The notion that local culture matters as much as any specific policy is not limited to health care. In fact, over the past few decades, organizational theorists have observed this phenomenon in companies across a range of high-reliability industries, from airlines to chemical plants to nuclear facilities. What is less clear is why or how this happens. After all, the academic and policy communities invest much effort researching the best interventions and piloting them across a variety of care sites. It is hardly apparent why shared values, in so many contexts, trumps carefully designed procedures; and even less clear how an abstract ideal is translated into tangible improvement.
The key may be in understanding industries whose work, like hospital medicine, naturally involves complex and unforeseen errors. In these environments, trial-and-error is not an available strategy for improvement: every trial is the consequence of a unique set of complications (think ER caseloads with a variety of socioeconomic backgrounds and comorbidities); and each error can propagate rapidly in equally complicated ways (think the Deepwater Horizon oil spill). Ironically, these are the same reasons why ostensible solutions are difficult to adopt – in practice, they involve a high level of uncertainty for which evidence provides no comfort.
Social science has helped uncover how health care overcomes this uncertainty. The classic 1966 study Medical Innovation -- one of the first formal social network analyses -- tracked the curiously swift diffusion of doctors’ prescriptions for the antibiotic “wonderdrug” tetracycline in four Illinois cities. Researchers catalogued the extensive interpersonal connections between doctors in the study and found that the spread of tetracycline adoption closely tracked with the doctors’ professional relationships. More than clinical trials and carefully constructed guidelines, informal conversations proved irreplaceable as a tool for teaching and convincing doctors to adopt.
In his description of the study, sociologist Everett Rogers wrote that “subjective evaluations of the new drug, based on the personal experiences of a doctor’s peers, were key…when an office partner said to a colleague: ‘Look, doctor, I prescribe [tetracycline] for my patients, and it cures them more effectively than other antibiotics,’ that kind of message had an effect.” As conversations with early adopters proliferated through the social networks, the risk involved in adopting the treatment steadily lessened. In this way, the “meaning of the new drug was socially constructed.”
The model for delivery innovation, then, was not simply objective research or guidelines; it was doctors themselves.
The tetracycline study is part of an exploding body of literature which finds that health care, by nature, seems to be susceptible to the vicissitudes of its social environment. A 2003 study through the Brookings Institution reviewed claims data from Florida cardiologists and found that their tendency to order costly and risky operations (like bypass surgery or angioplasty) over non-invasive drug treatments was much less dependent on the patient than the practice style of that physician’s social network. Even on the patient side, a 2007 article in The New England Journal of Medicine garnered international attention for describing how obesity spread like a contagion over a community of 12,000 people over a period of 32 years. At some point, we are all practicing socialized medicine; that is, medicine embedded in social networks, personal anecdotes, and local values.
In adopting a culture of excellence, the best hospitals have harnessed this social mode of learning to both align incentives for its staff and reduce the uncertainty of adopting quality improvements. Formally, academicians have termed this organizational strategy “collective mindfulness” – a mental framework of operation that relies on flexible responses within team-based settings. Informally, we might call it something else: friendship and trust.
Ultimately, research analyses are just crude ways of expressing what we already know: that although medicine is a science, health care is still a deeply human, and thus deeply imperfect, endeavor. And even the most powerful solutions are nothing if they can’t be anchored to the particular circumstances of time and place. If innovations in health care delivery are to work, they must rely on the very things that make them imperfect.