A Boids Eye View of American Health Care ©

When you watch a flock of birds fly through the sky, or a school of fish swim through the water, it is amazing how each individual seems to know what the whole group is doing. They don’t even have a drill sergeant calling out, "To the right flank—MARCH!," yet everyone seems to know exactly what everyone else is doing. 

This group behavior is called flocking and is a particularly good example of how complex behavior arises from relatively simple rules. Craig Reynolds used three simple rules to model the behavior of these "boids:"  keep a proper distance from your neighbor (separation), aim in the average direction of those closest to you (alignment), and always try to aim at the center of the group (cohesion). Simple rules can govern complex behavior. 

Paul Plsek is a systems analyst that looks at our health care system. He wrote an appendix applying systems technology to our health care in the recent report of the Institute of  Medicine,  Crossing the Quality Chasm. This book is aimed at helping us in America to bridge the chasm between the health care we have now and the health care we should have with the money we currently spend. Plsek’s appendix points out that our health care system is a complex adaptive system—it’s a "boid." As such it adapts to stresses in an organic way. He points out that all of the governmental efforts to control health care have tried to make it more mechanical and predictable—and they haven’t worked because the system just adapts and grows somewhere else. Will our government pay attention? Don’t hold your breath. 

Based on the "boid" rules I tried to come up with some similar rules that apply to our complex and adaptive health care system.  

• Alignment means that we move together, or don’t look at anything new until double blind placebo controlled trials have been done. 
  • We all practice in boxes defined by acceptable medical practices.
  •  People who practice out of these boxes, and do things like chelation therapy, are scrutinized closer and are more often called before their respective state boards.
• Separation means that we don't crowd the other doctors and that we wont really compete. 
  • What competition there is is directed at getting a larger share of third-party-payer money. 
  • More time is spent on gaming the system than on helping patients become more healthy. 
• Cohesion is what gives the flock its identity. 
  • Without this rule the birds would go off in different directions and the flock would not exist. 
  • Whether we like it or not the single characteristic that best defines American health care is its expense. 
    • Costs in America are more than double the average costs of the next highest costing 10 nations.  
    • This may seem a little harsh to some, but relying on privatization to deal with health care means that profits are important. 
    • It also means that inexpensive, yet effective treatments are not given as much consideration as ones that have a larger profit margin. 
    • The New York Times recently pointed out another example of this kind of gaming the system—that the increases in spinal fusion surgeries was due to the profits from that procedure more than the medical benefits (NY Times, 31 Dec 2003. Reed Abelson and Melody Peterson, "An Operation to ease back pain bolsters the bottom line, too."). 

While our leaders claim that we have the best health care in the world they are looking at only one aspect of it. 

• The World Health Organization ranked its member's health care systems and we came in 37th—not exactly the best that our leaders claim. 
• The reasons for our poor performance were our life expectancy (24th) and the equitability and availability of health care to all of the population (54th). 
• The area of health care where we unquestionably do excel above every other country in the world is in critical care. 
  • Given the ready availability of a trauma center or a cardiac unit Americans have excellent chances of denying death when confronted with critical emergencies. 
  • We don’t do nearly as well with chronic illnesses, like diabetes. 
  • Why this difference except that those needing critical care aren’t going to haggle about how much it costs. 
  • Our expensive health care system is exactly what we have chosen when we emphasized privatization and its associated profits. 

Like most of you, I’m glad that we have this expertise. But at the same time I’m not too sure about the role of profit in determining how our health care system functions.  Plsek argues that changes to complex systems need to be small, and that they need to come from within the system, but as long as our system is following the "boid" rules effective change is unlikely to come from within the mainstream of the system. It is much more likely to come from the margins.

Common Sense Medicine® is about our system of health care and about the  changes that can help it to be fairer in distribution as well as more effective in keeping people healthy. If you like what is said here please share it with your family, friends and especially your legislators.