How might we design health systems to promote health and wellbeing and not just treat illness and disease and manage infirmary and chronic conditions? What if health systems were about health?
If we were to apply design thinking to health systems, what might be do?
In a previous post, I suggested that knowledge translation is too important to be trusted solely to health professionals, partly because they have largely failed to take up the charge. Taking a step back — a systems thinking perspective — one realizes that to design better knowledge translation, we need to design better health systems.
Julio Frenk, Dean of the School of Public Health at Harvard, believes this too. In a 2010 paper published in PLOS Medicine, Frenk comments on the state of health systems and examines how we might re-think them in light of global health challenges.
Health systems are the main instrumentality to close the knowledge–action gap. To realize this potential, it will be necessary to mobilize the power of evidence to promote change. Yet all too often reform efforts are not evaluated adequately. Each innovation in health systems constitutes a learning opportunity.
Frenk’s article is an invitation to engage in systems and design thinking about health. Both approaches invite pause to consider what the problem is in the first place. For design thinkers, problem scoping is the first step.
For systems thinkers this is akin to setting the boundaries around the problem.
Once we set the boundaries and find the appropriate problem, we then frame it appropriately for design. Problem definition is something often over-looked or under appreciated, but is the core of effective problem solving and design.
If I had an hour to solve a problem I’d spend 55 minutes thinking about the problem and 5 minutes thinking about solutions – Albert Einstein
Health systems are typically defined in light of professional services and policies aimed at making the sick well. They are essentially illness and disease (sick care) systems. This conceptualization, still dominant in the professional and policy discourse in many Western countries, places medicine at the centre of health services with the allied disciplines working alongside, but rarely ventures its gaze beyond the institutions of care or the conditions such institutions are designed to treat.
Frenk, writing in PLOS Medicine, suggests its time to expand our view of what makes a health system if we are to truly promote and sustain global health and see three key points as provoking such re-thinking:
First, health has been increasingly recognized as a key element of sustainable economic development , global security, effective governance, and human rights promotion . Second, due to the growing perceived importance of health, unprecedented—albeit still insufficient—sums of funds are flowing into this sector . Third, there is a burst of new initiatives coming forth to strengthen national health systems as the core of the global health system and a fundamental strategy to achieve the health-related Millennium Development Goals.
In order to realize the opportunities offered by the conjunction of these unique circumstances, it is essential to have a clear conception of national health systems that may guide further progress in global health.
Frenk offers some suggestions:
Part of the problem with the health systems debate is that too often it has adopted a reductionist perspective that ignores important aspects. Developing a more comprehensive view requires that we expand our thinking in four main directions.
First, we should think of the health system not only in terms of its component elements (like human resources, financing, hospitals, clinics, technologies, etc.) but most importantly in terms of their interrelations. Second, we should include not only the institutional or supply side of the health system, but also the population. In a dynamic view, the population is not an external beneficiary of the system; it is an essential part of it.
It’s important to note the mention of the role of the population and its dynamical impact on the system. As populations change dramatically in their composition and form of residency within countries, including a greater movement to urbanization, so too will the myriad factors that influence health systems. The people are the system and thus it will change as populations change. While Frenk lists this as one point of many, it is a radical departure for reductionists or those who see health systems as being about care, not people.
A third expansion of our understanding of systems refers to their goals. Typically, we have limited the discussion to the goal of improving health. This is, indeed, the defining goal of a health system. However, we must look not only at the level of health, but also at its distribution, which gives equity a central place in assessing a health system. In addition, we must also include other goals that are intrinsically valued beyond the improvement of health. One of those goals is to enhance the responsiveness of the health system to the legitimate expectations of the population for care that respects the dignity of persons and promotes their satisfaction. The other goal is fair financing, so that the burden of supporting the system is distributed in an equitable manner and families are protected from the financial consequences of disease.
Frenk’s third challenge is to affirm the very point of health systems at all.
While not explicitly speaking of systems thinking or design thinking, there is much that both fields have in common with Frenk’s argument. Design thinkers might ask: What have we hired our health system to do?
Frenk argues that our health systems must go well beyond just making gains in measured health outcomes towards dignity, respect and social justice.
Finally, we should expand our view with respect to the functions that a health system must perform. Most global initiatives have been concerned mainly with one of those functions, namely, the direct provision of services, whether they are medical or public health services. This is, of course, an essential function, but for it to happen at all, health systems must perform other enabling functions, such as stewardship, financing, and resource generation, including what is probably the most complex of all challenges, the health workforce.
Frenk did not identify specific solutions, but did pose some key questions for health systems design.
If we were to take this challenge up as designers and systems thinkers, what might we do? Here are some suggestions for inquiry:
- Consider new definitions of health like the one posed in the British Medical Journal that emphasizes looking at the social and environmental influences on health beyond just the absence of physical symptoms. Further inclusion of a psychology of human flourishing might add to this definition.
- Map out a new system visually with people at the centre, not professionals or institutions. What does that look like? Tools like a Gigamap might provide the kind of multi-media, multi-sensory visual way to conceive of the interrelationships that make up health system. System dynamic models can help this out as well.
- Engage people across this system to validate this map and co-create possible future models that could serve to shape discussion at multiple levels and mobilize civil society to support healthy environments.
- Create small scale, safe-fail / fail-forward, prototypes of small-scale innovations that can be tested, developmentally designed, and rapidly re-developed as needed to start shifting the system as a whole.
Designing health requires designing health systems. Applying new thinking and envisioning a system that is dynamic, comprised of people and just institutions is a start.
Photo: Bartolomeo Eustachi: Peripheral Nervous System, c. 1722 shared by brain_blogger used under Creative Commons Licence
What is quality when we speak of learning? In this third post in series on education and evaluation metrics the issue of quality is within graduate and professional education is explored with more questions than answers about the very nature of learning itself.
But what does learning really mean and do we set the system up to adequately assess whether people do it or not and whether that has any positive impact on what they do in their practice.
What do you mean when you say learning?
The late psychologist Seymour Sarason asked the above question with the aim of provoking discussion and reflection on the nature and possible outcomes of educational reform. Far from being glib, Sarason felt this question exposed the slippery nature of the concept of learning as used in the context of educational programming and policy. It’s a worthwhile question when considering the value of university and professional education programming. What do we mean when we say learners are learning?
The answer to this question exposes the assumptions behind the efforts to provide quality educational experiences to those we call learners. To be a learner one must learn…something.
The Oxford English Dictionary defines learning this way:
the acquisition of knowledge or skills through experience, practice, or study, or by being taught: these children experienced difficulties in learning | [ as modifier ] : an important learning process.
• knowledge acquired in this way: I liked to parade my learning in front of my sisters.
This might sufficiently answer Dr Sarason except there is no sense of what the content is or whether that content is appropriate, sufficient, timely or well-supported with evidence (research or practice-based); the quality of learning.
Knowledge translation professionals know that learning through evidence is not achieved through a one-size-fits-all approach and that the match between what professionals need and what is available is rarely clean and simple (if it was, there would be little need for KT). The very premise of knowledge translation is that content itself is not enough and that sometimes it requires another process to help people learn from it. This content is also about what Larry Green argues: practice-based evidence is needed to get better evidence-based practice.
How do we know when learning is the answer (and what are the questions)?
If our metric of success in education is that those who engage in educational programming learn, how do we know whether what they have learned is of good quality? How do we know what is learned is sufficient or appropriately timed? Who determines what is appropriate and how is that tested? These are all questions pertaining to learning and the answers to them depend greatly on context. Yet, if context matters then the next question might be: what is the scope of this context and how are its parameters set?
Some might choose academic discipline as the boundary condition. To take learning itself as an example, how might we know if learning is a psychology problem or a sociology problem (or something else)? If it is a problem for the field of psychology, when does it become educational psychology, cognitive psychology, community psychology or one of the other subdisciplines looking at the brain, behaviour, or social organization? Successful learning through all of these lenses means something very different across conditions.
Yet, consider the last time you completed some form of assessment on your learning. Did you get asked about the context in which that learning took place? When you were asked questions about what you learned on your post-learning assessment:
- Did it take into account the learning context of delivery, reception, use, and possible ways to scaffold knowledge to other things?
- Did your learner evaluation form ask how you intended to use the material taught? Did you have an answer for that and might that answer change over time?
- Did it ask if your experience of the learning event matched what the teachers and organized expected you to gain and did you know what that really was?
- Did you know at the time of completing the evaluation whether what you were exposed to was relevant to the problems you needed to solve or would need to solve in the future?
- Did you get asked if you were interested in the material presented and did that even matter?
- Was there an assumption that the material you were exposed to could only be thought of in one way and did you know what that way was prior to the experience? If you didn’t think of the material in the way that the instructors intended did you just prove that the first of these two questions is problematic?
Years of work in post-secondary teaching and continuing professional education suggests to me that your answer to these questions was most likely “no”, except the very last one.
These many questions are not posed to antagonize educators (or “learners”, too) for there are no single or right answers to any of them. Rather, these are intended to extend Seymour Sarason’s question to the present day and put in the context of graduate and professional education at a time when both areas are being rethought and rationalized.
Learning to innovate (and being wrong)
A problem with the way much of our graduate and professional education is set up is that it presumes to have the answers to what learning is and seeks to deliver the content that fills a gap in knowledge within a very narrow interpretation. This is based on an assumption that what was relevant in the past is both still appropriate now and will be in the future unless we are speaking of a history lesson. However, innovation and discovery — and indeed learning itself — is based on failure, discomfort and not knowing the answers as much as building on what has come before us. There is no doubt that a certain base level of knowledge is required to do most professional and scientific work and that building a core is important, but it is far from sufficient.
The learning systems we’ve created for ourselves are based on a factory model of education, not for addressing complexity or dynamic systems like we find in most social worlds. We do not have a complex adaptive learning system in place, one that supports innovation (and the failures that produce new learning) because:
If you’re not prepared to be wrong, you’ll never come up with anything original. – Sir Ken Robinson, TED Talk 2006
The above quote comes from education advocate Sir Ken Robinson in a humorous and poignant TED talk delivered in 2006 and then built on further in a second talk in 2010. Robinson lays bare the assumptions behind much of our educational system and how it is structured. He also exposes the problem we face in advancing innovation (my choice of term) because we have designed a system that actively seeks to discourage wide swaths of learning that could support it, particularly with the arts.
Robinson points to the conditions of interdisciplinary learning and creativity that emerge when we free ourselves of the factory model of learning that much of our education is set up, “producing” educated people. If we are assessing learning and we go outside of our traditional disciplines how can we assess whether what we teach is “learned” if we have no standard to compare it to? Therein lies the rub with the current models and metrics.
If we are to innovate and create the evidence to support it we need to be wrong. That means creating educational experiences that allow students to be wrong and have that be right. If that is the case, then it means building an education system that draws on the past, but also creates possibilities for new knowledge and learning anchored in experimentation and transcends disciplines when necessary. It also means asking questions about what it means to learn and what quality means in the context of this experimental learning process.
If education is to transform itself and base that transformation on any form of evidence then getting the right metrics to evaluate these changes is imperative and quality of education might just need to be one of them.
Jonah Lehrer is/was as big as it gets in science writing and two weeks ago proved the adage that the higher one climbs the farther the fall after admitting to some false content in his stories. This is bad news for him, but may be much worse for all of us interested in making science and innovation knowledge accessible for reasons that have as much to do with the audience as it does the message and messenger.
Jonah Lehrer was one of our most prolific and widely read science writers until he admitted fudging some quotes about Bob Dylan in his new book, Imagine, which looks at the process of discovery, creativity and innovation. The discovery by fellow journalist (and fervent Bob Dylan fan) Michael Moynihan set off a wave of reflections and investigations of Lehrer’s work revealing passages in the book (and other pieces) that had been reused from his other writings without proper self-attribution and sparking questions about the integrity of the author’s entire body of work. The “fall of Jonah Lehrer” was big news at a time when the London Olympics were dominating most of the media’s attention.
This case is a testament to the wide appeal that Lehrer’s work had beyond the usual ‘science geeks’ while illustrating the power of the internet to enable the kind of curation and investigation to support on and offline fact checking. But what it spoke to most for me is the role
The Writer and his Craft
Much digital type has been spent on the Lehrer incident. Search Google and you’ll find dozens of commentaries looking at how things transpired and how Lehrer ironically succumbed to the cognitive biases he wrote about.
Roxane Gay, writing in Salon, took a gendered approach to the issue and questioned whether our fascination is less with the science and more about the ‘young male genius’. Lehrer’s youth was something she saw as critical to amplifying the fascination with his work. She writes:
When young people display remarkable intelligence or creativity, we are instantly enamored. We want or need geniuses to show us the power and potential of the human mind and we’re so eager to find new people to bestow this title upon that the term and the concept have become quite diluted.
I agree with her on the point about our desire to over-inflate the accomplishments of youth (as if we are *amazed* that any of them could possibly do anything brilliant, which is as offensive to them and it is to older people), although a careful look at Lehrer’s articles and much of the press around his work suggests that he was much less a focus of the attention than his ideas.
Call it “Gladwellization.” It’s not just lucrative, but powerful: your ideas (or rather, the ideas you’ve turned into compelling anecdotes for a popular audience) can influence everything from editorial choices across the publishing world to corporate management and branding strategies.
But with this comes mounting demands to produce, and to recycle. You have to be prolific, churning out longer pieces that give your insights some ballast, and brilliant, bite-sized items. And yet you can’t be too new either: people want to hear what you’re already famous for. In this cauldron of congratulation and pressure for more and more, it’s not hard to see how standards might erode, how the “ideas” might become more important than doing the necessary due diligence to make sure they sync with reality.
‘Snappy Science’ and Synthesis
Innovation is about ‘new’ and there are good reasons why its a challenge to get the message out that this ‘new’ can be adapted, small, and unsexy and still make a large difference in the long run instead of big, bold and transformative right away. We are in an age of selling “snappy science” and it says more about the media and audiences than the authors and scientists producing the original work.
This snappy, bite-sized science might sell books and make for great TED talks, but it is a misrepresentation of what we actually know and do as scientists. Rarely does a single finding lead to a solution, rather it is an amalgam of discoveries small and large brought together that gets us to closer to answers. Synthesis is the driver of change and synthesis is what journalists do particularly well. Malcolm Gladwell, Steven Johnson and Jonah Lehrer are among the best synthesizers out there and I would imagine (no pun intended) that they contribute to more to public and professional understanding of social innovation than all of the original-sourced scientific knowledge on the subject combined.
When I hear Malcolm Gladwell cited as an original source in serious discussions with colleagues on scientific matters, I realize we have a problem…and an opportunity. Gladwell’s writings popularized the concept of tipping points, but his work is based on a wealth of scientific data on complex systems. They are not his original ideas, but they are his syntheses and (sometimes) his interpretations. This is important work and I am not taking anything from anyone who makes science data digestible and accessible, but it is not the original science.
That Jonah Lehrer is as well known as he is tells me that there is an appetite for science and I’ll freely admit to using his work (and that of the other authors I’ve mentioned) to inform what I do in a general sense. It is good work, however I also acknowledge that I have the scientific training to know how to go beyond the initial articles to critically appraise the information, place it in context, and I have the resources to go to the original sources in academic journals. Most people (professionals and lay people) do not. This access is going to decrease as resources shrink.
It is for this reason that synthetic work is so important. My Twitter feed often is filled with references to such synthetic work, rather than original works of research because I aim to fill role that is somewhere between journalism and the science of design, systems and psychology. I am not a pure science blogger, nor am I speaking to the lay public, but rather other professionals seeking to enrich their knowledge base. That is a role I’ve created for myself, largely because there is a high demand and low supply.
We have a need for synthesis and a demand for it, but little acknowledgement of the value of this role in professional scientific circles. Yet, when we leave journalists to do the work for us, we allow a different system to take charge. John McQuaid ended his article with this caution:
Book publishers don’t do fact-checks, so there’s no fail-safe, just the conscience of the writer. Reach that point, and all is lost.
Filling the gap, meeting a need and shooting the messenger
Journalists like Johnson, Gladwell and Lehrer fill a gap, which is why I am saddened by the loss of one of them and angry at what has transpired. While there is no doubt that Lehrer made mistakes, they were of a rather minor nature in the grand scheme of things. Synthetic work is designed to provide a big picture overview, not guide microscopic decisions. I would like people to read Lehrer and learn about the creative process and the role of neuroscience in making our lives better, to appreciate systems thinking and decision making because of Malcolm Gladwell, and see innovation, emergence and discovery in new ways because of writers like Steven Johnson.
Yet, when we seek more and more from these authors, we might get less and less. This is what happened to Jonah Lehrer. As more people found themselves drawn to his work, the pressure grew for doing more, faster and getting that ‘snappy science’ out the door. GOOD magazine in the ‘tyranny of the big idea‘ goes further:
The problem is that it’s unreasonable to expect that every new piece of media should upend conventional wisdom or deliver a profound new insight. To think that Jonah Lehrer could expose an amazing new facet of human psychology every week, in 1,000-odd words no less, is ludicrous. There are only so many compelling, counterintuitive, true ideas out there.
But the demand for them doesn’t abate. That’s why you see so many science writers talking about the same handful of studies (the Stanford prison experiment, the rubber hand illusion, Dunbar’s number, the marshmallow test) over and over. That’s why you see pop economists who should know better creating flimsy and irresponsible contrarian arguments about climate change for shock value. That’s why you get influential bloggers confessing they’re only 30 percent convinced of their own arguments but “you gotta write something.” That’s why the#slatepitches meme hits home.
Search Censemaking and you’ll find many of these topics not just because they are punchy, but because they are useful.
I hope we haven’t lost Jonah Lehrer as a voice just as I hope more people stop putting writers like him on a pedestal, where they don’t belong (nor do the scientists who produce the research). Synthesis is about bringing ideas together to produce innovative insights that often lead to bigger conversations about how to socially innovate. Synthesis is bigger than science, but dependent on it. It means paying attention to parts and wholes together and is the epitome of systems thinking in knowledge work.
It also means taking responsibility as knowledge producers and consumers and be wary of shooting the messengers while asking more from the messages they deliver.
Unless we are prepared to give people time to search, appraise and synthesize research on their own — and train them to make informed choices — the role of synthesizers – professional, journalistic, or otherwise – will become more important than ever.
Photo from Wikimedia Commons and is used under licence.