Are You “Top Brain” or “Bottom Brain”? Implications for Healthcare Reform

Recent evidence suggests that they way in which we think and behave may be controlled by how well we use different systems within our brains.  In the past, the concept of “left-brain” versus “right-brain” has been accepted as a way to explain the differences in which people perceive and attack problems.  This theory is actually based on very little real science.  New evidence backed by years of neuropsychiatric research now suggests a completely different paradigm for how individuals process stimuli, respond to events and ultimately make choices and execute plans (aka behavior).  Certainly, no “system” in the brain functions completely in isolation from the others–but how we use them relative to each other significantly impacts how we may function as leaders and as members of a team.  Understanding the neuropsychiatric basis of thought and behavior can help us identify those destined to lead, those with creative minds for designing concepts, those that can see the “big picture”, those who can interpret and respond to emotion effectively and those who are adept at execution of tasks.  As we examine the current state of healthcare reform, it is evident that a more effective team must be assembled in order to achieve success.  Currently, the efforts in Washington are beginning to fall apart–the rollout of the ACA Exchanges has been a debacle.  The politicization  of healthcare has limited our ability to effect real reform.  Effective teams are diverse in composition and complementary in talents–they should not be based on political party affiliation.  As we develop a new healthcare system,the ability to place people in the positions best suited to their strengths is paramount in order to achieve the best possible patient outcomes.

This past week in the Wall Street Journal, authors Kosslyn and Miller, explore the way in which the brain processes information and how this process impacts our behavior and our ability to lead others.  Dr Kosslyn, a neuroscientist at Harvard, describes the new way in which higher brain functions are now thought to occur.  Rather than “right brain” and “left brain” cognition, new research divides brain functions into “top brain” and “bottom brain”.  Anatomically, the “top brain” contains the parietal lobe and the larger part of the frontal lobe.  The parietal lobe is known to manage input from many different sensory modalities and is essential in determining spatial sense and navigation.  The upper part of the frontal lobe is known to be associated with planning, recognizing consequences of actions, and short term memory actions.  In essence the frontal lobe is all about reward, attention and motivation.  In contrast the “bottom brain” consists of the occipital and temporal lobes (with a bit of the lower portion of the frontal lobe included).  The temporal lobe is important in storing visual memories, comparing incoming sensory input with stored information and processing emotion and language.  The occipital lobe is important in processing visual input.  Together, these “bottom brain” functions are utilized to compare new information with old and to apply meaning to our experiences and the world around us.

These two “brain systems” do not function independently–they work in concert and to differing degrees in different people.  The ways in which these two systems interact and function together may very well explain how some are effective leaders, others are creative thinkers and still others are more interpretive and can better understand and deal with emotion.  The authors theorize that the way in which we combine the “top brain” and “bottom brain” functions falls into 4 categories.  I found that these categories are very applicable to business and to medicine–many of the important functions of business committees and medical teams can be represented by each of these four cognition types.  However, it is important to note that although each type is different–none are better or more desirable than others.  That being said, each category of cognition may be more likely to succeed at a particular job or in a particular role on a team.  Successful reform of our current healthcare system will require the assemblage of a competent team of experts that will address the most pressing issues in healthcare today–each member should have different talents in order to bring new ideas to the table.  Ultimately, our job is to provide high quality, effective, compassionate care to our patients every single day–no matter what political party we endorse.  We must create a system that allows doctors to do what we do best–diagnose, care and treat.  I believe that by putting people in positions that play to their strengths and creating groups with complementary talents (by applying this new neuropsychiatric theory) we have a chance of actually achieving successful and sustainable healthcare reform.

According to Dr Kosslyn’s research individuals may be separated into distinct groups based on the ways in which they use the “top” and “bottom” brain systems: (Here are my thoughts as to how each cognition type may impact a team assembled to fix the issues with healthcare reform)

1. Mover:  According to the top/bottom brain theory, a mover typically uses both top and bottom brain in complementary ways.  Based on the situation presented, the Mover is able to combine input from both systems and respond to situations as they evolve by integrating inputs from both systems to varying degrees.  These people are well suited to lead others because much of what they do involves planning and then responding to the consequences of their actions and choices.  They learn from their mistakes and take calculated risks.  In our current healthcare crisis, Movers will be essential in crafting a system that will provide essential healthcare benefits for patients in a way that will not bankrupt the system nor deprive some of care.  Movers will adjust to issues with the website rollout and adjust plans (or delay individual mandates)  as the situation dictates (rather than press on with systems that do not work).  Movers will ensure that care will be based on good outcomes data supported by  randomized controlled trials. (rather than arbitrary government requirements for box checking).   These people excel at weighing the risks and benefits of a particular therapy and organizing others to execute the plan.  Movers in medicine are insightful and self aware–they work hard to improve outcomes and are able to adapt when things do not go as planned.

2. Perceiver:  These individuals tend to utilize the bottom brain in more diverse ways and do not rely as much on the top.  These people are adept at making sense of what they perceive and try to place their understanding of emotions or situations in context.  These people are essential in medicine and provide a broad view of the issues at hand–think “the 10,000 foot view”.  These team members do not usually create or execute plans–rather they provide insight and perspective.  They serve as essential advisors for leaders in healthcare reform.  They can provide candid feedback and help others see mistakes and shortcomings so that they can be corrected.  For example, “maybe we should delay the rollout of the exchanges given the fact that our software is not yet ready to meet the needs of those that will try to register this month”  Often these are the wisest members on the team.  The Perceiver will be essential to the success of any healthcare reform–the Perceiver will focus on success of implementation rather than meeting arbitrary deadlines and building a legacy.

3. Stimulator:  These people typically use the top brain a great deal but utilize bottom brain functions very little if at all.  These people are great at creating and implementing plans but are unable to learn from their mistakes.  They do not incorporate the consequences of their current actions into future plans.  However, these people are highly creative and think about problems in very different ways that others–in healthcare reform these people will come up with the ideas that ultimately may result in success.  The status quo and the “tried and true” will not suffice.  Healthcare reform is a daunting task and will take the efforts of those who think in extraordinary ways.  These people can be effective but MUST be held in check by a strong leader who can help to curb their enthusiasm at times.  However, thinkers of this type often produce innovative ideas that change the course of history.

4. Adaptor:  These people utilize neither the top or bottom brain systems in complex or analytical ways.  These individuals tend to be impulsive and respond to the situation at hand.  As the authors of the Wall Street Journal article state, they “go with the flow”.  They are, however, responsive and action oriented.  These types can be essential members of the team.  They are effective as “worker bees” and can accomplish a long list of tasks.  In healthcare reform we must have  these cognitive types–they are the workhorses that make the plans happen and accomplish the much needed day to day implementation.  (think website design and rollout)

How our brains function has much to do with how we behave in groups and how effective we can be in the care of patients.  In the past, we have separated thinkers into right and left brain–now, we have a better way to think about cognition.  The degree to which individuals utilize the top and bottom brain functions can determine the best role for them on a team.  A team cannot exist with just one type of thinker–all must play a role and all complement one another.  As we continue to struggle with healthcare reform, we must assemble talented teams of individuals in order to be successful.  Although it remains a highly political issue, we must rise above the politics and focus on the patients that we claim to serve.   We must utilize individuals from all four groups of cognitive types in order to improve care and create real reform.    Identifying the best people to serve on a particular team is critical–putting each individual in the best role for success is essential.

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