Learnings from the nature to design and manage cancer care service

An organization is like an organism. It can be organized as small as a single cell organism or as complex as humans. Some organization thrives while others just survive; but rarely that an organization dies, unlike an organism, which once born has an expiry date. But the species like an organization continues to evolve and rarely perish unless there is a major natural catastrophe like the extinction of dinosaurs. One can get clues on building a thriving organization by observing how an organism and species evolve and thrive in the nature. (Warnings: this is going to be a long read as I had to kill time during the long Dubai to San Francisco flight. Join the ride if you have time).

All living organisms are established in a modular layered fashion (cardiovascular, respiratory, neurological, musculoskeletal and urological modules). These modules evolve over millions of years and continue to evolve with changes influenced by competitive pressure from the environment in an attempt to achieve equilibrium, which rarely feasible. Each of the modules and layers are added and refined over time as the organism evolve for better adaption to the environment. Each of the modules are self-sufficient, however inter-dependent. For sustainability, the nature has introduced sufficient redundancy in the system, especially for critical functions, so that loss of some of the components will not affect the critical function of the module.

The modules are organised in layered fashion. As the complexity of the organism increases, layering is incorporated to the control of the modules. Although each of the modules have self-correcting feedback regulatory system, to ensure that the organism function well, the coordination of functions of modules are controlled to meet the overall purpose of the organism. What is that overall function of an organism is hotly debated. One may consider this as the survival of the organism or species, or its fundamental script- the DNA. The anatomic and physiologic location of control and command unit of an organism is discussed and debated extensively. From a reductionist view that lies in an anatomic region such as pineal body. However so far, such an anatomic central region could not be clearly identified and validated. A more accepted view is the conscious of the organism, which is a collective manifestation of all the modules rather than a central conscious.

Along with the evolution of each of the modules, the organism and the species evolve with time to better adapt to the changing environment, the fittest will survive in the competition for limited resources. These evolution takes place by two processes- conventional process and robust process. The conventional evolution take place to make the organism to adapt to the general variation in the environmental conditions. The classic example is the change in the beak size of the beagle in the Galapagos islands to suit to the change in the availability of the food. This change in morphology of the beaks, though good to have, is not essential for the survival of the species. The robust evolution takes place to acquire features essential for the survival of the species. An example is the evolution of the brain stem. Brain stem functions are essential to sustain an organism, such as the heart function or temperature regulation. Brain stem has evolved to such a way that it can respond to extreme variability in the environment, which is normally not encountered in the regular living of an organism, but however some of its members, in some generations may have encountered such extreme changes in the environment. Acquiring the skills to adapt to such extreme variation is important not just for the organism, but for the species. An example is the extreme variation in temperature a species at different regions of the earth needs to face- such as desert to arctic conditions.?

Let me give an example of the modular, layered architectural design of organism as described by Michael Gazzaniga in his elegant book "The consciousness instinct". At its elemental level, the simple joint movement is regulated at the spinal cord level as a reflex- e.g. knee jerk reflex. These reflexes are essential to protect human against harm as in stepping on a hot object. This simple limb movements can be evolved to a very complex coordinated movement through practice and innate qualities acquired through evolution. Observe a golfer hitting a ball. It requires coordination between movements at multiple joints of arms, back and legs. To put the ball into a particular location the player needs to coordinate with other modules such as the eyesight to measure the distance. In addition to the proprioceptive inputs to estimate the force required to hit the ball in what trajectory, over time, the player acquires skill and can become good at it, provided there are no other constraints and can become a regular golfer. This coordination between modules happens at the cerebral level. This evolution to acquire the skills are by conventional process. It can be improved by practice. A professional master golfer not only needs to judge the distance and trajectory of the stroke, should overcome and master other constraints like wind, humidity, and also internal conflicts like other distracting thoughts. This level of mastery needs arduous practice in addition to innate skills.

In biological system, question often ask on what really controls the organism. Is there a top-down hierarchy or a distributed hierarchy. For simple module level activity, the control is local, but for inter-modular activities, the control is in a distributed fashion- never top down; Or perhaps a higher conscious, collectively formed by all or critical modules.

Application of nature’s principle in Engineering: Can we learn from nature and apply the design principles in human creations.

Gazzannia further explains the application of the modular layered design principle by describing construction of an airplane. The Boeing A380, which I'm now travelling is constructed in various modules- the jet engine, wings, interior etc. At a high level, the design engineer needs to know basic information, such as the weight of the plane, interior capacity, the distance to travel etc. however the finer details such as the dimension of the seat and leg room need not be known for the overall design engineer. The latter can be evolved over time with user experience and market competition. For example, retrofitting premier economy class to the already built plane. This is analogous to "conventional evolution".

On the other hand the master designer needs to build the plane for extreme weather conditions- not normally encountered in routine flights. Such as severe air turbulence. This cannot be gained by evolution through the conventional process, where regular constraints such as altitude, tail wind, and temperature are encountered. Adoption to extreme variables needs "robust evolution" from history of airline flights. Incorporation of the design to withstand extreme conditions must be inbuilt in the design, even though such conditions may not be encountered in the lifetime of an airplane.

Application of nature’s evolution in managing cancer services: Can we apply the time-tested nature’s modular and layered design, which has survived the test of millennia to create robust cancer services. Cancer service needs to be flexible and needs to constantly adapt to various changes- such as attitude and expectations of the care givers and care providers and disruptive innovations, at the same time there is little margin of errors.

Over the past three decades I have had the unique opportunity to observe the birth and growth of several cancer centers of different complexity and structure. The world's first cancer center- Roswell Park Cancer Institute- when it transitions from its large century old building to a new, lean and smarter cancer center of today. The Bellevue Hospital, New York, has been planning for a cancer center when I joined as a faculty three decades ago, which still appears to be in planning phase. Academic cancer center of Amrita Institute of Medical Science, which is under the shadow of a large multi-specialty medical center and the medical college, however, continues to train outstanding oncologists. The corporate cancer center of Narayana Health city, which like Amrita Cancer Center struggling to find its rightful place in the large health city complex. I served Cochin Cancer Research Center, a public cancer center as its founding director, which appears to have got stuck in the birth canal like a baby in breach position. My current organization- Karkinos Healthcare which is trying to develop a unique distributed Cancer Care Network recently got a rare lease of second life.

During the struggle to rebuild our current organization, the question I ponder was whether one can take the learnings from the modular layered architecture of the nature to create a thriving cancer service. We are building an organization of a kind which never existed in the past. As my colleagues’ comment "We are like building an aircraft while still flying". One day I hope to narrate our learnings when we reach a steady state in building our organization. As in any living organism, the evolution process continues in search of equilibrium in a constantly evolving ecosystem- the process of evolution that never stops.

Let me attempt to apply the learnings from the nature's modular layered design architecture to establish a cancer care service. Although many appears to be obvious, but to fall back to nature when things are not going well.

1. As a first principle, recognise that cancer centers are built to deliver multi-disciplinary cancer care. The building and the team should be developed to facilitate this central tenant. This can be developed in a modular fashion, each module (such as surgery, radiation, medical oncology, diagnostics and rehabilitation) like the golfer should interact with each other. Refinements to reach the professional level can be achieved over time with perseverance and practice. But the fundamental design for inter-modular communications is to be made mandatory from the beginning.
2. While each of the modules within the multi-modular architecture must have the freedom to refine, improve and evolve over time, it must be in sync with other modules and overall goal of the organization. Additional modules may be added in the layered design principle.
3. Like the master designer of airplane, though it need not pay attention to finer details of each of the modules, it should put in place safety, quality of care and sustainability as the fundamental to the design, akin to the robust process of evolution. These fundamental features should withstand extreme variations and turbulence of the system, let it be an individual patient care or at the organization level. In healthcare there is zero margin of error.
4. Although the clinical team are often reluctant managers, they must be forced to be made the decision makers supported by administrators. In the corporatization of healthcare MBAs are made decision makers and given the responsibilities to own the profit-and-loss. This is a fundamental flaw in design- a dangerous and shortsighted move with disastrous consequence. We have seen the collapse of one the most efficient health system of the world- NHS through overengineering. I personally witnessed during my over a decade tenure in the system. In one of the cancer hospitals I worked, I had to struggle hard to convince the administrators to start a pain and palliation service. While our surgical oncology service, which earned the maximum revenue, we could get most of our equipment including surgical robots, the histopathology service which is the core in making accurate diagnosis could not get a basic automated Immuno Histochemistry Machine. Again, a fundamental flaw in the design, failing to observe that the overall function and survival of an organization require interdependency of the modules. Two of the most profitable and thriving healthcare organizations which has lasted the test of time are led by clinical administrators- CMC Vellore and the Mayo Clinic. While in CMC Vellore, senior medical staff in rotation along with the support of finance and administrative staff manages the organization at the Mayo Clinic, dual administrative structure with clinician and a professional administrators exist with the technical clinical person with final say in decision making. ?
5. Can we learn from the nature about the overall command and coordination structure of a cancer center.? In almost all cancer centers around the globe, a director is appointed as CEO of the center. This top-down approach makes the decision making nimbler and more accountable. However as observed in the history of several major institutions, it can have disastrous consequences if the power gets concentrated at the top. In nature although a central command and control system exists, it is not concentrated in one region. Regions such as pineal body is speculated, so far this could not be confirmed anatomically or functionally. The central coordination is carried out by collective manifestation of conscious of individual modules to meet the overall purpose of the organism. This self-correcting feedback regulatory system will ensure least errors in the decision making and the decisions are made to meet the overall purpose of the organism. In the cancer center too, each of the multi-disciplinary group should be managed independently, however the overall management should be a collective decision of these individual modules executed through central cooperative. This will ensure self-corrective feedback regulatory system. It should be led by a technical experts supported by administrative and financial team. ?
6. When it comes to individual patient care, treatment decision making and planning is most crucial than execution of the treatment. A robust process of interconnected modular, self-correcting decision support system of multi-disciplinary tumor board with a pain and palliative care physician to be established to manage every patient- simple to complex.

I just arrived in San Francisco.? On the drive from the airport to my son who works for NVIDA I asked him what motivates him and the members of the organization to remain at the top of the filed since inception- He says it’s the work culture. Compared to its competitor- Intel, it has 1-10 workforce, but far more productive and innovative. Despite most of the employees are financially very well off, they remain very committed to the organization.

7. In healthcare, especially cancer care, creation of a work culture that develop a purposeful organization is essential to the success. Each employee should strive for compassionate, uncompromising care with a startup mindset recognizing that resources (knowledge, infrastructure, personnel) are always limited and continues to innovate to be on the cutting-edge and have a never-give up attitude. It will create an organization that evolves and sails through day-to-day challenges as well as major turbulence in the system.

The organization is like an organism, it can learn and adapt to the surroundings and evolve to form a thriving enterprise.

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