First Principles of Healthcare

Chaos is in the interactions, not in any cause or effect.

So to see chaos, focus on the interactions. And to see chaos in healthcare, focus on the interaction between individual behavior and broad healthcare policy.

Healthcare policy is decidedly uniform. Whether it is a law, guideline, or explicitly conveyed action, a policy applies to everyone equally. For example, we know the parameters for high blood pressure. Defined by the American Heart Association, all hypertensive patients reflexively follow the parameters in managing their condition.

But blood pressure and its response to medication treatment vary among patients. In fact, no two patients respond the same to a given blood pressure medication. There are inevitable variations in how well a patient can adhere to the blood pressure guidelines.

Implicitly we understand this. We know blood pressure fluctuates over time to be a few points higher or lower than the referenced parameters. But we fail to understand the consequences of this in aggregate – across broad populations of patients.

Individual fluctuations are acceptable variations, something we call noise. Among broad populations, the noise compounds upon each other, becoming chaos.

Chaos arises out of the interactions of different individuals to the referenced standard. Some can adhere more closely to the guidelines, while some struggle to, even when they are compliant with lifestyle modifications and treatment medications.

But chaos is not fixed. It varies dynamically over time. Some patients who may have initially adhered closely to the guidelines may become lax in their diet, risking hypertensive spikes in the process. And some who struggle initially may overcompensate with higher than necessary medications or become indifferent after seeing no initial success. The responses fluctuate wildly.

So wildly that suboptimal adherence to blood pressure treatment is responsible for 10% of the total annual cost of managing blood pressure in the United States, according to a 2019 peer reviewed study in Circulation Research.

This is not out of a lack of awareness or understanding on the part of patients. The same study finds that most hypertensive patients know the consequences of poor hypertensive management. Yet adherence remains inconsistent. In fact, adherence is inconsistently inconsistent per patient.

Most assume this to be a problem with how we treat patients, a flaw within the healthcare system. But it is not so much a deficiency as it is a characteristic of healthcare. Healthcare is dialectical, a perpetually non-linear, unpredictable reverberation of reactions and counteractions unique to each individual.

Many compliant hypertensive patients justify eating a high salt meal because they have been compliant with their medications – “you have been doing so good, one meal won’t hurt you.” Just like many noncompliant hypertensive patients justify a high salt diet precisely because they have not been compliant – “it’s not like you have been taking your medications, what’s one meal going to do?” And the same patients, regardless of past adherence, justify becoming more compliant if they experience a hypertensive crisis or ischemic stroke.

Healthcare has no steady state; it is a perpetual stream of fluctuations going back and forth. This is what makes healthcare chaotic, but this is also what gives healthcare its humanity.

Physicists who study chaos dissect it into more simple terms, reducing chaos into its component parts. Similarly the chaos of healthcare should be studied through the internal thoughts of patients – the chaotic, dialectic stream of beliefs, decisions, and actions that define a patient’s behavior.

When viewed this way, much of what transpired during the pandemic makes sense. Mask mandates and calls for vaccinations are broad healthcare policies instituted at various levels of government, intended to apply to all patients uniformly.

But the individual responses to the policies fluctuated quite noticeably. Some adhered to the policies, believing them to be important, while others adhered to the policies, despite seeing them as pointless. Some resisted the policies, for a range of reasons based on their political affiliation, socioeconomic status, or healthcare insurance.

Regardless of how draconian or accommodating a pandemic policy proved to be, it was met with a range of responses. That fluctuated over the course of the pandemic, reverberating back and forth across media outlets, school board meetings, and internet platforms.

We see this lack of consensus as a problem. And we look for sources to blame – social media, political rhetoric, or even the pandemic-induced isolation. But the lack of consensus towards healthcare policies is yet another characteristic of healthcare. Healthcare is an aggregate of individuals, who approach their health differently, through disparate beliefs.

And when we enact healthcare policies, we attempt to impose or to guide certain actions uniformly. But individuals affected by the policies react varyingly to the uncertainty within them. They respond not to what the policies explicitly state, but to what they implicitly fail to convey. A reaction that is different from the assumed intention of the policy, that also initiates a dialectic wave of reactions and counteractions between policy makers and the patients affected.

With each wave being unique to each individual, that among broad populations form waves of chaos as each individual responds to broad policies through their unique healthcare experiences and perspectives.

And no matter how technologically sophisticated healthcare becomes, or how robust the data analytics proves to be, healthcare will always reduce into a fundamental dichotomy between broad policy and individual perceptions.

All of which is to say, healthcare is chaotic and dialectic – the first principles of healthcare.

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