Trust, communication and tribalism

1. 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

2. 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?

3. 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

4. An evolutionary perspective

5. 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

6. An evolutionary perspective • Both hobbits [as they became known] and humans are evolved for clear niches in their environments • We are, fundamentally, hunter-gatherers

7. 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?

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. An evolutionary perspective • Do you want proof? • Look around you, at your neighbours … • What do you see?

16. 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

17. 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?

18. 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

19. 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

20. 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?

21. 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

22. 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

23. 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”

24. 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”

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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?

33. 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

34. 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

35. 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:

36. Continue on the present course, ie continuous improvement Problem: our evolved nature keeps getting in the way, no guarantee of success The evolutionary cleft stick There are three options [continued]:

37. 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

38. 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

39. 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

40. 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

41. 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?

42. 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?ijkey=cmiiRJZwgAzcHJD&keytype=ref

43. Conclusion, part 2 • Time for • Final comments • Arguments • Discussion • Questions.