Trust, communication and tribalism
HealthGov Conference: Effective
Governance of Health Professions in
Australia
Systemic and individual responsibility
Professor Jeffrey Braithwaite
Centre for Clinical Governance Research, UNSW
Tuesday 11 December 2007
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 today’s problems in
health
What do you think of that idea?
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
An evolutionary perspective
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
An evolutionary perspective
Both hobbits [as
they became
known] and humans
are evolved for clear
niches in their
environments
We are,
fundamentally,
hunter-gatherers
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?
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
An evolutionary perspective
This is millions of years of surviving in
lightly wooded savannah grasslands
In small kin-based groups using stone
tool technology
Based on trust, communication and
tribalism
Originally in Africa, then radiating
across the world
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
Life’s more complex
It’s social and political
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
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
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
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
An evolutionary perspective
Do you want proof?
Look around you, at your neighbours …
What do you see?
An evolutionary perspective
So what we are
evolved for over
millions of years: to
be tribal – ie,
hunter-gatherers
To exploit the
environment
successfully; to
survive and thrive
Human nature in contemporary
health settings
How are these characteristics displayed
in contemporary settings?
Gaze as an anthropologist in your
mind’s eye
What do you see in your workplaces;
how are people behaving back in your
hospital, public health facility,
department, ward, division, unit?
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
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
Human nature in contemporary
health settings
When this works well it works very well –
based on trust
But when it doesn’t … it really doesn’t
It’s like ‘the girl with the curl’
Every one of us has experienced both
Comments?
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
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
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”
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 illustrati[ive] of
the influence and power exercised by a
section of the medical community”
“Warnings to those who were contemplating
disloyalty as whistleblowers”
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
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
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
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
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
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
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
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?
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 today’s
health system
But not smart enough to solve the problems
of working together that system demands
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?
To communicate better and trust more?
Many say yes, but some are more
sceptical
The evolutionary cleft stick
There are three options:
1.
2.
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 don’t
know how to do this, it
would likely damage
the health system, no
guarantee of success
The evolutionary cleft stick
There are three options [continued]:
3.
Continue on the
present course, ie
continuous
improvement
Problem: our evolved
nature keeps getting in
the way, no guarantee
of success
A way forward?
The enquiries have made two types of
recommendations
1. Bottom up: systems, collective, culture
change approach
2. Top down: find, punish and discipline
approach
Neither seems to be the perfect
solution, and they may conflict if used
together
A way forward?
A final paradox: we don’t 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
A way forward?
Examples:
The Battle of Britain, Summer 1940
The 9/11 terrorist attacks in New York,
2001
The region’s tsunami disaster on Boxing day
2004
A way forward?
Question:
Could the studies and enquiries showing
health care’s 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
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?
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/repri
nt/mzi060?ijkey=cmiiRJZwgAzcHJD&key
type=ref
Conclusion, part 2
Time for
Final comments
Arguments
Discussion
Questions.