April 29, 2022
Dear Interested Readers,
Is Healthcare Enlightened Now or Suffering From Postmodern Cynicism and Burnout?
About five years ago, I was delighted to get the good news from Stephen Pinker, a professor of psychology at Harvard, that the world had never been better. Professor Pinker’s book, ENLIGHTENMENT NOW: The Case for Reason, Science, Humanism, and Progress, was a followup to a book he had published in 2011, Better Angels of Our Nature which was his first attempt to celebrate our progress. In Enlightenment Now he added more data to his positive assertion. The first book generated some pushback, and the second book raised even more objections to his optimistic argument.
In her New York Times review of Enlightenment Now, entitled “Steven Pinker Continues to See the Glass Half Full,” Sarah Bakewell wrote:
This book will attract some hammering itself: It contains something to upset almost everyone. When not attacking the populist right, Pinker lays into leftist intellectuals.
Pinker was writing from the middle. The far-right wants us all to believe that the values we cherish and the positions that provide us what we deserve are at risk from the criminals and rapists that are illegally invading our country. The far-left wants us to admit to our greed and stop violating the rights of the underserved and the planet. Both sides blame the other for the sad state of our collective affairs and predict much grief in the future if their ideas are not promptly accepted.
Pinker’s assertion is that if we focus on the progress we have made over the last 200 years in defeating disease, lifting billions out of poverty, and ushering in an age of technological miracles we would accept that things have never been better and the best is yet to come. His critics argue that his pollyanna world view is a setup for future disaster because it undermines the pushback against real threats.
When I first read the book, I drank Pinker’s Kool-Aid. I wanted to believe that he was right. He wanted us to have the courage to believe that we would survive Trump and that the trajectory of progress based on science and reason that began with the initiation of the “Enlightenment” in the 17th and 18th centuries could be the continuing foundation for an optimistic modern world view. He contended that we were better than we thought and could keep getting better. In my mind, if what Pinker said was true, there was some possibility that at some moment in the future healthcare would evolve or be transformed to yield the benefits of the Triple Aim through the fulfillment of the objectives and methodology outlined in Crossing The Quality Chasm: A New Health System For The 21st Century.
I am not trained in philosophy, and I know for a fact that there are many among the “Interested Readers” of these notes who are much better-informed historians and philosophers than I am, so I hope a reader will inform me if what I am about to layout is wrong or misleading.
As science and technology utilized reasoning and some of the characteristics of “the Enlightenment” the pace of progress quickened. At the end of the 19th century and in the early 20th century an optimistic worldview called modernism evolved which expressed the hope for a better world that Pinker claims has indeed been created. At least in the West, liberal political ideas created hope for improved human rights.
There were plenty of exceptions. One needed to discount Jim Crow politics, and inequality for women and other marginalized groups, but colonialism seemed to be declining and before World War I some attention was given to social problems like child labor. Communism started out as an attempt at a progressive idea but it was always intolerant even before it controlled Russia. After World War I, far-right movements in Germany and Italy were built on a foundation of militant nationalism with authoritarian leaders. With the Russian Revolution, communism emerged as a far-left experiment in another form of authoritarian rule. The run-up to World War II demonstrated that oppression is possible from both ends of the political spectrum.
Rather than leading to a better world, modernism devolved into two World Wars, a devastating depression, the Holocaust, and Stalinism. Bummer. The Civil Rights movement, Medicare, Medicaid, the Great Society, and the early efforts of the environmental movement were good mid-century ideas in the spirit of modernism until Vietnam divided us and Reagan was elected by convincing us that a deregulated business environment and less government were good ideas and that welfare queens were our greatest domestic threat.
Sometime during the seventies and eighties, our contemporary philosophers decided that the good vibes of modernism and the collective efforts to create a better community had been either a mistake or a failure and that the focus should be on the individual rights and opportunities. Clearly, optimism and rational thought had failed to produce sustained results and the chaos of the moment called for a “postmodern” view of the world. The disasters of the twentieth century were presented as proof that optimism and a belief in science and rational thought were not capable of guaranteeing an improved world. The positive worldview of modernism was replaced by the cynicism of postmodern philosophy and a sense of vulnerability to generalized chaos that prevented collective actions aimed at improvement. In the minds of many, authoritarian power as demonstrated in China, and not the process of reason, compromise, and the promotion of human rights advocated by liberal democracy seemed to be the best strategy for the future.
It has always seemed to me that we never lived in a purely optimistic modern world and that postmodernism only existed theoretically. It feels like there has always been a polarization of political ideas about the way forward which is augmented by identities and the status quo with intense competition between those in the majority and those in the minority. Last week Ezra Klein and Ivan Krastev, a prominent European political scientist, discussed the tensions in Europe that are necessary to understand if we are to make sense of what has happened and is likely to happen in Ukraine and Europe. In their conversation, they never used the term postmodern, but they did emphasize the need for power that “threatened majorities” require, and the need for “rights” that minorities demand. I struggle to understand and connect with the full meaning of postmodernism so perhaps I should give you Wikipedia’s description:
Postmodernism is an intellectual stance or mode of discourse defined by an attitude of skepticism toward what it considers as the grand narratives and ideologies of modernism, as well as opposition to epistemic certainty and the stability of meaning. Claims to objective fact are dismissed as naive realism. Postmodernism is characterized by self-referentiality, epistemological relativism, moral relativism, pluralism, irony, irreverence, and eclecticism; it rejects the “universal validity” of binary oppositions, stable identity, hierarchy, and categorization.
That definition is full of “isms” and I rest my case that fully understanding all the nuances of postmodernism is an intellectual challenge beyond my conceptual capacity. I guess that my favorite acronym as a description of our environment, VUCA (volatile, uncertain, complex, ambiguous), is a postmodern concept. VUCA concepts have evolved as a system of thought in business and the military to deal with postmodern chaos and uncertainty. One prominent aspect of postmodern thought is how the individual protects the “self” and deals with the uncertainty and challenges of a chaotic and uncertain world. The Triple Aim is an attempt to balance the needs of the community with the needs of individuals. Is the Triple Aim a bridge between the optimism of modernism and the cynicism of the postmodern world?
One criticism of Enlightenment Now is that Pinker seems less interested in individuals and is willing to sacrifice individual needs and concerns to the benefit of “the whole.” It is my opinion that in our desire to transform healthcare the concerns of individual healthcare providers and individual patients have aided the perpetuation of the status quo. The greatest resistance to the Affordable Care Act arose from patients who liked their own care or professionals who feared a challenge to their clinical autonomy and future income.
One of the reviewers of Pinker’s Enlightenment Now referenced his dismissal of the individual, his downplaying of challenges to the environment, and his apparent lack of concern about inequality in his formulation as her primary reasons for disregarding his optimism:
His optimism is resilient. Pinker expresses mild alarm about climate change… He also shows a modicum of concern about inequality, though he says we mistakenly conflate “inequality with unfairness,” …
Besides, he has little patience for individual tragedy; it’s the aggregate that excites him. Even if manufacturing jobs have gone to China, “and the world’s poor have gotten richer in part at the expense of the American lower middle class,” he still sees this as cause for celebration: “As citizens of the world considering humanity as a whole, we have to say that the trade-off is worth it.”
But life isn’t lived in the aggregate, and it’s crude utilitarian sentiments like this — a jarring blend of chipper triumphalism and unfeeling sang froid — that makes “Enlightenment Now” such a profoundly maddening book.
If we look back to the late eighties and early nineties through the current lens of Russia’s invasion of Ukraine, the sense of victory of capitalism over communism, and democracy over authoritarian oppression associated with the wall coming down in Berlin and the dissolution of the Soviet Union, we must have a little retrograde cynicism about the demise of the USSR. Whether we are emerging from the COVID pandemic or are on the verge of its next surge, I am feeling a little bit of postmodern cynicism about American healthcare. I have begun to ask myself how in the world I could ever have had an enthusiasm for Pinker’s analysis or optimism. I still hope that in time there will be some directional truth in his analysis, but at this moment things are dark both for Ukraine and the Triple Aim. His 2017-8 enthusiasm feels like it was based more on wish than on reality.
I am not alone. Others have seen the conflict in Ukraine as a manifestation of the tension between a modern “West” world and postmodern Putin. Most of us have looked the other way for years or have not been bothered at all to seriously consider what Putin might be planning as he was selling gas and oil to Europe and the West despite his disdain for us. On the Internet, I have found evidence that some more focused experts have suspected his motivation for some time. An example is a thirty-page paper from the London School of Economics and Political Science in 2019 entitled “The Weaponization of Postmodernism: Russia’s New War with Europe.” An opinion piece in the online publication The Australia Today entitled “The Cold War Struggle is Resurrected: Postmodernism vision and its tenets” presents an excellent discussion of postmodernism that begins with the war in Ukraine as its starting point. The author begins:
Ongoing Russian attack on Ukraine raised the concern of western NATO nations, who declared to impose sanctions on Russia. The world is divided into two halves of West versus the East, this phenomenon seems similar to the world of capitalism in the modern world, followed by a criticism of capitalism in the postmodern world.
The modern period noticed industrialisation, market-oriented capitalist economies, enlightenment, democracy, violence and struggle. The modern period also witnessed two world wars and followed by the Cold War during the postmodernism period, but the dissolution of the Soviet Union did not end their struggle. This needs to be discerned through the eyes of postmodernism philosophy.
Putin’s behavior is a rejection of the values of the modern West. I don’t know if his opportunism is the product of an organized system of thought that could be categorized as postmodern, but my point is that the war in Ukraine is yet another test of the ideas of liberal democracy which are in conflict with a postmodern reversal to authoritarian rule from democracy in at least one country on every continent including Europe. In America, we have had our dance with Trump and he would love a comeback, and if he fails there are many other wannabe inheritors of his authoritarian “light” philosophy in the GOP.
It is unlikely that order, reason, and the values the West endorses can be assured for any certain measure of time through negotiations with Putin. We talk about how brave the Ukrainian people are to defend their homeland and fight for sovereignty and freedom. We talk about the importance of supporting them without most Americans really realizing that their struggle is a proxy for our struggle. For Professor Pinker’s view of the future to get on track the war in Ukraine needs to be resolved in a way that protects the future of liberal democracies and at this moment that outcome is not assured.
What do we observe when we look at the health of our nation through the lens of modernism and postmodern thought? There is a partial answer and some guidance in an article, “Postmodernism and Medical Education” published by Rachel Ellaway in the June 2020 edition of The Journal of the Association of American Medical Colleges. She reviews the ambiguities and controversies within the poorly organized philosophy of postmodernism, but in her conclusion, after a long discussion she writes:
As an approach within medical education, postmodernist perspectives can help to expose and analyze the political and ideological positioning of much of what we do, particularly in the interests of addressing systemic problems of justice and equity.
She concludes by saying:
…given that what constitutes truth and our obligations with respect to truth have become increasingly central to public debate, it is paradoxical that postmodernism both supports relativist ideas about the nature of truth and provides tools and techniques to problematize and deconstruct the ideologies and agendas that have brought about this crisis of public trust and accountability.
I may be wrong, but I am going to use her words to say that when we think about our twenty years of failure to actualize the transformation that Crossing the Quality Chasm advocated in 2001, we must consider that the application of facts, the suggestion of a plausible solution by our best experts, and the presentation of a logical pathway to improvement is not sufficient to accomplish the desired outcome of a transformation of our delivery system. I found an opinion piece in the British Journal of Medicine from the mid-nineties that described the problem as it was appreciated through the lens of postmodern thought in Britain’s National Health System (NHS). The editorial was written by Dr. Paul Hodgkin, and is entitled “Medicine, postmodernism, and the end of certainty.” It begins:
“The Enlightenment is dead, Marxism is dead, the working class movement is dead and the author does not feel very well either.”
I came across a curious word the other day—credicide…it means the active killing of belief rather than just its simple demise….What is dying of course is not just Progress, Education, Science, Justice, or God—though all these do look anaemic shadows of their former selves. What is dying is the House of Belief itself…
He tries to assert that Medicine alone is hanging on to its “enlightenment.”
Medicine alone seems to remain curiously immune to these epidemic uncertainties. Health is one of the few remaining social values that garners unambiguous support. This is largely due to our continuing and communal belief that there is one truth “out there” which can be known, understood, and controlled by anyone who is rational and competent…
Within medicine one response to the relativism and uncertainty created by postmodernism has been to emphasise the evidence on which medicine is based…Evidence based medicine promises certainty…Read in this way, evidence based medicine is a reaction to the multiple, fragmented versions of the “truth” which the postmodern world offers. It is also a serious attempt to invent a new language that might reunite the Babel of doctors and patients, managers and consumers.
So far, things seem logical, but is that really the way it is now in America even if it was a description of Britain in 1996? If we believe in “medical truth” and evidence-based medicine why don’t we all fall in line and accept best practices and practice guidelines? Apparently, Dr. Hodgkin was being facetious. We discover that things were not perfect in England in 1996. The article continues:
However, an evidence based approach will only work for as long as we all view medicine as “modern”—that is, as making statements about an objective, verifiable external reality. To the postmodernist the question is whose “evidence” is this anyway and whose interests does it promote?
So what is to become of us serious medical technocrats in this postmodern age where multiple versions of the truth abound? …dismissing postmodernism simply because the technology of medicine is universally applicable is too easy for at least two reasons.
Firstly, until now medicine has been glued together by a set of myths that everyone subscribed to: doctors battled against death and disease, we lived under the one true church of the NHS, and Science lit the way to a world of health for all. Today these comforting narratives are less believable. In a very postmodern way, doctors have to juggle competing ways of seeing the same situation. Clinical reality as perceived by clinicians has to be reconciled with patients’ beliefs, “resources” have to [be] balanced against individual patient need, and ethical dilemmas spring hydra-headed from medical advance.
Secondly, the anything goes nature of postmodernism is being radically reinforced by the anything is possible nature of technology. It is not only Marxism and the Enlightenment which are dead; utterly unquestioned biological givens are disintegrating all around us: the stability of the climate, the immutability of species, a life span of three score years and ten, the unchangeable genetic make up of ones’ unborn children. “Facts of life” melt away, and our collective sense of bewilderment and wide eyed possibility rises.
To his list, I would add that even in our enlightened world the desire for “clinical autonomy” and individual economic interests will often trump “best practices” or the attention to ideas like the Triple Aim or the six domains of quality: patient-centeredness, safety, equity, timeliness, efficiency, and effectiveness. The pressure on all medical professionals and managers and their personal struggles against exhaustion in the hierarchy of the professional workforce can become so powerful that high-minded values can succumb to burnout and organizational politics. Or as Dr. Hodgkins writes:
As technology expands the bounds of what it is possible to do, it seems inevitable that clinicians will become agents of the postmodernism that they have so far ignored…At some point in this process medicine’s modernist centre fails. Doctors will no longer be able to comfort themselves with the hard edged certainty that their work is “fighting disease.” Instead they will have become purveyors of choice—or agents of control—within the plastic limits of the flesh.
Dr. Hodgkin wrote his article in 1996. He finishes with a clouded view of the future that we can now see as prescient. Our ideas about how to deliver better care haven’t lowered the cost of care. Healthcare inequities have been even more pronounced during the pandemic. Despite Dr. Pinker’s view of our progress against disease, we have been ravished by a pandemic, and inequality in society and in healthcare persists. We still have millions with no access to care, and millions more who can’t afford the medications they need. He saw it coming:
Postmodernism may seem altogether too hip and slippery for the staid old world of medicine. Yet we are no more immune than the Amish or the makers of the Betamax to the pluralistic, fragmented webs of power and knowledge that our accelerating technoculture is creating. It is the nature of postmodern societies that no new over arching visions are possible. The language is no sooner minted than it fractures into different perspectives, and simultaneously we sense, somewhere in our bones, that it is certainty itself that has ended.
When I retired at the end of 2013 surveys of the general population about their most serious concerns still showed that medical care was an important issue for voters. According to the Gallup Poll, in March 2022, healthcare was the most important concern of 3% of voters. 35% of voters ranked the economy as our (their) greatest concern. With the economy, the war in Ukraine, immigration, social concerns about race and gender, the fights over public education, and a host of other competing priorities, I would expect it will be a long time before we will generate an effective debate that fosters real improvements in healthcare delivery or the control of its rising costs and declining access.
What will happen? Unless healthcare decides to “heal itself” we will probably witness a continuing decline in access, satisfaction, and safety. Improvements in the social determinants of health are possible if healthcare providers can form effective coalitions with savvy business leaders, education leaders, and progressive political leaders. When I compare how I saw the world in 2011 when Pinker published Better Angels or 2017 when he tried to bolster his argument with Enlightenment Now it feels like we have lost ground or have come to a narrower, steeper road. I hope that I am wrong. I still would like Pinker to be right.
It’s A Start
The fish in today’s header was much smaller than the picture suggests. It’s hard to see, but if you are a fly fishing person you may recognize that the yellow perch is hanging from a “prince nymph with a bead head” that is less than a half inch long. I did not measure the pretty little fish, but my guess is that it was not much longer than my middle finger. It was so light that I did not realize that it was on my line until I retrieved it.
Monday afternoon was gorgeous. The sky was almost completely clear of clouds. There was a little bit of breeze, but the air was in the mid-sixties although the water temperature was in the forties. I spent over an hour setting up all my rods. I did some minor repairs. I needed to put on some fresh “leaders,” and check out my flies before heading out with the expectation of starting the “fishing” year with a nice rainbow or a four-pound aggressive largemouth bass. I had high hopes. The New Hampshire Department of Fish and Game had put 1,500 rainbow trout into our lake on April 4th.
All 1500 of those rainbows said no to my ambition. I guess there was no way for them to know that I am a catch and release fisherman. The end result of my first effort was the little tyke in the picture. It was nice to see it dart away the moment I tossed it back into the clear cold water. Who knows? I may catch this same fish again in a few years when it is bigger. The biggest yellow perch that I have pulled in over the last few years was seventeen inches long. I did know that I had something on my line that day!
The weather has been wet and gray since Monday except when it is clear and cold in the thirties or low forties with a stiff wind. Fishing in that environment is a low-yield process so Monday was my only day on the water. The weather forecast for the weekend is better. I have high hopes that I will pull in that first rainbow this weekend. If not, I know I will enjoy being out on the water in my pedal kayak. I hope that you have plans for some outdoor adventure this weekend. Being in nature is a great antidote for a case of burnout or postmodern cynicism.
Be well,
Gene
