Social Complexity

By Gerrit Van Wyk.

I’m Confused.

Thirty years ago, I belonged to the specialist medical community of a metro-pole of about 1 million people in South Africa. At the time we were faced by three threats; healthcare insurers instituted managed health care practices to stem rising costs which started impacting on our practices, three of the major insurers in the area faced bankruptcy, and the proposed health care platform of the leading party in the run-up to the first free and fair elections in the country was set to turn health care upside down if implemented.

Family practitioners in the area had a forum for negotiation but the specialists were unorganized and a group of opinion leaders therefore convened a meeting to discuss the impending storm during which a committee was elected to manage the day-to-day affairs with myself acting as secretary. Every specialty would be represented during meetings to represent the voice of the group.

Given the historic distrust of insures, it rapidly became clear the membership wished to resist the upcoming changes rather than partner in negotiating our future as a longer-term strategy. My argument was it is better to participate in change than allow stronger more powerful forces to make changes without consultation or our consent. I volunteered to make a presentation about this during a well-attended general meeting, showing scenarios based on different approaches. The key to making a best outcome work would be everyone must share a common understanding of the problem and what must be done, and then commit and cooperate towards that.

I’ve heard it said getting a group of doctors to cooperate is like herding cats, and so it was. Everyone seemed to understand intellectually what was happening and what needed to be done, but I only realized afterwards every specialty has its own subculture and those cultures don’t get along. I eventually quit in despair and spent the next twenty years trying to figure out what I could have done differently to make this work.

The consequence of all this, as expected, was managed healthcare became entrenched, the insurers went bankrupt with everyone suffering financial losses, and when the African National Congress was elected their Health Charter became official policy.

I learned in business school that leaders spend the bulk of their time creating strategies and implementing them. What they didn’t tell me is evidence shows only 5-15% of those are implemented or implemented as planned, which means leaders spend most of their time preparing for something with an 85-95% chance of failing, for which they are generously rewarded. I find this shocking for two reasons.

Firstly, Narcotics Anonymous say to keep doing the same thing and expecting a different outcome is insane, and secondly, no-one in the business community ever stops to ask what is going on here and what could we do differently? What happened to me thirty years ago was I embarked on a similar Quixotic quest and predictably skinned my knees, and it became my obsession to figure out what’s going on.

What I discovered was my colleagues didn’t cooperate not because they didn’t understand what was going to happen and what we needed to do, but because of underlying social dynamics I didn’t see or understand. I also learned none of the models taught to me about how society works explain that dynamic and if we want to meaningfully change health care, we need to understand that dynamic.

We know intuitively our social world is complex but what we don’t see is that complexity is an ocean supporting pockets of conscious experience drifting around on it like ships. We are conscious of the ships and what happens in them, but not of the ocean supporting them and what happens below. Our social world is an ocean consisting of networks of relationships and interactions from which the ship-like things we are conscious of emerge. Stacey suggested it’s useful to think of our social world as if it works like complex adaptive systems (CAS), which are computer simulations, but contrary to what some people think, it’s not the same because it is much more complex.

Like the agents of CAS, we respond to others around us based on simple social code without being aware of it, who in turn respond to us. Nothing we do doesn’t affect others in small but sometimes big ways, and those effects can ripple through networks of relationships unpredictably and sometimes in significant ways. We adapt to what we experience and learn from it, which influences how we react to similar situations in the future. The engine driving it all, and containing lots of the code, is language and conversation.

Communication works like a telegraph with a message sent to a receiver, but conversation is an active ongoing cycle of speaking and listening during which we try to decipher the meaning of what others try to convey to us.

As John Donne said, no man is an island and as humans we seek out and belong to groups for protection, but the groups and connections also shape who we are, and the image we have of ourselves as individuals, and collectively of the group we belong to. We cooperate within groups who compete or cooperate with other groups for advantage. For example, as Canadians we sometimes cooperate and sometimes compete with Americans, doctors sometimes cooperate and sometimes resist managers, and, as I discovered, doctors are not all the same, there are micro-cultures sometimes cooperating and often competing for attention, resources, power, etc.

There are small pockets of thinkers using conversation and dialogue to bring about change, and one of those approaches succeeds long term in 85% of cases, proving the importance of knowing and understanding the complexity of human behavior. Those odds are about 10 times better than what we’ve been doing and keep on doing. In other words, unlike existing approaches it seems to solve the implementation dilemma.

Had I known all this in advance, I would have approached our predicament very differently and may have had a better chance of success.