“Heroism of Incremental Change.” Part 1

So much has been written about the importance of “transformational” change in health care, schools, and criminal justice.  Seeking fundamental changes quickly in how institutions operate is dramatic, visible, and garners media coverage. Too often, however, glowing rhetoric exceeds actions.

Making small changes, for example, in how health care for millions of previously uninsured Americans is delivered and paid for is undramatic and often goes unnoticed. The Affordable Care Act–Obamacare to many–is a prime example of an incremental change in health insurance for more Americans that is both important and substantial. The current “repeal and replace” political rhetoric promising dramatic changes in the Affordable Care Act that will “transform” health insurance remains, as I write, just words.

Similarly, claims for “transforming” changes in teaching and learning through “personalized learning,” robotics, and virtual reality are, well, still magical incantations that have yet to transpire in most U.S. schools.

But small changes in schooling can accumulate and help students learn. Teachers spending more time with individual students and increasing teacher collaboration are less visible, less media appealing changes. Setting aside time in daily schedules when children and youth can interact with teachers outside of lessons sounds so procedural, even trivial to starry-eyed reformers yet remains significant to individual teachers and students because those adult-student relationships are at the core of learning.

Or small changes in getting police officers in largely minority communities to treat individual citizens with respect, even at a time when social media saturates police-citizen interactions, reformers greet such changes with yawns and shrugs. The yearning for massive, swift, and head-turning change is strong among Americans. Yet….

In most things in life, the important changes are small and, over time, may accumulate into a transformation. Giving a six year-old responsibility for daily chores around meal time and increasing their responsibilities in small chunks as the child gets older can lead to driving privileges at 16. Yes, such planned changes gather slowly and build up to substantial shifts in behavior.

Sure, there are dramatic interventions that change lives:  the eight hour surgery that removes a brain tumor; the pilot who landed a crippled jet in the Hudson River in 2009; a successful mission to rescue hostages. Those decisions, those events, those changes have powerful effects on individuals and their families.

Yearning for the dramatic intervention overlooks, however, the building up of small changes over time that accumulate in a family, school, and organization behaving in ways that become evident over time. Consider policymakers allocating annual funds to fix the inevitable wear-and-tear  in bridges, highways and dams before a collapse occurs. Those actions become the heroism of incremental change. We need more of this rather than the showy, media-grabbing attention of promised “fundamental” or “revolutionary” change that disappears in the next 24-hour news cycle.

Consider surgeons and mortality rates.

Avoiding mistakes in operating rooms can save lives. Errors in surgery often cost lives. Studies showed that having surgeons and nurses go through a simple checklist prior to administering anesthesia and wielding the scalpel would reduce deaths from surgery.

*confirm the patient’s identity.

*Mark the surgical site.

*Ask about allergies.

*Discuss any anticipated blood loss.

*Introduce yourself by name.

Such checklists, according to studies done in the U.S. and Europe have shown sharp reductions in surgery-related fatalities (See here, here, and here)

A small addition to what surgeons and nurses do daily saves lives. Yet even this incremental change has been hard put to show sustained gains over time because implementation of checklists vary among hospital staffs.

Implementation is the key word. It is a ho-hum activity to policymakers and wannabe reformers because it lacks pizazz and eye-catching tweets or headlines. Putting an idea into practice requires careful attention to detail.

Where surgery is dramatic and can be life-saving, primary care physicians traffic in colds, headaches, stitching up cuts, painful knees, lower back pain, and listening to patients. Surgeons may use checklists and reduce errors but surgeons are not in the business of listening.

But primary care doctors are. . They aim for  prevention, stability in patient health, step-by-step progress in combating difficult problems, one patient at a time. And this incremental approach reduces mortality rates

A Boston surgeon visited and wrote about a nearby clinic to see primary care physicians in action.

The clinic is in the Boston neighborhood of Jamaica Plain, and it has three full-time physicians, several part-timers, three physician assistants, three social workers, a nurse, a pharmacist, and a nutritionist. Together, they get some fourteen thousand patient visits a year in fifteen clinic rooms, which were going pretty much non-stop on the day I dropped by.

People came in with leg pains, arm pains, belly pains, joint pains, head pains, or just for a checkup. I met an eighty-eight-year-old man who had survived a cardiac arrest in a parking lot. I talked to a physician assistant who, in the previous few hours, had administered vaccinations, cleaned wax out of the ears of an elderly woman with hearing trouble, adjusted the medications of a man whose home blood-pressure readings were far too high, and followed up on a patient with diabetes.

An expert in primary care told the Boston surgeon that the success of primary care is that patients and doctors develop relationships over time. The surgeon visiting this clinic writes:

I began to understand only after I noticed that the doctors, the nurses, and the front-desk staff knew by name almost every patient who came through the door. Often, they had known the patient for years and would know him for years to come. In a single, isolated moment of care for, say, a man who came in with abdominal pain, [to] Asaf [primary care expert] looked like nothing special. But once I took in the fact that patient and doctor really knew each other—that the man had visited three months earlier, for back pain, and six months before that, for a flu—I started to realize the significance of their familiarity.

For one thing, it made the man willing to seek medical attention for potentially serious symptoms far sooner, instead of putting it off until it was too late. There is solid evidence behind this. Studies have established that having a regular source of medical care, from a doctor who knows you, has a powerful effect on your willingness to seek care for severe symptoms. This alone appears to be a significant contributor to lower death rates.

Observing the care, I began to grasp how the commitment to seeing people over time leads primary-care clinicians to take an approach to problem-solving that is very different from that of doctors, like me, who provide mainly episodic care.

Unlike surgeons, primary care doctors see patients time and again, develop relationships as they tend to their aches, pains, and wounds. And they listen. They are the “heroes of incremental change.”

Part 2 turns to teachers as the “heroes of incremental change.”

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10 Comments

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10 responses to ““Heroism of Incremental Change.” Part 1

  1. Caetano Siqueira

    Hi prof. Cuban. It would be really interesting to read about your thoughts on Incremental Change and how you measure it in education. How do we know that something is really changing if change is small at each step and frequently uncoordinated? Is it possible to catch it while it is happening or do we have to wait until it has accumulated for a long time? Is it possible to foster this kind of change (from a district level, for example) or it only happens “organically”?

    • larrycuban

      Very fine questions some of which I can answer (and have answered) but most of which I cannot. When I looked at teaching over a century (How Teachers Taught, 1890-1990) I identified many incremental changes in curriculum, instruction, and school organization that accumulated over time. Fostering such change, however, has been low on the agenda of school reformers who too often use the rhetoric of “transforming,” “revolutionary,” and “major” change, i.e., reform. Thus the smaller, bite-sized increments that do occur seldom reach the media or are even noticed.

  2. Its interesting how incremental change develops conditions for the emergence of morality.

    I think List & Pettit’s work of judgment aggregation theory and the creation of group agent dynamics is prescient here. The conditions for slightly moral landscapes and small-change ripples rather that total-change tsunami’s provide just the right fuzziness for decision history to produce interpretable intentions. As they suggest, this enables people to align to perceived intentions.

    The functional aspects of this are described by lots of different academic traditions (culture anyone?). But what I personally find so fascinating is the under appreciated role morality and group dynamics play. Change is bound by an adaptive group’s resistance to purposeful usurpation. But it is enabled by having low-to-moderate norm enforcement which, as lots of simulations show, is a requisite to enable large group size.

    • larrycuban

      Thank you for your comment, Chris. I am unfamiliar with the List and Pettit work and, frankly, your two sentences– “Change is bound by an adaptive group’s resistance to purposeful usurpation. But it is enabled by having low-to-moderate norm enforcement which, as lots of simulations show, is a requisite to enable large group size”–I do not understand. But I will work on it a bit more.

  3. Sorry Larry – easy to get caught up in technical fields…

    Evolutionary biology, in particular, David Sloan Wilson’s multi-level selection theory, explains why human (social) groups live in tension between doing what’s best for the individual and doing what’s best the group. One consequence of this tension is a natural tendency to resist individuals who might exploit the group, perhaps by dictatorial usurpation. Without a tendency to resist such behaviour, groups quickly collapse. Pervasive self-interest swamps altruism.

    Thus groups are enabled and sustained by lots of altruists. This makes the groups really effective at coordination and spotting freeloaders (usurpers). In fact, they are exquisitely sensitive in this regard.

    So the most successful groups should be composed of nothing but honest, self-sacrificing altruists? Unfortunately this isn’t the case. Norms are tough. They exclude lots of people. If you relax your group norms a bit, more people participate. So now my group of really efficient altruists has to compete with a group of semi-efficient altruist / self-interesters. Size matters and in many cases groups of pure altruists are outcompeted. (This simple theory does wonderfully well at explaining the evolution of human society)

    In practice this means there is always tension between being too group-oriented (altruistic) and too self-interested. Neither pole is stable. The middle ground maximizes benefits, but it is an unstable equilibrium. Simulations (and standard complexity theory) show that the middle ground experiences complex oscillations. People oscillate between acting for the benefit of the group and acting for the benefit or themselves (or your own niche group).

    Surprisingly enough this simple physics seems able to explain educational change cycles and educational reform resistance. But you do have to add a couple more pieces to explain why things like business don’t experience these dynamics while education does. And, why things like religion don’t have the frantic surface waves of change that education does.

    But it is all very quantifiable & model-able. Quantitative social science tools have really exploded as of late… Hence my over-exuberance. 🙂

    • larrycuban

      That’s helpful, Chris. Thanks. I am unfamiliar with this literature. Thanks for the citations so I can get familiar.

  4. Aankit

    There is no reference by name to Atul Gawande in part 1, despite you borrowing the title of his New Yorker piece, while in part 2 you name two white men – erroneously calling Steven Dubner an economist, he is a journalist. Seems like a small issue considering the scale of school reform issue, but also telling of the systemic blindness that hampers “incremental care” of our students.

    • larrycuban

      Thank you for correcting my reference to Stephen Dubner as an economist. I will change that in the post. As for mentioning Atul Gawande by name, the title of the post is in quotes and I have links to his article in the post itself that clearly identifies him as author. Thank you for taking the time to comment.

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