Our systems are broken. Schools are losing relevance for our kids. Doctors and hospitals can’t keep up with their demands and pressures. Listen to Brent & Matt discuss who is filling in the cracks in our public systems. Hear the similar challenges facing both education and healthcare from two professionals that have started private businesses in publicly funded sectors. It’s hard being an individual that doesn’t feel well and be reliant on a bloated bureaucratic system for help. How do we advocate for ourselves?
Listen below to episode 4 of 8 in Season 1 of Why Things Hurt & How We Learn with Brent Stevenson and Educational Consultant Matt Giammarino.
Click here for the Podcast page with links to all 8 episodes
Full Transcript:
Brent: I work with lots of healthcare professionals and I see lots of teachers and parents, and both groups agree that the systems are broken in one way or another. What does that mean? If you could start from scratch, what's a better idea? What's the solution to us? With you particularly right now, watching what's happening in the States and how they just are trying to get rid of the Department of Education... seems bold. Is it just compounded with bureaucratic fat on it that needs to be cut back? Is it better to break it down and start from scratch? Or can we take the bloated system that we have and make it markedly better?
Matt: In the education system, the system is broken because the average student does not come out well-educated. And to the extent that they do, it's not because of school. It might be because of individual teachers or individual educators, or even individual schools, but it's not because the system itself is dedicated to producing huge mental growth for the participants. Is that kind of analogous to the healthcare system being broken—like, people are not in fact healthy?
Brent: It's not really about the capacity to promote health. It's good at keeping people alive. It's not necessarily good at making people healthy. People refer to it more of like a "sick care" system where we're looking after sick people—we're not trying to promote people to be healthy. At its root, it's not the government's job to make you be healthy. Being healthy is a day-to-day choice of things that you choose... you can try to provide principles that people should live by; it doesn't mean they're going to do it. And then when human nature gets in the way and people get sick, and they blame the government for not being able to help them well.
Matt: Yeah. And are you saying that that's not a fair thing to expect of the government? Because that's definitely one view of the education system.
Brent: Yeah, I don't think at all it's a fair thing to expect of the government—on either education or healthcare. I think it's a hybrid of personal responsibility, both in looking after yourself, and then having some better expectations of government systems, but not attributing most of the blame towards them.
Matt: Interesting. I definitely have the opposite intuition—although mine is more on the education side. Shooting for a low bar, which in this case is some form of childcare and college/workplace readiness, is an incredibly missed opportunity. Especially on the perspective of global competition. If our government systems could provide healthy, well-educated people, we'd have an incredible global advantage.
Brent: I agree. And I think that's where the two systems need to be integrated to each other. The school system is an opportunity to teach people how to be healthy, because that starts at a younger age. Some countries actually provide healthy meals—in like Japan and France and stuff—learning how to cook and eat healthily. Maybe kids don't get any exposure to that at home, but they have an opportunity to do that at school. Same with learning the basic importance of exercise. It doesn't necessarily need to be "let's just play basketball." I think physical education should be physical education, not just playing sports. There's an education piece to health that gets missed, and that's where having some healthcare professionals in schools would make a difference. I think some of the education system is starting to really divert from what kids and people and parents actually need.
Matt: Yeah, except... some of those things have been explicit maneuvers—that's not the right word—explicit policies. For example, they're supposed to get an hour of physical education a day. And they do, in the sense that my kids have learned squats and flexibility; it's not just sports. And actually, at my kids' high school, they take this huge amount of pride in their program, how it gets everyone into shape. But the reality of that program is that "getting everyone into shape" is putting these kids on incredibly long runs. And there's a couple of kids who love it, they zoom through it. There's a couple of kids who it's exactly what they need. And then there's about half the kids who walk it, and they're bored, and they're bummed. They're not into it. And they're not getting physical education, even though this is a school-wide program to make sure every kid is in shape.
But the lack of differentiated instruction—meaning that they don't teach the kids who are slower at their level—basically means those kids don't get the impact of the program. And what I think is really important for the systems part is: when they don't get the impact of the program, nobody pays for it. Nobody is punished for it—which is weird to say, but appropriate. And nobody even tracks it. Nobody has any sense that those kids did not have the outcome. No one takes responsibility for that outcome. And when I think about how the system is broken, I'm pretty sure that's the fundamental thing. Because any system, to do anything, requires tightly integrated feedback loops.
Brent: I agree that when it comes to government-based programs, you are broadly trying to help a very diverse group of people, which is almost impossible in any context. That's where you know you're entering a system that's not designed for you. So that's where the piece of personal accountability goes: "How am I going to make the most out of this system that has parts of it that are going to help me, parts of it that'll be neutral, and parts of it that might be traumatizing to me?"
Matt: Yeah. And when I'm working with an individual client, that reality is something I'm talking about the whole time. Sometimes it's upsetting to the point of tears. It is like, "What? I have to figure this out?" But when I zoom out to the systems perspective, the fact that that's all on the individual is a result of the system failure. The system should, in fact, hold some of the knowledge and information. That's been a problem for the last hundred years as we become hyper-individualist. All the parts of society that would teach you—like your grandma saying "don't eat so much sugar" in the low-fat era, you know, you needed that grandma. So we're missing the cultural knowledge and the cultural support, we put it all on one individual, and then it's like, "Well, I have this psychological problem, I can't do that, so am I just fucked?"
And at the core of that is that we don't track those outcomes, and nobody takes personal responsibility for those outcomes improving.
Brent: So you think the key part to improving the system is having more feedback loops in it to be able to make ongoing change, so it's a system that evolves with time as opposed to gets kind of left behind with time?
Matt: Said it so well I have goosebumps. Literally. Yes, that is exactly it. Is that choices are made at huge levels between basically the oligarchs of the teachers and the government. And they mandate things down to districts, and it's trickle-down thinking—or they'll have district programs but they'll trickle down in the district—and the base things of personal responsibility are not built into the system.
So just a couple of examples—I think I've talked about it before—but if a principal wants to observe a teacher, they have to give the teacher a day's notice. That's insane if you care about performance. Because the boss has to have their ears on everything happening all the time. And they have to make subtle adjustments all the time. They have to ask people to do things they find uncomfortable all the fucking time. And there's no mechanism for that at all.
Feedback is formal, it goes through multiple processes. And so when a student is doing badly, you'll sometimes have a meeting with like four people from the school. But none of them have an actual lever to change anything for that kid besides removing them from bad classes. They can do that. But in terms of someone one-on-one getting in there—which is the second piece of the system that's missing, I think—which is that you need people to work one-on-one with you over a long period of time as you grow. And like, maybe the system can't do that. I don't know. If that could be unrealistic. But I think the idea that it's going to work without that, I don't think that's going to happen.
Brent: Where do you see that breaks down? Do you think that's at the top-level people making decisions? Or do you think that's the strength of the Teachers Union that's protecting them from what they have to do and what they don't have to do? It protects them from having a principal come in and watch them kind of thing. So, that stops a feedback loop.
Matt: I think the interesting question is: why did the Teachers Union have to go that route? To protect them? It's because people who were becoming principals had low integrity and would play favorites and would themselves not be accountable for their performance. So, I think that the big organizations make big choices. And in a core way, they take away consent and autonomy from the people on the front lines. If I want to help a kid who is struggling, but I have extremely limited maneuvers, then some rule from on high says I have to send this email to this person... or it says if I offend this person they can complain through this channel and this is going to happen to me, so I'm not going to say anything that could be remotely offensive.
So yeah, I think that this is a thing that comes from on high. But if you think about companies, companies have this problem all the time. And they know that they can't be setting all policies up in the executive suite or with the union. They know that to be effective you have to let frontline workers make choices within a structure.
Brent: So it comes back to the difference of the maneuverability of a small business versus a huge corporation. If you allowed the individual schools and principals to make their own policies and functions around what their community and neighborhood functions like... as opposed to having a provincial or state-level or federal-level mandates. The trickle-down effect from really up high end up might be well-intentioned, but end up off course by the time they actually get to an individual kid.
Matt: Yes. I mean, large companies do have that problem. But when they're set up entrepreneurially and modularly, then what happens is the principal—who is running one portion of the business—can go to the Ministry, who would be like the CEO, and say, "Yo, I got these ten kids. I need another two hundred thousand dollars to hire one-on-one aides." And that money should come from the central authority whose main job is to finance the productive activity of the people on the front lines. That just doesn't exist. Instead, it's more like, "We've earmarked these dollars and you decide what to do with this very limited supply of dollars."
A related issue—and I'm curious if this happens in healthcare—is that they just will not put extra money into extremely complicated situations. But the Pareto principle—do you know the Pareto principle? That 20% of your students will cause 80% of the problems? And then the other version is that of that 20%, 1% cause 80% of those problems. So really you have a few amount of users costing so much trouble. And I've been in meetings with six to eight professionals making more than a hundred dollars an hour, talking about how they can't get a thousand dollars together for this student. We paid more than a thousand dollars to have you say that you couldn't give them a thousand dollars.
Brent: I'm guessing at a broad government level there's more and more kids that have some level of IEP or special levels of anxiety or autism or whatever. So, yes, the best way to help each of those kids succeed is give them a one-on-one model, but that's not really going to be realistic to be able to fund or do on a broad government level, most likely.
Matt: That's probably further than we could go, yeah. But I mean they have no affordance. Like they can't just go one-on-one. They can't even say, "You know what, you need to be in a different PE class with the other slow kids." They're not allowed any mechanisms of creativity. Well, that's not fair. But pretty much.
Brent: Yeah. There's layers to the issues and the problems. And that's where I kind of come back to... okay, well, we're not going to make any kind of perfect-level system that's going to address this. But if we could start again?
Matt: Well that one I have a lot of trouble with. Because we won't be able to start again, probably. And I'm really curious what you think about this in the health sector. What I think should happen is that we should jostle the fuck out of this system. We should break it in subtle ways. And it's concerning to even say this because there's real people who will be affected by the mistakes. But I do have a bunch of changes that I think should happen that would upend some of the power dynamics.
And I don't know how they get worked out legally. But the very first one I think is that teachers should have a budget of ten to thirty thousand dollars per year that's entirely discretionary for them to spend on things for their classroom. Right now they have something like no budget. And that very act of putting dollars in the hands of teachers allows them to make discretionary choices that improve the lives of their students. So that's the kind of intervention I think is appropriate.
The one I think that should be there in health... is I think you should be able to show up to a center anytime and say "I don't feel good." And they just deal with you right there. They're going to let you stay until you feel like you need to go—like not overnight maybe, that's not my thinking. And to be clear, I'm not thinking that they're going to have a magic solution. I'm thinking that they're going to provide the scaffolding for the person to figure out what they need to do. "I need to sleep better. I need to take responsibility for this. I need to take responsibility for that." Sometimes I think that you just have to have a place to go.
Brent: Yes, I think that would work well in having a community health center that is not a hospital. If people don't see it as a place to go as a medical emergency. People are having not enough access to family doctors, but even when they do go to a family doctor, they're going to family doctor expecting what a multidisciplinary team could provide—which they don't have the skill set for. And so if they can't get into a family doctor, their other main option that's available is the emergency room. And as soon as they walk into the emergency room, it's immediately costing the system thousands of dollars. They might just have a headache. Or they have a chronic issue that is never going to be helped in an emergent way. But will ruin their life if it's not helped.
Matt: You have to have a place to go.
Brent: Yeah. If you say "I don't feel well" and you can go into a place that does have a few different streams that might be a nurse practitioner, a physiotherapist, and a counselor, and maybe like a dietician or something... that's more your starting point than starting with a medical practitioner who is very well-trained to make sure you don't die. But not necessarily trained to give you mental health advice, life advice, parenting advice...
Matt: Even physical health advice that's not emergent. You know, in the same way that some learning is not about an "aha" moment, it's about grinding at something for a few years until your brain changes. Same with the body. Sometimes you need the support to keep working on something physical long enough to actually see the change and not have that immediate gratification loop only.
Brent: Yesterday, I had a guy come in who was like about 70, and with persistent dizziness all the time. It started at the same time where he was having some issues with his heart. And he went into the hospital and did tests about his heart, got medications about his heart. It kind of calmed it all down. All of his medical tests are clear, he's on the things he needs to be on. He's been dizzy all the time since then. Went, got referred to go do vestibular physio—which is all sort of stuff with your inner ear, which is one of the sources that can give you dizziness. Did ten weeks of vestibular stuff... these exercises... tried to outwork it, doing all sorts of things. And you could see pretty quickly that he's a very anxious person. And what's more anxiety-provoking than having something go wrong with your heart and have to go to the hospital?
And then that's going to trigger off warning bells on a doctor that's trained to like—"there's different things that could make this person die, let's look into those." You're going to facilitate you going down a very anxious path. And they can check off boxes and they establish: "No, you're not going to die." But then that makes you more anxious: "Well then what's wrong with me?"
And trying to head him and his wife kind of there... and sort of walked him through what stress and anxiety can do to you. And acknowledging that that experience is intensely stressful. And that you're not needing to get particles in different places into your ears. You need to focus on what you can do, you need to breathe, have a glass of wine, calm down, realize you're okay. And then see what you're at. It's a bit of a process.
Matt: It reminds me of something my doctor said, which was some of the best advice I ever got. He was a functional GP who was a trained GP you had to hire. And I was much iller at the time, and I was like, "Doc, I'm just so worried, I'm so anxious I'm going to die of a heart attack, like I'm going to die." And he said, "Matt let me tell you this story." And then he told me this story—I don't even know who it was, like some golf pro—has a heart attack. And he's lying there having a heart attack, and a doctor comes over to him and says, "You gotta relax. You're having a heart attack. If you get stressed, you're going to die."
And what I took from that was that the relaxing part isn't negating that you might have a health problem. It's not saying "it's all in your head," which is I think what people are afraid is being said. It's like the anxiety is causing a layer of distress that means you can't care for yourself. And there may be physical care that's required, but how would you know what it is? Because you're being driven by this force of fear that has your whole system in overload. So there's an interesting dance too between the anxiety piece and what we would think of as traditional doctoring—or in my case education. What's the point in teaching you this math thing when you're anxious and not going to remember it? If I don't bring your anxiety down, I can't do anything more concrete.
Brent: I think is really important to understand how your experience of anxiety impacts the story that you tell and how you see things, and how people will help you or not help you. And that's where you have to learn about yourself and how you see the world a little bit—which teenagers don't really have the capacity to do, their brain's not really wired to do that yet. You figure that out later in life.
Matt: They can do it through mentorship. Like, they can hold the space with somebody else. What I do is: "You can't realize this about yourself, and I can't tell you, but we can hold the space where you see it because I can do that for you."
Brent: Particularly it comes back to the healthcare context: If you are a very anxious person and you're starting from "I think I'm going to die," then that's going to trigger off warning bells on a doctor that's trained to make sure you don't die.
Matt: It's a missed opportunity because, like 15 years ago, I definitely had that kind of anxiety. And I could see the doctors be like, "I need to reassure him he's not going to die." But I actually had health problems that were not going to kill me, that I needed addressed urgently. But their energy was so around my stress about it that I didn't actually get the doctoring I needed. I just got the reassurance part. And that was a big problem.
Brent: When you're working in a system that has a lot of people coming at it and you have to triage or manage them, getting past that layer to try to get at the meaningful "doctoring," as you call it... kind of thing you need... is tricky. And that's where it can get exhausting. Particularly if people that are working really long shifts... I can come off as non-empathetic. So that's where, particularly if you really are in a more chronic loop of things, you have to try to figure out how you are trying to convey your story might be impacting how people are trying to help you. Where the kids start having challenges in school and the people that start having trouble in less-than-perfect systems... it's hard to help those people even in a one-on-one setting. Especially in ten minutes.
Matt: Because I was really helped by someone who I paid for 30-minute appointments. And that person would take the time to draw me the stress axis, and then show me how it would affect my mitochondria, and link that for me in a way that it landed so that I was like, "Oh, my anxiety is part of the problem." And just for my brain, you can't just tell me that. You have to explain the functional loop for me to go, "Oh, that makes a lot of sense." And that requires someone to take the time.
And coming back to "how do we know a system is broken?" In my opinion, if the person coming into the system has to think carefully about how to present themselves, that's not an ideal sign. Because people come in all fucked up to both systems. And it's part of the job of the professional to go, "This kind of fucked up means you're having this happen. And here's where we start with that. And let me explain to you what's happening." Because in a sense, if you don't have incredible—or even just good—interoception and self-awareness skills, it's just really hard to realize. It's hard to even realize that you're afraid sometimes.
Brent: Yeah. And that comes down to the teacher or the physio or the doctor having the bandwidth and the time to try to be able to compassionately help somebody. Which is what both don't really have.
Matt: That's interesting because we talked about how teachers don't have cash. Doctors don't have time. I mean, they don't have cash either. But their discretionary budget should probably be time. It's like: "We pay you for 100%, but we only book you 70%. And 30% is for follow-up—just like unbilled, un-MSP'd discretionary use of time."
Brent: That's where the province did start... they try to change. We've had our MSP system has been a fee-for-service kind of thing, so the more people you see, the more money that you're making, but you're only billing for certain things and the paperwork part was not part of it. So they shifted it to more of a salary model at a higher level. That seems to have been improved the situation. If you have a complicated financial reward kind of thing, people will figure out how to game the system. Usually at the degradation of the service.
Matt: Yep. That's a system rule. Whatever you measure and reward based on becomes the target, the incentive that everyone works towards.
Brent: It's part of the reason we've lost a lot of family doctors is they've been on a fee-for-service model and they realize there's more and more people looking for medical aesthetics things to do injection stuff into their Botox and their lips and their face and stuff. So a whole bunch of the GPs are realizing: "I could make 200 grand and work my ass off and try to help all these people... or I could make like 500 grand and go poke Botox in people and just line 'em up and inject, inject, inject and get paid by each one of those." It's an easier lifestyle and I make more money. Why are people not going to end up doing that?
Matt: Yeah. This clinic in our neighborhood, which was—before we got a doctor—was our savior clinic. They were run down, but they had good doctors. And then they basically just closed, stopped answering phone calls. And then I see the same company open this gorgeous, huge, capitally intensive aesthetics and plastic surgery kind of place. Same doctors. So that was just a stepping stone really to get enough cash to get the big beautiful practice, and now we're one doctor short—the only available doctor in our neighborhood.
And that's exactly, let's be honest, that's exactly what I'm doing. Like, I'm never going to teach in the system. Hopefully I'm not just doing the equivalent of aesthetics, but I'm certainly working on things that people want to pay for in a financial context that is way more empowering than being a teacher.
Brent: I'm in a privatized healthcare side. We live in a country that has public health, but back in the mid-90s delisted physio from that thing of what's publicly funded. Unless you're making under a very small amount of money, then you get a couple sessions covered. So there's this whole allied healthcare—like counseling, like physio, like nutritionists—that are more "what produces health" that is not covered. And a medical system that is covered.
Around the world, how people access healthcare depends on what the financial model of it is. Our family doctors are free, so we'll go do that first. And people that have the means to afford seeing someone like myself realize, "Oh this is more of a physio problem than a doctor problem." And a number of people have extended health coverage through their work but it may only cover 500 dollars in a year or something, which... yeah, it facilitates it, but some people can do it to one degree or another. But what they're able to afford will dictate the care that they're going to get.
So, I think particularly in different phases of life, physio in particular should be funded for pregnant women and through the phase where they're new moms for the first few years. I think if you funded physiotherapy and counseling through even like a five-year window starting at pregnancy and then get you through till your kid gets to kindergarten—where you support those people in the young families—I think you'll provide decreased mental health issues and give kids a more supported mother that can get them through. And then same on the other end of the spectrum of seniors. When they start getting into the kind of the 70- to 80-year-olds, their bodies are breaking down and start having a whole bunch of trouble. And they've usually retired and don't have extended health coverage, and start having hip and knee replacements and things. And there's the middle zone of people that are usually employed and have some insurance coverage.
The government could just be an extended health company that picks and chooses when they're covering some of the allied health people that will support giving people some paid access to that. Will take pressure off of the family doctors and probably keep people out of hospital emergency rooms.
Matt: 100%. One problem though is that it's not even a problem, it's just a reality, is that it takes years to realize those gains at a societal level. And political incentives are not always set up for that. And that's really frustrating. Because in a lot of cases you just have to be willing to do something that helps us in seven years when you're not Premier anymore. And that may be tough.
I think you're getting at one other interesting systemic issue, which I have found a few times. Which is that the government is not very good at hiring companies, I think. And they do a ton of procurement and purchasing of services through companies. I see it from the Ministry when they're dealing with complicated cases. And even there was a COVID grant my wife applied for, it was from a company, not from the government. And the company was like six months late in doing the grant, didn't meet any of the requirements that they said they were going to do.
So I wish that the government would pay for services to produce outcomes. For example, if the government had to hire me in dramatic cases—assuming I would be willing to do it, which I probably would not—it really puts incentives on them, because I'm really expensive, to figure out how to do that in-system. But the problem is, how do you assure that the "me's" that you hire actually do the thing and produce the outcome, and don't create another layer of bureaucracy between them? And I just think that's an interesting and complicated problem. I don't think it has a simple solution. And I'm totally for trying it. But that's again where the feedback loops have to be. Like if you're being paid to help diabetic people and they're not less diabetic, that has to be fed back into the system.
Brent: Part of the challenge of creating feedback loops is then you also have to create valid outcome measures to monitor and measure things. Which is just another layer of paperwork and somebody to analyze things.
Matt: And it has the problem we just said, that as soon as you pick a target, people optimize to that target. There's even some research in diabetes that when you only optimize to blood sugar levels, you actually might hurt other components of the metabolic system. So even that obvious one can have knock-on effects.
And for me, when I'm working with clients, the main thing I want parents to say is: "Yeah my kid's more relaxed and happy. It feels more confident about what they're doing." That's a pretty tough thing to reliably measure. There would be huge incentive for me to not lie, but push the results to show that it's happening, especially if I'm paid on any basis of that.
Brent: When you take things that are inherently human and try to quantify them into numbers, you lose a lot of the nuance of what's actually important. The ability to base it on qualitative feedback... repetitive case histories of things... the transfer of knowledge from a guru of something to the next generation of something... doesn't happen via tables and spreadsheets and numbers.
And even in trying to study, say, pain science of people... if you're trying to help someone that has a chronic pain thing, the first thing you do is give them a series of outcome measure sheets where they have to tick off boxes and label their pain on a scale of eight out of ten...
Matt: And you just constantly ask them to label their pain. Well, now they're highly attentive to pain.
Brent: Yeah. So, it has its place in things. But actually pulling it off is the hard part. And when you get to such a broad scale of a healthcare system or an education system, people want data behind the reason why you're going to put 50 billion dollars towards something.
Matt: Right. I think qualitative data is a good solution. And something interesting I learned in my master's about qualitative data is the idea of triangulation. Which is picking qualitative data that comes from really different sources, and looking for links between them. And quantitative data as well.
So if some local health thing is good, then the people who use it should say it's good. And the people in that neighborhood should be going to the emergency room less. And the doctor should be reporting that they feel more competent at their job. And as you start to see those three independent measures start to speak the same language, now you have real valid feedback even though you didn't reduce it to a number.
Brent: Yeah, that makes sense. I agree with that in principle, but actually pulling it off is the hard part.
Click here for the Podcast page with links to all 8 episodes