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
