Trust, communication and tribalism Professor Jeffrey Braithwaite Centre for Clinical Governance Research, UNSW Tuesday 11 December 2007 HealthGov Conference:

Trust, communication and tribalism

Professor Jeffrey BraithwaiteCentre for Clinical Governance Research, UNSWTuesday 11 December 2007

HealthGov Conference: Effective Governance of Health Professions in Australia

Systemic and individual responsibility

To begin …This briefing is deliberately controversialI am going to argue that we are evolved for a completely different existence from the one we have todayAnd that this provides a deep explanation for today’s problems in healthWhat do you think of that idea?

The find of a new human, Homo floresiensis, on the island of Flores in Indonesia, set the archaeological world buzzingIt lived until 13,000 years agoThis is very recent – a blink of the geological eye

An evolutionary perspective


Homo floresiensis is thought to have shrunk to pygmy size under the evolutionary pressure of living on a small islandNo predators, limited resources


Both hobbits [as they became known] and humans are evolved for clear niches in their environmentsWe are, fundamentally, hunter-gatherers


Humans and hobbits share some common adaptative problems

Need for oxygen, food, waterProtection from the environmentTo mate and pass on genesRaise offspring to continue the line

How good were your own ancestors at this?


Humans are selected for solving other problems from the PleistoceneThis was the last 2.5 million yearsSome 99% of human history was spent as hunter-gatherersHumans are adapted [naturally selected] for this way of life


This is millions of years of surviving in lightly wooded savannah grasslands In small kin-based groups using stone tool technologyBased on trust, communication and tribalismOriginally in Africa, then radiating across the world


Needs: a big brain to process all the social dataBenefits:

Shared risksGroups to rely on when things get tough

DownsideLife’s more complexIt’s social and political


Social consequencesTribalism – ‘us’ and ‘them’Exchanging social, material and intellectual resources becomes prominentSocial rank [hierarchy] becomes pronouncedNeed to ‘mind read’ – understand your mental state and others


Social brain hypothesisHumans [as compared to other primates eg chimpanzees and gorillas] develop considerable capacities to:

Read behavioural and facial cuesAnticipate othersDeceive if and when necessary


So what were we selected for, #1?Negotiating with othersTradingCollaborating with close tribal membersNurturing othersKeeping powerful people happy


So what were we selected for, #2?Second guessing rivalsIdentifying rapidly those external others who would constitute a threatProtecting our own patchOutwitting and defeating enemies


Do you want proof?Look around you, at your neighbours …What do you see?


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 eyeWhat do you see in your workplaces; how are people behaving back in your hospital, public health facility, department, ward, division, unit?


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 groupsThey value novelty, challenge, and social interaction


People value careersThey 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


When this works well it works very well – based on trustBut when it doesn’t … it really doesn’tIt’s like ‘the girl with the curl’Every one of us has experienced bothComments?


The upsideThrough skills and professional competence millions of people are attended to in their time of illness or health needThis is a highly noble pursuit, with many satisfied patients and staff


The dark sideA succession of studies and enquiries have shown established systems cause iatrogenic harm to hundreds of thousands of patients worldwideHere, we glimpse at behaviours that have evolved for our personal or group protection that may not lead to an optimal health system


Listen to two enquiriesBristol Royal Infirmary, United Kingdom:“Poor teamwork” … “The teams were not … multidisciplinary” … they were “profoundly hierarchical”“A sense of ‘them’ and ‘us’” … and … “poor communication”


Listen to two enquiriesKing 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 collaborationAnd hunter-gatherers have a huge propensity to turf-protect and treat badly anyone who threatens


In both the Bristol and the King Edward cases whistleblowers were ‘inadvertently’ left out, gossiped about, ostracised and generally castigatedNote that there is clear survival and group bonding value in doing thisThis does not justify such behaviours – but does allow us to understand them


Health professionals in these cases [and everywhere, in fact] tend to flock together in professional tribes rather than multidisciplinary teamsClustering like-with-like, and mistrusting, even shunning those who are different or represent a threat is a powerfully evolved tendency


It helped Homo sapiens to be so successful as a speciesBut 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


So … we need culture changeBristol, main report mentions ‘culture’ 191 timesKing Edward Enquiry mentions ‘culture’ 62 timesBut how difficult is this?Very


Humans have evolved behaviours to protect and position themselves over many millenniaThey are deeply structured into the fabric of modern society and its institutionsThe health system reflects these characteristics


Especially when intimidated or vulnerable, people will tend to:

Default to well-worn behavioural repertoiresRegress to a struggle for individual survivalIntensify relationships within their primary groups and coalitions

Organisational culture change is therefore likely to be very hard


Taken together, these are indicators of millions of years of adaptiveness for personal and small group protection at the expense of othersCan we alter this fundamental human nature?

The evolutionary cleft stick

Thus we are in a catch-22, cleft stick situationWe may be at the evolutionary point where:

We are smart enough to design today’s health systemBut not smart enough to solve the problems of working together that system demands

The evolutionary cleft stickCan 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


1. Wait for evolution to shape us as a more collaborative species

2. Attempt a big bang change to the health system, sweeping away unwanted behaviours, posturing, poor practices

Problem: takes too long, no guarantee of successProblem: we don’t know how to do this, it would likely damage the health system, no guarantee of success

There are three options:


3. Continue on the present course, ie continuous improvement

Problem: our evolved nature keeps getting in the way, no guarantee of success

There are three options [continued]:

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 clearlyThis has often happened in human historyA calamitous predicament occurs, and people pull together to resolve it

A way forward?

Examples:The Battle of Britain, Summer 1940The 9/11 terrorist attacks in New York, 2001The 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 actionMaybe, maybe notBut 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 extinctPerhaps we are destined to go the way of Homo floresiensisIf 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 readingBraithwaite 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

Conclusion, part 2

Time forFinal commentsArgumentsDiscussionQuestions.

Documents

Trust, communication and tribalism Professor Jeffrey Braithwaite Centre for Clinical Governance Research, UNSW Tuesday 11 December 2007 HealthGov Conference: