Why does human nature keep getting in the way of good health care delivery

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Why does human nature keep getting in the way of
good health care delivery?
Breakfast briefing for Australian College of
Health Service Executives WA participants

• A/Professor Jeffrey Braithwaite
• Centre for Clinical Governance Research,
  University of New South Wales
• 7 October 2005

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To begin

• This briefing is deliberately controversial
• I am going to argue that we are evolved for a
  completely different existence from the one we
  have today
• And that this provides a deep explanation for
  todays problems
• What do you think of that idea?

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An evolutionary perspective

• The find of a new human, Homo floresiensis, on
  the island of Flores in Indonesia, set the
  archaeological world buzzing
• It lived until 13,000 years ago
• This is very recent a blink of the geological
  eye

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An evolutionary perspective
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An evolutionary perspective

• Homo floresiensis is thought to have shrunk to
  pygmy size under the evolutionary pressure of
  living on a small island
• No predators, limited resources

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An evolutionary perspective

• Both hobbits as they became known and humans
  are evolved for clear niches in their
  environments
• We are, fundamentally, hunter-gatherers

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An evolutionary perspective

• Humans and hobbits share some common adaptative
  problems
• Need for oxygen, food, water
• Protection from the environment
• To mate and pass on genes
• Raise offspring to continue the line
• How good were your own ancestors at this?

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An evolutionary perspective

• Humans are selected for solving other problems
  from the Pleistocene
• This was the last 2.5 million years
• Some 99 of human history was spent as
  hunter-gatherers
• Humans are adapted naturally selected for this
  way of life

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An evolutionary perspective

• This is millions of years of surviving in lightly
  wooded savannah grasslands
• In small kin-based groups using stone tool
  technology
• Originally in Africa, then radiating across the
  world

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An evolutionary perspective

• Needs a big brain to process all the social data
• Benefits
• Shared risks
• Groups to rely on when things get tough
• Downside
• Lifes more complex
• Its social and political

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An evolutionary perspective

• Social consequences
• Tribalism us and them
• Exchanging social, material and intellectual
  resources becomes prominent
• Social rank hierarchy becomes pronounced
• Need to mind read understand your mental
  state and others

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An evolutionary perspective

• Social brain hypothesis
• Humans as compared to other primates eg
  chimpanzees and gorillas develop considerable
  capacities to
• Read behavioural and facial cues
• Anticipate others
• Deceive if and when necessary

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An evolutionary perspective

• So what were we selected for, 1?
• Negotiating with others
• Trading
• Collaborating with close tribal members
• Nurturing others
• Keeping powerful people happy

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An evolutionary perspective

• So what were we selected for, 2?
• Second guessing rivals
• Identifying rapidly those external others who
  would constitute a threat
• Protecting our own patch
• Outwitting and defeating enemies

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An evolutionary perspective

• Do you want proof?
• Look around you, at your neighbours
• What do you see?

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An evolutionary perspective

• So what we are evolved for over millions of
  years to be hunter-gatherers
• To exploit the environment successfully to
  survive and thrive

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Human nature in contemporary health settings

• How are these characteristics displayed in
  contemporary settings?
• Gaze as an anthropologist in your minds eye
• What do you see in your workplaces how are
  people behaving back in your hospital, public
  health facility, department, ward, division, unit?

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Human nature in contemporary health settings

• People work to earn a living to feed, clothe and
  house themselves and their families ie, to
  survive and thrive
• They also seek identification and protection via
  organisational and professional groups
• They value novelty, challenge, and social
  interaction

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Human nature in contemporary health settings

• People value careers
• They do most work socially, which we call
  meetings, case conferences, consultations,
  interaction, relationships and professional
  involvement
• They also mobilise technology clinical
  equipment, computers, phones but this is very
  recent

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Human nature in contemporary health settings

• When this works well it works very well
• But when it doesnt it really doesnt
• Its like the girl with the curl
• Every one of us has experienced both
• Comments?

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Human nature in contemporary health settings

• The upside
• Through skills and professional competence
  millions of people are attended to in their time
  of illness or health need
• This is a highly noble pursuit, with many
  satisfied patients and staff

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Human nature in contemporary health settings

• The dark side
• A succession of studies and enquiries have shown
  established systems cause iatrogenic harm to
  hundreds of thousands of patients worldwide
• Here, we glimpse at behaviours that have evolved
  for our personal or group protection that may not
  lead to an optimal health system

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Human nature in contemporary health settings

• Listen to two enquiries
• Bristol Royal Infirmary, United Kingdom
• Poor teamwork The teams were not
  multidisciplinary they were profoundly
  hierarchical
• A sense of them and us and poor
  communication

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Human nature in contemporary health settings

• Listen to two enquiries
• King Edward Memorial Hospital, Perth WA
• The culture was not supportive of staff members
  who were critical
• Ostracisation was seen as illustratiive of
  the influence and power exercised by a section of
  the medical community
• Warnings to those who were contemplating
  disloyalty as whistleblowers

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Tribalism, hierarchies and turf protection

• What does this mean in evolutionary context?
• Hunter-gatherer survival is predicated on
  individual alliances, and judicious collaboration
• And hunter-gatherers have a huge propensity to
  turf-protect and treat badly anyone who threatens

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Tribalism, hierarchies and turf protection

• In both the Bristol and the King Edward cases
  whistleblowers were inadvertently left out,
  gossiped about, ostracised and generally
  castigated
• Note that there is clear survival and group
  bonding value in doing this
• This does not justify such behaviours but does
  allow us to understand them

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Tribalism, hierarchies and turf protection

• Health professionals in these cases and
  everywhere, in fact tend to flock together in
  professional tribes rather than multidisciplinary
  teams
• Clustering like-with-like, and mistrusting, even
  shunning those who are different or represent a
  threat is a powerfully evolved tendency

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Tribalism, hierarchies and turf protection

• It helped Homo sapiens to be so successful as a
  species
• But tribes and hierarchies tend to close down
  productive interaction say between managers and
  clinicians, within and across professional
  sub-groups, between seniors and juniors and
  between clinicians and patients

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Tribalism, hierarchies and turf protection

• So we need culture change
• Bristol, main report mentions culture 191 times
• King Edward Enquiry mentions culture 62 times
• But how difficult is this?
• Very

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Tribalism, hierarchies and turf protection

• Humans have evolved behaviours to protect and
  position themselves over many millennia
• They are deeply structured into the fabric of
  modern society and its institutions
• The health system reflects these characteristics

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Tribalism, hierarchies and turf protection

• Especially when intimidated or vulnerable, people
  will tend to
• Default to well-worn behavioural repertoires
• Regress to a struggle for individual survival
• Intensify relationships within their primary
  groups and coalitions
• Organisational culture change is therefore likely
  to be very hard

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Tribalism, hierarchies and turf protection

• Taken together, these are indicators of millions
  of years of adaptiveness for personal and small
  group protection at the expense of others
• Can we alter this fundamental human nature?

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The evolutionary cleft stick

• Thus we are in a catch-22, cleft stick situation
• We may be at the evolutionary point where
• We are smart enough to design todays health
  system
• But not smart enough to solve the problems of
  working together that system demands

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The evolutionary cleft stick

• Can we change the health system to be less
  hierarchical, less tribal, and more inclusive?
• Can we learn to work more collaboratively across
  professionalised silos or entrenched hierarchies?
• Many say yes, but some are more sceptical

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The evolutionary cleft stick
There are three options

• Wait for evolution to shape us as a more
  collaborative species
• Attempt a big bang change to the health system,
  sweeping away unwanted behaviours, posturing,
  poor practices

• Problem takes too long, no guarantee of success
• Problem we dont know how to do this, it would
  likely damage the health system, no guarantee of
  success

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The evolutionary cleft stick
There are three options continued

• Continue on the present course, ie continuous
  improvement

• Problem our evolved nature keeps getting in the
  way, no guarantee of success

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A way forward?

• The enquiries have made two types of
  recommendations
• Bottom up systems, collective, culture change
  approach
• Top down find, punish and discipline approach
• Neither seems to be the perfect solution, and
  they may conflict if used together

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A way forward?

• A final paradox we dont have an obvious answer,
  but it is then that we might start to think about
  the question more clearly
• This has often happened in human history
• A calamitous predicament occurs, and people pull
  together to resolve it

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A way forward?

• Examples
• The Battle of Britain, Summer 1940
• The 9/11 terrorist attacks in New York, 2001
• The regions tsunami disaster on Boxing day 2004

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A way forward?

• Question
• Could the studies and enquiries showing health
  cares harmful outcomes come to constitute a
  similar crisis?
• This could galvanise people into action
• Maybe, maybe not
• But in the meantime we have a real problem no-one
  knows how to solve

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A way forward?

• Finally
• Even more worrying, all species will one day be
  extinct
• Perhaps we are destined to go the way of Homo
  floresiensis
• If we are, then the problem of patient safety
  will pale into insignificance
• If we are not, how will we address the problem of
  good health delivery?

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Conclusion, part 1

• Reference, for further reading
• Braithwaite J.  Hunter-gatherer human nature and
  health system safety an evolutionary cleft
  stick?  International Journal for Quality in
  Health Care 2005 http//intqhc.oxfordjournals.org
  /cgi/reprint/mzi060?ijkeycmiiRJZwgAzcHJDkeytype
  ref

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Conclusion, part 2

• Time for
• Final comments
• Arguments
• Discussion
• Questions.