The Void

And why helping professionals should embrace the suck

I often ask people, “What problem are you trying to solve?” Not the latest funding deadline or HR snafu, but the root problem that makes you get up in the morning. It’s also a question I frequently ask myself.

Given my emphasis on innovating with helping professionals, you might think my target problem is some deficit in their skills. And sure, some deficits exist, but they are more than balanced out by helpers’ creativity and determination — I’m not out to “fix” nurses or their peers.

No, instead when I think of the big thorny challenge I would love to overcome, I think of The Void.

The Void is my nickname for the space between our systems of care and the rest of life. It’s most prominent in healthcare, where it’s been conceptualized in many different ways, using concepts like health equity or the social determinants of health. It also includes our attempts to reckon with lived experiences of patients and families. It’s whatever is just beyond the edge of your clinical notes, whether it’s climate change or racism or violence.

Chances are you and your colleagues have talked about this stuff. You may have learned a conceptual framework or two. But despite lots of good thinking about The Void, we haven’t actually done much to address it. The consequences are well-known to anyone who looks at healthcare in an international context. As the Commonwealth Fund recently reiterated, the United States spends more on care and gets worse results than any other peer nation. Our failing system is in a class by itself.

In the best diagnoses of this failure, The Void plays a starring role. My preferred explanation is the one offered by The American Health Care Paradox by Elizabeth Bradley and Lauren Taylor. The authors’ core argument is that we pay such high health costs because of the lack of other social supports in the rest of our society. It’s not about deficits in the hospitals, but deficits in schools, jobs, child care. This is just one iteration of a paradigm population health experts have used for decades: the origins of the health problems we treat in clinics are not to be found in the clinical world of cells and diagnoses, but in the wider, wilder world of poverty, racism, pollution, and violence. In between is The Void, a great abyss of difference in understanding, methods, systems, and power.

I remember the first time I truly looked into The Void through a clinician’s eyes. I was talking with my father — he was a transplant surgeon but had also logged plenty of time in the trauma bay. I was in graduate school and had just learned about the social determinants of health, a relatively new idea at the time. Grounded as he was in the world of the body, Dad was skeptical of the idea that the “real” causes of disease could be social factors. Yet he had also seen enough suffering that he remained open to his son’s description of poverty as the root of disease. It was an academic discussion.

No, The Void didn’t open up in his eyes until I started asking how medicine might mobilize to address these root causes. That’s where I lost him. “It’s hard enough to deal with the fact that someone was shot,” he said. “I don’t think we can also address why someone fired the bullet.” It sounds like a quip, but it was more of a morbid rumination — I could tell that I had subtly undermined the integrity of the care he provided.

This is essentially the situation of every helping professional faced with the social origins of disease and other issues they confront. Some experience it as alienation or cynicism, others as full-blown moral distress. What if the care I’m providing doesn’t really matter because society has already denied this patient any chance for a healthy life? Or even: what if I’m part of the problem instead of part of the solution?

I’ve re-experienced that disconnect on the faces of other helping professionals for more than a decade. And where I might differ from some other messengers of social distress is that while systemic injustice is my obsession, the clinicians are still my people. I viscerally feel their fears and anxieties alongside their drive to make it right. I get their worries that “social determinants of health” will become just another charting requirement and “health equity” will become just another talking point — in fact I’ve commiserated with many of them just as this has happened. We’ve said the right things for years, but The Void remains.

Addressing how to overcome The Void is too complicated a topic for a single blog post. I’ve had the privilege of helping clinicians confront it in a number of different ways, like helping nurses see that racism isn’t always dressed in a white hood or helping social workers confront how families really see them. Qualitative research, design thinking, and interdisciplinary teams are all tools that can help helpers see what their professional settings may have obscured.

But what I want to emphasize here is that when you’re doing this work, The Void can't be avoided. There is no way around the discomfort that comes with seeing our work in a larger context. Meeting with community members comes with conflict and vulnerability. Reckoning with complex systems outside of healthcare can make you feel disoriented and dumb. And as much as we love value-based care models, the social determinants of health won’t be disrupted in time for a quarterly report (or even an annual one!). Our systems are’t just inadequate to effect the generational shifts necessary to address poverty and racism; they aren’t even designed to perceive them.

So feeling the effect of The Void turns out to be a good thing. It’s what it feels like to actually experience the realities of our broken systems. It’s a sign that you are moving in the right direction, and if you lean into the discomfort you will learn even more. “Embrace the suck,” as the folks in the Army sometimes say — I’ll be here to do it with you.