11 January 2019
Dear Interested Readers,
Thesis, Antithesis, and Synthesis: Developing a Poverty Dialog
I began my writing almost eleven years ago as a device that I hoped might promote a dialog within our practice. I felt that we had challenges ahead, and I was sure that within our group there was a collective wisdom that needed to be tapped. Getting others to talk is sometimes a challenge. Sometimes I felt like I was talking to myself. On the best days a few readers would respond to me. What I learned over time was that many people were not talking, but they were listening and thinking.
I have felt that if dialog is the objective, getting two people into the conversation is evidence of success. This note to you is constructed around two letters to me that have come in response to my last two postings. The writers do not know each other, but I know both of them. I have great respect for what each has accomplished. One of the writers, Joe, essentially agrees with my formulation. The other writer, Chris, sees the world from a different experience, and he has some concerns with what I have written. I am delighted that two writers with different viewpoints have joined the conversation. I hope that their words will be of interest to you and might motivate you to further explore your own ideas.
The German philosopher Georg Wilhelm Friedrich Hegel is credited with promoting the analytical triad of thesis, antithesis, and synthesis, although he never used the phrase. The triad envisions a dialog between two individuals or groups with opposing points of view on a subject or problem. A thesis that is a proposed solution for a problem or concern is presented by one party with the reasoning to back it up. That thesis is considered and refuted by the other party. The dialog or dialectic between the two parties that develops is best if it represents different perspectives on the analysis of a shared set of facts. The hope is that the product of the dialectic will be the creation of a new level of understanding that is shared by both parties and was not available to them before they heard their ideas challenged. The desired outcome is a greater understanding that fosters a solution that is a synthesis of the best ideas or insights that are generated by the dialog.
A month ago I discussed the theory of “wicked problems” and asserted that healthcare was a “wicked problem.” There are many references to poverty as one of the most complex of all “wicked problems.” I suspect that there is some kind of multiplication of wickedness or difficulty when we consider the issues of healthcare and poverty together. In the Wikipedia discussion of wicked problems three methods of resolution are offered and described as authoritative, competitive, and collaborative.
Authoritative
These strategies seek to tame wicked problems by vesting the responsibility for solving the problems in the hands of a few people. The reduction in the number of stakeholders reduces problem complexity, as many competing points of view are eliminated at the start. The disadvantage is that authorities and experts charged with solving the problem may not have an appreciation of all the perspectives needed to tackle the problem. [This is even less tenable when there is one authority who solves the problems on the basis of “gut feelings.”]
Competitive
These strategies attempt to solve wicked problems by pitting opposing points of view against each other, requiring parties that hold these views to come up with their preferred solutions. The advantage of this approach is that different solutions can be weighed up against each other and the best one chosen. The disadvantage is that this adversarial approach creates a confrontational environment in which knowledge sharing is discouraged. Consequently, the parties involved may not have an incentive to come up with their best possible solution. [Healthcare and the current struggles over immigration policy and “The Wall” may be examples.]
Collaborative
These strategies aim to engage all stakeholders in order to find the best possible solution for all stakeholders. Typically these approaches involve meetings in which issues and ideas are discussed and a common, agreed approach is formulated.
It is interesting to look at the issues that currently divide this country and to realize that we are not only divided by “wicked problems” like immigration, economic inequity, race, gender, and varying ideas about the appropriate levels of social service, not to mention how healthcare should be financed and who should have access to it, but we are also divided by the methods that we prefer to use to try to solve these problems. The thesis, antithesis, synthesis approach utilizing dialog, or if you prefer a dialectic, is compatible with the “collaborative” option. In our current political debates we often see the “competitive” approach used, Democrats v. Republicans each standing their ground with neither side giving an inch. A solution requires that one side have control of all three branches of government for much to be done. What some of us fear is that the competitive model will deteriorate into the “authoritative” model. This is a real threat when there is someone who proclaims that he alone has all the right answers and can solve our problems.
I am delighted that the past two postings about the “medicalization of poverty,” or if you prefer the challenge to the practice that it vigorously engage in ameliorating or at least beginning to contend with the “social determinants” of health, has produced some feedback. In my post earlier this week in response to an initial comment from “Joe”, I tried to add a little bit of depth to what I meant when I spoke to the “medicalization of poverty” or the social determinants of health which are closely related to poverty. In that same post I also tried to connect the necessity that we address the impact of poverty on our patients to the professional responsibility to care about the patient. I referenced Francis Peabody’s admonition that we seek to understand the world that our patients come from by focusing on the challenges and concerns that affect them. Peabody emphasized “caring about the patient” as the heart of the traditional role of caregivers while pointing out that the office and the hospital were perhaps difficult, if not impossible, venues in which to make progress in the effort to improve the health of those whose health was challenged by the social determinants of health. I also presented suggestions formulated by a Canadian physician, in part to show that the better access to care that was available to all Canadians was not the complete answer to how to mitigate the impact of poverty on health. Universal access to care is a necessary part of our attempts to reduce the impact of poverty on health, but it is insufficient. If we are to move closer to the goal of the Triple Aim we must have both universal access to care and increase our efforts to reduce the number of people who live in poverty. We must expand coverage while we also expand economic support and opportunity to the poor.
Also, in Tuesday’s post I mentioned that “Joe” had written a second letter and that I would pass that letter on to you in this post. Let’s consider Joe’s second letter to be “the thesis” since it essentially underlines and supports the bulk of the ideas that I have offered. As I said earlier in this note, I have been delighted to receive some friendly push back in response to Tuesday’s post on the medicalization of poverty from another interested reader, Chris. It has occurred to me that giving you both letters constitutes an attempt at “thesis and antithesis.” Perhaps someone else will produce a “synthesis” for us after considering the positions of Joe and Chris.
Here is Joe’s second summarizing letter:
Gene:
Thanks very much for your thoughts. I think you are absolutely spot on — and I think you’re early to the idea of “the medicalization of poverty”.
I do understand the frustration that docs must feel in being somehow expected to address issues of poverty. As I spend a fair amount of time with pediatricians who may be most familiar with the dire health impacts of poverty, I understand the dynamic you’re describing.
It may be that doctors must now take responsibility for advancing solutions to address the social determinants of health, to take the response “upstream” as it were. Essentially calling on others in our society, far better placed to deal with poverty, to do so. (This may be why outcomes in other industrialized countries are significantly better than ours: so much health and well-being is managed with broad and effective social safety nets.).
We’ve seen some evidence of the impact of this kind of advocacy when some ER docs spoke out on gun violence. And doctors do have standing and credibility when it comes to health and poverty, which would only grow when they begin to advocate for one or another response.
Trying hard to do something about serious issues without nearly enough of the required resources is indeed a source of burn out. When I’ve heard that issue discussed, it is almost never seen as a symptom, as a result of a broken system, but rather as it’s own malady. Unless and until that point of view changes, we may be able to “fix” the issue of burnout, but we will not be able to solve it. And so it will grow, unfortunately.
Hope this is helpful! Terrific that you do this, Gene — each issue has me thinking….and forwarding it on to one or another colleague. So thank you!
My best,
Joe
Chris wrote from a different point of view derived from an experience that I think reflects the mindset of many other healthcare professionals who are not so sure that “poverty” is a problem that they can effectively address, or perhaps even try to address, since it is “not what they signed up for” and are trained to do.
Gene,
I’m fascinated with the exchange between you and Joe. While the myriad components of systemic change you and Joe enumerate are available to us, many have been tried and for whatever reason many have been found wanting by the leaders that follow implementation. Note: many were abandoned with little analysis of their true value. It took me many years as a leadership / organizational consultant to notice for myself, “Hey, we’ve done this before. Have we explored the experience of those who were engaged back then? What did we learn from them that will help this new attempt?””
When I was a novice consultant…., I was often advised by customers, “Oh, you can skip interviewing Thomas, He’s a dedicated cynic, against everything new.” … Thomas is exactly who I want to talk with. He may look like a congenital naysayer. But he may just be an idealist who has been betrayed…He knows that things fall apart when the pioneers are gone. Thomas and his ilk have the experience to guide us around the potholes. He knows which ones are fatal flaws. But, new leaders rarely want to talk with the Thomases….
Idealistic designers of “new” systems ignore the Thomases at their peril…He and his cohorts are often one conversation away from re-assuming their natural state, being energetic advocates. But they have to believe you. No sugar-coating these conversations. Thomas can smell a con.
Here are a few challenges the Thomases of the world present:
- Didn’t HCHP and other pioneers build integrated teams with medical, psychological, psychiatric, nursing, social work professionals under each neighborhood care roof? Why was it abandoned? What makes us think we won’t reach the same point of “wisdom” that stopped past leaders in their tracks, causing them to abandon the proverbial baby with its bathwater?
- I began my career in a “Settlement House Type” psychiatric halfway house… Like the role of the old Settlement House “well adapted participants” my old role gave way to professional staffing of rehabilitative psych communities. True Settlement Houses had an array of helpful services. These models were the foundation of Social Work as a profession. Yet budding Social Workers in the last 20 years have abandoned these roles in droves, seeking greater professional respect. What makes us think that segmenting that social work role into Navigators, Health Coaches, and other titles will be more resilient?…
- If the latest research linking poverty with poor health outcomes seems to call for physicians to become social advocates, which policies should they advocate for, social welfare policy or full-employment economic policy? If economic growth has enabled millions to work their way out of poverty, shouldn’t we have better health outcomes for a great number of people? Why aren’t we seeing examples of those returning to work and their re-engagement with the healthcare system for preventive health services? With lower unemployment, increased workforce engagement, and new economic opportunities shouldn’t we be tracking the behaviors of those people rising out of poverty? Or has the problem remained the same or increased? And if so why? Are our assumptions about the implications of the research wrong?
- As for urging physicians to put their proverbial shoulders to the wheel, to what end? Each profession plays a role in the overall health of the public. Each professional in them has differing socio-economic, political predilections. Why would calling on all of them, physicians being your focus, have any coherent positive impact on health outcomes of the poor? Physicians study medicine, not societal development and economics. The problem I see is that without deep knowledge, the activists you prod will gravitate to Political policies that sound noble…Since we as a nation rarely manage initiatives from inception to measurement of results, the average citizen has no way of evaluating success or failure of initiatives voted on 5-10-50 years earlier… Was the War on Poverty good or bad? Did we win or lose? Did we spend too little or did we spend on the wrong things to actually end poverty? Is poverty now better than poverty then or worse?
One would have to possess an encyclopedic mind and well honed expertise in multiple fields to separate the wheat from the BS. Believe me…The other option is to develop a societal passion for exploring the views of others through personal dialog. This capability should of necessity prioritize the examination of opposing views to have practical efficacy and efficiency. Get right to it. Otherwise the truth seekers would be left in the dust by the action-oriented agenda-building policy-makers.
Alas we as a nation, a teaming mass of people, most with our heads down just getting our work done, are less able than ever to engage in “Non-violent communication” (I kid you not, this is a relatively new model of communication built by a consultant author, the innards of which have little to add to Dale Carnegie’s original masterpiece) the matters that matter…
There is real wisdom buried in Chris’ words. Did you notice his reference to dialog as a solution?
The other option is to develop a societal passion for exploring the views of others through personal dialog. This capability should of necessity prioritize the examination of opposing views to have practical efficacy and efficiency.
It was that statement form Chris that put me into the “thesis, antithesis, synthesis train of thought. Joe believes that healthcare professionals should engage in the search for ways to improve the social determinants of health for everyone. Chris is skeptical and points to the relative failures of past attempts, the lack of good process to know what we did or did not accomplish with our efforts, and the reality that most physicians have little expertise to bring to the effort. I think both of them reflect the attitude of significant constituencies. I know both writers well enough to say that both have worked hard to improve the delivery of healthcare services and advance the Triple Aim. They look at the same picture and see different opportunities and different barriers to success.
One of the most depressing realities of what we know about “wicked problems” is that solutions are so difficult we are advised to lower our objective from “fix it” to “just do something to make it a little better.” My sites are set even lower. I just want to get you thinking about what you can do. I really liked the “Key Points” and suggestions that were at the end of the Canadian paper that I quoted, although I can imagine some might say, “Been there; done that; it did not work.” Despite that possibility here they are again.
Key Points:
- Although physicians generally recognize that social determinants (e.g., income, education and social status) influence the health of their patients, many are unsure how they can intervene.
- An increasing body of evidence provides guidance on a number of concrete actions that clinicians can use to address social determinants in their clinical practice to improve patient health and reduce inequities.
- At the patient level, physicians can be alert to clinical flags, ask patients about social challenges in a sensitive and caring way, and help them access benefits and support services.
- At the practice level, physicians can offer culturally safe services, use patient navigators where possible, and ensure that care is accessible to those most in need.
- At the community level, physicians can also partner with local organizations and public health, get involved in health planning and advocate for more supportive environments for health.
- Growing numbers of clinical decision aids, practice guidelines and other tools are now available to help physicians and allied health workers address the social determinants in their day-to-day practice.
Whether you see the issues as Joe sees them, or whether you share Chris’ honest skepticism about the possibility or advisability of medical professionals accepting the challenge of addressing poverty as a professional responsibility worth their time and effort, let me invite you to join the conversation. Your ideas and participation in the conversation can be entirely in your head or you may offer your comments here for others to read. Perhaps you are already doing one or more of the things listed above as potential ways a healthcare professional might join the effort to mitigate the effects of poverty in their patients and the community they serve. I do believe that the challenges that poverty presents to the Triple Aim must be considered and addressed for progress to occur. Ever since Darwin introduced the ideas of evolution and natural selection we have known that change in biological systems is a slow process that depends on mutations that improve survival in a competitive world. Social change and change in complex systems may be a lot like evolutionary change; it may take many false starts and persistence over a long time for something better to emerge. If that is true there is hope for a better day in the future when we will see even more measurable improvement in poverty and its impact on the social determinants of health than we have seen so far.
Winter Joys: Red Skies at Sunset, Blankets of White in the Morning
December was a strange, and somewhat disappointing month. We had a ton of snow in November which raised hopes for a White Christmas. We had a lot of very cold dry weather in December that was punctuated by warm rains coming up from the South. It was not all bad. We had so much November snow that the rains did not wash all of our snow away, and we did have a thin residual blanket of icy white snow for Christmas. The white stuff wasn’t much good for snowballs, snowmen or constructing snow forts, but we made do. We pounded the ice into a snow cone consistency and fashioned a puny snowman and a modest snow fort from which a few snow balls were launched by little boys whose limited experience with snow was insufficient to make them discerning consumers. The unexpected benefit of the icy white surface was that with such a low coefficient of friction we had a fabulous sled run that would have never been as fast through powder as it was down an icy slope!
The grandsons are back in California, and we woke up Wednesday morning to discover that we had a big overnight dump of snow, as you can see in the picture below.
As pretty as the fresh snowfall was, it was not the only natural delight this week. Today’s header shows a sunset on Monday evening that had people posting pictures to Facebook. I lifted one of those shots to pass on to you. It is a big “like” or “share” that I am sure would not upset my neighbor who posted the picture for everyone to enjoy.
Beautiful red sunsets have a lot to do with the red end of the light spectrum and just the right mix of clouds. They have inspired poets like Rabindranath Tagore who wrote:
“Clouds come floating into my life, no longer to carry rain or usher storm, but to add color to my sunset sky.”
I think that Monday evening’s red sky was an indication that the weather was changing. As we look forward in the forecast, the highest temp expected in these parts for the weekend will be sixteen degrees. At night we will dip below zero. The long range forecast is that it will be many days before the thermometer is expected to reach thirty two. Ah, January and the “Bleak Midwinter.” It is a beautiful time to “bundle up” and to be outdoors. I hope that you have plans this weekend to be out in nature looking to see what might surprise you. I plan to record the Patriots game, and then after the sun goes down I will sit in front of my crackling fire with a warm beverage, and watch it .
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
