Of Systems and Attributions

A pendulum epitomizes perfection of motion, oscillating with a precision consistent enough to measure dials on a clock.

But when we put two pendulums together, the perfection of motion disintegrates into the chaos of collisions, as the two pendular weights interact in irregular ways.

A single pendulum is predictable, precise. But a system of pendulums is unpredictable, chaotic.

This analogy captures the ethos of systems. The component parts that comprise a system do not define the system itself.

Healthcare, accordingly, is a system. The component parts, the individual interactions do not define, nor explain the complexity of the healthcare system itself.

Over the course of the many interactions, the patient visits, hospitalizations, reimbursement cycles, and so on, healthcare transforms into something fundamentally different than what any of us experience directly.

We like to believe we are logical individuals, who make rational decisions in our best interest, both short term and long term. But the broader healthcare statistics would suggest otherwise. These numbers tell a different story – of irrational individuals who consistently make decisions contrary to their health.

The component parts, the individual healthcare behaviors, do not reflect the broader system of healthcare. We see this when discussing medication compliance, when discussing biases in patient care in acute hospital settings, and when grappling with public policy issues.

Healthcare is complex, and the component parts cannot adequately represent the system as a whole.

Yet we fail to understand this.

We continue to look at healthcare through its component parts, attributing the characteristics of one component to the system at large.

Behavioral economists and systems experts coined a phrase for this – fundamental attribution error.

Fundamental attribution error is falsely blaming an individual or a component rather than the system, when the problem is actually systemic. The agent can be a patient, a group of patients, an organization, an industry, a government, and so on.

But the general premise remains the same, the error arises in attributing blame to a component of the system rather than tackling the broader system at large.

This is not unique to healthcare. We see this when addressing climate change. The climate is a complex system, and even the most robust systems fail to predict the weather with any degree of certainty – because there is no simple cause and effect relationship.

Certain conditions may lead to dramatic weather changes while others may do next to nothing. Relationships are predominantly correlative, not causative.

When environmental activists blame a particular industry or pollutant for the overall global warming, they fall prey to fundamental attribution error. Activists blame excess carbon dioxide for rising temperatures, simplifying the complexity of the environment into linear trends that approximate only a fraction of the inputs necessary to understand weather patterns.

Interestingly, we still do not know if rising temperatures predispose the environment to excess carbon dioxide, or if carbon dioxide predisposes the environment to rising temperatures. The key narrative activists use to decry industrial pollution, particularly from the oil industry, is based on simplifying a correlative relationship, temperature and carbon dioxide, into a cause and effect.

We know it is a gross oversimplification. Environmentalists have long known you cannot attribute one particular cause to any one effect. But the narrative persisted, largely because it is simple.

And because it persisted, it became powerful – by first being repeated, over and over.

Repetition bred familiarity, and familiarity bred trust.

Soon the simplified, familiar narrative became the lens through which all of climate change is viewed – to the point that a person’s credibility, expert or novice, is gleaned by their perspective regarding this narrative.

If an environmental expert warns about simplifying climate change into cause and effect, then he is relegated as a sell-out to big industry.

If a charismatic teenager warns the public about carbon dioxide emissions, then she is praised as a true activist.

The conversation is no longer about the system, it is about the narrative.

A pattern of simplification and of attribution we similarly find in healthcare.

During the pandemic, we saw blame attributed all around. The public blamed the healthcare experts, healthcare experts blamed noncompliance to social distancing, and so on.

Very few had the patience to discuss the pandemic as a systemic crisis, inherent to healthcare, transpiring naturally every century or so.

And those who tried found their words falling upon deaf ears.

Nobody wanted to hear how complex the pandemic was – they were too frightened to think.

A fear that has permeated patients and providers alike during the opioid epidemic. An epidemic defined by fundamental attribution errors, in which contrived narratives define how patients are treated clinically.

At the heart of the epidemic is a complex concept – pain and the treatment of it. At an individual, patient level, its component level, pain presents in one way. At a systemic level, healthcare at large, pain presents another way.

And the different perceptions of pain at the component and systemic level determine the differing approaches to patient care, and the attribution errors.

At an individual level, each patient presents with a unique set of symptoms related to pain. Some explain it better, others have more definite symptoms. The uncertainty in the presentations requires a provider to act, ensuring the pain is adequately treated.

Policy makers, however see the cumulative effects of pain treatment, the societal effects of pain medication abuse. The uncertainty in adequately addressing opioid abuse and mortality prompts policy makers to curtail overall opioid supplies.

As a result, individual actions diverge widely from systemic policies. Individual providers focus on treating the pain, policy experts focus on reducing diversion. We then simplify the diverging perspectives into contrived narratives attributing blame to select individuals. Patients blame providers, providers blame law enforcement, and so on.

But such a disparity is inherent to complex systems. Instead of viewing these divergent perspectives as a problem in healthcare, we should view them as a feature of complex healthcare systems.

As no one is truly wrong – providers should focus on treating individual patients with pain and policy experts should focus on addressing broader societal effects of opioid abuse.

But the inability to see the inherent contradictions as something natural to complex systems prevents us from implementing the right systemic solutions to meaningfully address the opioid epidemic.

Like two figurative, colliding pendulums, each alone in perfect motion, when combined, produces an irrational confluence of actions and reactions, in which each side attributes fault to the other, rather than seeing two pendulums as part of one whole system.

When we have different perceptions of pain, we create different, incomplete solutions to address the opioid epidemic – resulting in a woefully inadequate approach.

Perhaps it is time we reconcile the differing perspectives as a feature native to all complex systems, and treat the opioid epidemic for what is it – a system through which well-intentioned individual actions produced adverse societal outcomes.

The problem is systemic, and so should be the solutions.

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