cognitive dissonance
I N N O V A T I O N T R A D I T I O N S
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INTRODUCTION
“In a time of drastic change,
it is the learners who inherit the future.
The learned usually find themselves equipped
to live in a world that no longer exists.”
Eric Hoffer (1902 – 1983)
PARADIGM SHIFT
The portion of our nation’s annual economy dedicated to health spending has more than tripled. This is best noted by the change in the portion of our nation’s gross domestic product devoted to health spending during the last 59 years. In 1960, health spending for our nation’s healthcare represented 5.0% of the national economy. For 2019, it was 17.9% at $3.92 trillion. No other segment of our nation’s economy has changed to that degree. In spite of this financial commitment, there are certain attributes of our healthcare industry for which old, but ignored, concepts have the ability to substantially improve its efficiency and gaps of deficient effectiveness. In short, the same breadth and depth of INNOVATION has not occurred at all levels of each resident person’s healthcare. It is time to change, rapidly by a lot, with a high level of precision.
By almost any standard, this Sub-Page is incomplete. It is likely that widespread disagreement exists about what should be included on any must-do list for INNOVATION conceptual gatekeepers. By conceptual gatekeepers, I refer to the agents of positive change and its leaders rather than those who restrict innovation. What follows is a preliminary analysis regarding the deficient areas of INNOVATION most affecting the day-to-day health care for the Basic Healthcare Needs of each person and their Family.
TRADITION
POPULATION HEALTH
In April of 2016, Raj Chetty, Ph.D. and his associates described a landmark study of Population Health. It appeared as a “Special Communication” in the Journal of the American Medical Association. Their study used 1.4 Billion person-years of de-identified life expectancy data to assess: *) longevity according to our nation’s Death Certificate data, *) county by county data from the Census Bureau according to a person’s address, and *) income levels according to the records of the United States Treasury Department. They evaluated a variety of community characteristics and their relationship to life expectancy. The study spanned 15 years: 1999 through 2014. The only other study with the dimensions of this size reported longevity and its relationship to a person’s Body Mass Index for more than one million individuals from life-insurance statistics.
For the longevity study, the authors were Raj Chetty from Standford University; Michael Stepner and Sarah Abraham from the Massachusetts Institute of Technology; Shelby Lin from McKinsey and Company; Benjamin Scuderi, Augustin Bergeron, and David Cutler from Harvard University; and Nicholas Turner from the United States Treasury. The variety of institutions and expertise represented by this group is admirable.
This population health report was statistically intense. One result deserves special attention. The study indicated that there was a shorter lifespan for persons living at poverty levels of income as expected. But this effect was not noted in all counties. There were a small number of counties where there was no effect of poverty on longevity. The communities with this result generally had a higher prevalence of resident persons with college education among the resident persons of the surrounding community. It is possible that the strength of the caring relationships within these communities was greater as a result of the level of cooperation and trust among their college-educated resident persons. Over time, this may have produced an augmented level of social capital and its attendant social cohesion to promote a more responsive character for their community’s Survival Commons, aka augmented safety net.
One of the benefits of collecting “large data” sets has now become possible. This study on “Income and Life Expectancy” represents a new frontier. Now, we are confronted with a need to explain it. To begin, there are no widely accepted definitions for social capital, social cohesion,or a community’s Survival Commons. — 3 —
As of a 1-1-2017 Google Scholar search, I found no effort reported to succinctly define a community’s safety net or its Survival Commons. Beginning in 2020, I began to persistently access the associated research of these concepts to define a set of thirteen interconnected definitions for Caring Relationship, Cluster, Collective Action, Community, Disruptive Process, Family, HEALTH, Person, Social Capital, Social Cohesion, Social Dilemma, Social Interaction, and Survival Commons. The definition for Survival Commons represents a reconfiguration of a community’s safety net.
As of 1-1-2021, the list of interconnected definitions began to expand to qualify as a Design Epistemology as defined by Professor Dino Karabeg. (Karabeg 2005, 2012) The “Design Epistemology for improving our nation’s Population Health and its Primary Healthcare” now represents 30 concepts to embrace the realms of knowledge applicable for guiding a Complex Adaptive System as a basis to manage an intentional paradigm shift.
PHYSIOLOGIC CONTROL SYSTEMS
Ashley Montagu (1905-1999), a sociologist, once said: “Man is the only 150 pound, non-linear servo-mechanism that can be wholly reproduced by unskilled labor.” All things considered, it is a very narrowly conceived observation about the human condition. However, it does represent the fundamental problem involving the evaluation and treatment process for any worsening in the stability of a person’s HEALTH. Furthermore, the absence of any currently recognized means to precisely evaluate this instability is a fundamental barrier for a research process to define efficient and effective outcomes for healthcare. Most studies for improving the assessment of physiologic stability, i.e., baseline homeostasis, are based on a time-defined evaluation and its subsequent re-evaluation.
Simply stated, a blood pressure taken on the right arm of a person sitting in a chair followed by another blood pressure taken 10 minutes later is a baseline testing sequence. The evaluation of the test will depend on whether the two results are the same, whether they are both normal, whether one is higher than the other and whether or not the person’s HEALTH is otherwise stable. All subsequent results are time and circumstance dependent. This scenario represents the Time Domain for evaluating blood pressure control. But, another theoretical system could be useful for evaluating biologic control systems. It is the Frequency Domain.
There are few, if any, evaluation methods for a person’s HEALTH that are based on the Frequency Domain. The one area of health for which it could have the most meaning is Senile Dementia, commonly referred to as Alzheimer’s Disease. Even though Alzheimer’s Disease is a specific sub-type of Senile Dementia, it generally represents the label of an illness most feared as the ultimate complication associated with aging. For senile dementia, the illness progresses to a phase characterized by increasingly Unstable HEALTH and a profound loss of a person’s short-term memory. To date, there is no reliable test to predictably evaluate the progression of this instability or the results of any treatment protocol intended to improve the eventual occurrence of rapidly evolving Unstable HEALTH.
A test based on the Frequency Domain might yield information when repeated every 6-12 months as a means to more precisely monitor the progression of physiologic instability over time. The test could be as simple as continuously measuring oxygen saturation and simultaneously the heart rate for twenty minutes. A cross-correlation analysis would evaluate the data, and a Fourier Transform would evaluate the power level of various periodicities. The character of the Fourier Transform might eventually be useful for monitoring the impending fundamental loss of physiologic stability and the futility of alternate options for its treatment.
Whether or not Frequency Domain testing would be useful as a tool to evaluate the physiologic stability of a person’s HEALTH, the basic point remains. There are substantial gaps in the ability of health care to understand the capabilities of any person’s HEALTH, especially its resilience. There are only a few tests that monitor and evaluate physiologic stability over time. Most prominently, there is a test for blood glucose by the hemoglobin A1c blood test. It represents a measure of the average blood glucose during the prior 90 days. Also, heart rhythm stability can be assessed by a monitoring device continuously for 30 days. Overall, little has been done to incorporate Frequency Domain testing into the assessment of a person’s biologic control systems and their resilience. — 5 —
COGNITIVE DISSONANCE
Leon Festinger (1919-1989) proposed the concept of “Cognitive Dissonance” in his book, published in 1957. I first clearly encountered the frustration associated with cognitive dissonance as a graduate student at the University of Nebraska Medical Center. I had taken a break from medical school for a Master’s degree in the Department of Physiology and Pharmacology (1965-67). Within the same Department, there was a bio-engineering graduate program that collaborated with the Engineering College at the University of Nebraska in Lincoln. I learned about Frequency Domain testing as a means to evaluate the stability of control systems through collaborative contact with their faculty. It was a valuable insight as I became aware of the fundamental differences between the conceptual systems of engineering and medicine. The discipline of engineering is highly deductive and that of medicine is interchangeably deductive and inductive. It is likely that cognitive dissonance is partly the reason why Frequency Domain testing systems have not been applied to any current healthcare research studies.
As a physician, I have also encountered cognitive dissonance during 1) my tenure as Chief of a “type A, Physician Assistant” Training Program for the Army during the second year of a two-year military obligation, 2) 41 years of private-practice angst with cash versus accrual accounting methods, 3) two years as Medical Director of a gate-keeper, risk-sharing health maintenance organization (HMO), and 4) 20 years as Chairman of a large health system’s, medical staff Formulary Committee. During these experiences, I have encountered substantial differences among the conceptual structures even within the healthcare professions.
Most importantly, there are many systems of thought that have not been incorporated by our nation’s healthcare industry. “Governing The Commons” by Elinor Ostrom would be the most notable example. It is likely that cognitive dissonance is a significant reason for this as well.
PROFESSIONAL DEVELOPMENT
Peter Drucker (2) and Stephen Covey (1) published books in 1991 that could lead to a dramatic improvement in the level of precision within our nation’s healthcare. Peter Drucker described the essential requirement for the successful management of information-based institutions: maintain an individualized process to promote its professional assets, i.e., professional development for each employee. Stephen Covey described a process for reconciling each person’s Mission Statement with the Mission Statement of their employer. For healthcare reform, each physician should maintain this commitment with an annual self-assessment: a Professional Achievement Plan. There are doubtlessly many alternate concepts for professional achievement, viz mentoring, that could implement the ideas of Drucker and Covey.
PARADIGM PARALYSIS REVERSAL
The structure and function of NATIONAL HEALTH, sustained over an extended period of time, would establish its own widely acknowledged and supported leadership for sponsoring a continuously evolving reform of our nation’s healthcare industry. Any reform that intends to promote Stable HEALTH For Each Resident Person will be difficult to achieve. Clearly, our nation’s healthcare needs a nationally sanctioned institution with a mandate to identify and promote solutions for the root causes of the fundamental problems within our nation’s healthcare.
Most importantly, a comprehensive healthcare reform solution must reflect the full spectrum of knowledge for the benefit of each resident person, community by community. With its decentralized governance, promoting a Congressional Charter for NATIONAL HEALTH could be the optimal strategy for promoting each community’s social capital for rebuilding our nation’s social cohesion. Locally initiated, regionally directed, and nationally instituted healthcare reform is our nation’s best option. — 7 —