No Easy Button

Recently, I re-watched the movie, Mona Lisa Smile. The 2003 movie depicts the story of Katherine Watson (Julia Roberts), a recent UCLA graduate hired to teach art history at the all-female Wellesley College, in 1953. In the movie, Katherine is determined to confront the outdated mores of society and the institution that embraces them.

There is a scene where Katherine is talking to Joan Brandwyn (Julia Stiles). In the scene, Joan is disputing a “C” grade that Katherine had given her on a paper. In the scene, Katherine explains the reason she gave Joan a “C” was because Joan had just copied the opinion of an art critic in her essay. Joan justified it by saying that she was “referencing an expert.” Katherine replied, “If I had wanted his opinion, I would have bought his book.”

In another scene, Katherine created new assignments with new art to review after she discovered the class had already read all of the assignments in the syllabus. Her students were not pleased. As the scene progresses, Katherine asked, “What is art? What makes it good or bad, and who decides? With no textbook telling you what to think, it’s not so easy is it?”

While some may think the movie is about feminism and privilege, I think it teaches us about critical thinking. For the past couple of years, I’ve wondered if we have lost our ability to be critical thinkers because it’s not easy. It’s hard. There’s no “easy button” to push that will magically provide all the answers and solutions.

For the past two months I’ve been participating in an Action Inquiry Group (AIG) for Systems Approaches to Injury and Violence Prevention. The AIG is a an opportunity to learn more about systems thinking, but it is also a space that allows for reflection and inquiry into individual and collaborative processes that can support systems approaches and help ensure they are impactful.

One of the components of systems thinking is to be able to discern the difference between challenges that are technical and those that are adaptive. Technical challenges are defined as those that are routine, relatively easy to identify and/or diagnose, and have a known solution. In a previous blog post, I mentioned reading the book, How To Make Diseases Disappear, by Dr. Rangan Chatterjee. Dr. Chatterjee provided an example of how physicians are good at treating acute medical problems such as a broken arm (a technical problem with a known solution that can be repaired with existing knowledge or expertise). However, Dr. Chatterjee noted that chronic diseases, which plague most of the population today, have many different causes. Hence, they present adaptive challenges and can be difficult to diagnose and address.

Dr. Chatterjee describes the human body as “one big connected system.” However, physicians often revert to treating one problem at a time. If a patient presents with depression, an antidepressant is prescribed. If the patient has high blood pressure, a different medication is prescribed. Dr. Chatterjee says that a patient may have a symptom (high blood pressure, depression) in one domain, but the cause is likely way upstream in an area that current medical training isn’t addressing.

Medical practice isn’t the only profession wrestling with adaptive problems/issues. There is ample evidence of persons in many disciplines struggling to understand the causes of our social, economic, educational, etc. problems. We are failing to recognize that these problems are adaptive, and we continue to try to apply technical” or traditional solutions that are insufficient, ineffective, and drain our limited resources.

There is a body of research that supports the systems-thinking approaches; however, these approaches require lots of hard work and a desire to reshape our thinking. That’s because adaptive problems require new discoveries and new approaches, which necessitate new learning, new knowledge, and new skills. It requires looking at issues from a different perspective, understanding the limits of our own knowledge, and contending with uncertainty. It involves looking at the entire system with its multifactorial symptoms and considering and anticipating all consequences.

It requires humility on our part – or to quote my best friend, “multisectoral humility.” Carolyn often says, “we need to accept that multiple sectors and stakeholders influence any situation, and that we need to question our assumptions, discover our cognitive and emotional blind spots, ask the right questions of the right people, and listen with humility to what we learn.”

I work within a health care system that serves the most needy and underserved population in our city. Parkland Health & Hospital System and its employees continue to create a world-class institution, where our medical teams develop and utilize innovative techniques to save lives, while contributing to cutting-edge research. But, I watch our health care providers (some of the best in the country, in my very biased opinion) provide care for a very sick population that only seems to be getting sicker. I hear from my colleagues across the country that other health care systems are struggling with the same issues. The technical solution would be to improve efficiency and processes or build new clinics and hospitals. But, as I think about the systems approach, I wonder about the bigger system that has created some of the problems, such as reimbursement policies and processes.

I’m fortunate to work in a health care system that understands that improving health is about more than what happens when you get sick. According to the Bipartisan Policy Center, medical care accounts for only 10% of what makes us safe and healthy, while our environment and our behavior determine 70% of that equation (the remaining 20% is due to genetics). As my colleagues at the Prevention Institute have noted that while medical care is important, it does not address the underlying cause of disease or injuries and violence, and is not the primary determinant of health. That’s why Parkland has applied the same commitment to evidence-based practice and innovation that has made our hospital a leader in trauma care and treatment to keeping our citizens safe and healthy in the community, and out of the hospital.

Twenty-five years ago, Parkland made a commitment to upstream approaches when it established the Injury Prevention Center of Greater Dallas. The reason was that in 1991, Dallas was facing a crisis. Injuries and trauma-related deaths had increased by 38% over previous years. Trauma-related injuries were growing at such a rate at that time that by 1995, the number of trauma patients would eventually exceed the capacity of Dallas area hospitals to treat them.

Something had to be done – but, not the same things that had been done in the past. Our leaders recognized that a new approach was needed. The traditional solutions of just increasing trauma services to patch individuals up only to send them back to be injured again were not solving the problem. In 1992, Parkland convened more than 100 area health, government, and business leaders to examine the issue. The group developed a unique plan to address the problem. Instead of focusing on treating and managing injured patients, the plan outlined the need for a community-based organization focused solely on the prevention of injuries and associated deaths. In an unprecedented move, the Injury Prevention Center of Greater Dallas (IPC) was established in 1994.

As we celebrate the 25th anniversary of the Injury Prevention Center, I do so with reflection, as well as appreciation and gratitude to the previous leaders who were bold and humble enough to consider new approaches to complex problems. I’m also grateful to our current leadership for establishing the Community Health Institute (CHI), which is aimed at upstream prevention of diseases and illnesses.

Adaptive problems are complicated, and solutions must be multifaceted and comprehensive. There are no easy answers. However, as my friend Stewart said in a presentation recently, “A questioning attitude will create the space for discovery.”

I’m excited to be part of Parkland and our efforts. As Walt Disney said, “It’s kind of fun to do the impossible!”