What I love about DPC is that we are doing just that, keeping the beauty of being a primary care doctor present while adopting the modern technology and innovations of the 21st century to help make our lives happier, healthier and hopefully a little bit wiser.
Many metaphors have been used to describe institutional stagnation. When a social institution such as healthcare fails to live up to society’s expectations, the impulse to understand why the institution is failing is certainly reasonable. One such metaphor used to describe the failure of our healthcare system has been the elephant and rider analogy. In particular this elephant and rider metaphor has been used to apply to direct primary care. The mind, so goes the metaphor, is like an elephant and a rider. Our choices on the one hand come from a rational rider who seeks to guide the elephant, while on the other hand they come from the elephant within us–irrational forces that guide our behavior despite our attempts at rational control of ourselves.
In this episode, Dr Roussel elaborates on the metaphor’s application to Direct Primary Care. “Does it work for DPC?” he asks, and if it doesn’t, what’s a better alternative?
[1:26] As the DPC movement continues to grow, one of the issues we’ve come up against is institutional changes. What does it take to change a system where perverse incentives discourage making a positive change?
[1:41] An analogy that’s been used to describe the situation is one that was originally introduced by psychologist Jonathan Haidt in the Happiness Hypothesis, elaborated on in “The Righteous Mind.” It’s been used by many other writers, other particular notable writers are the Heath Brothers & their book “Switch” about challenges with institutional change. The idea goes that we are all led by unconscious behaviors as a result of millions of years of evolutionary forces, creating our lower brain, our limbic system, I might even add autonomic nervous system and brain stem to that. This is the elephant in the analogy. We also have a neocortex, the reasoning, planning part of our brains. This is the rider
[2:30] The prevailing paradigm for the past couple of centuries really has been that we as humans will always make rational, reasonable choices. When in reality, say supporters of the elephant rider hypothesis, we are all led by the elephant. The unconscious thoughts, impulses, that stem from our primitive history.
[3:03] If we can all better understand this, we can be better riders of the elephant. We can live in harmony with the elephant, be aware of the effect of environment on the elephant, how learned behaviors don’t change quickly, how fight or flight can keep us from working together, etc. For healthcare, goes the analogy, if we can recognize the perverse forces encouraging doctors, healthcare workers, brokers, insurance companies to act in a way that does not benefit the system, that forces us to continue this dog-eat-dog way of behavior in the healthcare market, then we can start to change those forces, bring the elephant into the Savannah with lush green grass, water and all live in harmony.
[3:51] Now I’m simplifying the model but the basic idea is that that awareness of those forces–of our primitive impulse–can help us address the systemic issues at hand. To be clear, I’m certainly a supporter of mindfulness of systemic forces, and I love metaphor and I do like this analogy.
[4:23] I do think it’s important to point out some challenges when applying the elephant rider analogy to healthcare. That’s what I want to talk about. This is deep, and theoretical, I know, so I’m not offended if this episode is not your cup of tea, but I think discussing the purpose and the meaning of DPC is important to a movement that many of us believe is formed out of value, meaning and conviction.
[4:52] To start, one of my most influential classes in college was called ‘Civilization and Barbarism’ and the course focused on Shakespeare’s play The Tempest. In particular, we focused much of our attention, for the class, on the character Caliban, who has sort of a quasi-human almost animal character, with poor control of his appetite and ‘uncivilized’ behavior. The point of the class was to show that at the outset, to many literary critics contemporary to Shakespeare Caliban represented the European vision of the uncivilized native. On deeper inspection, the metaphor of Caliban can be equally applied to Western colonial powers whose attempt to ‘civilize’ the world actually represented an attempt to institutionalize their own primitive impulses. Now historically this is only partially true, but in any case the point is that awareness and mindfulness can serve as its own barrier to institutional change.
[5:57] The birth of the ascetics and many other derivative schools of the late Roman empire saw mindfulness not as a tool for social change but as a path to avoid the painful realities of a chaotic, fading civilization. The idea wasn’t to change the world but reach such a state of mindfulness that the outside world didn’t matter anymore. I point this out not to minimize the importance of the metaphor or of mindfulness but to bring up a couple of important caveats when thinking about institutional change:
- [06:31] There may be sinister forces at play with regards to resistance to change in healthcare. Some may indeed want to preserve the status quo simply because it keeps their company, making more profit than without the status quo–even if such a resistance comes at the expense of everyone’s wellbeing. That shouldn’t stop change from being pushed.
- [06:58] More importantly, pictoralizing the elephant and rider as two separate entities does encourage a mind-body sort of mentality that can be a slippery slope to the same sort of issues that started our institutional problems in the first place. Much of the over technicalization of medicine can be traced to a set of education reforms in the 1920s called the Flexner reforms, where the US DOE attempted to standardize medical education as an attempt to–to use our analogy–increase control of the rider over the elephant–to root out our uncivilized, basest instincts and encourage a more rigorous, scientifically-based medical education. This undoubtedly led to an over-technicalized medical education that in no small part contributed to over-specialization of the profession and even the CPT based coding system we now have that has made primary care so unpopular.
[08:09] To put it simply, I’m loathe to accept rational control of the subconscious mind as a path forward.
[08:18] So what does this mean?
- [08:23] I think it’s important to remember that Hippocrates in many ways is still a model for the profession. For Hippocrates medicine was a process on the one hand, with a history, physical, diagnosis and exam, but it was also an art. The process of phronesis I think describes clinical judgment beautifully. Not quite a technical procedure, rather an art of bringing together experience, art, science and knowledge. The point of the a good judgment was to help the doctor and patient reach a state of happiness, Aristotle called it eudaimonia, a balance of mind and body and society, a harmony worked towards though never quite fully achieved. I would consider this a much more unified view of the elephant and rider than a simple bottom and top, rider and elephant analogy.
- [09:23] The profession is in a constant state of flux with society where old habits are being thrown away, but it’s always important to discern what needs to be kept from what needs to be left behind. As we move from metaphors of health 1.0, 2.0, 3.0 etc, I think it’s important to figure out what was beautiful and good about being the docs that ‘our grandmother used to have’ from that which was wasteful and even harmful about that same system.
[09:56] What I love about DPC is that we are doing just that, keeping the beauty of being a primary care doctor present while adopting the modern technology and innovations of the 21st century to help make our lives happier, healthier and hopefully a little bit wiser.