Do hospital rankings matter?

Peter Drucker was one of the best-known and influential authority on management theory and practice during his life, and his writings are still widely read and referenced today.  He once said, "If you can't measure it, you can't manage it."  While he was referring to business practices, his concept of using measurement to drive improvement is just as relevant in health care.  We can't improve something unless we are first able to measure it.  Think back to the last visit to your primary care physician.  He or she monitors and improves your health by checking your weight, blood pressure, and cholesterol (likely several others too).  At the population level, we measure things like life expectancy, infant mortality, or even disease-specific outcomes as a way to both monitor and improve the overall health of our local population.

Just as important, the statistician and engineer, W. Edwards Deming said, "In God we trust, all others must bring data."  In order to trust and understand what it is that we are trying to improve, we have to be able to show the data in a meaningful way.  More importantly, the data has to be valid (we are measuring what we want to measure), accurate (the measurements we obtain are close to the true result of whatever it is that we are trying to measure), and reliable (we obtain the same results if we repeat the measurement more than once).  For example, as I have suggested before on a number of occasions, commonly cited population health metrics such as life expectancy and infant mortality may be valid and reliable measures of the overall health of a population, but they may not accurately measure the overall quality of a health care system (see, for example, the discussion here).

What about hospitals?  Do we have any good ways to measure (and then compare) the quality of the care delivered by individual hospitals?  Our society likes to rank things from best to worst - just think about all of the rankings we talk about in our everyday lives.  We rank sports teams, guitar players, colleges, and the best cities to live or retire.  We also rank hospitals, purportedly by the quality of care that they deliver.  There are a number of different organizations that rank hospitals, including the Centers for Medicare and Medicaid Services (CMS), Leapfrog, Healthgrades, Consumer Reports, and perhaps most famously, the U.S. News and World Report.

The validity, accuracy, and reliability of these different hospital ranking and/or rating systems have been called into question by a number of public health experts (see, for example, the discussions here and here).  A few years ago, a group of physician scientists and experts in outcomes measurement assigned a grade (think A, B, C, D, or F) to the various hospital rankings and ratings systems that are commonly used (these findings were published in the online journal, NEJM Catalyst in an article titled, "Rating the Raters: An Evaluation of Publicly Reported Hospital Quality Rating Systems").  Importantly, no rating system received an A (the top grade) or F (a failing grade).  The highest grade received was a B, by the U.S. News and World Report (USNWR).  The authors of the study concluded, "Each rating system had unique weaknesses that led to potential misclassification of hospital performance, ranging from inclusion of flawed measures, use of proprietary data that are not validated, and methodological decisions.  More broadly, there were several issues that limited all rating systems we examined: limited data and measures, lack of robust data audits, composite measure development, measuring diverse hospital types together, and lack of formal peer review of their methods."

What's perhaps even more concerning is the fact that these different hospital rating systems don't agree (see "Disagreement Between Hospital Rating Systems: Measuring the Correlation of Multiple Benchmarks and Developing a Quality Composite Rank").  In other words, these rating sytems aren't reliably measuring quality.  Conflicting information is rarely, if ever, helpful. 

Lastly, a recent article published in JAMA (see "National Hospital Quality Rankings: Improving the Value of Information in Hospital Rating Systems") asked the very relevant question on whether the U.S. News and World Report rankings were in fact measuring the local health of the population as opposed to the actual quality of the individual hospitals that were being ranked.  Using a similar argument to the one that I used above (that population health metrics such as life expectancy and infant mortality measure so much more than the quality of the health care delivery system), the authors of this article stated, " Socioeconomic factors have a major effect on patient health, and people of lower socioeconomic status experience comparatively worse health outcomes...Patterns of socioeconomic deprivation, race, and ethnicity vary markedly by region, and individuals in some regions are more likely than those in other regions to experience serious chronic illnesses."  

The authors of this latest study constructed a heat map (provided in the eSupplement) that compared the regional differences in life expectancy (which reflect the social determinants of health) with the regional distribution of the USNWR's top-ranked hospitals.  A striking pattern emerged.  Only the regions of the United States with higher life expectancy have hospitals on the USNWR Honor Roll.  The regions of the United States with the lowest life expectancy - and often the greatest health care disparities - had no hospitals listed on the USNWR Honor Roll.

Let's bring back the infamous "chicken and egg" question here.  Is there a cause-and-effect relationship here?  One could argue (and I won't - please keep reading) that the USNWR Honor Roll hospitals are directly impacting the local health of their populations and hence, the life expectancy is better in the regions of the United States where the local population has access to these hospitals.  However, if we use that argument, we have to reconcile why the U.S. has the most expensive health care delivery system in the world, yet has the worst performance on population health metrics, such as life expectancy and infant mortality.  I can't reconcile that fact, and there are other, smarter individuals who can't either.  I have continued to argue, as have many others, that these population health metrics have more to do with the social determinants of health and U.S. investment in programs that address these determinants and less to do with the quality of the hospitals in the United States.  As such, I can't and won't make the argument that the USNWR Honor Roll hospitals are the most important factor impacting life expectancy for the populations that they serve.

So back to my original question then - do hospital rankings matter?  I go back to the fact that the USNWR ranking system received the highest grade (a "B" grade) by a group of independent, objective, and unbiased experts.  It is by no means perfect.  However, I see the USNWR ranking system as a good place to start.  There are likely to be health outcomes that are most important and relevant to providers, patients, payors, and public health.  Ideally, the outcomes that are most important to these different stakeholders overlap - but that is just not always the case.  Similarly, while there are some USNWR measures that overlap with the measures that are most important to our patients and to public health, that's not universal either.  For that reason, hospitals should focus on improving the metrics that matter most to our patients and to the public.  As the saying goes, "A rising tide lifts all boats."  I would suggest that an overall focus on "outcomes that matter" will have the secondary effect of improving some of the outcomes that are most relevant to the USNWR.   

"The only winning move is not to play"

 Last night, my wife and I sat down with our adult son to watch the 1983 movie "War Games" starring Matthew Broderick, Ally Sheedy, and John Wood.  It was probably long overdue, given that our son is in the computer industry.  There were a couple of important insights, at least for me, that deserve mention.  

Most importantly, apparently 1983 was a really long time ago!  Wow!  The cars and clothes in the movie looked much older than I remembered.  I don't think I can remember the last time that I saw an old-fashioned telephone modem (the kind where you put the headset on the modem itself - here's the scene).  For that matter, it's been a while since I've seen an arcade, a dot matrix printer, or even a telephone booth.  Okay, maybe that last one is a bit of an exagerration.  How about all of the actors that played bit parts in the movie and would go on to be Hollywood superstars, or at least more memorable roles than this one (see for example, Dabney Coleman, Barry Corbin, James Tolkan, Michael Madsen, and John Spencer among several others).  I also learned (or should I say "re-learned") a different way to butter my corn on the cob (see a brief video clip here).  Incidentally, the corn on the cob wasn't cooked, as Matthew Broderick's character's father found out when he bites into it.  The mother responds with one of my all-time most frequently used movie quotes, "Can't you just taste all of the vitamins?"

Two particular quotes stuck out, at least for those of us who grew up during the Cold War.  The first, when Matthew Broderick's character asks the computer, "Is this real or is it a game?" (referring to the war game simulation, "Global Thermonuclear War" that the computer is running in real life).  The computer responds, "What's the difference?"  The second, after the computer figures out that, like the game Tic-Tac-Toe, nuclear war has no winners, "A strange game.  The only winning move is not to play."

The lesson here is probably worth repeating, given the state of world affairs today.  Earlier on in the movie, Professor Stephen Falken, the character who apparently was modeled after the real-life physicist Stephen Hawking and was played by the Shakespearean and Tony award-winning actor, John Wood asks Ally Sheedy's character, "Did you ever play tic-tac-toe?"  Here are the rest of the lines from the movie script during this scene:

Falken: Did you ever play tic-tac-toe?

Jennifer: Yeah, of course.

Falken: But you don't anymore.

Jennifer: No.

Falken: Why?

Jennifer: Because it's a boring game. It's always a tie.

Falken: Exactly. There's no way to win. The game itself is pointless! But back at the war room, they believe you can win a nuclear war. That there can be "acceptable losses."

It's a great lesson for all of us.  Tic-tac-toe is a game with a relatively simple strategy.  If you follow that strategy, there is never going to be a winner or a loser.  You will always play to a tie.  The same could be said for a global nuclear war - there's never going to be a winner or a loser.

The same lesson can be applied to organizations.  How many times do we get stuck in a metaphorical game of tic-tac-toe, one in which there are no winners or losers?  Or worse - there are no winners and everyone loses!  Maybe, as the computer suggests in the movie, we should just stick with chess.

Einstellung

There's a scene in the 1995 movie, Die Hard with a Vengeance (the third installment in the "Die Hard" movie series starring the actor Bruce Willis) that most mathematics teachers love!  Apparently, there is an evil genius in this movie (played by the actor Jeremy Irons) who sends our hero, NYPD detective John McLane (played by Willis) and his new best buddie, Zeus Carver (played by the actor Samuel L. Jackson) out to solve a series of riddles and puzzles in order to stop the detonation of his bombs.  They end up in Central Park and have 30 minutes to solve a famous riddle (at least for mathematicians and cognitive psychologists) called simply, "the water jug problem" (see the scene from the movie here).

Here is the problem.  You have in front of you a 5-gallon water jug and a 3-gallon water jug.  You also have access to a water fountain, so you can fill up both water jugs as many times as you want.  Your job is to put 4 gallons of water exactly into one of the jugs.  In the movie, the bomb will only be defused when they place the 4 gallons of water on a scale - an ounce more or less will detonate the bomb.  How do you do it?

The solution to this puzzle is all over the Internet, so I won't spoil things if I tell you how John McLane (Willis) and Zeus Carver (Jackson) solved.  Mathematically, the puzzle can be solved if you remember the following:

5 - 3 = 2

5 - (3 - 2) = 4

Does that help?  Here is the step-by-step explanation:

• Fill the 5-gallon jug to the top (the 5-gallon jug has 5 gallons of water now)
• Pour water from the 5-gallon jug into the 3-gallon jug and fill it all the way up (the 5-gallon jug now has 2 gallons and the 3-gallon jug now has 3 gallons of water)
• Dump out the water from the 3-gallon jug (which now is empty)
• Pour the water (2 gallons) from the 5-gallon jug into the 3-gallon jug (the 3-gallon jug now has 2 gallons of water, and the 5-gallon jug is empty)
• Fill up the 5-gallon jug all the way (the 3-gallon jug still has 2 gallons, and the 5-gallon jug has 5 gallons)
• Pour water from the 5-gallon jug into the 3-gallon jug, filling up the 3-gallon jug (the 3-gallon jug now has 3 gallons and the 5-gallon jug now has 4 gallons!!)

Apparently this puzzle has been around for a long, long time.  There are of course different variations, some of which include three different water jugs, not two, as in the Die Hard movie.  The three water jug puzzle was used in a famous set of experiments that demonstrated the so-called Einstellung effect.  

The word "Einstellung" literally means "setting" or "installation" in German.  The Einstellung effect occurs when a person is presented with a problem that is similar to problems that he or she has successfully solved in the past.  The individual will model the solution on these past problems, often times giving the solution to the problem at hand very little thought.  Oftentimes, an easier or more appropriate solution to the problem is available, but due to the Einstellung effect, he or she discounts this alternative solution.  In other words, the Einstellung effect is a cognitive trap - in other words, a negative effect!  It blinds us to alternative and potentially better solutions.  For example, McLane and Carver could have used another method to solve their water jug puzzle in Die Hard.

We are all at risk of succumbing to the Einstellung effect.  So how do leaders prevent their teams from falling to this cognitive trap?  The blogger Tammy Lenski offers a few suggestions:

Remind yourself about the effect - as is the case with most cognitive biases and traps, simply acknowledging that they exist and thinking about them as you solve problems can help mitigate at least some of their effects.

Challenge yourself and others to push past the trap - I will bring in one of the principles from High Reliability Organization theory here - reluctance to simplify.  The simplest explanation is not always the only explanation.  After acknowledging a cognitive bias, be prepared to push past it.

Allow incubation time - take the time to think about the problem.  As Albert Einstein once said, "If I had an hour to solve a problem I'd spend 55 minutes thinking about the problem and five minutes thinking about solutions."

Practice boketto - Dr. Lenski says that boketto is the Japanese term for staring off into space without thinking.  Try giving your brain a break and let the creative juices flow.  In many cases, you will find a new way to think about a problem, which may offer some new and creative solutions.

Consciously adopt a beginner's mind - The expert has been here before and may be more prone to the Einstellung effect.  Think outside the box by thinking about the problem as if you were seeing it for the first time!

As I start to wind up this post, I am reminded of another mathematical puzzle that can only be solved when you "think outside the box."  Connect all of the dots below without lifting the pencil from the paper.  

Here is the answer:

Did you solve the puzzle?  Or were you stuck in the Einstellung effect?

Hobbits and orcs, chickens and foxes, and the story of Velcro

"Life is all about metaphors and personal stories."  I wrote that sentence several years ago when I first created my blog website.  After more than 5 years and over 500 blog posts, I remain convinced that the use of metaphors, personal stories, and analogies is a great way to teach and to learn.  Let me start with, of course, a story that will hopefully illustrate my point.

George de Mestral was a Swiss electrical engineer who invented the hook and loop fastener which he called Velcro®.  As the story goes, de Mestral was in the Jura Mountains of Switzerland on a hunting trip with his dog in 1941.  Upon his return, he noted that his clothes, as well as his dog's fur were covered in the seed pods (reportedly Xanthium strumarium, the cocklebur plant).  He carefully pulled one of the seed pods off his dog and examined it under the microscope, where he noticed that the seed pod was covered in hundreds of tiny hooks.  It was a "Eureka" moment for de Mestral.  He quickly saw that a similar concept could be used to reversibly fasten different materials together. He would spend the next 10 years perfecting his design, filing for a patent in 1951.  He called his invention Velcro, a portmanteau of the French words velours ("velvet") and crochet ("hook").  The rest, as they say, is history.

Undoubtedly, de Mestral greatly benefited from being at the right place at the right time.  The invention of Velcro came at the same time as the "space race" in the 1960's, and NASA was one of the first to use de Mestral's product.  As I stated earlier, the Velcro story is a great example of analogical thinking or reasoning, which is defined as "the process of finding a solution to a problem by finding a similar problem with a known solution and applying that solution to the current situation."  

As it turns out, there are a number of older studies in the cognitive psychology literature on the use of analogical thinking.  I've previously written about a few of these studies in the past (see "All the world's a stage...").  Today though, I want to talk about another well-known puzzle that uses analogical thinking, called the "crossing the river problem."  Here is the basic concept - a farmer needs to get a chicken, a fox, and a sack of corn to the other side of a river.  He has a rowboat, which is just large enough for him and one other passenger or object.  If he takes the fox first, he will leave the chicken alone with the corn, and the chicken will eat the corn.  If he takes the corn, he will leave the fox alone with the chicken, and the fox will eat the chicken.  How does he do it?

I am not going to spoil your fun by giving you the answer!  But here's a hint - the man will have to row back and forth across the river a few times!  As it turns out, there are several variations of the "crossing the river problem," all of which are variations of the same theme as the chicken, fox, and sack of corn problem.  For example, here's one known as the "Hobbits and Orcs" problem:

Once upon a time, in the last days of Middle Earth, three hobbits and three orcs set out on a journey together.  They were sent by the great wizard Gandalf to find one of the lost palantiri, or oracle stones.  In the course of their journey, they come to a river.  On the bank is a small rowboat.  All six travelers need to cross the river, but the boat will only hold two of them at a time.

The orcs are fierce and wicked creatures, who will try to kill the hobbits if they get the opportunity.  The hobbits are normally gentle creatures, but they are very good fighters if provoked.  The orcs know this, and will not try to attack the hobbits unless the orcs outnumber the hobbits.  That is, the hobbits will be safe as long as there are at least as many hobbits as orcs on either side of the river.

I realize that fans of the J.R.R. Tolkien's The Lord of the Rings will question the "historical" accuracy of this problem, but try to figure it out!  Again, the only hint I will provide is that there will be several boat trips.  I've come across different versions of this problem.  Substitute missionaries for the hobbits and cannibals for the orcs, and you now have the missionary-cannibal problem.  Substitute jealous husbands for the missionaries and wives for the orcs, and you now have the jealous husband-wives problem.

They all sound so familiar.  The important question is whether figuring out the solution to one problem - say, the jealous husbands-wives problem - will help individuals find the solution to a similar problem - say the missionary-cannibal problem.  This is exactly the question posed by a study conducted in the early 1970's by a group of cognitive psychologists (see "The role of analogy in transfer between similar problem states" by Stephen K. Reed, George W. Ernst, and Ranan Banerji at Case Western Reserve University).  The results may surprise you, especially when you look at how similar these different problems really are.

As usual, the study subjects were undergraduate students enrolled in an "Introduction to Psychology" class (remember when you had to do sign up to participate as study subject?).  The study utilized the jealous husband-wife problem and the missionary-cannibal problem.  Importantly, while the two problems are similar, there are a few subtle yet important differences.  

Here is the missionary-cannibal problem:

Three missionaries and three cannibals having to cross a river at a ferry, find a boat but the boat is so small that it can contain no more than two persons.  If the missionaries on either bank of the river, or in the boat, are outnumbered at any time by cannibals, the cannibals will eat the missionaries.  Find the simplest schedule of crossings that will permit all the missionaries and cannibals to cross the river safely.

Here is a similar problem, known as the jealous husbands problem:

Three jealous husbands and their wives having to cross a river at a ferry, find a boat but the boat is so small that it can contain no more than two persons.  Find the simplest schedule of crossings that will permit all six people to cross the river so that none of the women shall be left in company with any of the men, unless her husband is present.  

Try to figure each problem out!  It's not easy.  The investigators conducted a series of experiments in which subjects were presented with each problem in sequence.  Transfer of knowledge did occur - in other words, solving one puzzle helped subjects solve the alternative puzzle, with a couple of important caveats.  First, subjects were told that the two puzzles were related (if they weren't, solving the first puzzle did not help them to solve the second puzzle).  Second, the Jealous Husband problem had to be presented first.  Why did the order of sequence matter?  The Jealous Husband problem is a little more complicated.

So, as the investigators wrote, "Our attempts to solve problems are greatly influenced by our previous attempts to solve problems."  However, it's not quite that simple.  Transfer of knowledge does occur, but there's more involved to simply develop an easy model with which to solve similar, related problems.  Analogical thinking is far more complex than we realize.

"The Chinese symbol for crisis..."

Senator (at the time) John F. Kennedy gave a speech at the Convocation of the United Negro College Fund in Indianapolis, Indiana on April 12, 1959.  Just a few minutes into his speech, he famously said, "When written in Chinese, the word "crisis" is composed of two characters – one represents danger and one represents opportunity."  Kennedy reportedly used this same statement on a number of speeches throughout his 1960 Presidential Election campaign.  Similarly, both former Vice President Al Gore and Secretary of State Condoleezza Rice have also used it.

It sounds really cool, doesn't it?  There is no question that a crisis can be a moment of danger for an organization (or country).  As change management guru John Kotter describes in his 8-step change model, the first step to creating the momentum to overcome organizational inertia and resistance to change is to create a sense of urgency - to use another overused phrase, a "burning platform".  When viewed in this context, a crisis certainly represents an opportunity to begin anew, to disrupt, and to change for the better.

The problem with Kennedy's statement is that it is unfortunately not true.  The Chinese word for crisi ("weiji") consists of two syllables that are written with two separate Chinese characters, "wei" and "ji."  Here is the Chinese symbol for "crisis" (weiji):

The first syllable (depicted by the first character) is "wei", which does in fact mean "danger".  However, the second syllable (depicted by the second character), "ji" doesn't mean "opportunity."  Rather, "ji" refers to a "crucial point in time" or "incipient moment."  In other words, the Chinese word for "crisis" means a dangerous, but pivotal moment in time (which pretty well sums up what it is meant by the word "crisis").

I don't now how many times that I've heard Kennedy's statement in a leadership context.  Analogies and metaphors like this are almost too good to be true, and in this particular case, it is exactly that.  It sounds good, and I wish that it really did mean "danger" and "opportunity", but that's simply just not the case.

Mandatory Training

Annual training and education is important.  However, I am going to make a full confession.  I have, at times, skimmed through our organization's annual training videos and fast forwarded as much as I am allowed before taking (and passing) the accompanying quiz.  Passing the quiz documents my understanding and fulfills whatever requirements have been imposed by whichever regulatory body.  I do wonder how much time and money are spent on (1) developing the training materials and (2) requiring completion of the training (usually while on the job) by all of the organization's employees.  

If you work in health care, you know exactly what I am talking about - think of the acronyms "R-A-C-E" and "P-A-S-S" as just two examples.  Even if you aren't working in the health care industry, you probably know exactly what I am talking about - all industries provide this kind of mandatory training.  The important question to ask is whether this kind of training is effective.  

Examining this mandatory training process purely from a quality improvement and safety lens, education and re-training is one of the least effective interventions, in terms of reliability (see here).  On a typical scale, the highest level of reliably effective interventions include forcing functions, automation, and standardization, while the lowest level of reliability interventions focus on education, training, and "pop-up" warnings/alerts.  In other words, annual training, as currently required and in the way it is currently provided in almost all health care organizations (if not all organizations) is not very effective.

Periodic (annual or semi-annual) training is designed to promote habit formation.  In other words, if we take this training over and over, the knowledge and skills will be second nature to us.  The problem is that as individuals are exposed to repeated training, there is very little in the way of marginal gain in knowledge, skill, or even habit.  As individuals become accustomed to this training, they mistakenly believe that they have mastered the concepts and spend very little "cognitive time" thinking about it (as I alluded to in the first paragraph).

Is there a better way to conduct this kind of annual training and education?  Perhaps a study by a group of investigators called "Training to Mitigate Phishing Attacks Using Mindfulness Techniques" published in the Journal of Management Information Systems will provide some insight (see also the review of this study in the Harvard Business Review).  Given the increasing number of cyber-attacks, particularly in the health care industry, a number of organizations have added cyber-security to their list of annual training requirements.  E-mail phishing attacks are on the rise and cost industry billions of dollars per year.  These investigators compared the traditional way of doing things (annual training using a rules-based approach) to an approach based on mindfulness.  

The traditional "rules-based" approach emphasized a specific set of rules (follow the rules to avoid phishing attacks):

1. Never clink on a link or open an attachment in an e-mail from an unknown sender

2. Access by a website by typing the web address yourself (as opposed to clicking on the link)

3. Do not reply to e-mails asking for private information

4. Real organizations such as banks or employers will never ask for private information in an e-mail

5. Be suspicious of a website that asks for private information

6. Look for cues such as HTTPS in the address bar or a lock icon in your browser to identify a fake website

The "mindfulness" approach asked individuals to:

1. STOP - take a pause whenever you open an e-mail that contains an explicit request for action

2. THINK - ask yourself the following questions:

    a. Does the request ask for private or proprietary information?

    b. Is the request unexpected or rushed?

    c. Does the request make sense?

    d. Why would the sender need me to do this?

3. CHECK - if the individual was suspicious of a phishing attack, contact the IT department.

Seems fairly straightforward, right?  The investigators randomized a group of more than 400 university faculty, students, and staff to one of these two training approaches versus a control group that received no training.  Ten days after the training, the research team launched a phishing attack.  They found that 23% of the individuals in the control group took the bait and responded to the phishing attack, while only 13% of the individuals in the rules-based training did so - in other words, some training is probably better than no training.  However, only 7% of those in the mindfulness training responded to the phishing attack!  

These are pretty amazing results!  We know that simple education and training is the least reliable way to effect changes in behavior.  This mindfulness study provides some confirmation, but more importantly this study provides a potentially more reliable and effective alternative, one based on mindfulness.  As organizations re-evaluate how they conduct their business, looking at investing valuable time and resources in more effective and reliable methods of annual education and training may be a great place to start.  And, it may make at least this individual much happier if he doesn't have to go through the same kind of training year after year!

"Experience is, after all, a slow road to knowledge..."

We are starting to see the proverbial light at the end of the tunnel!  At least in the United States, the COVID-19 numbers are definitely on the decline.  It's been a long and difficult 15 months (going back to when the World Health Organization officially declared the worldwide pandemic in March) for all of us.  It is tempting to talk about a "return to normal," but I think it is fair to say that we will never go back to the way things were before COVID-19.  Whatever you wish to call this new state, I do believe that we can and should reflect on the events of the past 15 months and learn as much as we can about how society dealt with all of the things that occurred (clearly we dealt with more than just a worldwide pandemic).

I have always found it incredibly helpful to learn from the past experiences of others.  No one currently alive has ever experienced what it's like to survive through a worldwide pandemic like COVID-19.  As the author and historian, Willie Lee Rose said, "Experience is, after all, a slow road to knowledge."  Eleanor Roosevelt similarly stated, "Learn from the mistakes of others.  You can't live long enough to make them all yourself."  For these reasons and more, I've been trying to learn what I can by reading about the societal changes that occurred during and following some of history's most famous pandemics, such as the infamous Black Death (worldwide plague from 1346-1353), the Great Plague of London (1665-1666), or the 1918 Influenza Pandemic.

I've also been reading more about the history of how we got to be where we are today as a society.  There are still a lot of books on my nightstand to read, but I was particularly impressed by a book by Colin Woodard called American Nations: A History of the Eleven Rival Regional Cultures of North America.  Woodard suggests that we should view the history of the United States through a different lens altogether, proposing that America is really a conglomeration of eleven different regional cultures and nation-states.  He further contends that there are two major "alliances" of nation-states that are commonly opposed to each other - a northern alliance, consisting of the nation-states of Yankeedom, the New Netherlands and the Left Coast and a southern alliance, consisting of the nation-states of the Deep South, Greater Appalachia, and the Tidewater.  The remaining nation-states (Midlands, New France, El Norte, and the Far West) will generally align with one or the other of the two major alliances, depending upon the political issue at hand.  It's a different way to examine our history for sure, but I found the book to be quite interesting.

I was particularly interested in statement that Woodard made in the epilogue of his book.  I thought it was actually quite profound.  He is discussing his thoughts on how the different nation-states will continue to influence the political direction of the United States as a whole, stating, "Another outside possibility is that, faced with a major crisis, the federation's leaders will betray their oath to uphold the U.S. Constitution, the primary adhesive holding the union together.  In the midst of, say, a deadly pandemic outbreak [emphasis added by me] or the destruction of several cities by terrorists, a fearful public might condone the suspension of civil rights, the dissolution of Congress, or the incarceration of Supreme Court justices.  One can easily imagine circumstances in which some nations are happy with the new order and others deeply opposed to it."  Woodard wrote these words in 2012, but they seem deeply prophetic now, especially in light of what happened on January 6, 2021.  

As we reflect on the events of the past year and a half, there is no question that our society has fundamentally changed.  There are likely to be more difficult days ahead, even as we slowly reset back to our new baseline.  As the ancient Roman Stoic philosopher, Lucius Annaeus Seneca (usually known as simply "Seneca"), said "A gem cannot be polished without friction, nor a man perfected without trials."  I hope that we will emerge better for the trials that we have all been through during all of calendar year 2020 and most of 2021.  

I feel as though we have reached a fork in the road, and our future as a country will depend greatly on which road that we take.  I hope that the path we take will lead to real progress forward, and that we will emerge as a society that honors and respects our individual differences.  As we contemplate where we are as a country, as well as where we need to go, there are likely to be important lessons in the experiences of the past - particularly how society emerged from pandemics throughout history.  History - the experience of others - can teach us and lead us the way.