Top and Bottom Versus Middle

I liked many things about this talk by Jacqueline Edelberg, a Chicago artist and political science Ph.D., about how she and other moms transformed their local school. Edelberg has written a book about it called How to Walk to School: Blueprint for a Neighborhood Renaissance. The man who introduced her told a story: In a classroom, he noticed a girl drawing a picture. What are you drawing? he asked. I’m drawing God, she said. You can’t do that. No one knows what God looks like, he said. They will soon, she said.

Edelberg’s story did sound miraculous: Her crummy neighborhood public school, within a year, became an acceptable place for her children. The change had many elements, including an after-school program, a farmer’s market, and painted doors, but I think the most important piece — which Edelberg said little about  — was this: Parents were allowed to attend every class. Within two years, said Edelberg, all the bad teachers left.

I call this way of governing top and bottom versus middle. In this case the top was the school’s principal (Susan Kurland, Edelberg’s co-author), the bottom was the parents, and the middle was the teachers. Acting alone, the principal couldn’t control the teachers — she couldn’t fire the bad ones, for example. With the parents’ help, she could control them.

It’s as old as Moses:

1. As I’ve blogged, the Ten Commandments was an agreement between Moses (top) and the preyed-upon men in his community (bottom) against the men who were preying upon them (middle) — stealing from them, for example.

There are other examples:

2. One reason surgical checklists — implemented by hospital administration (top) — work so well, I believe, is that they give nurses (bottom) power over doctors (middle). A nurse can tell a doctor to follow the checklist. The details of implementation also empower the lower-ranking members of the surgical team.

3. In China, what are called (in Chinese) human-flesh searches — a kind of cyber-vigilante-ism — go on with the approval of the central government (top). These searches, which are actually mini-crusades, allow ordinary citizens (bottom) to punish corrupt or otherwise misbehaving local government officials (middle).

I predict that someday someone in the American government (top) will realize that a way to greatly improve health care is to empower patients (bottom) against doctors (middle).

12 Replies to “Top and Bottom Versus Middle”

  1. I take umbrage at your statement about empowering patients against doctors. In today’s system it is not the docs with all the power, but the insurers and the government regulators. If obamacare becomes law it will give more power to the insurers and govt and even less to patients.

  2. doctorsh, that’s an interesting point you make. However, I’m not sure I completely understand, much less agree, without examples. For example, I don’t know what you mean when you say obamacare will reduce patient power. Could you expand on what you mean?
    I’ve had plenty of experiences where patient empowerment would help. One involved a surgeon to whom I was referred:

    Another involved my dermatologist: He wasn’t terribly interested in whether the drugs he prescribed actually worked. Which hurt me, of course. A third involved the mother of a friend of mine. She was given so many drugs they were actually killing her — her doctors didn’t notice. It was only discovered by accident.

  3. This is the idea behind “if you didn’t get a receipt, the bill is on us” policies. It makes the customers the policers of the cashiers.

  4. bjk, yes, and the system in China where restaurant receipts have scratch-off areas. A small fraction of scratch-off areas provide money. Taiwan has a slightly different system.

  5. Another top/middle/bottom example is described in Gladwell’s _Outliers_, the part about the airline crashes due to co-pilots not feeling empowered enough to be forceful when notifying about a dangerous situation.

  6. I really enjoyed that about the “How to Walk to School.” As an aside, I’ve always found it notable that God delivered Israel from Egypt by parting the Red Sea, and THEN the 10 commandments came. kind of like if you love and are grateful for what your neighbor, business partner, wife has given you, you do not even need to be told not to kill, lie, steal, etc. . . . . . Anyway, I digress, as a Chicagoan, really interesting idea to help prevent the exodus of young vibrant families to the ‘burbs.

  7. david, yeah, that’s another good example. And the more examples I know of, the harder it becomes for me to believe (as doctorsh seems to say) that patient empowerment would not be a good thing.

  8. Seth
    Empowerment in a workable system would be shared between patients and doctors. Presently all the POWER is held by the payers and rule makers who happen to be government regulators and insurers. Doctors have let the system be taken over by these entities. This has changed the way docs are able to care for their patients. Try going to a private solo doc who does not participate with the third parties and you may find a truly free and empowering system that works.

  9. Seth,
    Really interesting idea. Do you think this could also be applied to the medical research system?

    I work for a nonprofit organization (the Myelin Repair Foundation) which recently launched Where Are The Cures? ( to give patients (and friends/family) a voice and knowledge on how the medical research system is broken.

    As a nonprofit organization, the Myelin Repair Foundation ( is trying to speed up that process by bridging the gap between academic scientific discoveries and pharmaceutical companies. There are so many players in the process (NIH, FDA, other nonprofit disease research orgs, clinicians, patients, etc.) How could you create a Top & Bottom vs. Middle in this system?


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