OP-ED

Dear Humans, Diverse Social Networks are the Answer

In biology, it is clear that access to more genes leads to greater overall health. This is true because it allows for a greater likelihood that a genetic defect can be compensated by a gene from a different pool. This is the reason that inbreeding leads to more genetic diseases. This same phenomenon exists in social science. Complex social networks are healthier than more narrow (constrained) ones. Dr. Amar Dhand of the Brigham and Women’s Hospital’s Department of Neurology has, for example, shown that people are more likely to get to the emergency room in time to receive a clot busting therapy for stroke if they are part of a more complex, rather than constrained, social network.

The probable reason for this effect is the diversity of ideas that are available in the complex social networks is greater than in the narrow ones. Despite these advantages, human beings tend to resist diversity, depending instead on a competing drive to create cliques and clubs.   In Arlie Russell Hochschild’s book, Strangers in Their Own Land, she attempts to understand what she sees as a paradox.   Why do people vote in manners that seem to be contrary to their own self interest? In fact this is not a paradox, but rather simply a competition between two deeply ingrained human traits; one biological and the other sociological.

The phenomenon of professional burnout is a case in point. It is generally defined as a sense of cynicism, depersonalization and ineffectiveness. Some believe that we are in the midst of an epidemic of burnout, affecting as many as half of medical doctors, for example. The causes of burnout are protean, but at the core of the problem is the perception of unfairness; that one is the subject of a form of bias or prejudice whereby certain resources are unfairly distributed by a powerful force, such as the employer or the government. Any individual or group may be subject to this perception. Much of the conflict that is being expressed around the world can be understood as an analogue to professional burnout, in other words, caused at its root by a perception of unfairness. So what is perception and from where does it arise?

It is useful to employ a theory of mind. By theory of mind, I mean the capacity to put oneself on another’s position. It is different than sympathy or even empathy in that it allows one to understand other viewpoints without actually experiences them oneself. There is neuroscientific evidence that there are some nerve cells in the brain (mirror neurons), which are specialized to respond to actions performed by another individual. These cells may or may not exist in humans, but it is definite that certain neurological conditions damage the theory of mind, making it difficult or impossible to perceive the perspectives and feelings of others. In related conditions, one may even become disconnected from one’s own body or thoughts, such that even major deficits, such as paralysis, cannot be perceived, a condition called anosognosia (denial of deficit). In other words, we live in virtual reality. What the brain experiences is, in fact, reality.

Diversity is the solution to the apparent paradox. If one cannot perceive an aspect of the world, it can be helpful for another person to provide that insight. The more an individual, a group or society can provide diversity, the stronger it will become. This principle is not limited to one or another group. It is a basic biological and sociological trait of humans. Rather than a “republican” or “democrat” pollster, as they are always identified, what is needed is a diverse representation of the largest possible numbers of opinions, views and perspectives. Such an approach is the most effective immunization against burnout and its core cause, the perception of unfairness. The counterpoint to the narrow (constrained) network is the complex, diverse one. Wouldn’t it be nice if our media and our leaders could embrace this simple solution?

In the words or Robert Burns:

And would some power the gift would give us
To see ourselves as others see us
It would from many a blunder free us,
And foolish notion
What airs in dress and gait would leave us
And even devotion

Martin Samuels is a professor of neurology at Brigham and Women’s Hospital.

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6 replies »

  1. You just helped to explain why health outcomes studies structured to specific findings using convenience databases structured mainly for billing are a major problem. Not surprisingly we have published research studies that introduce more problems instead of offering real solutions. Given complex human interactions as the predominant shaping force in health and other outcomes, there should be a moratorium on such studies until the data is collected specific to the hypothesis and reasonable alternative hypotheses have been tested.

  2. It’s a beautiful blog. But I must confess that I think much of the social network research to be theory and hypothesis rather than conclusion or “solution,” as he says. Here’s the problem. People in broad social networks are likely to be already healthier than those in narrow networks. All one has to do is imagine all the confounders in what is necessarily associational research. These confounders are likely to include: popularity, endurance (for all those friends), attractiveness (weight?) and health, high SES (to be able to afford the networks!), urban vs. rural environments (think density and poor people in rural areas), etc. I imagine the members of this list can think of dozens of confounders that are not on any administrative dataset. This is a problem with much of our science. We can’t perform RCTs for many important questions.

    As far as professional burn-out, am I missing something? Dr. Samuels had a wonderful THCB blog on the terrible “training days” associated with one of the worst abuses foisted on doctors, especially PCPs, at his hospital, Brigham and Women’s: the roll-out of training for the Epic electronic health record. Dr. Samuels waxed poetic on that wasteful travesty. It was indeed a case of unfair burden on doctors and other clinicians. Lisa Rosenbaum, the New Eng J Med Correspondent and a cardiologist at the same hospital, wrote about it in a separate NEJM perspective in which she documented negative impacts on quality of life, even some burn-out and resignations among otherwise outstanding clinicians. It hit a chord at BWH and worldwide.

    I would like to see some good natural experiments on the effects of social networks. Meanwhile, let’s accept that the direction of causality is uncertain and we should be careful with the word, “solution.”

  3. I offer two definitions as a basis to consider the connection between a community’s COMMON GOOD and the stability of the HEALTH for each of the community’s citizens.
    .
    A CARING RELATIONSHIP may be defined as ‘an asymmetric interaction between two persons, occurring with certain repetitive and human ecologic attributes, who share a beneficent intent to enhance each other’s autonomy BY communicating with warmth, non-critical acceptance, honesty and empathy.’ The attributes may be parental, marital, etc. or incidental, long-standing, etc.
    .
    SOCIAL CAPITAL may be defined as ‘the cooperation and trust existing within the social networks of a community’s citizens that are spontaneously expressed by these citizens for resolving the social dilemmas they encounter daily with the community’s civil life.’ The prevalence of social capital within a community becomes the means to improve a community’s COMMON GOOD and its ability to mitigate the locally prevalent, adverse determinants of unstable HEALTH. It begins with the caring relationships connecting each person’s family, their neighbors, their extended family and their community originated private-institutions.
    .
    Our nation’s current, full-bore focus on solving the cost and quality problems or our nation’s HEALTH will not succeed without a community driven focus to promote the COMMON GOOD for each communitys’ citizens, especially their equitably available Primary Healthcare. No matter how we structure the health spending within our nation’s economy, there is no basis to believe that the current Paradigm for our nation’s healthcare will be able to solve its cost and quality problems. New ways of thinking will be absolutely required to reduce the paralyzing level of cognitive dissonance that currently exists. It can begin with a widely supported and integrated set of definitions for a caring relationship, collective action, common good, HEALTH, institution, and social capital.

  4. But a complex diverse network is just another idea that many diverse brains would not all agree with, some of whom desire more uniformity

    Surely you have limits: would we function harmoniously if we looked like the Mos Eisley Cantina on the planet Tatooine in movie Star Wars?

  5. I would be interested in some pieces here on burnout, especially aimed at interventions/therapies. Most of those offering this look like quacks to me. I suspect we now know a lot of the things that reduce risk, but sometimes those risks are baked into the job. Plus, family issues just happen to everyone. Sometimes I can see it coming on in a good young doc and it is so hard to help stop it.

    Steve

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