This post has been sitting in my head for a couple of days, after I started developing the ideas in it after last Monday's class. I've talked to six or seven friends about what I'm going to say, trying to clarify my ideas and get some other opinions. I've generally found people nodding their heads and agreeing, but we haven't come to any consensus that I'm able to write up in a nice, neat little package. I don't know why I'm telling you this, besides that I like writing to be transparent, and that it's the only thing I knew well enough to get this post started. So, be forewarned. I'm writing about ideas that aren't clear in my head, and I'm not sure how well I'm going to get them across. The topic may well be something I address again later in the semester though, so I'm less worried...
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Growing up, the D.A.R.E. program was a standard part of our education. Nestled between math and reading on alternate Thursdays, Officer Ralph paid us a visit. I couldn't tell you what D.A.R.E. actually stands for, but I can tell you the message that was drilled into my head over years and years: Drugs are bad. Don't take them.
It was the same message about smoking. Don't do it. And drinking and driving. Don't do it. A slightly different version about eating your veggies (do it lots!) and wearing a helmet while biking (do it always!). But certainly there were a lot of things that we all got told a million times growing up.
And yet.
I don't know a single one of my friends who eats all their veggies, and probably half the people I see on campus don't wear bike helmets. Smoking, while on the decline, is still a prevalent practice. In 2006, the National Highway Traffic Safety Administration estimated that 40% of traffic deaths were alcohol-related, and surveys suggest that nearly half of American adults have tried smoking marijuana, not even to speak of other drugs.
Why don't people do these things that they've been told for years are good for them? Why don't more people avoid practices that we've been told are dangerous? And why don't doctors wash their hands more frequently? Heck, why doesn't the general populace wash their hands more frequently? We're currently facing a potential swine flu epidemic, and while I sit here, I see seven students with their hands by their mouth, and another two wiping their noses. They've all had contact with the chairs and tables in the room, which I doubt have been sterilizing particularly recently, and I can't imagine that any of them will be rushing to the sinks as soon as class ends.
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I wanted a concise conclusion about all these problems to put here. I wanted to tie all of them to a single common failing. Unfortunately, at that, I failed. So here's where it gets a bit more messy.
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In general, I think a lot of systems are "broken". Not necessarily broken in the sense that they don't work at all. More "broken" in the sense that they're not designed correctly for the problems that they address. I said it in class and I'll say it again. I don't think we were asking the right questions about handwashing. Someone brought up that residents are expected to see up to 30 patients in an hour. Someone else mentioned that proper handwashing can take 5 minutes. Let's assume doctors are pros that have got this down to 1 minute. Washing their hands between every patient would reduce the amount of time doctors could see patients by one half. Another student in class mentioned that they had heard two percent of patients end up with serious infections in the hospital due to germs they caught there.
Tell a hospital administrator that their doctors can see one half of the patients they currently do, and you'll reduce the number of infections patients get by two percent. What are they going to say? It's a numbers game. If you told a university administrator that you could improve all the student's understanding of the material by 2% if you only accepted half the students, they'd laugh at you! It's numbers, and money talks. And I'm sure I'm oversimplifying, but I just don't see a way around this fundamental issue. No matter how much you motivate a doctor, you've also suddenly got to motivate the hospital to spend twice as much on doctors to cover the same patients? Help me understand this.
Let's go back to some of the stuff I mentioned earlier. Eating your veggies. Ask anyone and they'll tell you that it's a good idea. Everyone will probably tell you that they should be eating more, in fact. There are signs in the grocery store telling me that I should eat five servings of fruits and veggies a day. It's not an education problem. I know I should. Why don't I? Again, at least for me, it's partly a "system" problem. I'm not uneducated, or even that unmotivated to eat veggies. I don't do it because it's not convenient and it's not cheap. I don't care how much you tell me that I should, white bread, peanut butter, ramen, and mac&cheese (Yes, I am trying to see how many posts I can mention my favorite food in) is a hell of a lot cheaper and lasts much longer than veggies. And that's why I don't eat them. Telling me how good they are for me doesn't solve either of the issues. Make them easy and make them cheap and yes, I'll eat them.
At least more often. Because I'm not telling the whole story here. There's the part of me that is human, and, as a human, has taste buds. Cupcakes win our over asparagus approximately every day of my life. I don't run to the vegetables section when I first walk in the grocery store. They're not fun or exciting and it's easy to forget them, and it's even easier to not make them on those occasions when they are sitting in my fridge. Why? I think part of it is the non-proximate cause problem that we talked about in class, coupled with the issue of incremental baditude (words, I like making them up). I can totally skip the carrots today, I'll eat them tomorrow, I feel perfectly fine, I'm a healthy young adult. Broccoli or french fries with my meal? I'll take the fries... after all, I'm out celebrating! I only do this... twice a week! I'll just take some carrots with my lunch tomorrow. Am I doing untold damage to my body?
That's the problem. It's untold.
I think the same thing goes a long way in explaining the lack of helmet and precedence of smoking and drunk driving. Activities that almost everyone agrees are hazardous, and yet many still do. I won't wear my helmet this one time. I'll only have one, I'm quitting tomorrow. I'm sure I'll be fine if I drive tonight. One-off events that, taken by themselves, probably have relatively low risks. Higher than not doing them, but they're certainly not like partaking in almost certain death. Will something happen eventually? Maybe. But probably not tonight.
Of course, while a somewhat understandable point of view, it's not a totally rational one. But then, I'm not convinced that humans are particularly rational creatures. We've got these emotion things, which cause feelings like pride and embarrassment. Desires that make us want to be cool and to desperately avoid being lame. Urges to escape stressful situations. In some ways, these dangerous risky behaviors play to our human nature. Wearing a bike helmet still isn't cool. Smoking still relieves stress. And being too drunk to get yourself home sucks.
Educating us on the risks gives us more tools in our rational arsenal. Maybe gives us a better idea of how probability plays out over time. But it's never going to make me less human. It's not going to make me richer. It's not going to give me more time in the day, and it's not going to make the world fair.
I don't know what the solutions to any of these problems are, but I do think that as problem-solvers and change-makers, we need to be considering the system that led to the problem as a whole, right down to the very nature of people as imperfect human beings.
Kim -
ReplyDeleteI have to say that your writing is very fun for me to read - especially how you relate the topic of choice to the life of a typical college student.
I also agree with you that change does need to address that we are imperfect too. Agreed, but to prompt you further, what do you think we can do in the future to address this fact as we go about our professional lives? I am really curious to see what you think on how we can strike the balance between preaching and doing nothing.
See you soon!
-Alessandra
I hated asparagus and brussel sprouts as a kid. Now I prefer them to cupcakes. I don't know enough about biology to claim that the change in taste follows from a change in nutrient need. I can assert with confidence, however, that as you age your food preference will change.
ReplyDeletePeople react differently to education (or propaganda) messages. Some conform. Others revolt. Still others don't pay attention. Measuring the success of the message is harder than simply noting there are folks in each camp. Certainly it is worth drilling down to ask why individuals choose one path or the other. I expect there to be a multitude of factors the importance of which will differ on a case by case basis. Trust (or lack) in the messenger and in the message probably matters a lot. In turn that probably depends on a host of outside experiences. Other factors may come into play. Looking cool riding a motorcycle may matter more to the person than getting the added safety the helmet provides.
Your physician time constraint approach makes sense to me in the outpatient clinic setting. Even there, however, there may be other factors. The doctor gets to read some chart of what the patient has before entering the exam room and typically the patient has already been interviewed by a nurse. The doctor might make a quick and dirty calculation (sorry, I didn't intend a double entendre here) and then adjust the hand washing in accord to the perceived risk of infection.
I think the time constraint model is just too simple for inpatients or outpatients with complex medical problems who are being treated by variety of specialists. Gawande has a fascinating recent piece on cost/quality health care differences across communities that sheds light on some of this complexity.
Let me switch gears. I hope you get a chance to read my reflection from this morning. I had you in mind when I wrote that some students had all the ingredients but didn't put the whole picture together. It was good in class when you brought up the vest. But you trivialized the importance of that and so sped right past thinking about the doctor.
I'm not sure why, but I have a hunch. So I wonder if you'd do a favor for me and read something that is outside the course but I believe is quite relevant. In a message I sent to the class at the start of the summer I mentioned some alternative readings. One is the Contrarian's Guide to Leadership. It is by Steven Sample. He has all three of his degrees from the ECE department here. He is now the President of the University of Southern California. If you would, follow the link, mouse over the image of the book cover, and read the first pages on "thinking gray," which I believe could be an important concept for you.
Let that simmer for a bit and then I'd like to get your reaction. My guess is that if you had been thinking gray, you would have put all the pieces together in class on Wednesday. If that's right, then the next question is what to do to get you on the thinking gray path in the future.