The broken window theory in health: Examples of graffiti we can fix

I just left the most unusual conference I have ever attended. First, it was small: 25 invited participants. Second, it was all women. Third, it was all women who have done amazing things …make that “trailblazing things.” They were journalists at major news outlets, retired military officers from the highest ranks, senior leaders (in some cases, the most senior leader) at major federal and state health care agencies, Fortune 500 companies, large health systems, health care foundations, and national advocacy organizations.

It’s no surprise the nickname “Amazon warrior” resonated with this group. The conference was all about identifying our legacies. Legacy seems like a strange word for the living, and it’s even stranger when you feel like you haven’t done anything yet.

So how did I get invited, you might be wondering. I wondered the same. I was the youngest person in the room, which is pretty unusual when you work with students and residents most of the time. Believe it or not, I was invited by in large part due to my social media presence. After reviewing the list of participants, the organizers realized someone was missing: someone younger with a social media presence. Whoever said tweeting is a waste of time?

One of the most meaningful group exercises came on the last day of the conference; it’s worth sharing. We were asked to find “broken windows” in health care, and figure out how to address them. A broken window is something in the environment, often subtle, that reinforces the old context rather than a new one. As Malcolm Gladwell revealed in his popular book, The Tipping Point, the city of New York reduced crime by tackling smaller environmental issues, such as repairing broken windows and cleaning graffiti from subway trains. Addressing these problems showed someone cared. As a result, people started to “own” the subway and even to help prevent crime. An excellent video summary is here.

So how does this apply to health care? While there are criticisms of the broken window theory, what a boon it would it be if we could locate small cues in our environment to help shift the context of the larger, more complex problems facing health care to show we care. While it sounds like it should be easy to identify broken windows in health care, it was a challenging task. Problems in health care are so large that solutions may not be as simple and elegant as cleaning graffiti, but we need a place to start.

Here are three examples of broken windows we identified:

  • Media portrayal of health care, especially resuscitation. By correcting the media portrayal of resuscitation to show that it’s equally as traumatic as it is heroic, the public might have fewer unrealistic expectations of life-sustaining therapies at the end of life, which could result in fewer people opting for futile measures. Researchers have studied this (by watching episodes of ER) and reported their findings in a New England Journal article. Imagine tackling this problem with media tools to demonstrate to people what a “good death” is.
  • Patient gowns. While “patient-centered care” is the new catchphrase in our world, can we really say the system is patient-centered? Take the simple example of the patient gown, which represents a loss of control and is a source of embarrassment to patients. Does it make them feel disempowered to engage in their own health care? Could changing the gown—or doing away with it altogether—empower patients to take a larger role in their health care? Efforts have been made to redesign the hospital gown; my favorite is the collaboration between Bridget Duffy, former chief patient experience officer at the Cleveland Clinic, and fashion designer Donna Karan.
  • The term “health care.” It is well accepted that our system focuses on “health care,” not “health.” Prevention and health promotion take a back seat to intensive clinical interventions. It’s easy to assume that this will never change due to the payment system, or that return on investments in prevention are only realized in the long term. But what if we could change the context by using the word “health” instead of “health care” at every opportunity and juncture? By changing the dialogue, can we change the context enough to create a change in the system? I’m not sure, but at this point I will say it is certainly worth a try.

There are many more examples of broken windows in health care. By continuing the dialogue, hopefully we can locate the most promising levers for change.

Vineet Arora is an internal medicine physician who blogs at FutureDocs.

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