a term for the state of the field. Most of the improvement in life-expectancy in the last century was due to public health (clean water, sanitary sewers, hand-washing regulations in restaurants, refrigeration, etc.) and occurred prior to the explosion of hospitals, following the Hill-Burton Act, in 1946, as well as prior to the explosion of use of antibiotics.

That, incidentally is a problem now, as antibiotics are increasingly reaching the end of their useful lifetimes, and the long-term result of their use has resulted in "super-bugs" like MRSA and VRE. Suddenly we see "infection control" moving back onto the radar screen, in hospitals and nationwide. We might, gasp, even expect to see a massive media campaign on the concept of washing hands after using the toilet, although if it happens it will most likely be paid for by public health, not the AMA, which still can't even persuade all their own doctors to wash their hands regularly.

Meanwhile, cholera is breaking out in Baghdad I see by the news, since the US blocked the flow of chlorine to public health facilities there, so water treatment with chlorine to kill cholera has stopped - something we just take so much for granted in the US we forget it is there.

So, there are issues with how humans perceive causation, compounded with power politics around a truly huge flow of cash - larger than the defense department, larger than oil. There is a huge invisible effect of bias blinding most doctors, who are generally good and caring people as individuals, to the true magnitude of this problem. (By the time they are done with med school, they're trapped in the system.) Trying to make a living as a "family doctor" in the US today is a losing proposition, totally underfunded as one of the front lines in prevention. So, the nations problems pale in light of the larger, more tangible, personal cash flow problems of just making a living in an insane system gone haywire and dysfunctional.

Public health academics mostly just talk to each other, although that's a common trait for academics in general. There is a dawning realization that no one in government or policy making positions is listening to them any more, and some movement to try to figure out how to have more clout -- hard, since most public health workers in the US are at or near minimum wage since the field is so misunderstood and devalued by the population, in a self-latching loop.
(No cash = no advertising = no cash, etc.)

Meanwhile, since no politician can educate the public against this tide of confusion, and they can't hope to benefit from getting credit now for investing in prevention of future things that won't happen in someone else's term in office, we can't expect much from them.

Still, I did expect more from the New York Times, than not realizing the value of prevention.
At least they could have said "There is scant attention given by us and other media to the overwhelming body of evidence that prevention would save well over half of our health care costs" and done a research piece on why that is.

Probably the last psychosocial fact I didn't mention is relevant there. Prevention would require that people "shape up" and let go of bad behaviors and adopt healthy behaviors - and that would seriously cut into both the profits of some big industries (tobacco, fast-food, alcohol, etc.) and ask people to take personal responsibility for their own "outcomes" instead of the philosophy of "party today and regret it tomorrow" that has become so prevalent.

Again, that could be fixed, but there are strong financial interests in not fixing that aspect of American culture. We still want "mature" to equate to "irresponsible." It may be fun, but other countries with less of that will be eating our lunch soon, and that won't be fun.

GM is blaming its woes on health care costs. According to Harvard's researchers, the largest single cause of bankruptcy in the US is medical bills. Changing who the middleman insurer is for this process will simply change the letterhead on which you get your bill for the engine repairs of yourself and your neighbors, but won't lower the bill.

Nothing will actually lower the bill until we "do less of that" and switch from a repair-mentality to a prevention-mentality. That would be worth about, literally, a trillion US dollars a year, but would require about a billion of that going to revitalize our champions in public health. ( You'd think this would be worth 1/200th of the $200 billion we do choose to spend on the War in Iraq next year in order to make us all "safer" and more secure from bodily harm. )

The fact that we, as a nation, can't do the math and see that trade-off is not helped by today's New York Times. I had hoped for more. I suppose we could dig one more layer further upstream and ask why the Times can't get its own research together anymore.

Meanwhile, looking in our own mirror, on a national scale dawn is coming, the party's over, and the guys with the bill are at the front door. I can't help but notice that neither the grand state of Michigan nor the US Congress has managed to get a budget together for the new fiscal year, that starts in a week. It's the first day of fall and summer is over. Nobody seems to want to face the music and look at the mess we've made for ourselves.

It will be more obvious when the Michigan government shuts down in a week, and the Federal government shuts down in mid-November (judging from prior times they've pulled this stunt.)
Still, it won't do much to improve our image internationally as the guardians of the world's "reserve currency." Or maybe, we've abandoned that role too.

But, here's one suggestion for the UAW - if you guys take on that $50 billion retiree health care obligation that GM is offering you, check out this idea of "prevention" and make friends with "public health." If we can't get the cost of health care in the USA under control, that trickle of patients heading out the door (with their money) to medical tourism sites abroad is going to turn into a flood, and there goes another trillion dollar a year industry outsourced to Asia. Then no Americans will have any money left to buy GM cars, because their medical costs will be hemorrhaging into pockets abroad.

It's like "fuel efficiency". This isn't a local issue any more. It's a global competitiveness issue. If we don't fix it, customers will stop coming entirely. Hospitals need to emulate Toyota and get "lean" about their costs in doing defect-repairs ("health care"), but the whole US needs to get "lean" and stop passing the defects downstream to hospitals and start fixing them upstream at the source, for the very same reason - the economics are killing us.

And, meanwhile, hospitals should consider a different long-term strategy than simply being superb at fixing the defects that are passed on to them by failures upstream in the nation's public health system, as that only institutionalizes the large-scale system structural problem and costs.

Hospitals need to transition increasingly to having positive value-adding roles, not just defect repair roles. They should consider being at the forefront of physical and mental and social fitness, and building our capacity to cope with life and build innovative and thriving industries, not just cleaning up the breakdowns and depression that come from failures in those areas. Then, their success is aligned with our success, and odds of long-term survival of all of us is improved.

Of course, if Hillary Clinton is reading this, remember that one rule of "lean" is that you have to guarantee the employees that, if the cooperate in making things run better, they won't lose their jobs. They may have different jobs, but they won't lose their jobs. Ditto for hospitals - if they participate in reducing their defect management role somewhat and support fitness enhancement programs instead, they need to be guaranteed no one will lose his or her job.

As always, the focus must be on the "customer". And as always, there is a hierarchy of customers, from individuals to families to teams to departments to companies to states to nations. If we do this right, it should be a win-win-win-... etc for everyone. Fit and healthy and innovative employees are what our companies need to thrive, and vice versa.

The job of public health should be to catalyze that win-win transition, and break the "us" versus "them" logjam, of "either" individual fitness "or" corporate fitness. Let's do the "and" solution instead!

Wade

What goes around comes around

It's not just "a small world" we live on -- it's a small "us" we are part of: there is, really just one of "us" here, with plants, animals, and people of all types including those with a "j" as the fourth letter of their middle name, or other irrelevant distinctions, such as "race" or "ethnicity" or administrative governmental unit of origin.

It turns out, viruses and bacteria don't really care about those distinctions that we take as so important. When bad things are let thrive, they come for all of us.

That would be true even if we had all come here from different planets, due to the intense "system effects" that mean anything affects everything, and vice-versa.

It's even more true since we were all born here on Earth, as were our parents, and our grandparents, etc. on backwards. (aside from my 2nd grade gym teacher, who I think was from Mars.)

So, we need to be very careful of the glee we take when someone "else" has managed to shoot a hole in the bottom of "their end" of our lifeboat -- and more so if we were involved in handing them the loaded gun.

This basic physical truth is one basis behind the various religions' description of the Golden Rule - some variant of "Do unto others as you would have them do unto you". Or we have the Christian Scriptures, where Jesus says (see other versions)

KJV: And the King shall answer and say unto them, Verily I say unto you, Inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me. (Matthew 25:40).

Or, Islam's Book of Sincerity -'The believer will not truly believe until he wishes for his brother that which he wishes for himself.'

So, in today's papers we see some of that effect coming into play.

First, the home mortgage market. I wrote about the present disaster that is unfolding on us now back when there was still time to do something:

Honey, We're losing the house - Dec 7, 2006 (Pearl Harbor Day).
The Mortgage Trap Begins Closing - Dec 11, 2006
How does that help me? - Average American -- May 22, 2007
Rising Rates and the Soon to be Homeless - June 15, 2007
More on Foreclosures for the Baltimore Sun - June 15, 2007

So, what started as a large scale scam to dupe poor people into buying homes they couldn't afford and then close the trap on them has now turned into an international incident roiling stock markets around the globe. Now even rich people are being affected! Here's something from this morning:

In a Spiraling Credit Crisis, Large Mortgages Grow Costly.
New York Times
August 11, 2007

When an investment banker set out to buy a $1.5 million home on Long Island last month, his mortgage broker quoted an interest rate of 8 percent. Three days later, when the buyer said he would take the loan, the mortgage banker had bad news: the new rate was 13 percent.

“I have been in the business 20 years and I have never seen” such a big swing in interest rates, said the broker, Bob Moulton, president of the Americana Mortgage Group in Manhasset, N.Y.

“There is a lot of fear in the markets,” he added. “When there is fear, people have a tendency to overreact.” ...

For months after problems appeared in the subprime mortgage market — loans to customers with less-than-sterling credit — government officials and others voiced confidence that the problem could be contained to such loans. But now it has spread to other kinds of mortgages, and credit markets and stock markets around the world are showing the effects.

Those with poor credit, whether companies or individuals, are finding it much harder to borrow, if they can at all. It appears that many homeowners who want to refinance their mortgages — often because their old mortgages are about to require sharply higher monthly payments — will be unable to do so.

Some economists are trimming their growth outlook for the this year, fearing that businesses and consumers will curtail spending.

“You find surprising linkages that you never would have expected,” said Richard Bookstaber, a former hedge fund manager and author of a new book, “A Demon of Our Own Design: Markets, Hedge Funds and the Perils of Financial Innovation.”

... There were reports that a surprisingly large number of loans made in 2006 were defaulting only months after the loans were made.

There have been sudden changes in the mortgage market before, but this one may be both more severe and more damaging than those in the past.

I Investors made the mistake of assuming that housing prices would continue to rise, said Dwight M. Jaffee, a real estate finance professor at the University of California, Berkeley. “I can’t believe these sophisticated guys made this mistake,” he said. “But I would remind you that lots of investors bought dot-com stocks.”

He added, “When you are an investor, and everybody else is doing the same thing and making money, you often forget to ask the hard question.”

And that is how a problem that began with Wall Street excesses that provided easy credit to borrowers — and made it possible for people to pay more for homes — has now turned around and severely damaged the very housing market that it helped for so long.

Not everyone had evil intentions, although predatory practices certainly worsened the problem. We have yet another case of what Jay Forrester called (50 years ago) "The law of unintended consequences", although at this point in our history I don't think these can be called "unexpected consequences" -- aside from the expectations of the structurally blind who have been deceived by their own myths.

In fact, this area of self-induced blindness is fascinating, and scary, and relevant to understanding why so many personal, management, and governmental level policy decisions look so stupid in the morning. Or, as the cartoon strip Calvin says: "How come dumb ideas seem so smart when you're doing them?" And in turn, that is akin to my favorite Snoopy cartoon:

Did you ever notice
that if you think about something at 2 AM
and then again at noon the next day
you get two different answers?

I was trained as an instrument pilot, and we were carefully taught how to read each instrument so we could navigate when you couldn't see out the window. One item in the tool kit was curious - a 3 inch disk covered with suction cups, suitable for holding soap in the bathroom. "What's this for?" I asked. Well, it turns out that is to save you from the alternative, which is smashing the face of an instrument on the cockpit panel so you stop paying attention to the blasted thing when it has decided to lie to you convincingly -- you can stick this over the instrument so you don't see it anymore.

Because, it turns out, all our instruments, and senses, lie to us. It's only by comparing notes that we can detect that one of them is "acting up". It's invisible by itself, in isolation, as are the tricks our own minds play on us. As Calvin says, - why do these things look so smart at the time? This is a serious question and worth reflecting on.

But cockpit instruments, computer readouts, or the minds of Calvin, Snoopy, or you or me, all can lie to us in the most convincing way. Most of the time they are right, some of the time we know the results look "funny", and some of the time they are very wrong but still look perfectly right. The altimeter tells us we're climbing when we're descending and about to crash.

That's what "consultation" is for. We need independent confirmation by others, preferably others who are not subordinate to us or trying to please us, or selected as friends because they always seem "agreeable" - ie, agree with us whether we're right or not. One of the strengths of "diversity" is that a diverse group doesn't share the same blind spots. So when that hand goes up, even though that person is "obviously wrong", we need to pay attention, because maybe our "obviously" unit is broken. It happens a lot, it turns out, to all of us.

I have an entire book titled " Why do smart people do dumb things?". It's a good thought. Getting caught up in the herd stampede is often one of the wrong things to do, even though we've been genetically selected from those who did listen when the herd detected a predator coming that we had missed. The impulse to go with the herd is "hard-wired" into our DNA now, and hard to even detect, let alone block.

This is well known in stage magic, which my dad taught me. Even if some guy in the third row sees what you're doing, if no one around him believes him, he will actually "un-see it", and by a few minutes later will have forgotten he ever thought he saw it, even though the videotape shows him seeing it, and asking people around him if they saw "it".

Well, I said at the front that there were two items where what went around came around - or where efforts to discriminate against and exploit poor people turned out to come back and bite us. My point is, those aren't unusual events, and don't require "God to see what we did." -- those are "system effects" in a small world.

Throwing out the concept "God" and being "scientific" does not remove our ultimate accountability for our own actions. We are still in our own prop-wash, and need to adjust to that fact of life. We are not finally free to exploit our neighbors or even distant lands with impunity, and no "terrorist" or "God" is required to bring the deeds of our hands back into our lives, often with amplification.

The bogus mortgage scam is one. The other is the concept that we can deny some people health care, and "get a way with it" or even "be further ahead because of it." Obviously, that is the unspoken assumption -- that the fate of "them" over "there" is completely distinct from the fate of "us" over "here."

The lessons of small-world systems thinking is "Not!". We're in the same lifeboat, and look identical to invading viruses and bacteria, that we have much more to fear from than "immigrants". In the US alone, it's now estimated that over 75 million people go without "health insurance" each year.

Actually "insurance" is a bogus concept and not necessary to the equation, and only muddies the water with middle-men concepts and fragmented thinking. So let's be clear. About a third of the US population has primary care health problems that could be taken care of, that should be, but aren't, each year. This number is rising, inexorably.

God may or may not "see", but viruses and bacteria and other bad things can detect "lunch" when they see it, as well as predatory corporations like Tobacco or Alcohol can. And, given air travel, our own "backyard" now includes most of the globe. Diseases that find a portal into our world through the poverty in India or China can result in deaths from disease here in the USA in under 48 hours. It's a very small world to viruses as well, who get to ride international flights, first-class for free.

But when they get here, where will they gain a foothold? Hmm. Maybe they can start in the sections of our towns where we let people get ill or die, more or less abandoned, because "there's nothing we can do?"

A while back I reported on the lady who died slowly, screaming in pain, on the floor of the King hospital in LA. , while everyone stepped over her and the janitor mopped up the blood she was vomiting. We do have a culture capable of doing that, of not seeing, on so many scales.
( A Patient Dies in Los Angeles - System Views. May 20 2007)

Well, the scale has just moved up one more level in LA, as that hospital failed inspection and was closed this week - removing the only hospital for miles around for poor people in that area, replacing poor care with none at all.

Los Angeles Hospital to Close after Failing Tests and Losing Financing.
New York Times
Aug 11, 2007
Jennifer Steinhauer and Regan Morris

Excerpts:

LOS ANGELES, Aug. 10 — Martin Luther King Jr.-Harbor Hospital, built in the aftermath of the Watts riots and one of the few hospitals serving the poorest residents of South Los Angeles, is headed for closing after federal regulators found Friday that it was unable to meet minimum standards for patient care.

At a news conference Friday, county officials said the hospital would probably close within two weeks, after patients were moved to other hospitals. All 911 calls will direct ambulances to one of the nine other hospitals in South Los Angeles. An urgent care center will operate on the site 16 hours a day.

he loss of the hospital for residents of the Watts/Willowbrook area of Los Angeles.

“They are going to be left without a safety net for health care,” said Janice Hahn, a Los Angeles city councilwoman whose district includes Watts. “There will be no trauma care, no emergency care and a lack of the basic services this community needs and deserves.”

Nearly since its opening 35 years ago in Willowbrook in South Los Angeles, the center has been a symbol of both the political neglect of South Los Angeles and its struggle to emerge from blight.

It pointed to many successes — it was once a teaching hospital for the nearby Charles R. Drew University of Medicine and Science and featured a respected neurosurgery unit — and in a neighborhood riddled with gang violence and myriad health problems common to poor urban areas, it was a safety net, though an increasingly imperfect one, for the poor and uninsured. The nearest public center is several miles away, which, in an area with many poor residents without cars, means nearly inaccessible.

Debates over the hospital’s future have always been tangled in racial politics. “It is actually quite tragic that this hospital that came into existence with such high expectations now dies because of the culture of incompetence,” said Joe R. Hicks, vice president of Community Advocates Inc., a Los Angeles research group. “It suffered what has often been called the soft bigotry of low expectations, because the Board of Supervisors were aware that the hospital was being nicknamed killer king by people who lived in the neighborhood and they continued to hide the ball.”

Others echoed the criticism. “The Board of Supervisors failed to put enough money and personnel into the hospital,” said Earl Ofari Hutchinson, a Los Angeles political commentator. “And now,” he said, “we are asking the question we always ask: Where are all these people going to go?”

What's the thought here - that "these people" should just die quietly and not bother "us"?
Regardless, I'm struck by the quote referring to the "soft bigotry of low expectations", that saw problems and just kept on doing nothing , or maybe never actually really "saw"the problems, but just kept on stepping over the writhing body on the floor.

That was true of the ER staff there that night, and of the management of the hospital, and the oversight Board, and of the State of California, and of the whole United States. We continue to just keep on "stepping over the body" as if it's not there or not our concern.

At that IS of concern, because the larger scale analog to the hospital closing is the whole health care system of the USA collapsing under its own weight, like some bridge in Minnesota.

Blindness is contagious, like the measles. We have to learn how to be blind to the pain of others, but then, once we master that, we can apply that blindness to being blind across the board.

Maybe, that's not the best strategy for keeping the plane in the air. We made this mess, and we can clean it up, but first we have to come to grips with national-scale denial that there is a very serious problem.

A Patient dies in Los Angeles - Systems Views

The LA Times reconstructed the scene today from the videotape and interviews.

Parked in the emergency room lobby in a wheelchair after police left, she fell to the floor. She lay on the linoleum, writhing in pain, for 45 minutes, as staffers worked at their desks and numerous patients looked on.

Aside from one patient who briefly checked on her condition, no one helped her. A janitor cleaned the floor around her as if she were a piece of furniture. A closed-circuit camera captured everyone's apparent indifference....

Alerted to the "disturbance" in the lobby, police stepped in — by running Rodriguez's record. They found an outstanding warrant and prepared to take her to jail. She died before she could be put into a squad car.

How Rodriguez came to die at a public hospital, without help from the many people around her, is now the subject of much public hand-wringing.

Questions are being asked of "How could this happen?"

Rodriguez's son, Edmundo, 25, said he still couldn't understand why his mother died. "It's more than negligence. I can't even think of the word."

And blame is being focused on the last person in what always proves to be a very long chain of contributing events:

David Janssen, the county's chief administrative officer,... said that the preliminary investigation suggests that the fault primarily rests with the nurse who resigned. "I think it's a tragic, tragic incident, but it's not a systemic one."

But, while legal issues of blame proceed, from the bleachers we can start an analysis of the "system factors" that all came together in this tragic result. And, as with many previous studies in errors, odds are very high that there are many more distant factors that were are work here. It is important to delve into the always-surpising world of "How could this happen?"

You can read the Times article, and start with as much information as I have, but I'll try to put it into a "systems thinking framework."

First, though, let's abandon the idea that the nurse is "to blame." Yes, she may have made an error in judgement - but that's a type of problem humans have that is fully predictable, and the collection of other people around her should have caught that and reversed that error before harm occurred. So, remove the nurse entirely from your mental picture of the scene, and just look at what else was going on, as we change the "zoom" setting on the lens and back out to larger and larger contexts.

First, an entire room of other people, patients and staff, was apparently paralyzed. We need to ask how that sort of thing happens. This brings to mind the Kitty Genovese stabbing and slow death in New York City, where hundreds of people watched from their apartments and did nothing, not even call 911. It brings to mind Stanley Milgram's famous experiments, where subjects, told by a person in a white coat to deliver electric shocks to another person, continued to do so far past the point where the other person screamed and finally went silent. It brings to mind not only "It's not my job" but also "... and the last time I intervened I was punished and told if I did it again, I'd be fired."

It seems that everyone in the room, staff and patients, had been conditioned to observe an unfolding tragedy, and sit passively by and do nothing. Hmm. Sounds like the sort of operant conditioning and behavior modification that 20 years of watching television might create.

Actually, it also sounds like a lot of people were in a burned out, depressed, helpless, hopeless state and maybe had given up trying to change the world around them, and this was just one of a hundred things around them daily that was going wrong.

It appears that the patient was Latina, overweight, and had no health insurance or regular family doctor. We might investigate bias, bias, and an entire nation that seems to stand by indifferently while 50 million residents of the US with no "coverage" try to get adequate primary medical care by swamping emergency departments. This problem is very well publicized, but the American public is too busy with other problems right now to focus on that.

On a mid-range scale, it seems that California or Los Angeles is standing by, not helping, while another hospital that attempts to help the poor sinks into debt and finally drowns.
The LA Times article points out:

The incident has brought renewed attention to King-Harbor, a long-troubled hospital formerly known as King/Drew....Over the last 3 1/2 years, King-Harbor has reeled from crisis to crisis.

Based on serious patient-care lapses, it has lost its national accreditation and federal funding. Hundreds of staff members have been disciplined and services cut.

Janssen said he was concerned that the incident would divert attention from preparing the hospital for a crucial review in six weeks that is to determine whether it can regain federal funding.

If the hospital fails, it could be forced to close.

Then what? Then what will the people in this neighborhood do for primary and emergency medical care? Drive 45 minutes to Beverly Hills? The same problem of inner city hospitals closing is visible across the US. They want to move out to the rich suburbs and focus on care for rich people with great health "coverage." Or, they have no choice, because of the perverse "unintended side effects" of demanding that they must provide emergency services to anyone who shows up, whether they can pay or not - and a national health care system that means 50 million people can't pay. The public hospitals and all the caring staff in them are being burned out, gutted, and deleted.

One of the roles of the field of "Public Health" is to hold up such uncomfortable mirrors, stop focusing entirely on how to repair gunshot wounds in the Emergency Room, or how to get faster ambulance dispatch, and start asking why so many people are getting shot in the first place.

Yes, in this case a nurse resigned. But, in many ways, it appears that she was a victim too, and likely a person who went into nursing because she really wanted to help, and tried to help, and just finally ran out of the ability to cope with the job that society had created for her. Day after day, night after night, social tragedies that could at best be patched and sent back out into the world to be damaged again and return again. I doubt that she started as a mean or uncaring person. How many hours had she been on duty? How was she coping with the fact that even this job looked like it would evaporate soon? What else was going on that she needed to attend to?

No, I don't think that removing this single person will "fix" this problem and stop such things from ever happening again in this hospital or in Los Angeles or in the USA.

How can people just look the other way? It's baffling.

But, now that we've all seen this larger issue squirming in pain on the floor, and feel helpless to do anything about it, it must be time to shake our heads in disbelief at "those people", and go see what else is on TV.

I'm not trying to be mean - only to illustrate that this problem of being overwhelmed with other people's problems is not some local thing that only happens in this hospital ER in LA. That doesn't make it less of a problem - it makes it more of a problem.

When a whole nation says "there's nothing we can do..." it's right, but it's wrong.


Article: Tale of last 90 minutes of Woman's Life,
By Charles Ornstein
Los Angeles Times
May 20, 2007

The Future of Emergency Care in the US Health System
Institute of Medicine, June 2006

Crisis Seen in Nation's ER Care
The Washington Post (registration required)
June 15, 2006

Emergency medical care in the United States is on the verge of collapse, with the nation's declining number of emergency rooms dangerously overcrowded and often unable to provide the expertise needed to treat seriously ill people in a safe and efficient manner

Emergency Medical System in Crisis, USA
Medical News Today

Emergency Care - A system in crisis
Journal Watch

Kellerman AL. Crisis in the emergency department. N Engl J Med 2006 Sep 28; 355:1300-3.

Photo credit: In the Emergency Room by ebilflindas

The Sixth Discipline of Learning Organizations - part B

Yesterday, in my post The Sixth Discipline of Learning Organizations, I reviewed a few of the lessons Peter Senge's book The Fifth Discipline teaches that we can learn from thinking in circles, not in lines.

There are other properties of loops that are critical, but as subtle as the difference between the behavior of a spinning bicycle wheel (a gyroscope) and a stationary one, or attempting to throw a plate or a playing card that is spinning rapidly versus one that is not spinning. At first glance you might say - it's just spinning, so what? But the behavior of trying to throw a plate and a "Frisbee" is quite different - the plate may go 20 feet and the Frisbee 100 yards.

Spinning rapidly in a circle matters. All feedback is not the same. The speed of feedback in a feedback loop also matters. The feedback rate matters ( loops per second or per day or per year).

But this morning I want to start looking at vertically oriented loops in hierarchically structured organizations - for which a triangle or pyramid shape is more helpful than a circle for discussion.
(Imagine the pyramid shown on the back of every US dollar bill.)

Say that the "boss" is the eye on the top of the pyramid, and that the boss's orders come down the right side, through the "chain of command" (which is actually a branching tree shape.)

At the bottom of the organizational pyramid, where it actually touches the reality and "ground truth", employees attempt to carry out those orders, and imagine that activity moving us from right to left across the bottom of the pyramid. Finally, status reports ("mission accomplished!") move back up the chain of command being consolidated at each level all the way back to the boss at the top. So, we have a vertically oriented loop, or cycle, because now new orders come down the chain and that loop pattern repeats.

So far, so good.

In a static, simple world, if all employees except one named "Joe" report success, and Joe keeps reporting failure, the classic model would say that the action management needs to take is to replace Joe. The model says all employees are interchangeable machine parts and if a part fails to do its job, the part is broken and should be replaced. This is a simplified version of McGreggor's "Theory X" of management, very popular in the machine age, from 1850 - 1950.
Another implicit assumption is that the boss completely understands the tasks to be performed, and is the resident expert. If people don't "perform" it must be because they are "lazy" and what is needed is a "bigger whip." Employees are told to "jump" and they don't need to understand why or agree -- they just need to ask "yes sir, how high sir?"

That model worked for early industrial models, such as workers in textile mills, or slaves picking cotton.

But, in a dynamic, complex world, that model breaks down and doesn't work. Actions and responses that worked yesterday suddenly no longer work. The "cheese has moved." The organization has to learn new responses to the same old inputs. The response of the outside world to an action is no longer predictable, and has to be judged based on rapid-feedback and a quick poke to see what happens and learning from that. We move into McGreggor's "Theory Y" of management where the expertise is now on the bottom of the pyramid, where front-line
troops are as likely to reply "What bridge? The bridge is gone!" as "OK, yes we crossed the bridge." Now an ever-changing set of facts or dots of information have to be aggregated upwards and "reporting" has to change into continuous "sense-making" of shifting patterns and images of the battlefield truth.

Again, this model is not that strange. It's the basic model we use when we have to move a bit of food from the table to our mouth on a very windy day - we move the hand a little, see where it is now, move it a little move, see where it is now, etc., in a very rapid sequence that automatically adjusts for the wind. If we don't adjust for the wind, the hand and food will miss the mouth on the downwind side. We don't "compute" wind velocity and use Newton's laws to figure out what to do - we just do it and watch while it's happening. It's no big deal. It's the basic "cybernetic loop" of tiny intent, tiny action, tiny perception, and repeat the loop rapidly over and over. It's a loop we can use to cross an unfamiliar room in the dark. Move slowly, stay alert and aware, and adjust as you run into things. It works. It doesn't require quantitative analysis or calculus or a computer or a PhD in robotics. It just requires using a very basic action and sensory loop over and over.

And, like any feedback loop, causality disappears in the normal sense. Motion alters perception and perception alters motion and the two become one, in a very real sense, a single motion-perception action and a loop as an actor.

Again, no big deal. So why is this important?

The big deal is that our society is in the middle of adjusting to this change from "Theory X", and a stable, static world with expertise at the top to "Theory Y" with a very dynamic, unknown world and the expertise at the bottom. In fact, because of the property of loops, there really is no longer much of a "top" and "bottom" in the classical Theory Y sense of the terms.

Just as the level of the water could be seen to control the hand on the faucet, the staff at the bottom of the chain of command can be seen to be controlling the General at the top of the pyramid -- and both those models are wrong, because it's actually the shape of the feedback loop that now has taken on a life of its own, on a whole different scale, and is controlling both of them.

Senge's point, and mine, is that most of the organizational problems we see around us are because we haven't managed to get that much right. In some health care organizations, an extreme case of the expertise being on the "bottom" of the pyramid, the top management still thinks in "Theory X" terms and tries to see itself as the expert in everything and "gives orders" to move in a certain way. The body reports back "No -- what bridge?" and the boss sees this as stubbornness, stupidity, or hostility and things just get worse from there.

Arguably one of the best "learning organizations" around is the US Army. I've mentioned many times before role of Doctrine in FM22-100, the US Army Leadership Field Manual. The pyramid model I just described is the theoretical basis for the doctrine, and every field action is supposed to be followed with a "lessons learned" session. News, particularly surprising news about a misfit between upper management's concept of where the battle or bridge should be and what actual boots on the ground see in front of them, is supposed to be free to travel upwards. Management, as it were, is supposed to listen to the staff and learn what's actually going on, not what management imagined yesterday was going on. It's not insubordination to say "Sir, What Bridge Sir?"

By simple trial and error experience, repeated millions of times, the Army has finally figured out what works and what doesn't and come to some conclusions that are startling to the Theory X old guard, but not at all surprising to the Theory Y thinkers. For one thing, listening has to go upwards, at every level. It's as important that superior officers listen to junior officers as vice versa. If new conditions at the bottom don't result in a new picture of what's going on at the top, the whole pyramid will simply drive off a cliff or otherwise carry out actions that bear no resemblance to reality.

And, because the picture of reality is not perceived directly, but has to come up the chain of command and be re-filtered and consolidated at a dozen different levels, that process has to be incredibly accurate, frank, honest, and unbiased. Even a 10% "adjustment" in facts, repeated over and over at each level of consolidation, can result in a reported "reality" at the top that is 180-degrees out of whack.

In a profound sense, the key word is integrity, and not just integrity when the going is easy, but integrity when the going is tough - not because of enemy action but because of "friendly fire from above". That kind of integrity is also part of the other key word in the doctrine - character.

If the information flows freely and rapidly and can spin up to a high rate of rotation, as with a bicycle wheel or gyroscope, this whole design pattern becomes very stable, agile, nimble, and capable of navigating the most bizarre terrain as events unfold in surprising and unexpected ways. BUT, if there are pockets of resistance to the flow of information, such as cover-ups, that model breaks down. Or, if there are superiors who think "superior" means they know everything and they don't need to learn from their men, the model breaks down. So, another few important words are honesty and humility.

See US Army Leadership Field Manual FM22-100
and What relates Public Health and the US Army?
and the whole posting from my Capstone slide 7 Theories are Changing which has twenty more references to the literature on high-reliability organizations in nuclear power plants and chemical plants and aircraft cockpits and hospital intensive care units, and what makes them actually work in practice. It just keeps coming back to the same thing and the same model that's right in front of us be we haven't finished mastering.

And, again we have a place where our religious heritage has been observing what makes society work for thousands of years and has more wisdom to offer on this than scientists, although the science is beginning to catch up at last. Our religions have been stressing virtues - integrity, honesty, compassion, humility, etc. - for centuries but we haven't really been listening or haven't thought that "mattered any more in the modern age." Actually, the basic cybernetic model is ageless, and true at any size and scale. It's going to be something we have in common with aliens from other worlds when we meet. It's a universal truth every bit as solid as other physical "laws" we rely on.

These are truths that are seen by Hindus, by Muslims, by Christians, by Jews, by atheists, and by learning organizations like the US Army. They can serve as a basis for unity among even such diverse groups and cultures. They can link science and religion without either side having to admit they were wrong about something and lose face.

Grasping and implementing that truth certainly looks like it could give us far more "bang per buck" than investing in new technology, new weapon systems, new gizmos and gadgets, and other ways to shift the detail complexity around.

Also, see my early post Virtue drives the bottom line with many links at the end to such literature. (excuse the formatting near the top of that post - I'm technically challenged by the html editor.)

Another author's take on this subject is "Spirituality in the Workplace - The Sixth Discipline of a learning organization, by Harish Midha at the University of Toronto.

Peter Senge's latest book is Presence: Human Purpose and the Field of the Future and readers interested in that book might also be interested in Stephen Covey's book The Eighth Habit. All these books teach the same gospel - that we are going to have to come to grips with the nature of community to "make it" through our social problems of this century, and that community requires us to realize the power and impact of "virtues" when amplified by the feedback properties of complex systems.

Another post I wrote exploring the role of community, virtues, and organizational learning and agility is The Importance of Social Relationships (short)

I also recommend: Pathways to Peace - beautiful slides and reflections to music on the value of virtues

A general summary of what I think are my best dozen posts on related subjects is here.

This is also relevant:

Spiritual solutions for technical problems

Enjoy, and please, for reasons this whole post embraces, send me feedback! A human can't sustain a thought without some measure of social support! Criticisms and objections are welcome. Use the comment box below, or send to my email in my "profile" box above.

Wade

The hierarchy of life and implications for interventions

Apparently, we don't exist.

Every day more studies come out showing something that we'd suspected all along - namely, we actually have very little control over our own lives and even over our own decisions.

The people around us and our neighborhoods, at work and at home, are increasingly seen as the main cause of our beliefs, our decisions, and our actions.

Well, that just messes up everything, thank you. Our whole system of justice, and education, and rewards at work, and "the American way" are all based on the concept of rugged individualism, on one dominant person surrounded by a sea of "environment", making decisions, navigating the shoals of life, and deserving rich rewards for success or punishment for "being bad."

But that concept doesn't seem to survive the light of day, or a careful look at the evidence. And much of the evidence lately is coming from public health, including studies of the "health" of the "healthcare system" itself.

A very "robust" finding of the field of "social epidemiology" is that the physical health of a person seems to be very strongly associated with his or her "connectedness" with the tissue of society around them. The more someone is connected to the social fabric, the healthier they will generally be. The more someone disconnects and drops out of social interactions, the worse they will tend to be, across the board, in terms of almost every measure of morbidity and mortality. They'll be more depressed, more fatigued, less successful, less wealthy, more likely to be obese, more likely to have depression, diabetes, heart disease, asthma, the flu, common colds, etc.

But, does disconnection cause disease, or does disease cause disconnection?

The answer is "yes" to both, because this is not a linear chain of causality, but a causal loop. That means it can spiral downwards or upwards.

That's familiar. The more a person becomes depressed, the more likely they are to fail to cope, to get into trouble at work and home, and to worsen their situation at work and home. And, the worse their situation becomes, the more depressed they become. It's a "vicious cycle."

The ultimate end of that death spiral is, in fact death. There is complete disconnection and isolation, total dropping out, followed by catching the next excuse to die, from natural disease or neglect or violence, or violence against others (death by police). Just as a human cell, removed from the body, will lose the will to live and commit suicide ("apoptosis"), humans,
disconnected from the social body, lose the will to live, and find a way to die.

This is a real bummer in several ways. One unexpected way is that almost all research studies are based on statistics developed by a guy (Sir R. A. Fisher) studying crop yields where the causality only goes one way. The crops do not realizing they aren't growing and make midnight raids on the fertilizer shed. People, however, do. In fact, almost everything people do, or collections of people, are just drenched and dominated by feedback loops. And feedback loops invalidate classical statistics based on lines, not circles. (It's based on the "General Linear Model"). So, it's hard to study. So, people don't study it and go study something else.

Of course, there are tools that can easily handle such loops, including electronic circuit design or "system dynamics" or "feedback control system engineering." But those are almost unknown in public health so don't hold your breath.

Despite that, the evidence just leaps off the page. The most successful interventions in health care, as described in "Health Program Planning - An Educational and Ecological Approach" (4th ed) by Green and Kreuter, apologizes for abandoning classical models on page 3, with the comment that

"Ecological approaches, however have proven difficult to evaluate because the units of analysis do not lend themselves to the random assignment, experimental control, and manipulation characteristic of preferred scientific approaches to establishing causation."

Which is a long way of saying that the old set of "linear" tools and linear thinking really doesn't work, if you try to apply it to the real world that people, not billiard balls, deal with daily - a world dominated by feedback.

But, all is not lost. Even despite that, the healers of the healers, the designers of the health care system itself, have studied their own problem and concluded that the right unit of intervention is the small team on the front lines, which they call a "microsystem." In between the one doctor who is hard to change, and the hospital, which is hard to change, is the small practice team, which, fascinatingly, the Institute of Medicine has found easy to change.
(See Crossing the Quality Chasm.)

And, ta da!, big surprise, the recommended method of changing that unit of life, the small team, turns out to be "feedback." Well, of course it's feedback - that much becomes obvious once you shift lenses and realize that everything, at every scale, is more defined by what's outside it than what's inside it. (Mach's principle in cosmology.)

So, a single doctor or staff member can't really be changed by an intervention, because their behavior isn't really "theirs" -- it is a feedback property of the small team they work with. So, if a doctor or nurse "makes a mistake", it usually turns out that the place to fix isn't the individual, it's the larger structural team around them that effectively forced them to make the mistake. The system buys the gun, loads the gun, cocks the gun, hands it to the person on the front line who pulls the trigger.

And, on the flip side, there is no such thing as "the patient." Patients are people, and people come with a posse, an aura, their own small team of friends and family that mutually influence each other. So, ta da!, if you want to change how "a patient" behaves, or go a step further upstream and change what they believe, you have to address how the patient's "microsystem" behaves. The IOM didn't make that leap, but the rest of health education has realized that "family-centered" interventions are way more effective than "patient" interventions.

Of course, this really only changes the geographic and time scale, something the IOM hasn't yet realized.

This property of being defined by the outside peers is not restricted to cells or to people - it's a universal property of living things or any regulatory control system.

So, it's "scale invariant". That means if we flip to the next lens on our microscope and stand back another hundred yards, now we see the unit we are messing with is "the microsystem" but it is swimming in a sea of other "microsystems", and is ultimately dominated by the other microsystems as a peer group. Now, the time constant is much longer, so it may take months not days, but simply changing one small team and leaving its environment unchanged will sooner or later result in the change being undone, rejected like foreign tissue, and discarded by the larger living tissue of the body of the health care system. People will revert in hours. Clincial services may take months or years to revert, once the intervention pressure is released.

Man, how far does this thing go? Well, according to many people such as myself or Ken Wilber, it just keeps on going upwards. Wilber refers to one of these structural ladders of the hierarchy of life as a "holon." Norm Anderson, when at the NIH, refered to the same hierarchy from cells to tissues to organs to people to groups to neighborhoods to populations -- but nobody really wanted to hear that, so Norm left. The tissue rejected the novel idea.

Well, that math just gets impossible then, doesn't it? Not really, it just rotates. Large, tall, hierarchical structures have their own basic modes, as does anything else. There are almost certainly solutions that can be found, or descriptions, based on combinations of scale-invariant (symmetric) properties as basis vectors. And one such scale-invariant property is the concept of a regulatory feedback loop. At every level of this nested hierarchy, exactly the same problem has to be solved - how to maintain the equivalent of homeostatis in a sea of change. Cells do it. The pancreas does it. The Endocrine system does it. The body does it. People do it. Small teams (microsystems) do it. Hospitals do it. Health care chains do it. Whole cultures do it. Nations do it. They're all doing the same abstract dance, of seeking to reestablish their own feedback loop that works for them.

So it's kind of a fractal, a Christmas tree shape, where each branch is the same shape as the tree itself. The question is, what are the fundamental modes of vibration of such thingies? If it were made of steel and you plucked a branch, what would it sound like? (There would surely be harmonics of harmonics of harmonics.)

And, do such things have "resonant frequencies"? Is there some speed of change that will work far better than other speeds, or one that is far easier to "fall into" because it "aligns" with the larger resonance of the larger system around it?

Those are the interesting questions. In the short run, we have some immediate insights that don't need years of theoretical simulation and wisdom, based on this model or framework or lens, whatever you call it.

Here's a few:

1) To change a person, you have to change their peer group. They can move to a different peer group, or the peer group itself can be altered, but it has to happen.

2) etcetera. That is, you can't change that peer group, stably, without clicking up one more rung of the ladder, using a new power lens, and finding the peer-group's peer group.

3) Therefore, either you have a cascading, exponentially growing evangelical type of change, or you have a diminishing, exponentially decreasing, tissue-rejection kind of change. There is no such thing as a stable change of one "unit" at any scale. Life doesn't support constants, only growth or decay.

4) Our whole system of justice, education, rewards, and punishments is based on a flawed model of the world. That's all going to have to be rethought. All this emphasis on individual education has already run into the increasing emphasis on "teamwork" and "groupwork" and a realization that the unit of research, of discovery, of industrial production, of making or preventing errors is not a person, but a "Microsystem", a team, a cockpit crew, an operating room team, etc.

5) We're going to have to "bite the bullet" and start using the right tools to address these problems. They don't fit into the general linear model. All linear statistics break down and all linear thinking leads to erroneous intuition.

6) Collaborative IT systems are feedback loop generators, not huge replications of a single human-machine interaction. The "electronic health record", viewed this way, is part of the feedback loops that a patient uses to control his own life, or a doctor uses to control and manage their care for the patient, each side also calling on their own "microsystem" team to support this activity. Such systems cannot be evaluated or tested as if they were an Excel spreadsheet with a Graphic User Interface -- the human factors are feedback loops that can't possibly even show up in single user testing. The system will be made or broken on how the larger social fabric changes feedback loops when the system is put in place. That won't be revealed by the current CCHIT test suite.

7) This model would say that the right thing to be tracking for hospital adminstrators would be microsystems and teams, more so than individuals. The "dashboards" should reveal whether the microsystems are working, and, moreover, the people who need the dashboard aren't just the management outside the team, which is post-hoc, but the team members themselves for real-time self-management, steering and navigation. (That's straight out of the IOM's Crossing the Quality Chasm.)

8) Ditto for patients. This model would say that patient teams need their own Personal Health Record as part of a real-time feedback self-management model, that the doctors or clinical staff are only a very small remote second-order part of, for chronic disease management that involves life-style changes.

9) And, ultimately, this model points ever upwards. It says that people cannot be healthy unless their peer-group is healthy, and that cannot be healthy unless it's peer group is healthy, and, ultimately, all this depends on the national culture and planetary population being healthy.

So, yes, not only are you your brother's keeper, but your brother is, in many real ways, your keeper.

10) The "public" that "public health" must be concerned with (among others) is actually a fractal, nested, hierarchical part of the hierarchy of life. This cannot be made to "go away."
We need to "go to the mountain." Predictions as to the value of interventions in the behavior of a part of that hierarchy, on some level, whether cellular drugs or pancreas care of health system regulations, have to take into account that the parts are connected and will determine each other's behavior through feedback responses to interventional pressures.

It doesn't make sense to say "we put in a good system but the culture rejected it." The word "good" needs to be defined with respect to the whole hierarchy of life including culture. If the system is "good' in that metric, then the culture will, almost by definition, not reject it.

Well, that's pretty pedantic, and maybe you have a different view or some contrary evidence. I'd love to hear it. Let's have a good debate! See that "comment box" down there? Please use it and tell me whether you think I'm right, wrong, or need to increase my meds! Or email me. My email is in my profile.

Wade

Key findings from public health

Healthy "people" aren't localized rocks, but are normally well-interconnected bidirectionally into the social fabric around them.

Social connectivity is the most robust predictor of internal, "physiological", "biomedical" outcomes, such as morbidity, mortality, survival rate of surgery, resistance to infection, level of depression, outcome of diabetes, obesity, "mental" health, you name it.

Prevention is a thousand times more cost effective than repair. ( A lesson from software engineering and many other fields as well.)

The caring human loving touch of another individual is very important to human health and healing. Infants who aren't touched do poorly or simply die.

All interesting social phenomena (such as relationships, jobs, teams, family, stress, love, sex, the economy, depression) involve intimately bidirectional feedback loops.

But, classical statistical measures and attitudes, based on prediction of yields of crops, assume critically that causality is defined in one direction only, and that all phenomena of interest can be "isolated" from context and one part of it varied by the experimenter while other parts of it are "held constant." None of that applies to "complex adaptive systems", including social systems, which are inextricably interconnected, context-dependent, interdependent, and riddled with bidirectional feedback loops. Since the tools and expertise breakdown when applied to these areas, rather than admit that the tools and expertise are inadequate, the problem space is instead defined as "non-scientific" or "soft-science" and demeaned as unimportant or "non-scientific."

Possibly due to such schizophenia, the US "healthcare" system behaves as if none of the above solid empirical facts were known. There is no focus on social connectivity, less than 2% of the budget is spent on prevention, and machines and processes have replaced people at the bedside. People are treated like machines, and diseases are treated as if they were independent of each other and the rest of peoples lives. "People" are reduced to "patients". "Caregivers" are too busy to stay and chat for a while with "patients" and are increasing renamed "providers" which is ironic, since mostly they consume resources, particularly money, while being forced by "the system" to be too busy to stick around and observe the actual outcomes of their "treatments" on the people they serve. It's a lose-lose scenario, disliked by the patients, disliked by the caregivers, and apparently continues to exist because it's loved by the insurance companies. The whole thing needs to be rethought based on the above new facts of life.

Perhaps, not surprisingly then, the outcomes of the US Healthcare system are terrible, compared to peer countries. Infant mortality is something like 19th in the world. Costs are huge but a recent study showed that the BEST quartile of US citizens (the rich) have health outcomes worse than the WORST quartile of British citizens in the UK. (ref ?). Depression, obesity, diabetes are widespread and rampant epidemics in the US.

But, efforts to build healthcare interventions that are designed around social connectivity and whole persons are demeaned and ridiculed as being "non-scientific", or avoided because the feedback loops make computing "p-values" problematic for academic researchers, for whom such mathematical bases for certainty are held with a sort of blind obsession despite the fact that the assumptions of the theory (General Linear Model) don't fit the problem they're trying to address.

The result is that the most effective interventions are known, and involve teams of people assisting individual humans to modify or control their behavior and life style, but the advocates of these interventions are academically shunned and have to present their work in embarrassment in back rooms. The Office of Behavioral and Social Science Research (OBSSR) within NIH is treated like an awkward in-law.

Probably the single best book that summarizes interventions in health care that actually work is Health Program Planning : An Educational and Ecological Approach by Lawrence W. Green and Marshall W. Kreuter, now in it's fourth edition. (c) 2005 McGraw Hill, initial version written in 1961. It was around that year that non-communicable diseases began to replace communicable diseases as the leading causes of death, disability, and impaired quality of life, but the older, biomedical model had a very tightly held death-grip on the "health care industry."

On page 3 of that book the authors note:

Ecological approaches have proven difficult to evaluate because the units of analysis do not lend themselves to rand assignment, experimental control, and manipulating characteristic of preferred scientific approaches to establishing causation. Although the linear isolatable cause-effect model of scientific problem solving remains the point of departure for the training of health professionals, practitioners find ... they cannot ignore the contextual reality that health status is unquestionably influenced by an immensely complex ecological system. ...

To address those systems in our planning, we must first be able to see them ...
By definition, ecological sub-systems do not operate in isolation from one another ... [but] interact with one another to influence health. [We need] a kind of ecological map or "web" or "systems model" enabling us to visualize the network of relationships that need to be taken into account as we plan our intervention strategy tailored to the unique circumstances of the target population and the place where they live and work.

The primary tools up to this task are described by John Sterman in his tome Business Dynamics, 999 pages in length. The simpler techniques of mapping on a white-board is known as Causal-Loop Diagramming or CLD. These qualitative webs can be assigned some semi-quantitative values, such as directionality and general magnitude (large, small, strong, weak) and then simulated using tools such as Vensim (tm).

That, however, is a lot of work. "Systems thinking" didn't show up in the MPH curriculum until 2006, and is absent, by that name, in most courses, even at leading universities. Only MIT and Worcester Polytechnic Institute seem to have embraced these tools, although the Ross School of Business at the University of Michigan is starting to build a systems thinking program after the auto industry started demanding it.

Note that the pressure for innovation here is from business, and the academics are lagging behind, sometimes kicking and screaming, in stage 2 of Schopenhauer's three stages:

All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.
Arthur Schopenhauer

So, this pretty much summarizes the state of affairs today. Johns Hopkins Bloomberg School of Public Health has started a new department of Health Behavior along the lines of the new theory, but most health and public health people are famously non-quantitative, and so they are attempting to think through such problems mentally, unassisted by available tools used in other industries for over 50 years now in systems dynamics.

And, the biomedical establishment has a strong lock on most thinking and peer-review journals, and alternates denial and violent opposition to the "new paradigm" which it perceives as a throwback to mystical soft thinking instead of a more general version of the scientific method that can embrace feedback loops and complex adaptive systems without distortion of the tools or violation of the assumptions behind the models and statistics.

Even at Hopkins in the department of Epidemiology, the ratio of new thinkers to old-paradigm thinkers is essentially 3 to 70, and this new paradigm is ridiculed, rejected, opposed, despised, by most old-school thinkers who wish the answer to health had stayed down the microscope, under control, where they had strong muscles and good intuition - instead of showing up increasingly outside the window of the lab, in the social fabric of society, in all the places the scientists grew up despising and where their tools and muscles and intuition all fail.

So, where does that leave us humans?

Apparently, we can't expect either academics or health care workers to take the lead in fixing this terrible mess, and business is going to have to get down to business and do something about it.

(This is not without precedent - the center of innovation in the USA has increasingly moved out of universities and into businesses, despite the very strong marketing campaign with the opposite message. Witness the pulling-teeth it's taken to get systems thinking into the Ross Business School curriculum.)

Business today is much more cybernetic on a real-time basis than academia, and utilizes "good enough" models which, with cybernetic feedback control, get the job done and produce the desired outcomes - - while driving academics crazy because the underlying models are "so bad."
The National Institutes of Health is still heavily dominated as well by biomedically oriented researchers of the old school, who resist the new paradigm.

So, with a few exceptions, industry money may be the only way to advance health care in serious ways, and address the findings at the top of this post sometime this century when we're still alive to care about it.

We have, as in so many of M.C. Escher's paintings, (see this link:
http://en.wikipedia.org/wiki/Image:Escher_Waterfall.jpg
created a world that is locally-sensible and globally nonsense, but few people working locally are motivated to address the global wrongness, and no Masters or PhD student or young researcher would be encouraged to tackle a "large" problem, and so it sits there, unaddressed by academia and a thorn in the side of everyone: patients, doctors, nurses, payers, industry.
Like Escher's paintings, one is hard pressed to see or point to exactly "where" the wrongness is, and yet, standing back, it's clearly wrong.

That's where things are today.


[ M.C. Escher website: http://www.mcescher.com/ ]

South Dakota hospital gets $400 million gift

Global competition for pediatrics business increases:

From today's New York Times
Hopes Soar after Record Hospital Gift of $400 Million

by Stephanie Strom

excerpt:

Now, T. Denny Sanford, a low-key billionaire who made his home and fortune here, will help sustain the state’s economic boom with a $400 million gift to the Sioux Valley Hospitals and Health System, the state’s largest employer. Hospital officials hope the gift — the largest ever to a hospital, according to the Center for Philanthropy at Indiana University — will help transform Sioux Valley Hospitals, which will change its name to Sanford Health, into a national institution that will eclipse Johns Hopkins and the Mayo Clinic.

“He told me he doesn’t want this to be just another Mayo,” said Kelby K. Krabbenhoft, Sioux Valley’s chief executive.

It has four stated goals: to build five pediatric clinics around the country; to expand research, especially in pediatrics; to build a health care campus with more than 20 separate facilities, and to identify a promising line of medical research and follow it to a cure, much the same way John D. Rockefeller’s money found a cure for yellow fever and Bill Gates is searching for a cure for H.I.V./AIDS.