The Sorry State of American Hospitals: How Many Will Survive?

It appears that the anticipation and, finally, the arrival of Obamacare have caused dramatic changes in how healthcare will be delivered. Hospitals, currently consumers of about a third of all healthcare spending, may be the medical industry sector most affected. Some recent predictions for the future of hospitals have been quite dire. Let’s begin with some background.

An article in The Economist provides some basic data on hospital costs by comparing average costs per day in hospitals in a variety of countries.

The explanation for why US costs are three to ten times higher than those in other developed countries is quite simple.

"America has more than 5,700 hospitals….Most of these share a familiar business model: sell as many services as possible at the highest price."

The outrageous charges have already caused patients and other providers to try to limit hospital stays. This has eliminated any significant growth in hospital admissions in recent years. Many people thought that Obamacare would be good for hospitals as it provided healthcare insurance to millions more people, but that may not be the case.

"Obamacare itself is not all good news for hospitals. It will bring revenue from newly insured patients. But it will also cut the rates the government pays for Medicare, the health scheme for the old. By 2019 these will cancel each other out, reckon analysts at Bank of America Merrill Lynch. And the Medicare cuts already announced may not be the last."

The goal of Obamacare is to fundamentally reform the process by which healthcare is delivered. It is not doing this by fiat, but rather by offering financial incentives for providers to produce less expensive and more effective care. These incentives are built into Medicare, a program big enough to generate paradigm shifts throughout the medical industry.

"Obamacare also includes incentives for hospitals to provide quality, rather than quantity, of care for publicly insured patients. Medicare will penalise hospitals that discharge patients only for them to return within 30 days. Groups of doctors and hospitals can apply to be designated as accountable-care organisations, or ACOs, which will be rewarded for keeping the cost of Medicare patients’ treatments below a certain level."

The Obama administration has also shed light on the prices hospitals charge for services by publicizing their price lists. Elisabeth Rosenthal provided an excellent article on hospital costs in the New York Times for those interested in the details.

One of the reasons why hospital pricing is unconnected with reality is because hospital costs are determined by relatively inflexible expenses. A given hospital has to be able to cover whatever costs are residual from obtaining the land, building the structure, and filling it with the required equipment. The facility must be staffed with doctors, nurses, technicians, and various workers. The hospital does have some leeway in staffing levels, but if you build a 100 bed hospital, you better have access to enough people to care for the case where all 100 beds are occupied.

So if you spend a night in the hospital, blow your nose while in your room, and discover you have been billed $25 for tissue, that should not surprise you. Hospital costs have very little to do with services rendered. Yearly costs must be covered whether there are patients or not. Since patients are the major source of revenue, they must be charged whatever it takes to meet the expenses of the facility.

Hospitals have had little incentive to skimp on expensive features because they have always been able to raise their prices as needed. This has allowed numerous inefficiencies; perhaps the greatest is that hospitals have outgrown the demand. There are more hospital beds out there than are needed, and someone has to be charged for those excess rooms whether they are filled or not. This article discussed the issue and presented this chart of average hospital occupancy for a number of countries.

Note that the figure for the US is at about 65%, while other countries provide effective healthcare at occupancy rates of close to 90%. If we have hospitals with an occupancy rate of 65 percent when 90 percent is an attainable goal, then we have about 25 percent more hospital beds—or hospitals if you wish—than we need. We, as patients, are being overcharged to support that excess capacity.

If significant price pressure is placed on hospitals, it is hard to see how they can cut expenses without also cutting excess facilities.

While it is true that our hospitals are capable of providing the best medical care available, often they don’t. Very, very often they don’t. This article discusses recent estimates of how many patients are killed or hurt by avoidable medical errors in hospitals. The number of people who die because of faulty care in hospitals was estimated at an astonishing 440,000 per year. And ten times more are harmed by improper care. This makes the mere act of being admitted to a hospital the third largest cause of death in this country!

Another way to view these numbers is to consider that the death rate is 1205 per day. That is about equivalent to having four large commercial aircraft crash every day. Can you imagine what would happen if four aircraft crashed in a single day? The entire industry would be shut down indefinitely. Yet business goes on as usual in our hospitals.

All of this shoddy care is certainly tragic for those affected, but it also comes with an economic cost. Physicians and insurance companies have become more cost-conscious, and are coming to recognize that hospitals are part of the problem rather than part of a solution. It is becoming clear to many that hospitals are for use only when there is no alternative.

An article by John Tozzi in Bloomberg Businessweek discusses some of the trends that have emerged as healthcare providers experiment with accountable care organizations (ACOs).

"Three years into the voluntary program, 367 groups of health-care providers nationwide have formed ACOs. They’re responsible for 5.3 million Medicare patients, or about one in eight people on the federal insurance program for Americans 65 and older. Some 115,000 doctors in the U.S. are involved in a Medicare ACO in some way, according to data from Leavitt Partners, a consulting firm."

Results of this switch to ACOs are beginning to emerge.

"The first class of 137 ACOs, formed in 2012, has saved $380 million over the first year, Medicare announced on Jan. 30."

"ACOs have achieved those savings in part by doing something the law didn’t anticipate: excluding hospitals from their groups….more than half of ACOs are led by doctors’ practices and leave out hospitals entirely."

And why might that be?

"Those who run ACOs say that avoiding expensive hospital stays is the key to keeping costs down, especially for nonurgent care that can be performed for less in clinics or during home visits. ‘Hospitals, they want to do your robotic surgeries, your heart catheterizations, your PET scans, your MRIs—all the expensive items,’ says William Biggs, chief executive officer and medical director of the Amarillo Legacy Medical ACO in Texas. ‘We actually felt that hospitals were part of the problem’."

The goal of basing remuneration on quality of services rather on number of services appears to have had an effect. A person who needed chronic care in the past was a cash cow for the medical community. Now it is recognized that it is more economical to spend more time and effort to bring that patient to a state where less medical attention was needed. What does this imply for the future of hospitals?

"’If we make people a whole lot healthier, they’re not going to go to the hospital,’ he says. ‘You’re going to need 20 percent or 25 percent less hospital beds, which means 20 percent are going to close.’….’If we’re successful,’ [Stephen] Klasko says, ‘the hospitals are going to get killed’."

Jonathan Rauch provides insight into how Medicare patients have been treated by healthcare providers and how greater savings can be attained. He has produced an article in The Atlantic: The Hospital is No Place for the Elderly.

Rauch points out that longer life spans have changed the healthcare needs of our aging population. As people live longer they acquire not only significant medical problems, but multiple significant problems.

"Thanks to modern treatment, people commonly live into their 70s and 80s and even 90s, many of them with multiple chronic ailments. A single person might be diagnosed with, say, heart failure, arthritis, edema, obesity, diabetes, hearing or vision loss, dementia, and more. These people aren’t on death’s doorstep, but neither will they recover. Physically (and sometimes cognitively), they are frail."

"Seniors with five or more chronic conditions account for less than a fourth of Medicare’s beneficiaries but more than two-thirds of its spending—and they are the fastest-growing segment of the Medicare population."

These people are not going to recover from their medical ailments and they need frequent medical attention, but not the kind of intense but cursory assistance they receive in emergency rooms.

"Right now, when something goes wrong, the standard response is to call 911 or go to the emergency room. That leads to a revolving door of hospitalizations, each of them alarmingly expensive. More than a quarter of Medicare’s budget is spent on people in their last year of life, and much of that spending is attributable to hospitalization."

Hospitals are dangerous for all people, but particularly for the elderly.

"Hospitals are fine for people who need acute treatments like heart surgery. But they are very often a terrible place for the frail elderly. ‘Hospitals are hugely dangerous and inappropriately used,’ says George Taler, a professor of geriatric medicine at Georgetown University and the director of long-term care at MedStar Washington Hospital Center. ‘They are a great place to be if you have no choice but to risk your life to get better’."

Rauch examines other models for the care of the frail elderly. One example he describes is an organization called Hospice of the Valley that operates in Phoenix, Arizona.

"In the early 2000s, Hospice of the Valley began experimenting with an in-home program designed to bridge the frailty gap—that is, the gap between hospital and hospice. That experiment led to the development of a team-based approach in which nurses, nurse-practitioners, social workers, and sometimes physicians visit clients’ homes, provide and coordinate care, and observe people outside the context of the medical system. ‘That face time is what makes the program work,’ David Butler, Hospice of the Valley’s executive medical director, told me. Butler says that for the 900 people it serves, the program decreases hospitalizations by more than 40 percent, and ER visits by 25 to 30 percent."

This effort was run mostly on funds from charitable contributions and research grants. That is no longer the case.

"Insurance companies and other providers have begun asking Hospice of the Valley to contract with them to pick up their caseloads of high-cost, chronically ill patients. At the beginning of this year, the program was earning enough in reimbursements to cover one out of seven patients; today the rate is more like one in three. That is still not enough, but when a few more big contracts come through, Butler says, perhaps in a year or 18　months, enough of the patient base will be covered to tip the program into the black."

This is a model for care that even hospitals are beginning to turn to. Sutter Health, a large network of hospitals and doctors in Northern California, has been experimenting with a program it refers to as Advanced Illness Management (AIM) that is similar in philosophy and execution to that of Hospice of the Valley.

"….each patient is assigned to a team of nurses, social workers, physical and occupational therapists, and others. The group works under the direction of a primary-care physician, and meets weekly to discuss patient and family problems—anything from a stroke or depression to an unexplained turn for the worse or an unsafe home."

Why is an approach likely to limit hospital admissions of interest to a hospital chain? Rauch provides this comment:

"Jeff Burnich, a vice president at Sutter, told me that the business case for AIM is only getting stronger. ‘Most health providers, if not all of us, lose money on Medicare, so how we make up for that is, we cost-shift to the commercial payers,’ he said. But the space for cost-shifting is shrinking. ‘The way you bend the cost curve now is by focusing on where there’s waste and inefficiency, and that’s the end of life in the Medicare population.’ He expects to see a wave of hospitals fail in coming years if they don’t provide better value. ‘The music has stopped,’ he said, ‘and there are five people standing, and one chair’."

The Sutter strategy seems to be Darwinian: if only the fittest hospitals are going to survive, then we better aim to be among the fittest.

For three straight years the Congressional Budget Office (CBO) has had to decrease its projected Medicare and Medicaid costs. The net savings to the government from these changed projections adds up to $135 billion for the year 2020 alone. Change is here and more is coming; Obamacare is part of the solution, not part of the problem; and it is going to be a scary ride for some people in the medical community.

Introversion, Extroversion and Education: The Montessori Mafia? Kahn Academy?

Susan Cain examines the plight of the introverted children who must develop intellectually in an environment that is increasingly biased towards extroversion as the optimal personality in her book Quiet: The Power of Introverts in a World That Can't Stop Talking. She claims that between a third and a half of all people are introverted by genetic temperament. She provides this brief description of the difference in approaches of the two personality types in social situations:


"[Introverts] listen more than they talk, think before they speak, and often feel as if they express themselves better in writing than in conversation. They tend to dislike conflict. Many have a horror of small talk, but enjoy deep discussions."

"[Extroverts] tend to be assertive, dominant, and in great need of company. Extroverts think out loud and on their feet; they prefer talking to listening, rarely find themselves at a loss for words, and occasionally blurt out things they never meant to say. They’re comfortable with conflict, but not with solitude."

Cain is worried because our preschool and elementary schools are increasingly organized to encourage and even demand a focus on learning through group activities, an arena which introverts tend to find uncomfortable and one in which they are at a disadvantage. She believes this stifles learning and creativity in the class of student that is destined to be the most creative and highest in academic performance.

When researchers study the characteristics of people that would be defined as "creative" by society, they arrive at a prototype.


"One of the most interesting findings….was that the more creative people tended to be socially poised introverts. They were interpersonally skilled but ‘not of an especially sociable or participative temperament.’ They described themselves as independent and individualistic. As teens, many had been shy and solitary."

Cain draws a conclusion from the studies of creative people.


"….there’s a less obvious yet surprisingly powerful explanation for introverts’ creative advantage—an explanation that everyone can learn from: introverts prefer to work independently, and solitude can be a catalyst to innovation."

Cain tells us that standard intelligence tests indicate little difference between extroverts and introverts. However, when it comes to academic achievement and the ability to solve complex problems differences emerge.


"Extroverts get better grades than introverts during elementary school, but introverts outperform extroverts in high school and college. At the university level, introversion predicts academic performance better than cognitive ability….Introverts receive disproportionate numbers of graduate degrees, National Merit Scholarship finalist positions, and Phi Beta Kappa keys. They outperform extroverts on the Watson-Glaser Critical Thinking Appraisal test, an assessment of critical thinking widely used by businesses for hiring and promotion."

If one accepts these findings, then some of our teaching practices seem to be not only ineffective, but absurd. It should then be of interest to us to investigate alternate methods of education that are more introvert-friendly.

The Montessori method of teaching, as applied to early and preschool education, has been suggested as being effective at instilling creativity in individuals. Peter Sims, in a Wall Street Journal article, pointed out the disproportionate numbers of "creative" individuals who seemed to have benefited from a Montessori education. He also seems to have coined the phrase "Montessori Mafia."


"The Montessori Mafia showed up in an extensive, six-year study about the way creative business executives think. Professors Jeffrey Dyer of Brigham Young University and Hal Gregersen of globe-spanning business school INSEAD surveyed over 3,000 executives and interviewed 500 people who had either started innovative companies or invented new products."

"’A number of the innovative entrepreneurs also went to Montessori schools, where they learned to follow their curiosity,’ Mr. Gregersen said. ‘To paraphrase the famous Apple ad campaign, innovators not only learned early on to think different, they act different (and even talk different)’."

The Montessori approach:


"….emphasizes a collaborative environment without grades or tests, multi-aged classrooms, as well as self-directed learning and discovery for long blocks of time, primarily for young children ages 2 1/2 to 7."

This approach would seem to allow introverted children more freedom to explore at their own pace and to pursue their specific interests rather than be imbedded constantly in a team activity.

The term "Montessori mafia" is suggested by the fact that the entrepreneurs responsible for creating some of the most important and innovative institutions of this day benefited from a Montessori education in their formative years:


"….Google’s founders Larry Page and Sergei Brin, Amazon’s Jeff Bezos, videogame pioneer Will Wright, and Wikipedia founder Jimmy Wales…."

A partial list of significant Montessori students can be found here. In addition to the above, Jacqueline Kennedy, Anne Frank, and Julia Child are among the included.

Perhaps one should not be too surprised that children sent to expensive preschools by successful parents would also tend to be successful in later life. Nevertheless, as a group, they seem to attribute much responsibility for what they ultimately became to their Montessori experiences.


"When Barbara Walters, who interviewed Google founders Messrs. Page and Brin in 2004, asked if having parents who were college professors was a major factor behind their success, they instead credited their early Montessori education.　 ‘We both went to Montessori school,’ Mr. Page said, ‘and I think it was part of that training of not following rules and orders, and being self-motivated, questioning what’s going on in the world, doing things a little bit differently’."

Here, we have some indication that freeing children from the straitjacket of team approaches can be beneficial.

While the Montessori approach is mostly applied to very young children, there is a promising attempt to apply modern technologies to allow children of all ages to pursue knowledge more effectively and at a more self-determined pace. Michael Noer describes the approach of Salman Khan, founder of the Khan Academy in an article in Forbes: One Man, One Computer, 10 Million Students: How Khan Academy Is Reinventing Education.

The traditional teaching approach involves a teacher conveying concepts to a group of children who are expected to absorb what is being taught. Much of actual class time must be spent compensating for the fact that children are unique and they learn in different ways and at differing rates. The Khan approach is to invert this process—"flipping the classroom" in other words.


"….the idea is that students watch [recorded] lectures and work through problem sets on their own time, at their own pace. Once they prove mastery of a concept, adaptive software will suggest new ones, much like Amazon recommends new books. Teachers are kept abreast of students’ progress through back-end dashboards. Class time once reserved for lectures would be devoted to mentoring and one-on-one tutoring."

Teachers are provided software that monitors students’ performance and alerts them to the students experiencing difficulties. They can focus their time on these students and their particular problems. This should allow both teachers and children to use their time more efficiently.


"The Khan Academy, which features 3,400 short instructional videos along with interactive quizzes and tools for teachers to chart student progress, is a nonprofit, boasting a mission of ‘a free world-class education for anyone anywhere’."

"….covers a staggering array of topics–from basic arithmetic and algebra to the electoral college and the French Revolution. The videos are quirky affairs where you never see the instructor (usually Salman Khan himself, who personally has created nearly 3,000 of them). Instead, students are confronted with a blank digital blackboard, which, over the course of a ten-minute lesson narrated in Khan’s soothing baritone, is gradually filled up with neon-colored scrawls illustrating key concepts. The intended effect is working through homework at the kitchen table with your favorite uncle looking over your shoulder."

"Over the past two years Khan Academy videos have been viewed more than 200 million times. The site is used by 6 million unique students each month (about 45 million total over the last 12 months), who have collectively solved more than 750 million problems (about 2 million a day), and the material, which is provided at no cost, is (formally or informally) part of the curriculum in 20,000 classrooms around the world. Volunteers have translated Khan’s videos into 24 different languages, including Urdu, Swahili and Chinese."

Both the Montessori and Kahn Academy methods recognize the fact that learning happens when individuals devote concentrated effort to understanding new concepts. Teachers can teach, but it is up to the individual to learn. And it is individuals who must exert the effort, not teams.

Instead of enduring incessant battles between the various constituencies over who is to blame for the sorry state of education, perhaps it is time to recognize the fact that the world has changed and methods that have been essentially stagnant for over a century are in need of a fundamental overhaul.

Introversion, Extroversion, and Human Productivity

Susan Cain provides a fascinating look at the two opposing personality characteristics of introversion and extroversion in her book Quiet: The Power of Introverts in a World That Can't Stop Talking. She explains how the extrovert has become the idealized personality type in our society and what this means for those who are not comfortable in environments designed for such people. She also discusses strategies whereby those who need quiet can cope with a world that is determined to be noisy.

Psychologists claim that between a third and a half of people in the US are introverts. It is difficult to determine a precise number because people fall at all places along the introversion-to-extroversion scale. It is also possible for individuals to morph (at least temporarily) from one personality form into the other as situations demand, so simple, brief observations can also be misleading. Nevertheless, psychologists believe that the tendency towards either of the two personality types is genetically wired because they can measure differences in physiological response to certain stimuli even in infancy. Paradoxically, the infants who respond most strongly to external stimuli are the ones who are most likely to shrink from excessive external stimulation in later life.

Cain provides some dominant characteristics of the two types. In terms of comfort levels for external stimulation:


"….introverts and extroverts differ in the level of outside stimulation that they need to function well. Introverts feel ‘just right’ with less stimulation, as when they sip wine with a close friend, solve a crossword puzzle, or read a book. Extroverts enjoy the extra bang that comes from activities like meeting new people, skiing slippery slopes, and cranking up the stereo."

In terms of how the two might comport themselves in a work environment:


"Introverts often work more slowly and deliberately. They like to focus on one task at a time and can have mighty powers of concentration."

"Extroverts tend to tackle assignments quickly. They make fast (sometimes rash) decisions, and are comfortable multitasking and risk-taking."

And in terms of social styles:


"[Introverts] listen more than they talk, think before they speak, and often feel as if they express themselves better in writing than in conversation. They tend to dislike conflict. Many have a horror of small talk, but enjoy deep discussions."

"[Extroverts] tend to be assertive, dominant, and in great need of company. Extroverts think out loud and on their feet; they prefer talking to listening, rarely find themselves at a loss for words, and occasionally blurt out things they never meant to say. They’re comfortable with conflict, but not with solitude."

What is of interest here are work environments and employee productivity. Given a mixture of these two personality types, are current business practices augmenting or inhibiting productivity?

Cain tells us that standard intelligence tests indicate little difference between extroverts and introverts. However, when it comes to academic achievement and the ability to solve complex problems differences emerge.


"Extroverts get better grades than introverts during elementary school, but introverts outperform extroverts in high school and college. At the university level, introversion predicts academic performance better than cognitive ability….Introverts receive disproportionate numbers of graduate degrees, National Merit Scholarship finalist positions, and Phi Beta Kappa keys. They outperform extroverts on the Watson-Glaser Critical Thinking Appraisal test, an assessment of critical thinking widely used by businesses for hiring and promotion."

Extroverts are better than introverts


"….on many kinds of tasks, particularly those performed under time or social pressure….Extroverts are better than introverts at handling information overload."

However, there are fundamental differences in how the two types approach complex problems.


"Introverts seem to think more carefully than extroverts….Extroverts are more likely to take a quick-and-dirty approach to problem solving, trading accuracy for speed, making increasing numbers of mistakes as they go, and abandoning ship altogether when the problem seems too difficult or frustrating."

Cain sums up the introvert approach with a quote from Albert Einstein.


"’It’s not that I’m so smart,’ said Einstein, who was a consummate introvert. ‘It’s that I stay with problems longer’."

When researchers study the characteristics of people that would be defined as "creative" by society, they arrive at a prototype.


"One of the most interesting findings….was that the more creative people tended to be socially poised introverts. They were interpersonally skilled but ‘not of an especially sociable or participative temperament.’ They described themselves as independent and individualistic. As teens, many had been shy and solitary."

Cain draws a conclusion from the studies of creative people.


"….there’s a less obvious yet surprisingly powerful explanation for introverts’ creative advantage—an explanation that everyone can learn from: introverts prefer to work independently, and solitude can be a catalyst to innovation."

Given this background, one might expect that businesses have learned to provide their employees flexible environments where privacy is available for those who choose to concentrate on difficult problems. Instead businesses seem to be moving in the opposite direction.


"It is the story of a contemporary phenomenon that I call the New Groupthink—a phenomenon that has the potential to stifle productivity at work and to deprive schoolchildren of the skills they’ll need to achieve excellence in an increasingly competitive world."

"The New Groupthink elevates teamwork above all else. It insists that creativity and intellectual achievement come from a gregarious place."

What Cain refers to as the New Groupthink seems to have arisen from a misinterpretation of experiences derived from the internet where collaborative projects have produced spectacular results.


"On the internet, wondrous creations were produced via shared brainpower: Linux….Wikipedia….MoveOn.org…. These collective productions, exponentially greater than the sum of their parts, were so awe-inspiring that we came to revere the hive mind, the wisdom of crowds, the miracle of crowdsourcing. Collaboration became a sacred concept—the key multiplier for success."

What is overlooked in evaluating this internet-based collaboration is that the contributions are coming mostly from independent individuals (probably introverts) working alone in isolated environments. A given individual can evaluate the efforts of others and think long and hard before arriving at his particular contribution and making it public. That is a special form of collaboration that has nothing to do with a physical "crowd."

The New Groupthink believes this internet-based success can be recreated with real crowds (teams), not virtual ones.


"Some of these teams are virtual, working together from remote locations, but others demand a tremendous amount of face-to-face interaction, in the form of team-building exercises and retreats….and physical workspaces that afford little privacy. Today’s employees inhabit open office plans, in which no one has a room of his or her own, the only walls are the ones holding up the building, and senior executives operate from the center of the boundary-less floor along with everyone else. In fact, over 70 percent of today’s employees work in an open plan…."

And how has this been working out? Psychologists have studied productivity in open and private configurations, and others have tabulated data from company performance.


"A mountain of recent data on open-plan offices from many different industries corroborates the results of the [psychologists’] games. Open-plan offices have been found to reduce productivity and impair memory. They’re associated with high staff turnover. They make people sick, hostile, unmotivated, and insecure. Open-plan workers are more likely to suffer from high blood pressure and elevated stress levels and to get the flu; they argue more with their colleagues; they worry about coworkers eavesdropping on their phone calls and spying on their computer screens. They have fewer personal and confidential conversations with colleagues. They are often subject to loud and uncontrollable noise, which raises heart rates; releases cortisol, the body’s flight-or-fight ‘stress’ hormone; and makes people socially distant, quick to anger, aggressive, and slow to help others."

That certainly describes great places to work.

Introversion and extroversion, or at least high- and low-sensitivity individuals, seem to be common in other species besides humans. This suggests that the mixture of types might have been selected because of higher survivability of the species. In other words the species is more secure and more sustainable when it has a variety of responses to outside stimulants. Nature has decided that not everyone should be an introvert or an extrovert. Why can’t our businesses and schools arrive at the same conclusion?

Introversion, Extroversion, and a Theory of Leadership

Susan Cain provides a fascinating look at the two opposing personality characteristics of introversion and extroversion in her book Quiet: The Power of Introverts in a World That Can't Stop Talking.

Psychologists would claim that between a third and a half of people in the US are introverts. It is difficult to determine a precise number because people fall at all places along the introversion-to-extroversion scale. It is also possible for individuals to morph (at least temporarily) from one personality form into the other as situations demand, so simple, brief observations can also be misleading. Nevertheless, psychologists believe that the tendency towards either of the two personality types is genetically wired because they can measure differences in physiological response to certain stimuli even in infancy.

Cain provides some dominant characteristics of the two types. In terms of comfort levels for external stimulation:


"….introverts and extroverts differ in the level of outside stimulation that they need to function well. Introverts feel ‘just right’ with less stimulation, as when they sip wine with a close friend, solve a crossword puzzle, or read a book. Extroverts enjoy the extra bang that comes from activities like meeting new people, skiing slippery slopes, and cranking up the stereo."

In terms of how the two might comport themselves in a work environment:


"Introverts often work more slowly and deliberately. They like to focus on one task at a time and can have mighty powers of concentration."

"Extroverts tend to tackle assignments quickly. They make fast (sometimes rash) decisions, and are comfortable multitasking and risk-taking."

And in terms of social styles:


"[Introverts] listen more than they talk, think before they speak, and often feel as if they express themselves better in writing than in conversation. They tend to dislike conflict. Many have a horror of small talk, but enjoy deep discussions."

"[Extroverts] tend to be assertive, dominant, and in great need of company. Extroverts think out loud and on their feet; they prefer talking to listening, rarely find themselves at a loss for words, and occasionally blurt out things they never meant to say. They’re comfortable with conflict, but not with solitude."

Cain tells us that these two personality types can be found throughout the animal kingdom. One is led to speculate that evolution might have preserved both traits because both contribute to the survival of the specific species. If that is the case, then evolution may have arrived at the current distribution as a rough attempt at optimization.

Cain points out that society had begun, starting early in the twentieth century, to glorify one personality type at the expense of the other.


"America had shifted from what the influential cultural historian Warren Susman called a Culture of Character to a Culture of Personality—and opened up a Pandora’s Box of personal anxieties from which we would never quite recover."

If one goes back and examines photos of relatives that date back a century, one is likely to encounter serious and perhaps even grim expressions on their faces. These people might have viewed the smiles we now conjure up for a photo as, perhaps, evidence of some form of mental deficiency.


"In the Culture of Character, the ideal self was serious, disciplined, and honorable. What counted was not so much the impression one made in public as how one behaved in private. The word personality didn’t exist in English until the eighteenth century, and the idea of ‘having a good personality’ was not widespread until the twentieth."

"But when they embraced the Culture of Personality, Americans began to focus on how others perceived them. They became captivated by people who were bold and entertaining. ‘The social role demanded of all in the new Culture of Personality was that of a performer,’ Susman famously wrote. ‘Every American was to become a performing self’."

The idealization of the extrovert personality made some sense as society and the business environment changed and emphasized success in interpersonal relationships. Cain’s complaint is that the emphasis on one personality type needn’t have downgraded the utility of the other.


"Introversion—along with its cousins sensitivity, seriousness and shyness—is now a second-class personality trait, somewhere between a disappointment and a pathology."

Extreme shyness is now considered a mental illness to be treated with brain-altering drugs. Children who prefer solitude risk being diagnosed as having an inferiority complex. School children are constantly encouraged (forced?) to participate in team learning exercises. A set of values that originated in the world of salesmanship are now dominant in our culture—and are imposed upon our children.


"’This style of teaching reflects the business community,’ one fifth-grade teacher in a Manhattan public school told me, ‘where people’s respect for others is based on their verbal abilities, not their originality or insight. You have to be someone who speaks well and calls attention to yourself. It’s an elitism based on something other than merit’."

In a chapter titled The Myth of Charismatic Leadership, Cain takes the reader to the cathedral for "elitism based on something other than merit:" Harvard Business School (HBS). She also refers to it as the "Spiritual Capital of Extroversion."


"The essence of the HBS education is that leaders have to act confidently and make decisions even in the face of incomplete information. The teaching method plays with an age-old question: If you don’t have all the facts—and often you won’t—should you wait to act until you’ve collected as much data as possible? Or, by hesitating, do you risk losing others’ trust and your own momentum?"

"The HBS teaching method implicitly comes down on the side of certainty. The CEO may not know the best way forward, but she has to act anyway."

The message to HBS students would seem to be that if you want to be a leader, then when in doubt, don’t appear doubtful; act as if you are certain. This is a message that markets well to those who are ambitious and have money to spend.


"If we assume that quiet and loud people have roughly the same number of good (and bad) ideas, then we should worry if the louder and more forceful people always carry the day. This would mean that an awful lot of bad ideas prevail while good ones get squashed. Yet studies in group dynamics suggest that this is exactly what happens. We perceive talkers as smarter than quiet types—even though grade-point averages and SAT and intelligence test scores reveal this perception to be inaccurate."

How might real-world data assess the efficacy of the HBS approach to leadership? Is charismatic leadership actually a myth?


"Contrary to the Harvard Business School model of vocal leadership, the ranks of successful CEOs turn out to be filled with introverts….’Among the most effective leaders I have encountered and worked with in half a century,’ the management guru Peter Drucker has written, ‘some locked themselves into their office and others were ultra-gregarious. Some were quick and impulsive, while others studied the situation and took forever to come to a decision….The one and only personality trait the effective ones I have encountered did have in common was something they did not have: they had little or no "charisma" and little use either for the term or what it signifies’."

Cain alerts us to the results of a study by the management theorist Jim Collins whose goal was to determine the characteristics of companies that outperformed their competitors.


"….when he analyzed what the highest performing companies had in common, the nature of their CEOs jumped out at him. Every single one of them was led by an unassuming man….Those who worked with these leaders tended to describe them with the following words: quiet, humble, modest, reserved, shy, gracious, mild-mannered, self-effacing, understated."

"The lesson, says Collins, is clear. We don’t need giant personalities to transform companies. We need leaders who build not their own egos but the institutions they run."

So it seems that both the attributes of introverts and those of extroverts can be useful in leadership positions. For a more nuanced look at desirable leadership characteristics, Cain suggests the reader consider the work of Adam Grant, a management professor at Wharton.


"….when he looked closely at the existing studies on personality and leadership, he found that the correlation between extroversion and leadership was modest….these studies were often based on people’s perceptions of who made a good leader, as opposed to actual results. And personal opinions are often a simple reflection of cultural bias."

Grant believes a failing in most studies of leadership is that account is not taken of the personnel environments in which leaders find themselves. His theory is that introverted leaders are more effective when surrounded by proactive employees, and extroverted leaders are more effective when surrounded by passive employees.


"Because of their inclination to listen to others and lack of interest in dominating social situations, introverts are more likely to hear and implement suggestions. Having benefited from the talents of their followers, they are then likely to motivate them to be even more proactive. Introverted leaders create a virtuous circle of proactivity, in other words."

"Extroverts, on the other hand, can be so intent on putting their own stamp on events that they risk losing others’ good ideas along the way and allowing [proactive] workers to lapse into passivity….But with their natural ability to inspire, extroverted leaders are better at getting results from more passive workers."

Nature saw fit to preserve both personality types through the ages, why would we think that the world of business requires the dominance of one over the other? And why would we consider that society would be better off if we went against the wisdom of the ages and transformed everyone into loud, high-energy bores?

The Decline of Free Trade? Good or Bad?

Joshua Kurlantzick published an article in Bloomberg Businessweek with a title guaranteed to gather attention: Farewell to the Age of Free Trade. He sees forces at work that will alter the relationship between international trade and economic growth that has held for the last 70 years.

"Since the end of World War II and the birth of the modern global economy, business leaders have come to accept an iron law: International trade always expands faster than economic growth. Between the late 1940s and 2013, that assumption held true. Trade grew roughly twice as fast as the world economy annually, as fresh markets opened up, governments signed free-trade pacts, new industries and consumers emerged, and technological advances made international trade cheaper and faster."

"Now this iron law may be crumbling. Over the past two years, international trade has grown so slowly that it has fallen behind the growth of the world economy, which itself is hardly humming."

Kurlantzick blames the decline in trade on the failure of emerging markets to grow as fast as expected, and on changes in corporate attitudes that have limited the desire to integrate more fully with other entities. He discusses some of the reasons why these failures occurred, suggests that there has been an increase in protectionist measures by many countries in recent years, and complains that there is no country or world leader in a position to carry the banner of free trade and push aggressively for its continued growth. He finishes with this gloomy assessment:

"An era of shrinking trade would be disastrous. The past 200 years show that trade makes the world economy more dynamic. It brings people from different countries together and links economies to each other, fostering interdependence. Leaps in scientific progress usually occur during times of growing trade and migration, because these types of exchanges create intellectual ferment. And although conflict between states can still occur, enmeshing nations in webs of trade does create incentives for countries not to fight wars against their trading partners. Restoring faith in free trade isn’t just an act of economic self-interest. It’s essential to building a more prosperous and peaceful world."

If that seems a bit overwrought, it is because it is. Times change! The only "iron" economic law is that humans will tend to be greedy. And how many would agree that periods of growing trade have been of unalloyed benefit to humanity. There are those who might claim that free trade has led to continuous economic disruption and frequent episodes of growth in inequality of wealth.

Free trade has a simple dynamic that was discussed in On the Future of Capitalism: Trade and Income Inequality. It leads to the concentration of wealth in the hands of those who control capital, and the lowering of income for those who have only labor to offer.

David E. Bonior took the occasion of President Obama’s State of the Union address to remind both the president and us that there is an inconsistency involved with promoting free trade and claiming the desire to combat income inequality. Bonior wrote an article for the New York Times titled Obama’s Free-Trade Conundrum.

"In his State of the Union address….President Obama focused on reversing the growth of economic inequality in the United States and restoring the American dream. At the same time, he also announced his support for fast track authority that would limit Congress’s role in determining the content of trade agreements."

"The president’s call follows on legislation introduced earlier this month to grant him fast-track authority as a way of forcing Congress to speed up its consideration of the Trans-Pacific Partnership, a 12-nation pact with Latin American and Asian nations."

"But Mr. Obama’s desire for fast-track authority on the T.P.P. and other agreements clashes with another priority in his speech: reducing income inequality."

It was just a month ago when we reached the twentieth anniversary of the North American Free Trade Agreement (Nafta). Bonior suggests we consider the outcome of that agreement before we rush into others.

"At Nafta’s core — and proposed for the T.P.P. — are investor rights and privileges that eliminate many of the risks that make firms think twice about moving production to low-wage countries. Today, goods once made here are being produced in Mexico and exported here for sale. Indeed, American manufacturing exports to Mexico and Canada grew at less than half the rate after Nafta than in the years before it."

"As a result, our trade deficit has ballooned. In 1993, before Nafta, the United States had a $2.5 billion trade surplus with Mexico and a $29 billion deficit with Canada. In 2012, the combined Nafta trade deficit was $181 billion, even as the share of that deficit made up of oil imports dropped 22 percent. The average annual growth of our trade deficit has been 45 percent higher with Mexico and Canada than with countries that are not party to a Nafta-style pact. The companies that took the most advantage of Nafta — big manufacturers like G.E., Caterpillar and Chrysler — promised they would create more jobs at their American factories if Nafta passed. Instead, they fired American workers and shifted production to Mexico."

A large number of people lost their jobs and ended up taking much lower paying work—if they found work at all. This flow of workers seeking low wage jobs helped keep wages from rising as competition for these positions increased. Income inequality has long been associated with international trade.

"….in the early 1990s a spate of studies resulted in an academic consensus that trade flows contributed to between 10 and 40 percent of inequality increases. Indeed, since Nafta’s implementation, the share of national income collected by the richest 10 percent has risen by 24 percent, while the top 1 percent’s share has shot up by 58 percent."

Politically conservative economists will argue that the depression of wages is countered—and even balanced—by the drop in prices of imported goods.

"But when the Center for Economic and Policy Research applied the data to the theory, they found that reductions in consumer prices had not been sufficient to offset losses in wage levels. They found that American workers without college degrees had most likely lost more than 12 percent of their wages to Nafta-style trade, even accounting for the benefits of cheaper goods. This means a loss of more than $3,300 per year for a worker earning the median annual wage of $27,500."

As the cost of trinkets has gone down, the price of shelter, education, and healthcare has continued to rise and consume a greater fraction of our income. The Walmartization of our economy provides no help in those areas.

Kurlantzick’s concerns are considerably overdrawn. "Free trade" has always been an economic idealization. In the real world large and wealthy countries rig trade agreements—such as Nafta—to benefit themselves. All countries act in support of their own interests. That is what they are supposed to do.

Let’s take a look at those economic benefits that have accrued from the last 200 years of trade—the ones of which Kurlantzick is so proud.

There is an interesting book on the history and the future of migration: Exceptional People: How Migration Shaped Our World and Will Define Our Future by Ian Goldin, Geoffrey Cameron, and Meera Balarajan. These authors tell us just about anything we might wish to know on the subject of migration. In the process they provided some interesting data on income inequality between countries.

"Today the wage disparities between countries are larger than ever before, and the processes of globalization appear to be exacerbating inter-country inequality....The income gap between the richest country and the poorest country in the world about 250 years ago was about 5 to 1, whereas today it is about 400 to 1."

How are we doing in recent times, particularly in the age of free trade and globalization? Branko Milanovic, a World Bank economist, computed the GDP per capita over time for 144 countries, and applied the standard formulation to determine a Gini coefficient for the world. In this formulation, all countries, no matter the size, are a single data point. His results are presented below.

So globalization and free trade not only lead to income inequality within countries, they apparently lead to income inequality between countries.

If a country chooses to maintain a domestic food supply, even if imported food is cheaper, that can be a smart thing to do. If a country does not choose to cede an entire industry, and its associated technology, to another country, that might be a very smart decision as well. If the efficiency of importing goods rather than producing them domestically is compelling, then an import duty is a good way to cover the costs of the economic disruption that will ensue. Trade will continue, but let’s base it on mutually beneficial considerations and on a case-by-case basis, rather than on ancient dogma propagated by misguided economists.

The Self as Brain: Dreams, Speech, Laughter, and Other Wonders

In her book, Touching a Nerve: The Self as Brain, Patricia S. Churchland puts to rest the notion that humans are, in some miraculous way, conscious in a sense that is not limited by the physical characteristics of their brains. She succeeds in presenting us with a description of the brain as an evolved collection of capabilities that can create the phenomena and impressions that delude us into believing that we are always consciously in charge of our lives and actions. Rather, what occurs is a clever and complex interaction between our conscious and subconscious components that renders us who we are and determines what we do.

Components of our brain are described, for convenience, as being part of the conscious brain or part of the subconscious brain. In fact, the two are inseparable in the sense that they must function together in a coherent fashion or we have severe problems. It is the description of how dependent our conscious selves are on subconscious activities that is perhaps the most intriguing aspect of Churchland’s exposition.

Consider memory, a function that we assume is under our control; it is something we believe we can recover accurately as needed—unless we can’t recover it at all. The conscious brain has no long-term memory. Memory is a mostly unconscious function that is recorded subconsciously. We can express the need to burn some information indelibly into memory, but, in fact, we have little conscious control.

Memory and consciousness both evolved as survival mechanisms, not as a means to memorize poetry. In an evolutionary sense, memory is designed to deliver to our conscious brain the information it needs to survive. In the most general sense, memory is the storehouse where everything we have learned about how to respond to changes in our situation is contained.

If the occasion at hand consists of having just said something stupid and hurtful to a close friend, the friend’s response is first noted subconsciously and the emotions the subconscious deems appropriate are activated along with a physical response (blushing, tears…) and a suggested vocal response. We can override the vocal suggestion, but usually the subconscious is correct because we have consciously and subconsciously created the tendency to recall these responses and associated emotions from memory due to experiences endured over the course of a lifetime. We have consciously participated in the training of our subconscious.

As an evolutionary mechanism designed to promote survival, it is difficult to see how memory would become a mechanism for remembering in perfect detail things that have been experienced. Some scientists continue to profess such a belief and have gotten themselves into great trouble as a result. In fact, memory seems to be highly fungible. It can decay over time; it can be selective in the sense of only storing the aspects of an event that are consistent with previously held convictions (think politics); or it can be altered over time to become more consistent with some other constraint.

If memory is necessary to our survival then our subconscious must have an immediate and specific response to deliver when a dangerous situation arises. There is no time to ponder alternatives. In other words our brain hates uncertainty; it prefers to make everything fit into a consistent picture. If an observation is made that is inconsistent with a preconception, the brain is quite capable of discarding the experience as an outlier (think politics), but if the new information is sufficiently compelling, the brain will alter the preconception, or create a new category to deal with the situation experienced.

What is of interest is the lack of conscious control we have over the memory function. When we want to remember something, all we are really capable of doing is pausing and hoping that the information will suddenly pop up into our consciousness.

The actual long-term storage of memory is a mysterious process. It is believed to occur during sleep.

"Your brain is not doing nothing while you are asleep. One of its jobs during sleep is consolidation of memory—transferring and organizing important information acquired during the day to long-term storage in cortex while culling out the unimportant stuff."

How "unimportance" is determined is unknown.

Sleep itself is also a mystery. It seems to almost as old as life itself, but all of its functions have yet to be determined.

"But the evolutionarily ancient character of sleep implies that it is important for even more deeply biological reasons that we have not yet uncovered. That is, even if memory consolidation operates during human sleep, it is doubtful that memory consolidation is the main function of sleep in fruit flies. However sleep benefits fruit flies, it probably benefits us in much the same way."

If sleep is a mystery, then dreaming is a mystery within a mystery. Churchland does not attempt to explain dreaming, but she does enlighten us about our physical state while dreaming. Dreams can become quite real and could cause us to take action in response to them. This would be rather dangerous in an evolutionary sense. Our species would not have survived long if every time we had a dream we ended up falling out of our tree. Evolution provided us with a mechanism to impose a near state of paralysis on ourselves to protect us from harm during dreams.

"Remember when tried to scream or run in a dream? Alarmingly, barely any sound comes, and your legs are leaden. Why can you not run, literally run, away from that fire-breathing monster? There is a brain answer: because there is a special bundle of neurons in the brainstem that makes sure that you cannot move during dreaming. In the dream state, these brainstem neurons actively block any motor signals that might emerge from the motor cortex, destined for the spinal cord and then the arms and legs. In effect, during dreaming you have a kind of temporary paralysis that actually prevents you from acting out your dreams. This was first discovered in cats by a French neuroscientist, Michel Jouvet, who showed that if the special brainstem network is damaged, then the cat will indeed jump up during dreaming and will run around as though chasing something."

Churchland tells us that speech, the words we utter, is largely a subconscious process.

"Paradoxically, speech is usually considered the paradigm case of conscious behavior—behavior for which we hold people responsible….Nevertheless, the activities that organize your speech output are not conscious activities. Speaking is a highly skilled business, relying on unconscious knowledge of what to say and how."

What we say depends on what we know and knowledge is stored in the subconscious. The string of words it presents us to say depends on the experiences that have been accumulated over the long period of maturation. This notion is rather surprising until you examine your own experiences.

"We are consciously aware of the gist of what we want to say, but the details come out of the subconscious brain."

"You will have noticed that if you stop to consciously prepare precisely what you will say next, you become tongue-tied. Then you do not talk in a normal fashion at all."

Saying scripted words in a way that seems normal and natural is an acquired skill, not a natural one. That is why not all of us are cut out to be actors.

Laughter is also indicated as a subconsciously generated response.

"Different people find different things funny, and in some way that we do not understand neurobiologically, what you find funny is a reflection of you—your age, your past experiences, your personality, as well as various contingencies at hand."

"When John Cleese in a Fawlty Towers sketch becomes so annoyed with his stalled car that he rips a branch from a nearby tree and beats the car, the crowd erupts with laughter. Ask yourself (if you indeed did laugh): Did you consciously decide that this is funny? Almost certainly not. You will be laughing before you can begin to say what makes the scene funny. If you consciously decide to laugh, it is forced and not as enjoyable as spontaneous laughter. What provokes your spontaneous mirth is begun by your unconscious brain, which, incidentally, will be sensitive to whether in the given circumstances it would be rude or improper or dangerous to laugh."

We have all witnessed scenes in which animals perform ritualistic behaviors when encountering other animals of their species. These are useful in finding a mate or in determining or discouraging a threat from another. We might think that we have evolved beyond that stage, but Churchland reminds us that we have a bit of ritual still programmed within ourselves.

"Careful observations by experimental psychologists show that unless the context is ominous, two persons regularly and subtly mimic each other’s social behavior. Yes you do it too."

She provides this example of an encounter with someone we wish to be on good terms with:

"Once you are introduced and begin chatting, you will tend to mimic the smiles, gestures, and speech intonations of the man. Ditto for him with regard to you. He takes an appetizer, then so do you. You use an exclamation such as ‘remarkable!’ and after a few seconds, he echoes ‘yes remarkable.’ This subtle and unconscious mimicry is especially common when two individuals meet for the first time, but is certainly not restricted to those occasions. We all do it all the time and not just at first meetings."

People seem to feel more comfortable when they are being mimicked. Subconsciously we seem to realize that.

Churchland’s book has provided a rewarding and enlightening experience for this inexpert but curious reader.

Other articles posted based on Churchland’s writing are:

Free Will an Illusion? Patricia S. Churchland vs. Sam Harris and The Self as Brain: Efferent Copy, Voices, and Schizophrenia.

For those interested in the subject of human memory I recommend Memory: Fragments of a Modern History by Alison Winter.

The Self as Brain: Efferent Copy, Voices, and Schizophrenia

Patricia S. Churchland has produced a fascinating book discussing some of what is known about the interaction between our brain and what we consider to be our mind: Touching a Nerve: The Self as Brain. Her message, of course, is that the two are one and the same. The brain is all there is:

"….we are what we are because our brains are what they are."

Some may find that notion incredible—or even threatening. Others will wonder in awe at the complexity of that pulpy mass of cells and chemicals that determines who we are, while at the same time allowing us some control over who we can become and what we will do. Churchland describes the issue of free will as rather murky because the definition of the concept is too subject to misinterpretation. Rather, she suggests those who doubt should ask themselves a different question: "Do I have the capability of exercising self-control?" If the impulse to grab that donut comes up from my subconscious, can I say no I won’t, and send my subconscious the message that I prefer to respond differently to the image of a donut in the future? If I can, then I am exercising what most people would consider free will.

Churchland discusses at length many interesting and complex problems. She considers matters like mankind’s seeming propensity for violence, how evolution managed to create what we call "maternal instinct," and how evolution could develop what we might call moral behavior. For those discussions you will have to read the book. Here we will begin with the weighty question of why humans are unable to tickle themselves.

Components of our brain are described, for convenience, as being part of the conscious brain or part of the subconscious brain. In fact, the two are inseparable in the sense that they must function together in a coherent fashion or we have severe problems. The brain has many components. Some are focused on quite specific functions, while others are more integrative in nature. One of the mechanisms the brain uses to maintain coherence is to send out signals telling the components when an action is going to take place. If you are going to reach out and press a doorbell, the components that are responsible for responding to that sense of contact need to know to anticipate it or an incorrect conclusion may be drawn as to what that contact means.

The signal the brain sends out informing itself of an upcoming action is referred to as efference copy. This mechanism not only supports the stability of the interaction between brain and body, but also provides a way to economize on brain resources. We cannot tickle ourselves because our brain sends out the message that we are planning to use our fingers to stimulate ourselves and responds accordingly. If someone else tries to tickle us there is no efferent copy and the brain interprets the event differently. It is of interest to note that these efferent signals must be timed properly in order to be effective. If one creates a mechanism with which to tickle oneself, the mechanism will only be effective if it is delayed a few seconds before operating.

Consider the simple act of turning your head 90 degrees to the right. The efferent copy alerts your brain that the focus will be on what is in view at 90 degrees. As your head turns, your brain eliminates the need to understand what is being sensed as the head is turning and only delivers to our consciousness what is perceived after the turn is complete. Our subconscious is smart enough to let us know if something dangerous or otherwise interesting should happen to come into view during the turn.

This mechanism of efference copy is critical in placing us in the context of our surroundings. The intention to turn our heads tells the brain that our surroundings can be considered stationary. If someone else is doing the turning there is no efference signal and it has difficulty determining whether we are moving or the world is moving—a rather disorienting situation.

Churchland tells us that speech, both verbalized and non-verbalized, is accompanied by efference copy.

"When you say out loud, ‘I need to buy milk,’ then a signal leaves the movement-planning brain and loops back to the sensory brain to indicate the source of the sound. When you merely think, ‘I need to buy milk,’ this is covert speech (inner speech). Again, a movement-planning signal informs the sensory brain about the source of the covert speech—me."

The development of the complex wiring required to attain a functioning brain in a growing embryo is fraught with uncertainty. Brain construction does not always follow the "normal" path. This leads to variations among individuals in addition to genetic variations, and it can lead to malfunctioning of certain capabilities.

One of the current areas of research involves investigating failure of the mechanism for efference copy as a possible cause of schizophrenia.

"So sometimes a person may think ‘I need to buy milk,’ but because there is no efference copy signal or none with the right timing, he may fail to realize that his thought is actually his thought. He may in time come to believe that the FBI has put a radio in his brain and is transmitting voices into his brain. Auditory hallucinations are a not uncommon feature of schizophrenia, and a leading hypothesis to explain them refers to the failure of the mechanism for efference copy…."

"Incidentally, it has been claimed that many schizophrenics can tickle themselves, another small piece of evidence in favor of the theory that attributes auditory hallucinations to imprecise timing of the efference copy signal,"

Thinking of schizophrenia in this manner makes the condition seem much less ominous than the "broken brain" image that became popular in scientific and popular media. One might conjure up ways of dealing with this malady if efference copy malfunction was in fact the source of the problem.

T. M. Luhrmann provided an interesting article in The American Scholar titled Living With Voices. She does not refer to the efference copy mechanism. Her topic is new knowledge about people who are learning how to deal with auditory hallucinations. Her observations are not inconsistent with Churchland’s suggestions.

The standard view was that voices were the symptom of disease and if people were sufficiently drugged that the voices disappeared, then the disease had been treated and the people had been helped.

"Modern American psychiatry treats auditory hallucinations as the leading symptom of serious psychotic disorder, of which the most severe form is schizophrenia….These days, schizophrenia is often imagined as the quintessential brain disease, an expression of underlying organic vulnerability perhaps exacerbated by environmental stress, but as real and as obdurate as kidney failure. The new post-psychoanalytic psychiatric science that emerged in this country in the 1980s argued that mental illnesses were physical illnesses. Many Americans and most psychiatrists took away from this science a sense that serious mental illnesses were brain dysfunctions and that the best hope for their treatment lay in the aggressive new drugs that patients often hated but that sometimes held symptoms at bay."

Luhrmann describes the efforts of the Dutch psychiatrist Marius Romme and his wife Sandra Escher to look deeper into the meaning of these "voices."

"More than 20 years ago he was working with a patient who had been struggling with her voices. She came in one day and told him that a book she had been reading had helped her because it made her feel that her voices had meaning."

Attributing meaning to these voices was a revolutionary concept.

"In the mid-1980s, Romme advertised for voice-hearers on national television in the Netherlands. The local network ran a segment on Romme and his patient….and asked voice hearers to send postcards. Seven hundred cards arrived.　More than half were from people who seemed to experience audible voices, and many of them had never seen a psychiatric professional. They coped with their voices just fine."

It must have been startling to learn that most of those who claimed to hear voices learned how to cope with the issue on their own. This is what they learned from these people:

"The people who were comfortable with hearing voices told the same story; their experience had a trajectory. Some voices had started out mean and difficult, and the hearers had first responded with startled fear, but once they had chosen to interact with them, the voices settled down and became more manageable, sometimes even useful….That was the kernel Romme and Escher took away from the event: if people could accept their voices and create a relationship with them, they could get their voices to change."

What Romme and Escher came to claim was that hearing voices is a normal phenomenon rather than a sign of "brain disease." It is just more common with some people and rare for most.

"Its method, to treat voices like people, is almost the inverse of the biomedical understanding of psychotic voices and a completely different perspective on how to handle them. The organization insists that hearing voices is a normal human experience, which indeed it is, although what is common (and thus "normal") is hearing a voice as you slip into sleep, perhaps calling your name, perhaps your mother’s voice. About half of a standard subject pool (read: university undergraduates) will say that they have had some experience like that at least once. Many more will say so if the experimenter gives them examples."

Romme and Escher have turned this new understanding into a movement.

"In 1993 they published Accepting Voices, with techniques, case studies, and commentary by mental health professionals and patient activists (the activists sometimes call themselves survivors of psychiatric care). More detailed manuals and books followed. The workshops grew into conferences. Soon Romme and Escher were the unofficial leaders of a movement."

"These days, the Hearing Voices Network is an international organization with members in many countries, including the United States, and 180 groups in Great Britain alone. It has a newsletter, a web page (intervoiceonline.org), and a society that meets annually."

Our brains are always bubbling away with thoughts—some of which occasionally pop up to the surface. Some of our thoughts can be disturbingly violent or things that we would never consider verbalizing. We deal with these thoughts because we know they are our own thoughts and they are private. Wouldn’t it be startling—even maddening— if some of our more shameful mental output actually seemed to be audibly expressed by some unknown and uncontrollable mechanism?

It may be that those who suffer from auditory hallucinations and have the most trouble dealing with them have some sort of life-experience or trauma that produces troubling thoughts that are particularly intense and frequent. It could also be true that the emotional stress associated with these "hallucinations" can augment their frequency and intensity.

The notion that "hearing voices" is, in some forms, common, supports the notion that efference copy can fail under certain conditions. Given variations in other brain functions among individuals, it would not be surprising to find a spectrum of people for whom this failure is more frequent.

There is no proof yet, but the findings discussed by Churchland and those presented by Luhrmann seem to be converging on a consistent description of the cause and treatment for auditory hallucinations. If this holds together, we have an entirely new—and better— way of dealing with people now labeled as schizophrenic.