EQUAL TREATMENT. Decision making groups need to consist of different kinds of people, notes Henrik Sjövall in a chronicle. There are a number of individual factors that affect how we think, and it is worthwhile learning to understand and respect each other in heterogeneous work groups.
Diversity is an overused word, but if you use it correctly, it reflects something very important. I learned about the significance of that word a few years ago, when I took a prefecture course. During the course, we took a test where we were to report on how we would like to handle a number of decisional situations. Then we were divided into groups. The group I found myself in was given the task of arranging an institute day. We rapidly came up with the idea that we would use soccer at Ullevi as a metaphor, with the well-meaning message that it is not enough with just players – someone has to punch the tickets, handle the lighting and sell the popcorn. We had a lot of fun and were as please as could be with what we had done.
After lunch, we built new groups, with new people and were to build a bridge using colored cardboard. I came up with a number of ideas, but nothing I suggested was liked: “it will be to flimsy”, “wrong color”, “it will take too much paper”. I became irritated (“you can build your own damn bridge yourselves!”), and went and sat down and sulked in a corner. They did manage to put one together in the end, albeit a boring and wobbly bridge, in my eyes.
Then we got the results. During the morning’s test, they had gathered people with the same personality type, and in the afternoon they had placed me in a group that was totally opposite to most of my personality traits. My gut feeling was that the morning group was the best, we had had such fun! The seminar leader then quietly pointed out that the result (the soccer metaphor) was rather dubious, “Is it really suitable to use a model (soccer) that many are not interested in and additionally has a gender profile where the man is the hero down on the playing field, while the women punch tickets and sell popcorn?” That was something we had totally missed in the general enthusiasm.
The afternoon group, though, that was heterogeneous (at least for me)? Well, when I was ostracized and sat down to sulk it was no longer that either anymore, and the result was also “so-so”… If anyone from the afternoon group had been part of the morning group, then that person would probably have been pushed out (which I might not have noticed?) and we would have lost that “wait a minute” voice we needed.
you need to try for heterogeneous groups
The conclusion of the exercise was that you need to try for heterogeneous groups. It is demanding, but we need to respect each other and try to communicate, despite our differences; but if you do, you will be richly rewarded.
Another difference between people is that they use different intellectual strategies. A book that elegantly illustrates this, is Daniel Kahneman’s “Thinking, Fast and Slow”. The message is simple: the human brain has two main ways of working – fast thinking that consists of pattern recognition (“this must be a heart attack!”) and slower, fact-based and systematic thinking. Depending on our personality, we are more easily able to use the one or the other, both women and men. A problem with pattern recognition is that it is built on ignoring some of the details and if these details happen to be significant, you risk not just winding up on the wrong planet, but sometimes in the wrong universe. Pattern recognition draws the major outlines and ignores the details that do not agree with how they want it to be. Which, as you know, can have disastrous results – it is not unreasonable to believe that that is how the Macchiarini scandal occurred.
Slow thinking, then, does it have any disadvantages? Yes, sometimes it takes too long. In a worst case scenario, the patient can be dead before you have finished thinking. The choice of thinking strategy is not carved in stone; it is just as hard to get fast thinkers to calm down as it is to get slow thinkers to dare to ignore some of the unimportant details.
We are often unaware of these processes, fast thinking is significantly more exciting and you usually choose this strategy first, if you have the slightest aptitude for it. Fast thinking also generally “runs over” slower thinkers, which as we all know can have devastating consequences (the Macchiarini affair again).
Our attraction to pattern recognition can contribute to the systematic discrimination of groups by our using pattern classifications that are not relevant. Let me give you an example of how a patient’s gender appears to affect their place in line in emergency healthcare. A few years ago, I heard a talk given by one of the hospital’s logisticians, Malin Lönnbark. She had compared the wait times of men and women at three emergency departments, and found a difference that disadvantaged the women, they had consistently longer wait times. It varied considerably, but generally it concerned 15-30 minutes, depending on the clinical situation. No one seemed to really want to get involved with this, so I created a master project and found a medical student, Josefina Robertsson, who was assigned to figure out the connection. She counted the wait times of close to 150 000 patients at Östra’s emergency department and found a moderate, but statistically robust difference, to the disadvantage of women. We tried using subgroup analysis to construct a hypothesis for the mechanism; we looked at such things as reasons for seeking medical care and triage level (that is how urgent was it) and even tried to figure out where in the care chain the phenomenon occurred. It showed that there was a difference for all three triage groups (red = in principle needs immediate help – life threatening; orange = urgent, but not necessarily immediately life threatening; and green = neither red nor orange – not life threatening), but that the difference was greatest for the green group. The difference occurred early in the healthcare chain, even before the patient had seen the doctor.
When we looked at what significance the patient’s age had, we found that the gender difference had disappeared for the elderly, red triaged patients (which seems reasonable) but oddly enough it occurred for young people in the same group. That felt disturbing, so we continued to search and at last found a possible medical explanation: among the red triaged, there is a subgroup of patients with rapid breathing that is due to anxiety, and in this group, women are over represented. When the diagnosis of hyperventilation is made, they remain in the red triage group, but do not need to be handled with the same urgency. This means, that the wait time for this group, as a whole, increases. When we removed this subgroup, we no longer saw any gender related difference in wait time in the red triaged group. Medical severity, thus, eliminated the relatively weak gender signal, in this case.
It is well known that socioeconomic factors substantially affect most medical outcomes, so we tried looking at that too. As we had no ethical reason to cross check income records, we tested our hypothesis by grouping the patients by the district they lived in and comparing the average incomes. Unfortunately in Gothenburg, we have pronounced segregation, so we simply compared the gender signal size with the “poor” and prosperous neighborhoods. And that is when we found something else that was troubling: the gender difference was robust in the poorer neighborhoods, such as Angered-Bergsjön and was even found in Majorna (an old working class neighborhood) but was not seen with those seeking healthcare from Askim-Hovås! The latter group was, however, relatively small (normally these patients seek help from Sahlgrenska’s emergency facilities, not Östra’s) but, still, it is a noteworthy finding. Can it be that well-educated women are treated about the same as well-educated men, but that we are more likely to give less educated women longer wait times than less educated men?
Now, how should this be interpreted? The subgroup material is relatively small and it is entirely possible that there are medical background factors that we have not identified. But, it must be admitted that the signal acts exactly like a discriminatory signal is expected to. From Malin Lönnbark’s prestudy, we also know that there is a similar signal at Sahlgrenska and at Mölndal, which indirectly points to the same thing.
To sum up: I have taken up examples of how personality, intellectual strategy, gender and socioeconomic factors can affect our decisions in different ways, albeit, often subconsciously. The best way to handle this, is to create heterogeneous decision making groups, where you learn to understand and respect each other, despite perceived differences. When I speak about equal treatment with supplementary education students, doctors from the four corners of the world (image), I usually pick up two pens and lay them down next to each other, with a minimal lengthwise difference (image). “This is the similarity between people that we speak far too little about, and this is the difference that we speak endlessly about, and moreover, search for, all of the time. And even worse, we attach values to the difference, values that cloud our judgement.”
We have to stop seeing differences between individuals as a problem, and instead see them as an opportunity. Sweden has a tradition of good teamwork; and the extra effort that is needed to create good heterogeneous work groups and ensure that we learn to communicate, usually gives great returns. We need to work on this. I usually tell the students that there is no art in giving someone you like and who thinks like you a good consultation. The art of medicine is when a person that is the exact opposite of you, who you might even dislike and who you have difficulty communicating with, is still satisfied with their visit.
As the equal treatment representative, I will continue to embrace the diversity of people, with a focus on this being seen as an important resource. Much of what we call discrimination is, however, something completely different; a counterproductive, arbitrary and primitive categorization of people based on phenomena that has nothing to do with this. This conflicts, as you know, with the Constitution itself. If you advance heterogeneity as a resource, you reduce the risk of negative discriminatory treatment of groups. Succeeding with that delicate balancing act is an important task for globalized modern society, where Sweden has excellent opportunities to be a model country.
TEXT: HENRIK SJÖVALL
