Similarities in Dissimilars

The name Homo sapiens was applied by the 18th-century taxonomist Carolus Linnaeus in 1758. Sapien – the wise – suggests that the defining attribute of our species is a distinct and unparalleled cognition. We think differently from all other animals, and we are able to share those thoughts with one another in ways that are distinctively different from any other species. We inhabit a world of stories (real and imagined), abstractions, counterfactuals, impossibilities, and paradoxes. This world was made possible by symbolic representation and its outward expression – language. We find ‘similarities in dissimilars’ and express them as metaphors, similes, and analogies. In fact, language is so intertwined with our unique mode of thinking, that according to the Whorfian hypothesis, the world view of a culture is limited by the structure of the language it uses. The lack of words for concepts or the lack of relationships between concepts makes it hard to express those concepts and decreases the likelihood that the culture will learn much about them. Conversely, an established and ingrained metaphor or analogy is treated as reality (rather than a model of reality) and directs and restricts novel and alternative relationships between concepts. 

In our current world-view of healthcare dominated by the language of economics, war, and industrialization, patients and doctors have been recast as customers and service providers, respectively. Healthcare is an ‘industry’ that delivers the commodity of health to ‘consumers.’ This optimum delivery system is dichotomized as socialized or as an efficient free-market system. We wage imaginary ‘wars’ and ‘battles’ against imagined volitional agents such as cancer and addiction. Manufacturing and service industry methodologies such as LEAN, Six Sigma, and checklists are a routine part of the lexicon of healthcare. LEAN consultants are assessing patient throughputs and errors in healthcare are compared to the Six Sigma standard of the airline industry. We assign value with economic, manufacturing, and service industry measures such relative value units, patients per hour, customer satisfaction surveys. Comparable to restaurants and hotels, physicians and hospitals are evaluated via Yelp reviews. In response, hospitals and health insurers launch marketing campaigns to promote a ‘narrative’ of service excellence. Despite the best effort of all stakeholders, by most quantitative health measures, the ‘healthcare system’ is failing to deliver on this narrative. Life expectancy in the United States is decreasing, infant mortality is increasing, large swathes of the population are prematurely saddled with mostly preventable chronic diseases. Qualitatively, ‘customers’ are discontent with ‘uncaring’ healthcare ‘providers’ or ‘greedy’ pharmaceutical companies and health insurers. ‘Service providers,’ on the other hand, are wilting under the cognitive and emotional strains of increasingly psycho-social-biological complex patient populations on the one hand, and the time constraints and demands imposed by an increasingly bureaucratic hierarchy, on the other hand. 

The theoretical biologist, Stuart Kauffman formulated the concept of the adjacent possible to not only describe the scope of possibilities but also the constraints available to evolution. As he says, things have to be “possible before they are probable.” Analogously, the adjacent possible can also be used to describe a set of looming future that is available to present. This mystical and ephemeral concept grounds our current abstractions in history but also delimits the scope of what is possible. However, the adjacent possible is not a linear (from X –>Y) process and does not imply directionality, but an amorphous and infinitely fluid process across multiple dimensions. Each new combination of concepts brings forth new relationships into the adjacent possible. Effectively, there are multiple future states, but they are all a function of the current state. If we are to move out of our current state of an increasingly ineffective healthcare system, we need to explore new concepts, introduce new metaphors, and define new boundaries in the search for a new sample space of adjacent possibles?  

The “gift” of symbolism and language has been an unquestioned boon to homo sapiens. We can essentially represent the world in an infinite variety of representations. Our cognition itself is grounded in symbols and consequently, these symbols shape our thinking and the ways we know the physical world – individually and collectively. It is often said that the “price of analogy is eternal vigilance.” Similarities in dissimilars or dissimilarities in similars must always be remembered as metaphors that are not intrinsic and essential properties of each category. Therefore, although the metaphor can be suitable in certain contexts it is not optimal in all contexts.  For example, in the interest of transparency and democratization, it might be advantageous to review physicians and hospitals like restaurants and hotels. In the interest of improving efficiency, it might be useful to model patients like widgets on an assembly line. In the interest of safety, it might be useful to use checklists like airline pilots. However, physicians are not restaurants, patients are not widgets, and human physiology is different than the mechanisms of an airplane. Therefore, wherever these analogies fail to serve the function of the system they must be relinquished for different frameworks that will move the system into adjacent possibles.