One Size Doesn’t Fit All
One example I like to use to demonstrate the flaws of reductionist science tools comes from the early days of the US Air Force. I first learned about this history from the book called The End of Average by Todd Rose, Director of Mind, Brain and Education at Harvard’s Graduate School of Education. Rose had a learning disability and did not initially graduate from high school in part due to the one-size-fits-all approach in our education system.
In the early days of the US Air Force, planes were crashing at an alarming rate. As these planes were getting faster and more complicated, crashes seemed to increase and were occurring during regular exercises, not in combat. At first, no one could figure out why. There did not seem to be mechanical malfunctions or any obvious pilot errors. One theory was that they needed to look at updating the size of the cockpit.
Initially, in the 1920s, hundreds of pilots were measured, and a perfect sized cockpit was designed based on the average sized pilot. With the increase in plane crashes, the thinking was that the average size for pilots had changed, especially since there were many more pilots in the Air Force. But that thinking was challenged by a 23-year-old scientist, Lt. Gilbert S. Daniels, who had recently graduated from Harvard where he studied Anthropology.
One of Daniels’ projects at Harvard included the evaluation of human hand shapes and sizes from hundreds of male Harvard students. In calculating the averages for various dimensions of a hand, Gilbert found that no individual hand had similar dimensions to the average hand. With that experience, he proceeded to measure over 140 physical dimensions of all 4,063 pilots in 1950. He looked to see how many pilots would fit into the average range.
What he found was surprising; none of the pilots were in the average range. He concluded that there were no average sized pilots and therefore no pilot fit well into the cockpit. Some pilots fit so poorly into the cockpit that they couldn’t fly the plane safely and that is what led to most of the plane crashes in the early decades of the US Air Force. This discovery resulted in adjustable size accommodations inside cockpits and limitations on the size of pilots.
But this one-size-fits-all strategy is what we still have in healthcare today. We design a study with controls and inclusion/exclusion criteria and attempt to prove that one thing is generalizable to all patients everywhere. It doesn’t work and it can’t. That’s because we are complex biologic organisms, constantly changing, with uncontrollable biologic variability. This reality will not change.
We need to apply a much more robust scientific understanding of our world in healthcare. We need to learn the techniques of how to apply Systems Science to actual patient care, to our whole healthcare system, and to our health in general. I hope these ideas will generate a great deal of hope – that we are not stuck in a failing system that is destined to get worse and worse and cost more and more.
I also hope this knowledge will generate action to apply these principles to real patient care all over the world – something I have not been able to accomplish through the traditional academic methods of speaking, teaching, publishing and being in a leadership position in my field of surgery. It’s time to reimagine healthcare through the lens of Systems Science and create a globally sustainable healthcare system.