Friday, March 27, 2020

Facing Change around a Force Majeure

“The only sense that is common in the long run, is the sense of change—and
we all instinctively avoid it.”  -- author E.B. White

Force Majeure:  Extreme circumstances that prevent fulfilling expectations and contracts

Change at its best is what we want to do when we choose it – when the outcomes are seen as positive and productive.  Whereas when change is forced on us, as with the pandemic we are now coping with, we are resistant and fearful.  Change taps into our fear of uncertainty as circumstances shift hour to hour.  As closings step up and markets worsen, independence and autonomy are challenged in the US as nowhere else, because Americans hold autonomy as our ultimate right--and loss aversion sets in.

No matter how autonomous we think we are, there is nothing like a universal health crisis to make socialists of us all.  When groupthink is unavoidable, we can adapt — for awhile.  So what is the tolerable timeframe for the world’s largest quarantine effort ever?  Since the scale of this effort is first-time, and enforcement has been inconsistent, no one really can tell.  Britain tried to limit it by age to 70-plus, but the prime minister was persuaded that this wasn’t going to be enough.  The whole Indian nation, however, at 1.3 billion, was considered manageable.  In the US, closing down Disneyland can be considered the watershed response. 

Cultural aspects
Which is why it is time, after some weeks of this worldwide endurance test, to consider the cultural dimensions of change, especially the forced kind.  “Sheltering at home” has a comforting sound – but this looming crisis has made such a policy feel more like a relaxed house arrest.  The intimidating safety measures everywhere have forced brutally complex decisions to be made on fast-shifting platforms.  Emergent problems—many third or fourth-level side effects—have yet to clarify just which changes will morph accustomed ways of living into a different system altogether for reevaluating assessments and choices, both private and public.  

The mental effort to grapple with these decisions in the fallout of lockdown will stand as the foremost momentous moment of change so far for this century.  For openers, among the issues forced by “medical law” are human rights to assembly and against restraint of trade, and more generally, weighing the value of prevention as calculated against the infection and death toll of the disease.

As social primates, we are built to connect to each other in group life and community.  We found out long ago that solitary confinement is a grim punishment.  In 1829 Philadelphia’s Eastern State Penitentiary introduced solitary confinement rather than packing prisoners into mass cells, as was the historic custom. The theory was that the solitary penitent (hence “penitentiary”) would use solitude to think about the error of his ways and repent.  Far from being cured, however, prisoners went mad in their forced isolation.

As Americans,we aren’t used to limits to our freedom.  When we seek out private time, it’s because it’s our idea, not the government’s.  Not since the Spanish flu pandemic of 1918 has anything like the current quarantine even been attempted, making 2020 the world’s broadest experiment in mass behavior.  These mandates make anti-smoking campaign and seat-belt laws look like ineffectual prodding.  In its sheer scope and broad-band effects, this is the perfect “AQ test” – Adaptability Quotient – Harvard Business Review’s term for the “new competitive advantage” of adaptability to change needed to thrive in a fast-changing environment. 

Following the view of the future by William Gibson, the science fiction writer, as already here, change is not evenly distributed.

It’s a science fiction scenario. If Susan Sontag were still alive, she would add the viral lifestyle to her “imagination of disaster” scenarios as our latest toxic action chain.  In the 21st century, fear and panic took over as a microscopic lifeform emerged, killing first Chinese, then Italians, then New Yorkers—any and all others it could.  It forced friends and family apart, ended religious congregation, tanked the stock market, erased businesses and jobs.  This is no alien invader .  This is more like a home invasion from a virulent strain of the flu right here on earth, disrupting every aspect of life as we know it. 

Humans had to decide how to manage the trade-offs between the unintended consequences of prevention efforts and a devastating percentage of deaths following contact. In H. G. Wells’ classic science fiction novel The War of the Worlds (1897) it was not military might that defeated the invading Martians in their fearsome war machines.  Instead the final defense was tiny earthly microbes, to which humans had developed herd immunity over centuries.

In today’s scenario, we are the Martians.  

White Squirrel
This magnitude of change is therefore not so much an exotic black swan, but the more domestic backyard squirrel – a white one that can’t be trapped or easily killed, a metaphor by our business-school colleague Bill Costa at New Hampshire’s Franklin Pierce University.  As the uncertainty sinks in deeper, even your own home, center of comfort and reassurance, starts to look somehow alien, as if it could any moment fade away.  The image of the future begins to loosen and float uneasily as dozens of scenarios – mostly unsettling—edge in to fill the space of stability and habit.  So much change in the course of days and weeks, rather than years or decades, is mentally and emotionally devastating, and will continue to twist any semblance of normalcy.  Rarely has humanity been so put upon to examine basic operating assumptions, concepts, and practices no one had to think about pre-2020. 

We don’t mind change itself—we just don’t want change forced upon us. We resist problems arriving too fast, too many, too fear-driven, and too global.  Attending a school far from home, getting married, moving to a new home, a new job or career…always appear with a level of stress, but they are also experienced as upward moves that meet our goals.  Positive changes involve choices that enable our dreams and talents, keeping us in control so that we can handle the outcomes.  But negative changes driven by fear, uncertainty, and doubt are net losses.  They leave us unable to determine what has changed and what has not, what is temporary and what permanent, about the new normal.
The aftermath: most long-term implications are across the board and won’t be apparent for months or years to come, the perfect storm of uncertainty and loss aversion for making policy, or deciding to buy or sell a house, finish college, or even travel.  The viral crisis is the perfect object lesson in change with thousands of data points – not the result of disease itself but caused by the massive effort to anticipate and modify its occurrence.  In its destructive high tide, it raises terrible questions about the cost of prevention to the lives of billions versus letting the disease take its course and cause distress for millions, then death for 10% of that number.   Without the ability to analyze a vast number of variables—many of them interactive—no rational decision-making is feasible.  When everything stabilizes, there will be plenty of work in sorting through the options to even know what ways of thinking and acting will still be functional, and which will dry up, never to emerge again.

Perhaps we can begin to ask a series of “CIS” questions, short for “Can I still …” Stay with my 2019 plans? Take a new job?  Retire?  Change careers?  Continue with my start-up campaign?  Have children?  Move, remodel, or rent my house?  Count on which things to be different, and which to stay more or less the same?  Have a future anything like the one I could count on – up to now?  Understand how my entire circle of relationships might have regrouped because of the epidemic’s fallout?  And, of course, prepare for the next issue of pandemic.  

The knock-off decision-making crisis will be based on how many options will require deep analysis, and which can be made as we make 90% of choices: by cultural (shared-values) intuition.  This will require a new mindset anchored to the continuity of cultural ideals, while following a new trajectory shaped by the most widespread health crisis in history.

Sunday, February 23, 2020

Loss Aversion

Psychologists long thought that people were risk-averse, which is pretty ridiculous in historical hindsight, since taking risks is what put us on the top of the food chain. On the other hand, we are loss averse.

We will go to great lengths to avoid a loss, far more than we will work to gain something.  This is the reason people hold on to their poorly performing stocks and sell off their well-performing stocks. It’s the same motivation – you don’t sell your poorly performing stocks because you hope they will go up and avoid a loss. You do sell your well-performing stocks if they go up quickly--to avoid a loss in case they go down again.  Professional investors don’t do this, but they make a lot of money on those who do.

Every year there are approximately 60 million patients on Medicare. Every year during the months of October to December, everyone with a Medicare plan has a chance to pick a new health insurance provider.  This sounds like a good thing—choice is one of our rights as Americans to make our own futures.  However, the reality is not that simple. 

This is a perfect example of “information asymmetry,” in which of the parties involved, the providers have overwhelming advantage in understanding how the system works in practice. The consumer doesn’t understand the limits of their policy until they become a reality.  (Because the “Evidence of Coverage” is a document written by lawyers, for lawyers, in the healthcare industry.)
The customer has the impossible task of reviewing and comparing and choosing one out of dozens of plans across specialties, none of which they truly understand. There is the additional gotcha of unforeseen illness (such as cancer) or injury.  As Barry Schwartz puts it on his book The Paradox of Choice (2004), “Bottom line – the options we consider usually suffer from comparisons with other options.”  Why?  Because we focus on what we will be giving up far more than on what we will gain. 

So each year, millions face the choice of 1) keeping their existing supplementary insurance company; or 2) switching to a different insurance provider who they hope may provide the same or better benefits.  This process can consume hundreds of hours, further complicated by the legalize difficult even for professionals to understand. Customer service is lengthy and agents can be uncertain about how things work.  Even when it appears that one can get a better plan (without an actionable definition of what “better” means), the quality of this decision will be unclear--until there’s a medical need.

Loss aversion is immediately apparent in this dilemma.  To switch, the consumer needs assurance that it makes more sense to switch than to stay put, and that the complexity cost to execute the switch is not a loss.  Things get even more complex when there have been issues with the current plan – would a new plan be any better, or just the same, or even worse?  Plans change their Evidence of Coverage every year (even on minor points), so that the consumer contract is in annual flux.  Loss aversion becomes uncertainty avoidance when it is just too much aggravation to enter the switching process.  Health insurance is one of most highly technical areas of consumer choice, combining medical science with the law, both highly trained – with pricing consequences in the hundreds of thousands of dollars.  And whatever the gain, it must be balanced off at twice the perceived loss for making a change in order for its value to be felt.

The bottom line is this:  Rather than risk a loss outcome, customers will take a passive loss (by inaction) by failing to make changes to their insurance provider—even when they are having significant problems. (Rather the devil you know than one you don’t.)  And dental insurance is even more difficult to gauge as a good or bad product, along with pet insurance, burial insurance, cancer and accident coverage, and long-term care, which never permeated more than a quarter of the market.  A plan that offered kidnap insurance, complete with ex-FBI agents, went out of business because no parent could calculate the odds versus the cost with any confidence. The Medicare consumer needs assurance that it makes more sense to switch than to stay put, and that the complexity cost (along with just the hours required) to execute the switch is not a net loss. 
Loss aversion logic also explains why people stay in bad relationships, bad jobs, and poor-prospect careers, explaining interpersonal conflict, poverty, and underachievement in general.  It explains why people hang onto under-performing stocks and sell their performers.  Why do people not take good advice that might free them from these behaviors?  Because following advice requires giving up behaviors and situations that are perceived as normal, and the energy and organization required are disruptive changes seen as a net loss. 

In other words, if you have to choose between two or more options, each with a potential for loss, when there is no significant advantage among them, most people will do nothing.

A second interesting example of loss aversion is the big-ticket purchase of college education, second-only in scale to a home purchase.  College is one of the most poorly defined decisions, along with other key life choices: car, career, and spouse.  For the college decision, the investment in college, once a no-brainer since graduates make twice the income of nongraduates, has become problematic as school costs have risen by a factor of 14 since the late 1970s.  At the same time, the return on investment –the wealth premium—has dropped from 247% in the 1930s to 42% in 2019 (wealth assets—Fed Reserve study), which figures in the student debt crisis as a national economic issue.  Degree inflation, in which the basic work-ready degree has raised the bar from high school to college, adds to consumer pressure to find more affordable channels.  These loss factors make the college decision far more problematic and uncertain than for previous generations.  To add to the complexity, there are more school types today than ever, including the for-profit sector. 

The two-car dilemma
Another case study of loss aversion is the two-car example. You are looking to buy a new car and you visit dealerships to narrow it down to two. Each one has different features you would like to have, neither has all of them, but these are the two cars you’ve narrowed your search to.
In other words, each car has something you would like to have – in your mind they have equal value, and you need a car, so you have to pick one. They are both cars you like, so you choose one.
You like the one you chose. But you also liked the other car - so you spend the next few weeks wondering if you should have chosen the other car. because when you make a choice, you gain one car but you lose the other – and we respond more to avoiding loss than we do to gain.  All of which sets us up for buyer’s remorse in any big-ticket purchase decision. 

So for business, your thinking as well as marketing should focus on avoiding a loss as well as gaining something.

Tuesday, January 21, 2020

Symbolic Thinking: The Mindset of Culture

 In Prehistoric Art and Civilization (1998), Denis Vialou summarizes the history of mankind:

More than two million years ago, Homo habilis invented the tool.  Next, Homo erectus made use of fire; then Homo sapiens conquered the world.  In just a few millennia, in the era we call the Palaeolithic, human beings, walking upright and with tools in each hand, imposed a new knowledge and a new way of life on the world.

Human inventiveness began with the discovery of tools 1.76 million years ago from the first knapped hand ax, fire 400 millennia ago, the invention of language at least 200,000 years ago, artistic expression, and written language only 5,000 years ago.  From these long-ago origins came computing and artificial intelligence, the moon landing, and exploration of other solar systems and a Mars mission in the wings.  In fact, all technology includes the very first inventions from the ancient world and prehistory, including the stringent mental exercise of mathematics, and were basic to all the applied science of the 20th and 21st centuries and their advances in bioscience, genetics, computing, the global space program, and others based on Big Data.  Symbols are a type of tool that keeps on developing the mindset as ideas multiply and find expression in problem solving.

Indispensable to all these stunning achievements is the longest-running of them all: the aggregate development of culture by thousands of human generations whose lifetimes worked nonstop to improve and adapt the myriad ways in which we can think, behave, and make decisions, both as collective minds in groups and as solo individuals working out the problems of the universe as well as our next cup of coffee.  The strength and plasticity of culture, as well as the human brain, makes us the world’s most adaptable and successful species—through the collective brain and creativity of humankind. 

Symbolic thinking

Our unique human ability to imagine, manufacture, and put to use symbols is an act of absolute liberation from the material world and from the present moment, allowing us to see beyond what is in front of us, backwards into the past, and forward into the rich potential of the future.  Emerging evidence from archeology is showcasing that symbolism began to emerge as part of a great cognitive revolution in the form of art (now beyond 40,000 years ago) and mathematics at 30,000.  While the flowering of mathematics in applied problem solving goes back only 500 years to the Scientific Revolution, its origins are ancient and worldwide as a symbolic language of its own that developed independently as a trained skill, from simple computation to defining infinity. 

However great the potential of abstract thinking, engineering still must fit the numbers and concepts to the human form.  The operations researcher must fit the design of space vehicles like the LEM to the dimensions of the human body and brain.  Animal traps and weapons ballistics had to fit what humans could fashion, carry, and track.   In this way, our own inventions must work for us.  Culture, as the Ur-invention, became the invisible force driving our brains, bodies, and behavior both as individuals and groups (thinking, learning, expression, and problem solving), from our first survival on the African plains to the sophistication of urban life on-earth and off.  On the Internet and in subcultures, using technological acumen and prolixity---cultural intelligence underlies and animates everything human, yet is certainly the least understood of anything humans have produced. 


Culture could not begin its own invention without our species' ability to think symbolically.  This mindset began in the Paleolithic, the early phase of the Stone Age, about 2.5 million years in duration, marked by stone, wood, and bone tools, and cave art starting with the monumental act of leaving handprints created by our prehistoric relatives.  These handprints in red ochre have moved back in time from the Maltravieso cave in Spain, dated back 64,000 years and painted by a Neanderthal, well before Altimiria’s bison of 16,000 to 9,000 BCE, the “Sistine Chapel of Paleolithic Art.”  Discoveries in the Blombos cave in South Africa then moved the clock back on art-making with a 100,000-year-old pre-European animal-bone paintbrush and palettes, abalone shells for mixing red ochre paint, and sea-snail shells with holes for stringing and wearing as jewelry. 

In his article on symbolic thought (New York Times, Dec. 5, 2014), Ferris Jabr notes the significance of a simple handprint:  “The suggestion of a human hand on a cave wall, a nation’s flag, even a Rothko—each is a powerful mental heuristic designed to conjure a particular emotion, a memory, an idea.”  The elegance of symbols, Jabr says, is that they bypass the issues of changing the world in the act of changing the way we perceive it, enlarging its possibilities by acts of thought alone.  That is, by the power of ideas.


Evidence of language is also moving backwards on the timescale of human evolution.  Like art and jewelry, speech is intimately involved in conceptual and imaginative thinking.  Recent research points to language development as occurring millions of years ago rather than the benchmark of just 200,000 (Sawallis et al., 2019).  Two forces, first, the reshaping of the human throat, and second, syntax, the way words work together in sequential order to convey linguistic meaning, are considered the critical events in the body and brain that make symbolic communication possible. Unfortunately, linguistic evolution, unlike physical development, doesn’t have much data to work with because soft tissue doesn’t leave fossil evidence.  But speech is not just a physical and muscular act made possible by laryngeal descent—our lowered larynx compared to other primates.  It is a mental capacity that is at once intensely social and inherently symbolic. 


The oldest known mathematical artifact is the Wolf Bone of Czechoslovakia, with 55 notches in two groupings, dated at 30,000 years ago; the second-oldest is the Ishango bone discovered in Zaire, dated 10,000 years earlier, with three columns of marks suggesting computation either as a tally or a calendar.  Hunter-gatherer societies used number systems, and the names for numbers can be tracked as they gradually increased in independent lexicons over time. 

The earliest mathematical texts are Egyptian and Babylonian dating to 2,000 BCE, covering arithmetic, geometry, and the Pythagorean theorem, continuing in ancient Greece.  The Greeks introduced deductive reasoning and formal proofs to conceptual thinking about math.  The Romans applied math to surveying, structural and mechanical engineering, bookkeeping, lunar and solar calendars, and the arts.  The Chinese added place value and negative numbers.  The Hindu-Arabic numeral system is in worldwide use today, coming from India in the first thousand years BCE.  From the Maya of Mexico and Central America came the most critical concept to computation – the zero, a triumph of abstract cognition. 

Wednesday, December 18, 2019

The Culture Concept

Deep culture undercurrents structure life in subtle but highly consistent ways that are not consciously formulated.  Like the invisible jet streams in the skies that determine the course of a storm, these currents shape our lives, yet their influence is only beginning to be identified. 
                                                                                    ---   Edward T. Hall, Beyond Culture, 1976

A half century ago, in Beyond Culture, anthropologist and cross-cultural researcher Edward Hall exhorted what he called the enterprise of “cultural literacy.”  Understanding that cultures were different solution sets to recurring life problems—resulting in cultural relativity--can help us to appreciate, then reconcile, the cultural distinctions causing problems on the world stage. 

Cultural Analysis, as worked up over the past three decades, is one of the outcomes of that enterprise.  How can insights from culture as an integrated thinking framework, as mind frames, not just a collection of customs and costumes, be unearthed and deployed?

How culture works – American style
As a shared pragmatic toolbar, culture condenses and clarifies decision making by supplying a subtext of shared values.  This background acts as a screening device for all sorts of decisions.  From the allocation of time and attention (who do I spend Christmas vacation with this year since my parents divorced—Mom or Dad?)  to career (If I decide on medical school, what will this career cost me in time, attention, energy, and family resources?  Should I leave my tenured teaching job to start my own consulting business?)  

In answer to this last dilemma, in the US, as a center for entrepreneurship: yes, go for it—even though the ten-year success rate for new businesses is just one in three (Small Business Administration, 2019).  While this less-than-half statistic argues clearly against, the culture says do it anyway—the risk is considered worth such a noble independent effort, which is a showcase for our ultimate faith in personal genius.  The same endorsed effort drives professional sports, media celebrity, venture capital, science, music, art, and literature.   Because American culture values individuality above everything else, the entrepreneur is the American national hero, and a lifestyle model for free-market capitalism worldwide.

Besides the free market, US cultural values inform these decisions by rubrics like majority rule, a future (ahistorical) orientation, and general tolerance for risk-taking—including the failure rate, like the two-thirds majority for businesses (with a full 50% failure rate at the five-year mark).  Building in a value directive that works on autopilot across groups and centuries converts the natural stress of such decisions into a far easier-to-manage set of habitual thinking habits that don’t require constant problem-framing setups, idea-searching, or group debate.  This releases time equity for other projects that don’t operate on the basic survival or well-being ground level, but require group consensus at some level. A prime example is the US space program of the sixties, which President Kennedy exhorted the nation to push not because it was going to be easy, but for the opposite reason – because it was intrinsically hard to achieve.  This equation is in perfect alignment with US cultural values, meaning “We can do this. It’s a challenge, so we’re going for it.”   This same message, that “It will be difficult” read into a Japanese context, would be taken to mean “It’s impossible.  Don’t try it.”  In the Japanese reading, “difficult” could be projected into “failure,” which implies social disruption and possible disaster.  Americans (the space program again) accept failure as a necessary component of trying new and difficult ventures. Of course, to read the differences goes much deeper than language because it’s culture speaking.  (Lindsay McMahon, 11.17.11, 

Beyond description
Such judgments are the bread and butter of cultural analysis, whose mandate is to deconstruct artifacts, events, behavior, and language to discover their “inner life” as value markers.  What is the most relevant information that can be de-engineered from the big data of culture?  What are the most telling clues about what people say, do, and think within their home culture, then compared to another culture?  This means determining what questions need to be asked.  This goes beyond ethnographic description in order to elicit insights to yield salient cultural intelligence we can use to understand ourselves and others in terms of core beliefs and motivators.  My favorite starting question about any cultural feature is “What is this for?  What are people trying to do and be in terms of core values through this tool, artifact, ritual, habit, or belief?” 

Useful answers depend on following a trail of clues based on posing the right question. Museum labels and consumer research aren’t often helpful here.  Culture insight requires another level of perception and evaluation.  It isn’t easy to get at, which is because cultural core value is the highest-ranking kind of knowledge to hold.   It asks not just what, or how, or who, but the million-dollar research question, which is “Why?”  Asking the Why question can lead to the alignment of practice and theory (values) that can reveal the ideals that drive culture as a motivational engine.  It explains, for example, the heavy stress that is the cost of freedom of choice in America.   This can be discerned as different in kind from the Japanese stressors as the outcome of commutarian cultures, with different causes and attempted solutions.

Cultural inclusion
Ever since Richard Hoggart at the Center for Contemporary Cultural Studies in Birmingham, England coined the term Cultural Studies in 1964 (The Uses of Literacy in 1957 was the start-up document), the influence of culture – the invisible yet irresistible force—now includes mass media and digital technology.  This inclusion extends the domain of culture, ancient to current, to become a focus of study in its own right, beyond a descriptor of foreign ways of life, extending back to antiquity (and prehistory) and into future inquiry as global and extraterrestrial human mind frames.  Going back to my own work in the field of Popular Culture, the boundaries of what culture can be have now far surpassed the older liberal-arts meaning of Culture as the elite in art, literature, architecture, music, and media, or as ethnic rites and customs in exotic environments. 

We can now regard culture as the great universal system that unites all people around their encounter with problems, potentials, and opportunities, however much the detail and description of those cultures may differ in what they advocate (their lead values).  Culture is the single most powerful force that all humans obey and have followed for at least the past 50,000 years as worldwide human migration was completed.  This historical period marks the final emergence of modern humans as evidenced by established civilized group life—jewelry, art, tools, and ritual objects.  At this point, the shape of the human vocal tract allowed for the sound range of modern speech.  Language is learned by childhood just by hearing it in one’s group, just as culture is embedded in the brain of a certain size—based on a measure of 1450 cc—ours as well as the first homo sapiens sapiens.  This leaves 95% of our common past without written language, far more recent at just 5,000 years ago.  This is important because cooperation allowed by communication is the bedrock of civilization--as Exhibit One of behavioral modernity.  Civilization marks our coming of age as cultural creatures.

Anthropologists have been at this enterprise many decades without a uniformly accepted definition for the field of studying “what makes us human—including biology, communications, and the history of humankind” (Hall, 1976).  So far cultural analysis can distill this study into a working definition of culture:

Culture is the uniquely human invention, passed on and built across generations, that works as the mind frame shared within the group, designed to solve problems across the board from individual to social goals and purposes.  Culture works to ensure survival, guarantee group cohesion, and inculcate the next generation, while self-perpetuating its own set of ideas and ideals across generations. 

James Burke’s The Knowledge Web (2000) takes apart the history of informational networks from “electronic agents to Stonehenge and back.”   As the most extensive integrated information system of them all, “enculturation” acts as a kind of instant expertise available to any and all, built up over thousands of years by millions of humans living in every environment.  This expertise is the outcome of the neural network of culture’s multiple knowledge webs, echoed in the learning activity that can now be visualized in the structures and wiring of the brain itself.  Language and mathematics, the twin basic means of encoding information, along with visual intelligence, are the leading tools of knowledge-sharing produced by culture.  It is the leading toolkit of humanity.

Friday, November 8, 2019

Mission Impossible Part II: State of the Art for Customer Service

How could a passenger disappear on a flight from New York to Singapore because their ticket was miscoded to show the wrong date of arrival?
Why can’t a mother of three with a husband under a Domestic Violence Order get a divorce decree after six years in and out of court, despite her many expensive attorneys’ attempts to find out why?
Why did it take four years of repeated applications and inquiries to renew an ordinary passport through the mail?
Why does a healthcare system declaration of Patient Rights apply only to its hospital in-patients, excluding the thousands more getting out-patient care in its many department clinics?  When the patient finally got the right person to answer their phone, he was told that out-patient problems had to be resolved at the specialty department level even though the problem was with the department manager herself. The hospital saw nothing odd in telling the patient to take their complaint to the very person they were complaining about.
Why does no one at the Philadelphia city government level recognize their own new City ID cards, nor can explain what they cover?  How is it that no one at the many City Hall desks seems to know where to direct cardholders to a simple list of covered benefits?
Why does a low-vision eye clinic not answer its telephone, nor post its location in an assisted-living building without an identifying sign? 
And so on.  Of course there are millions more consumer horror stories to add to these.  The consumer complaint narrative has become the latest form of self-expression, arguing for the right to fair treatment in the face of the uncaring big company. Fairness – not to be confused with the legal concept of Justice — is a uniquely American cultural value. 
Seventy percent of the US economy is consumer-driven.  It would seem there would be effective methods of resolving the inevitable conflicts of interest that result. The old term ombudsman, though hardly ever used anymore, once provided a disinterested third-party mediator who could resolve these problems.  Starting in the 1950s, such an agent began to appear as an impartial, independent “legal representative” (following the Swedish definition) who could be relied on to investigate “maladministration” in response to complaints by the public.  This role seems to have disappeared from the consumer issue landscape, however, since the 60s.
Consumer dissatisfaction now extends far beyond a few stray complaints about shoddy manufacturing or persistent auto-repair problems; it has become a way of life for the majority of Americans who spend their spare time between phone and internet trying to work their way through the labyrinth of help programs and customer service for medical, legal, insurance, banking, schooling, and governmental issues that have gone awry at the personal level. 
You would think that the world revolved around the customer and customer satisfaction, given the fierce competition for every dollar spent in the consumer marketplace.  But no, that’s not the case.  Business, government, and even nonprofits have just devised more and better ways to evade customers—sending us online, without telephone access—or when we do succeed in breaking the telephone or text barrier, finding ways of making things so complex that even experts have trouble wayfinding through the clutter.  That clutter now includes confusing the pathways to solutions and creating dead ends without alternative pathways to get directions or information needed to solve even the simplest-sounding problem.  Rude, unhelpful customer service has become the norm, the latest iteration of “You can’t fight City Hall.”
Mega-companies--the ones with customer service--are the prime adversaries of their own customers.  Given the term “customer service,” companies should have the best interests of the consumer as their core motivation. Experience demonstrates, however, that they are more about customer management. These companies make profits, often huge ones, and their goal is to maintain profitability. When dealing with customer service, it’s not unusual to find yourself in an adversarial relationship.  It’s not an equal fight by any measure.  The sophistication of big business, big healthcare, and big government is many times that of their customers, and they are fully aware of this fact.  For the customer, efforts to be dealt with fairly amount to an ongoing Mission Impossible. 
This is because expecting a company to cure its own complaints is akin to expecting that everyone who is a patient can also negotiate like a health-care lawyer—and understand the system, its rules, definitions, and intentions.  This is unrealistic.  It’s difficult enough just to learn enough to navigate the departments, procedures, doctors, support staff, locations, price structure, let along start in on your own insurance coverage and what that means in payments due.  Patients don’t even appreciate how to frame questions to produce the answers they need—or what do with the answers.  In response to your questions—if you can manage to understand how to frame them—customer service agents can’t tell you why anything happens, just cite policy.  Leaving the patient to try constructing a logic framework to explain what’s going to happen, when, where, and how much it will cost out of pocket.  Add to this conundrum the coded messages, abbreviations, and proprietary terminology that make up just one bill (or even “This is Not a Bill”), and the average person is overwhelmed before even beginning to see any useful answers.
Perhaps this is the reason that less than 4% of customers complain formally (TARP Research, 1999).  Instead, they spread negative world of mouth.  One in ten leave the business and never return—harder to do with a hospital or health system.  The White House Consumer Affairs Office reports that unhappy customers will tell  9-15 people about their bad experience; 13% tell 20 or more.(Nov. 2, 2017).  But essentially, complaining is just too complex, too time-intensive, and requires too much effort.  Too many steps involved, too much time and anguish for an uncertain outcome.  Relating the same story again and again to each new agent without any quick fix, the problem balloons into a bigger one and becomes an anger-inducing project that won’t go away but keeps magnifying the initial wound with ongoing frustration.  With government agencies consumers suspect the agency doesn’t care, and might even penalize efforts to correct its own mistakes.  A firm belief rules dealing with the IRS, postal services, city government – that these entities have no interest in improving their service through customer feedback and get no reward for resolving problems. 
The larger consumer reality—the core situation, really--is that we depend on these many organizations in order to operate.  They are no longer optional luxuries.  Our computers and smart phones must be functional to connect us to everything we need to get done—including all the tools, data, and services needed on any given day.  However adept  we’ve become in navigating all these necessary systems, we aren’t savvy enough to advocate for ourselves against the bureaucratic forces that operate outside and against our own best interests.  Calling itself a “service” makes it an arrogant pretender.  The company that can devise better ways to champion the consumer—as Amazon appears to do—will emerge as winning competitors in the customer services arena by assuring their customers that they don’t have to go it alone.  Can customer service be said to be a failure—one that takes over our time and mindspace?  Many would say it needs to be fixed.
Consumers need a champion.  The battle between big and little players means that some service is needed to step up to the plate to give a wide-range assist to Joe Customer.  This will eventually begin to happen as the outcome of consumer rights fueled by the big data needed to build expert systems with the human help of practiced experts across many fields of consumer activity--from finance to health care, social media and computers, social security, travel, home buying, assisted living, college applying, etc.  As Charles Schwab has said with reference to an on-line consumer rights attorney group, “The idea of bringing even a small percentage of the professional services market online, in the way did with retail, is a multi-billion-dollar idea.“

Monday, October 28, 2019

Mission Impossible Part I

Thanks for nothing!
A personal rant on system thinking

This is a rant –I hope a higher-level one – about healthcare customer service, “service” we all endure just by being self-insured and/or Medicare clients.  As I hope my ongoing Cultural Intelligence blog is showing, I’m a reasonably educated person, having served as a consumer reporter for a Philadelphia newspaper, and an investigator of group behavior and the social mind.  If I’m having this kind of difficulty in dealing with routine healthcare, I shudder to even imagine what less well-equipped patients (and their families) are enduring.   So I’m judging that if I’m having this much trouble, others must be, too.  (Part II talks about customer service state of the art as the broader set of issues.)

I’m closing in on the 125th hour (all unpaid) of trying to get ordinary patient information from my prize-winning national-reputation healthcare organization in Philadelphia.  At some point, as a new patient, it occurred to me to actually research their mission – in just three words, “We Improve Lives,” the pledge to make my life better.  So far, it has done the opposite: by chewing up my work schedule, domestic tranquility, and sleep, and indeed making my healthcare mission an impossible journey. By forcing me to repeat-call many offices, very few of which call me back.  Then it’s back in my court to begin again the next day, telling my war stories over again to whatever office or functionary will listen.  I’m in constant contact with the Billing office, the Rheumatology department, Internal Medicine, my primary doctor, and three other specialists.  I have insurance through Medicare, but they seem to be less than able to help me out in my dark quest around the medical campus in search of answers.  All this effort is just in the service of trying to understand the system’s errors as these affect me.  My health is actually fine.  At over 65, I am interested in keeping it that way by following a solid screening schedule.  For the very sick and injured, this bumpy ride through the healthcare system has to be an unimaginable unmanageable nightmare. 

First, as one of my colleagues, a psychiatrist, put it, these days medicine is an inherently defensive practice.  So just contacting anyone is a tricky wicket.  At the other end of the scale is the mandate of Patient Rights, which you would think would open up dialogue everywhere on every topic of concern to patients.  I assumed the patient was at the center of any practice and the whole organization (again, this headlines the hospital’s home page: "People First").  But acting as my own advocate over the past three months has shown this to be a weak philosophy in practice.  Across the many offices and practices where I’m becoming notorious is great variability in how I’ve been treated and regarded – almost as if they have no relationship except payroll and signage.  The fact that these entities consider themselves almost sovereign states for policies and accountability reflects the problems of all organizations without a strong cultural ethic.  Or, it seems, accountability for their attitudes and actions.

The patient rights issue is probably central to explain my continued suffering.  I trust this parallels the human rights movement.  My review of this policy: 80% of all statements refer to hospital in-patients, while I’m an outpatient only.  When I pointed this out, the Patient Experience office told me that this hospital-based policy is nevertheless applicable to every patient type.  I have difficulty seeing how smoking policies and nursing care have any relevance to getting information from a busy front desk at the billing office.  My questions are around why I’ve been billed twice directly as a first-person (self-pay) case, when my insurance should be billed first, me second.  I had a horrified period when the first bill arrived by mail and I had to assume my insurance had denied payment.  It took a week just to get Billing to call back to explain that this was a back-office computer error that had happened not just to me but many other patients.  Nevertheless, there was never anything like a notice to give those affected a heads-up that this error had occurred.  When two months later the same thing happened in exactly the same way, I wondered how much my healthcare had paid for this terrific new “integrated” EPIC program that couldn’t bill properly.  A search on the internet under the EPIC name confirmed that millions are being spent in fixes across the healthcare landscape for this programming.

When I went up the ladder into the third month of this malfunction, I got a curious response:  the billing VP said he was going to be honest about the mistakes made.  Apparently this approach did not include any notice to anyone.  I tried to explain system theory to him – systems have their own dynamic of reward and punishment, or inattention and denial – regardless of the moral character of those who live and work within it.  I don’t think he paid much attention to anything I said.  The ethic seems to be to get through any discussion asap, asking along the way, “Is there anything ELSE I can do for you?” establishing the fiction that anything at all has been taken care of. 

Time and again the agents for the organization would insist that their efforts were genuine and that they were doing their best job under the pressures of an ever-expanding healthcare empire.  That’s not possible to prove or disprove, and it does nothing to help the patient find out what is going on—with charges or with outliers like security breaches. Two phrases are the litany of customer service: “I don’t have any idea,” and “You will have to call ____ office for that.”  I am often misdirected to inappropriate people and places, costing additional time--and always added frustration--for all parties.

Soon after the “system theory” came up, I received several lab test orders by mail.  I assumed they were all mine, until I was ready to walk over to the Outpatient Lab.  (No office seemed to know any room numbers within the large medical building where the lab is located – I had to physically research and inform the organization of the exact room number.)  I noticed I had, not my own, but another patient’s name, date of birth, patient account number (patient ID is actually a billing code), full address, and a list of ordered tests. 

This is called a PHI privacy breach.  What is the first thing any patient thinks of when they get someone else’s record?  It’s “Where is MY record, why did I get someone else’s, and what happened to breach my right to patient privacy?”  Many hours and calls later, I am still trying to find out, but this is at least considered serious enough to send to the Privacy / Compliance office.  That manager is out sick for awhile, so I need to wait a week or more to find out what the drill is to get that sorted.  Meanwhile, if my lab order (which I never received) is out there with another patient, I hope they don’t have criminal intent.  There’s quite enough of my personal information there to open bank accounts and much more. 

Finally talking with the practice manager in charge of said information, she was notably focused on getting the wrong patient order back in her hands.  I reported that the lab had confiscated it when I showed it off (and caught the fact that it was not my order, a fact I wanted to confirm for myself).  When I asked what had happened to my information, everything was done to dismiss my interest in the privacy breach—as personal opinion or hopped-up anxiety.  And then the topper – “I’m sorry you feel that way.”  This is the Number One Phrase to Never Say to a Patient.  I had a rare laugh to hear that coming from a practice manager.

I don’t think HIPAA will take that view – at least, I expect vigilance to be more active higher up.  I was shut out of any emails I could use to send a list of the normal clarifying questions to find out how the practice handles such security breaks.  Meaning I am going to be forced to walk the document over to their offices myself.  And have it signed for at Reception. 

Meanwhile I’m without answers on either issue, and seriously wondering what has happened to patient care, and whether the same clutter, obfuscation, and confusion is reflected on the clinical / medical side, where it could do real harm.  The Hippocratic Oath, Do No Harm, still rules the practice of medicine.  It’s just that patient care doesn’t know about or adhere to it.   So where is Quality Control and Standard of Performance in all this mess?  No one ever mentions them.  Why not?  Because there is no comprehensive way of dealing with these standards.  Yet it’s very clear how absent they are, and how much leadership needs to do to begin to grapple with the service fundamentals. 

Above all, however, medicine is now all about the UX or user (patient / client) experience, as is all else in the emerging world of the Experience Economy.  And yet service is worse, costs are higher, and answers are harder to come by than ever before.  It is astonishing how much verbal punishment and time abuse attends just trying to find, understand, and fix the system’s problems – not caused by patients, but left to them in order to hold their own healthcare services together.  Of course medical staff is paid to answer my questions and fix breaches in billing and privacy; I’m not.  Yet my sources for damage control are disconnected, siloed, largely uninformed outside their own m├ętiers and titles, and often within as well.  I’m calling it patient hazing.  It violates my rights across many aspects, from simple policy requests to holding me responsible (on the “MyChart” website) for big bills my insurance should pay.  I’m thinking hard about whether I want to sign again next year.  The problem is that I just changed over all my providers, including my primary doctor, to this system – if you have ever had to endure this, you know that no one really wants to repeat this process, much less twice in one year.  (This transfer was the outcome of insurance changes, not any issue with my former plan, which covered another hospital center.) 

Now, you must be thinking – haven’t you tried to contact the Patient Advocate?  Of course.  There just doesn’t seem to be one, or it remains disguised under another title, or their office doesn’t return calls.  So, with my growing file folders of notes and documents I’m constantly generating to document my encounters and clear up inconsistencies and fill gaps…I’m heading into my 125+ hours in the coming week (and maybe this weekend), as a lone advocate for myself.  I really wish I knew who had my back, but I think I can safely say that to the system I’m Patient Zero in a whole new sense.  And this is one of the country’s leading-reputation centers.  What are things like in rural areas with less money, fewer high-end specialists, skilled nurses, and billing clerks? 

Probably better, would be my guess, because people at least have some chance of knowing one another, other departments, how they operate, and the System may have an intelligible culture. 

Tuesday, September 24, 2019


“We must therefore rediscover, after the natural world, the social world, not as an object or sum of objects, but as a permanent field or dimension of existence.”  
 ― Maurice Merleau-Ponty, Phenomenology of Perception (1945)

Spectacle is a powerful artform and cultural artifact.  This artistry resides in an artform that is also a show of force that operates as an extraordinary showpiece of music, staging, dance, or drill designed to awe or impress--that includes the viewer as a partner in its power. It celebrates the singular human ability to cooperate adaptably.  In its ability to put is in step with each other, spectacle is the ultimate human art, and possibly even the original great artform, one that outshines cave art. 

Spectacles are a type of magic in their ability to overcome our differences and the feeling of being “slightly out of step with others,” as geographer Yi-Fu Tuan put it (1). Parades, pageants, and giant rallies raise that question: “How do they do that, all together?”  It has origins and ties to the rituals of religion in its sway of emotions involved in empathy, trust, and consilience—in every world culture.  The core of religion, as in the word origin, is to “tie together” in communal surrender to a higher order. 

The whole entourage is animated in the total synchronicity of a single mind, as in a flock or swarm, by following a few simple rules: match speed and direction, and stay an equal distance apart.  (This is also the rulebook in robot coding in AI.)  The rules are simple but effective algorithms –the way culture works.  Which is that no one is obviously in charge, yet the brain software seamlessly coordinates thousands of discrete thoughts and activities.  It is the perfect staging that celebrates the performers as well as those enthralled by them. 

This is because of the core arts of music and rhythm, with their hold on the social emotions of converge.  Both have an inborn power to connect us, something dance halls and the military are quite aware of.  Singing the national anthem together at the Super Bowl or “My Old Kentucky Home” at the Kentucky Derby delivers the thrill of deeply uniting force, creating a sense of belonging and safety and strength in numbers.  Melody and rhythm have the ability to activate the limbic brain, bringing the many into one at rock concerts, as in the iconic generational symbol for the baby boom, Woodstock.  In this way, thousands of heartbeats can be channeled just by sound alone, augmented by sight, a psychological showcase of performance or procession intended to unite, impress, and inspire. The fiftieth anniversary of Woodstock is this year, a low-tech event that shaped the Boomers in August 1969 and is still the milestone of Generation Woodstock coming of age.  Thanks to the same sound systems for the masses, Hitler programmed the sweeping music of Wagner for his own national theme at the Nuremberg rallies.

Why is spectacle so emotionally compelling?  Music, choreographed group motion, themed costume, immersion in a whole-brain experience among hundreds to thousands of others.

Spectacle creates a hyperreality we enter in real time and space.  Think of the legacy of such events – campfires, hunting ceremonies, processions, mass celebrations, funerals, warfare ceremony—modern sports are a ritualized version of war (the FIFA World Cup, like the Olympics, has three billion viewers worldwide).  Spectacle has a meaning quite fundamental to human bonding as well as creativity, with a profound effect on our capacity for diversity.  This is the same appeal to be found in current escape rooms, with their single-minded focus on solving problems in a group that is so clarifying (2).  There is a formula for this focus throughout cultural study. 

This is because spectacle operates at two levels as it connects them:  primal physiology and group encounter.  It is an integrative force. Spectacle breaks down the walls between individuals, allowing us to converge with thousands of other minds.  The dynamic that rules a Roman procession is in this way the same one that occurs in falling in love.  As synchronizing sound, movement, and expectation builds coordination, it promotes trust and theory of mind, our ability to read the motives and moves of others.  Oxytocin is boosted, increasing interest and direction toward social cohesion. 

Does Spectacle create community across groups?    

It is no accident that the highlight of the Roman Catholic high mass is its music, commonly cited by Catholics as the core of the Church’s continuing appeal.  Level of apotheosis, miracle, mind-reading: single mind and single heart convert and scale up from the micro level to the macro: group mind, group heart.  A show of force and skill becomes an artform in real time – to impress outsiders but also the performers themselves.   This artform showcases our best human talents: our capacity for solidarity, visible, immediate, and affecting.  Cathedrals and theaters are ornate and magisterial to match up to our impressive ability to move from the personal to processional ways of thinking and feeling.   The long-running Main Street Electrical Parade at Disneyland is an old-style example of a low-key techno-music parade with basic light show and simple melody that has become a national favorite moment.  The other park spectacle marks the end of the day at the World Showcase in EPCOT and consists of fireworks, spotlights that target the circle of national symbols, set to music keyed to each culture.

Music plus large-scale choreography does something extraordinary:  they tap into each brain to create an irresistible group psyche.   This artform is ingenious in drawing into concert two basic human impulses, the individual and social.  They are instantly immersive whole-brain and whole-body experiences starting with music and rhythm, going straight to our ancestral limbic brain for instant cooperative with other people.  This is our uniquely human capacity – add a cause or purpose, and the result is a form of theater that showcases a deeply human artform, perhaps the first ever – a performance that promotes both the noble social goals of civilization and the primal need for affect (expression) and belonging  at the most personal level.

There is a reason that rock concerts make more money than the tracks that make up the program.  The group virtuosity of orchestra, Carnival, the British coronation, military extravaganzas, the Olympics, the Million Man March (actually about half that number, the size of Woodstock) consolidate both private and social virtuosity. Nazi rallies were held to re-instill pride in Germans after a humiliating defeat in WWI.  Collective morale is showcased at the Russian May Day, ancient Roman games in the colosseum, the Super Bowl, and religious and triumphal processions so often portrayed on ancient Egyptian, Greek, and Roman monuments.

To celebrate the city and its ethnic enclaves, Philadelphia’s Mummers Parade is a classic example of an historic form that has survived and thrived, season after season, into the present as an emblem of identity.  On the west coast, it’s the Rose Parade.


1.      Yi-Fu Tuan, Escapism, Johns Hopkins University Press, 1998.

2.      Rachel Sugar, “The Great Escape,”, August 7, 2019.