All good things… come by grace and grace comes by art and art does not come easy.
—Norman Maclean, A River Runs Through It
I would try to make lists. A list of all the stores and businesses going up and down the main street and who owned them, a list of family names, names on the tombstones in the cemetery and any inscriptions underneath.… The hope of accuracy we bring to such tasks is crazy, heartbreaking. And no list could ever hold what I wanted, for what I wanted was every last thing, every layer of speech and thought, stroke of light on bark or walls, every smell, pothole, pain, crack, delusion, held still and held together—radiant, everlasting.
—Alice Munro, Lives of Girls and Women
A leading global provider of health care equipment and systems was trying to understand the future of long-term care for the elderly, especially given the aging populations in countries as varied as Japan, France, Canada, and the United States. We partnered with them for a sensemaking study that involved interviews and observations with more than 450 people across thirty-three different institutions in these four countries. The study included retirement homes, dementia homes, day care, and assisted living, and the goal was to form a perspective on where long-term care was headed and how the patient and caregiver experience was changing.
Until recently, the model for long-term care was following the curve of so many other rapidly growing industries. Financial pressures and the increasing elderly burden were—and still are—creating a strong demand for efficiency. Caregivers and their institutions felt a need to put more focus on the parts of the care that were easily measured and that provided an obvious return on investment—including a high resident-to-caregiver ratio, a low number of falls, and low occurrence of pressure ulcers. In this way, caregivers and institutions started to view the residents primarily through their bodily needs—bathing, toileting, moving in and out of bed—and they standardized their care to be as efficient as possible. As one caregiver in the study put it, “I don’t want to say we are robots, but we do have a job to do… there simply isn’t time getting to know them. You don’t know their history.”
This drive for efficiency in long-term care resembles the trajectory we know so well from the corporate farming system and its reliance on monoculture, or the education system and its drive for metrics, accountability, and standardized testing. This is the culmination of our modern era of management science: a highly optimized system that measures patients by quantitative accounts.
But a pattern emerged in the study that provides a new vision for long-term care. It is a development that has much to teach us about our attitudes toward abstracted knowledge in the form of measurements and returns on investment. Ultimately, it offers us a clearer understanding of what people are for.
It is the changing of the shift at an assisted living facility in California, and “Randall,” an 87-year-old resident, is beginning to grow agitated. This is a regular pattern with Randall, who suffers from dementia. The shift change—which occurs at 3 PM every day—is filled with the commotion of moving bodies, new faces, the whirl of change. It triggers something from deep inside Randall and he often starts acting out, engaging in angry conversations with his own hallucinations.
“Barbara,” one of his caregivers, ushers Randall into the dining room and slowly, methodically, clears the rest of the residents out of the space. Randall starts to wander through the room, tipping tables and moving chairs. He grabs Barbara’s arm and grips it with intensity for several seconds. She moves her arm away with a nonchalant comment, “I don’t bend that way, dear.” And then she tries to distract him: “Look at the light coming in the windows, Randall. Look at how bright it is out there.” All the while she performs a subtle dance with the other residents. She gives some of them a tap, waking them up if they have fallen asleep at the table, offering them support while they get out of chairs and get out of the room. She glides seamlessly around residents in wheelchairs and walkers, pushing them one by one into the hallway so Randall can be isolated. When the room is completely empty except for Randall, she shuts the doors and stays to observe him, making certain he is safe by watching through the glass.
“We put him in the dining room so he can get his energy out,” she told researchers in the study. “This space has more room for him and better light when he is feeling agitated. When the other residents see Randall in there, they know they don’t want to be a part of it.”
This type of distress is typical for residents with dementia, and it is a game changer in the world of long-term care. The Organisation for Economic Co-operation and Development (OECD) projects that between 2015 and 2035, dementia in the United States will increase by 55.6 percent. In Canada, they estimate an increase of 63 percent, and in Japan an increase of 74 percent. The agitation that typifies some dementia patients is so time-consuming for everyone involved that the entire model of efficient care is being turned upside down. Facilities need to focus on how to keep the mood of agitation from spreading and on how to minimize friction, both inside and outside of care tasks. Easily quantified measurements like occurrence of pressure ulcers have no bearing on the care a resident like Randall needs. What matters much more are the personalized strategies—artful hacks—that his caregivers perform every day.
This kind of care requires that the team of caregivers get to know Randall better, both his previous life and how he experiences being in the institution. For example, Barbara discovered that he was a schoolteacher for several decades. His reaction to the 3 PM shift change was not random. His muscle memory responded to the hours of the school day—the energy of the 3 PM release, with kids in the hallways and movement away from the classroom and toward home. When the shift change occurs at the facility, Randall feels confused and frustrated that he doesn’t recognize his surroundings. He senses that something is going on but doesn’t know what he is supposed to do. His caregiver team put these pieces together by placing his behavior in a context with his life outside the institution. Barbara calmed Randall down by addressing him as “Mr. Johnson,” the name his students used in class. In anticipation of the chaos of 3 PM, she and the rest of the staff began distracting him with songs and stories while the new caregivers signed in.
“We’ve got it down to a kind of science,” Barbara told the researchers. “Sometimes he just needs a change so we know when to switch people. Sometimes he responds really well to a softer voice that is almost like a whisper. But sometimes he needs you to respond in exactly the same tone as his. Almost like an echo of his voice. You kind of have to feel him out.”
And when none of the artful hacks manage to calm him, Randall’s team has devised a protocol. They guide him gently into the dining hall and isolate him briefly so he can “get his energy out.”
Randall’s caregiving strategies are written up on whiteboards and on typed sheets of paper and passed back and forth among his caregiving team: “Randall was a woodworker. Offer him Montessori blocks,” and “Randall was a guidance counselor. Ask him about his work.” There is no way to codify this type of knowledge, because it is only relevant for the care of one person: Randall. If his institution attempted to apply management science to it—to “scale up” this knowledge—they would find it difficult to apply. The best care involves getting to know each patient within a social context and then devising a series of strategies that best suit their individual needs.
This personalized caregiving may seem like an elaborate and costly strategy, but, in fact, Randall’s facility has found that it is the most efficient way to deal with Randall and his dementia. With the right combination of hacks, cues, and distractions, they can get Randall bathed, fed, and calmed much faster than if they expediently checked off their list of bodily needs and ignored Randall’s growing discomfort and specific triggers. And, it goes without saying, personalized caregiving aligns more fully with the vision of the caregivers. There is less burnout and stress and a greater sense of purpose for the staff when they are encouraged to get to know each patient as a person.
You might look at these examples and say, well, sure, we all want good care, but it’s too expensive to maintain. What we are discovering, however, is that the real expense is care meted out only through management science and codified knowledge. As it turns out, good-quality personalized care is cheaper care when it comes to dementia. The cost-effectiveness is a direct result of its efficiency. According to caregivers and their management in every country we studied, this more personalized care of dementia patients saves time in the day. When the entire culture inside the facility is calmer and more peaceful—when friction is averted—fewer patients suffer from falls and there are fewer pressure ulcers. The entire system works better.
“The focus is shifting more from the task to the person,” one administrator in the study told us. “If you can create relationships with the people you’re caring for, it’s going to be better for them. They’re probably going to have fewer behaviors, more quality of life and peace. This then makes our work easier and quicker.”
Such a shift necessitates a fundamental change in our assumptions about time and cost. This “new efficiency” in dementia care is entirely local and contextualized: it cannot be abstracted and scaled. Because there is no other Randall in the world, there is no standardized solution that can account for the behavior of Randall. Caregivers today rely on analog, “homemade” ways of sharing resident-specific knowledge—tips and tricks—with each other to make their work easier: notes on paper or whiteboards, or simply conversation. More can be done to make their experience-based, resident-specific knowledge readily available to them when it matters the most, often in care situations where residents easily become scared or agitated. The exciting potential of new technology is not that it makes standardized procedures quicker but that it can help support personalized care. In other words, caregivers need support knowing exactly which “buttons to push” with each resident and adapting the care accordingly—rather than support pushing the same buttons more and more quickly.
In many situations—certainly not all, but many—human intelligence is still the most efficient intelligence for addressing contextual challenges. It is an efficiency based not on scalable knowledge but on a profound understanding of the particular.
At age 82, Wendell Berry is an American treasure. He has been farming the same plot of land in Henry County, Kentucky, for several decades as well as teaching at his alma mater, the University of Kentucky, and has written over forty works of fiction, nonfiction, and poetry. In the 1980s, from his porch on his farm, Berry had a front-row seat to the transforming landscape of American agriculture. He wrote a prescient essay in 1985 entitled, “What Are People For?” that serves as a perfect coda to our sensemaking journey.
In the essay, Berry tracks the development of increasing urbanization and the hollowing out of American rural life and community. He calls attention to the name economists give to the masses of people that used to work in the farmlands: the “permanently unemployable.” According to the agricultural economists, these were the least efficient producers: “[T]oday, with hundreds of farm families losing their farms every day, the economists are still saying, as they have said all along, that these people deserve to fail… and the rest of us are better off for their failure.”
The knowledge these people held and the work that they did has now been eradicated by varying combinations of machinery and chemicals. Some called this displacement a triumph of agricultural science, but Berry wonders what is going to happen to all those people now deemed useless. “Is the obsolescence of human beings now our social goal?” he asks.
Back in the 1980s, Berry’s question referred primarily to the work and knowledge of the farm. But thirty-five years later we might say the same thing of almost every kind of human labor. Today it is white-collar jobs—accounting, radiology, law, journalism, and stock trading—that are endangered just as much as, if not more than, blue-collar jobs like farming, driving, and manufacturing. In 2013, Oxford University researchers argued that machines could perform almost half of U.S. jobs within the next twenty years.
These and other such statistics might prove to be inflated, but there is no question that generalized IT systems and robotics play an important role in our lives today and in our futures. It is always worth celebrating developments that make our lives better and more meaningful, but what is to become of all the wisdom embedded in each and every one of these displaced jobs?
There is a vast wealth of knowledge contained in the small but significant gestures that occur in our worlds every single day. And we dismiss that knowledge at great risk to our future well-being, productivity, safety, and the nourishment of our own human spirits. When I echo Wendell Berry in asking “What are people for?,” I am not suggesting that we do away with algorithms and machine learning. This is not a nostalgic call to return to the ways of the past, nor is it an attempt to hide away on a technology-free island. When I ask, “What are people for?,” I am not asking an either/or question. Instead, I am reminding us that a culture frozen under a spell of the hard sciences is not much of a culture at all. When we revere technology and its solutions above all else, we stop seeing the agility and nuance that characterize human intelligence at its best. By putting technology above us, we stop synthesizing data from other sources. We miss out on a sustainable efficiency that comes from holistic thinking, not from optimization.
Most important for sensemaking, when I echo Wendell Berry’s question, I ask why, in the Western world—and in America in particular—the idea of engaging in cultural inquiry has become a notion of needless luxury. Why are art, poetry, and music something we only dabble in as a hobby on weekends? Why is watching a play or going to a concert a privilege for snotty people, and reading a novel a waste of time? Art, we assume, is only relevant for the lucky few. “What’s the impact to the bottom line?,” people ask. There are no billable hours from time spent on stories or songs. Serious poetry and rigorous theory are discussed only by ladies who lunch. Snuggling up with a novel is my time, not productive time.
And yet, the answer to the question is clear: “What are people for?” People are for making and interpreting meaning. And the realm of the humanities is an ideal training ground for such an endeavor. It offers us more than two thousand years of material as our playground. Yes—of course—works in the humanities exist to bring us delight and pleasure. But they are also helpful, practical tools for dealing with the core questions of strategy that exist in any culture or organization: how to understand other worlds, customs, meanings, and competitive markets. These skills—at the heart of sensemaking—are the very skills that can never be outsourced. Machine learning will never come close to achieving insights into them. This is because they require a perspective, and algorithms simply have no point of view.
When you listen to Brahms, or try to understand the 1930s through the minimal but intensely soulful music of Son House, or sit down with the poetry of Sylvia Plath, you are also exercising analytical muscles that can make your start-up, your social enterprise, or simply your current position better. You can make it more fun and, above all else, more truthful. Let go of the shallow dogma of business schools and the promise of universal principles from the natural sciences. The humanities aren’t a luxury; they are your competitive advantage.
So before you ridicule your daughter for wanting to study Confucian philosophy or look down on the people who choose to major in medieval French poetry, remember that you are quite likely working for such a person. It wouldn’t be surprising if the chairman of the board or the president who runs your company is a former history major or really into Slavic studies or an expert on ancient Greek. If your son is truly passionate about math, by all means encourage him to go into the world of STEM. But pushing yourself or your children away from the humanities and into natural science solely as a utility function isn’t actually very useful—either for them or for the future of our society. We certainly need masterful chemical engineers, mathematicians, and software developers, but we also need brilliant poets, singers, philosophers, and anthropologists. We need to synthesize the best ideas from all of these points of view, not attempt to optimize ourselves as individuals or as a culture.
For when we optimize ourselves, we lose sight of the meaningful differences between Randall—an old man with dementia—and any other old body taking up space in a residence. Optimization is about counting resources in an effort to scale them, and technology is the master of scale. But it need not be our master. Let us demote technology to a colleague or, better yet, a well-trained assistant or sidekick. When we claim our space as the sole interpreters of culture, we can emancipate ourselves and see technology for what it is: simply one more tool in the arsenal. It can help us to arrive at extraordinary places, but we still need to figure out what to do once we get there. The answers to that dilemma will only ever be solved by inspired acts of mastery that are drawn out of us by our context.
So when you go about your day today, I invite you to break the spell. Look around you. Listen for the moments when the pervasive mood of the culture is telling you to marvel at the magic of a new app that can track your digital footprints or a start-up in the health care space that can give you a real-time diagnosis for your symptoms. These are neat tricks—and useful ones at that. But we must remain more circumspect. Steve Jobs used to say, “This will change everything.” Instead, try breaking the spell with this mantra: “This will change some things.” After all, any broad-based education in the humanities shows us that nothing changes everything. Whether it is power dynamics, family strife, the rise and fall of great empires, our relationship to the gods, or our experience of falling in love, the ideas and stories and artistic works on offer in the humanities are always relevant. Our own human yearning for love, for knowledge, for purpose, and for excellence is never new, which is precisely why it never gets old.
Once the spell is broken, look around the world with fresh eyes. You might discover something extraordinary happening on our streets, in our homes, and at our schools every day. It is just as deserving of our wonder as the Hubble spacecraft or a Google-designed Go-playing algorithm. Today, if just for a moment, take some time to marvel at the way George Soros can experience knowledge about the market in his body. Or think about Bjarke Ingels, who allows contextual specificities—not conventions—to determine the shape of his buildings. Consider Sheila Heen, who is able to assess in a matter of seconds how a room filled with dozens of near strangers will best learn. Appreciate Margrethe Vestager and the ways she carves out space for human touchpoints within the hulking beasts of bureaucracy. Wonder at Chris Voss and his ability to decode shades of doubt, opportunity, manipulation, and anger within a message of negotiation. And make your best effort to taste the wine of Cathy Corison—for when you taste a Corison Cabernet, you are really tasting everything that Corison believes in. You are tasting one person’s call to greatness within the context of a single plot of dirt.
Celebrate these and other masters of our world. And then look even closer. You will see magic of a more humble sort is all around us. You might see a schoolteacher create immediate cohesion and structure on the playground in a single gesture. Maybe you will bear witness to the work of a skilled manager taking the temperature of the team. It might be as simple as picking up a great novel from the past and entering—with full heart and head—into another world, connecting with another human across time and space.
There is so much to marvel at—from the most extraordinary heights of our greatest athletes, singers, politicians, and business leaders—right down to the mastery of a caregiver who knows to touch her patient’s arm ever so gently.
“That noise must be the sound of your students in the hallway, Mr. Johnson.” She says just the right thing at just the right moment in just the right way, and Randall is able to calm down and find peace at the end of the long day.
What are people for? Algorithms can do many things, but they will never actually give a damn. People are for caring.