Salus: A Sample Chapter

Chapter Four

The Gut and Health at All Levels

 

Dr. Caroline

The following decade unfolded as yet another chapter of medical uncertainty. I entered menopause just a few years before my fiftieth birthday. As I began to piece my life back together, much like the Scarecrow in The Wizard of Oz stuffing himself after being scattered by the crows, I pushed forward to create a new life as a single woman navigating menopause. Physically, the years were unkind. I was once again diagnosed with an autoimmune disorder, Epstein–Barr virus. This led me back into the familiar cycle of searching for meaning amid the continued absence of an effective medical solution.             

Despite these challenges, I persisted in seeking both understanding and relief. Traditional medical interventions continued to offer limited answers, prompting me to explore complementary and holistic approaches in search of more effective solutions. Each setback reinforced the reality that my health journey would require resilience, self-advocacy, and a willingness to navigate both conventional and alternative avenues of care.

As I approached the age of 63, I felt as though I had made significant progress in restoring my health through consultations with holistic, naturopathic, and functional medicine professionals. However, following my first COVID-19 vaccination, I experienced a sudden and dramatic decline in energy, accompanied by the return of severe, chronic pain as if a switch had been flipped.  Over the next five years, my focus shifted to understanding how to optimize physical outcomes through the integration of neuroscience, addressing metabolic abnormalities, hormone replacement therapy, and targeted complementary alternatives, such as nutritional support. I begin to work at a facility that emphasizes integrative health.

This approach marked a new phase in my ongoing journey toward health restoration, integrating evidence-based medical strategies with holistic and functional care to achieve the best possible physical outcomes.  It has become abundantly clear that, without a progressive, multidisciplinary team of practitioners, it is exceedingly difficult to identify effective solutions for individuals who have experienced significant adverse childhood events and the subsequent cumulative burden of polystatic stress, without sufficient polystatic support to counteract it.

Dr. Steven Bloor

Caroline still drops in now and then to update me on her life. Instead of endless concerns and symptoms, she talks about her strengths as a person, how resilient she has become as a result of all the life-challenges she has faced or overcome. She talks about how she has learned to transform her suffering into a positive, meaningful narrative that gives her the energy to help others. She is working full time as a therapist and exploring newer modalities to dig more deeply into helping those suffering from mental, behavioral, and physical symptoms. She quickly reminds me she is not an expert in physical ailments, but she did suggest supplements and has been trying to partner with local physicians to help other patients like herself find comprehensive, advanced primary care. She works part-time at Dr. Wellington’s clinic as she was one of the early success stories of that practice, and she’s teaching at the local community college, hoping to help younger people recognize there is a positive pathway for them through all the suffering our youth are experiencing these days.  

 

I feel a bit embarrassed about my own journey into understanding fully how to help my patients no matter what is going on. I’ve grown as well into realizing that I am a partner for my patients and the key they need from me most is the curiosity to keep asking questions and seeking potential solutions, and the courage to stick by them as they struggle through their health challenges. I’m going to read-up on Allostatic Load and the functioning of our Gut (and its tie-in with the nervous system). I want increased understanding of anything that may help me get a better sense of the many factors contributing to the stress and illness with which my patients are suffering. 

 

I’m no longer that young physician hoping to be a hero in the hospital.  I’m now a more humbled and hopefully wise partner through my patient’s journey through suffering and health.  I’m very grateful to Caroline for helping teach me how to be a better doctor, for her and for others who seek out my care.  I think I’m going to retire from this bedeviled health system I’m working for and work part-time with Dr. Wellington a few days a week. I think I will find that far more fulfilling than filling out all this paperwork to convince a hostile health plan to send me $20 for a visit.  Enough is enough.

_____________________

Several times during the multi-session Salus Health Care Forum, attention was directed to a unique perspective: what if the health care system is itself to be considered “the patient.” This fits with the systemic perspective that resides at the heart of the Salus Biopsychosocial model. This Salus-P3 approach begins with the assumption that many elements of a system are connected to one another, even when they are operating at different levels of the system. It is appropriate, therefore, to consider ways in which both diseases and treatments concerning individual patients in a healthcare system might connect with (and even replicate) the diseases (dysfunctions) and treatments to be considered by the healthcare system itself. Perhaps this is the direction in which both (now) Doctor Caroline and Dr. Bloor are moving.

Moving to this perspective, Gay Teurman proposes that some operations of healthcare systems might operate like the Gut in one’s body. She reflects on her own experience inside the current health care system. Like Dr. Bloor, Gay is not pleased with what she has seen and experienced in contemporary healthcare systems. She looks at the people she is attempting to help. They’ve seen medicine, they’ve seen holistic care, they’ve seen both. They’ve been around the gamut, and nothing that they’ve been incorporating is working. Often, nobody’s looking at their Gut or their constitution based on all things, biological, mental, and neurobiological challenges. The system is clogged with information and actions that do not relate to one another. Nothing is synthesizing (digesting) this information, coordinating these actions, or addressing the outcomes (products) of this dysfunctional system.

As participants in the Salus Forum, we decide to view the health care system as an unwell patient needing help. In searching for a diagnosis of the “ailment” we might ask: What is the Gut of the health care system? Is this Gut being overlooked like the guts of people we treat? Why aren’t we looking at that nexus as a means of shifting how we all integrate what we all purport that we want to do—which is collaborate more and have a care system that’s more a wellness care system than a medical management system. Why is it all so fragmented? Why are so many of us fragmented?

As a health-oriented psychologist living and working in one of the largest counties in the State of California, Dr. Teurman still has difficulty with integrating referrals back and forth with medical community doctors, neurologists, and medical professionals. She can’t even have them understand how what she could do might serve the patient. As a practical person, Dr. Teurman doesn’t live in possibility very long. She asks: How do we make integration happen?

As we were thinking about the health care system and considering it to be the patient, we might ask: What’s going on in the patient’s Gut? Is it appropriate that we ask this question, because the Gut is where we focus from a biological perspective? As the patient, how does our “Gut” process everything? The way that we look at a patient—like Caroline—in an integrative manner. The way that we treat a patient—as Steven Bloor would hope might occur—from an open, curious viewpoint.

The Gut’s Function: Transformation in Our Body and Our Health Care System

The human Gut, or the Gut of any organism, is in the business of taking some foreign entity that is brought into the body and somehow transforming that foreign entity into something that provides energy and nutrients for this body. There’s a transformative process. Somehow, a medical system is one that takes a foreign entity called disease, illness or injury and does something to transform it into health.

This being case, then we should ask: Is our healthcare system diseased? Are we looking at dysbiosis? The Gut of this healthcare system is no longer working as it was intended, or maybe it never has. But if the Gut is the central organ that supports our nervous system, our brain, all of our veins, our blood flow, if the Gut is that central to shifting dis-ease, where do we start and how do we treat our healthcare system?

Perhaps it is best to first examine what it means to conceive of an “Organizational Gut.”

The Organizational “Gut”

We might first ask: Where is the Gut in an organization? It would seem that the C-Suite is the Brain, and the Informal Network is the Central Nervous System. What about the Gut? We can probably equate the Gut’s Microbiome with the employees of the organization. But, what about the Gut itself?

It seems that the Gut serves many functions and operates as both a mirror that provides information to other parts of our body and as a motor that generates the energy to drive our body. Furthermore, our Gut is both an Assimilator that converts food to energy and an accommodator that acknowledges shifts in the body’s status (“gut feel”). In many ways, our Gut operates like a committee that is meeting diverse needs in our body and is coordinating these needs.

Committee of the Gut

There are many ways in which human beings bring together entities from inside their mind and body along with entities from outside their body in order to create meaning or energy. At nighttime, this assembling and assimilation often occurs through our dreaming function. Deirdre Barrett (Barrett, 2001) has labeled this function “the committee of sleep.” When we are awake, there is similar dream-like assembling that occurs when we are daydreaming or engaging in meditation or other mindfulness processes.

However, the major assimilation we do during the day involves something other than memories, images or psychological desires. Vital assimilation occurs when we convert the food we digest into energy.  However, the Gut is much more than just a digestive organ. The Gut serves as a central hub within a network. It represents six interconnected roles that reflect how healthy systems operate. As with the dreams we weave, the Gut operates like a committee, with many contributing agents.

Within the metaphor of the “Committee of the Gut,” each role can be envisioned as a member with distinct responsibilities that together ensure the overall health and adaptability of the system. This committee evaluates incoming substances, decides how to process them, and coordinates responses to meet both immediate needs and long-term balance. By acting collectively, the committee sustains both the integrity and the flexibility of the entire organism.

Self-Organization: Viewed from a systemic perspective, the Gut is not a passive organ but a self-organizing center. As we find in many systems, the Gut, being the central hub, has a central committee.  The Gut embodies the dual functions of:

• Indicator (diagnostic, reflective, sensing the state of the whole)
• Instigator (active, generative, reorganizing, and catalyzing change).

In other words, the Gut doesn’t just belong to the system; it organizes the system by bridging matter (food), meaning (information), and momentum (energy)

Assimilation (that which is easily digested) versus accommodation (that which is new and requires an altered process of digestion). Parallel to the process of learning (Piaget, 2001). Piaget believed that learning is a dynamic balance between assimilation and accommodation, a process he referred to as equilibration.

• Too much assimilation → rigidity (clinging only to what is familiar).
• Too much accommodation → instability (constantly shifting frameworks with no coherence).

As we have found with the process of Allostasis, the Gut reflects Piaget’s model: it takes in what can be easily digested (assimilation) but also adapts its processes when confronted with new foods or substances (accommodation).  Similarly, the Gut grows by both consolidating what is familiar and reorganizing itself in response to the new.  In both cases, the goal is to transform the outside world into something the system can utilize without losing coherence.

Members of the Committee: We have identified six members of the committee. There are undoubtedly additional functions. However, our preliminary list should provide us with a vivid image of the many functions being served by our Gut.

Indicator Role (Feedback Loop): The Gut will act as a sensor and reporter, providing real-time data about the biological system. Signals such as hunger, bloating, discomfort, or even “gut feelings” are feedback loops that inform the brain and body about current conditions.  As is the case with many (if not all) systems (biological or otherwise), the Gut plays an important modulating role. It acts as a kind of dashboard, revealing system stressors (e.g., poor diet, unresolved emotion, microbial imbalance) before they escalate into breakdowns elsewhere.

Biochemist Role: This committee member functions by testing the level of toxicity, status of neurotransmitters, and introduction of a “new” ingredient that is not often processed by the Gut (accommodation).

Telegraph Operator Role: This member facilitates internal communication by sending messages to other committee members.  What do we do about processing or expelling this “new stuff”?) The telegraph operator also facilitates external communication by sending information to the Vagus nerve, which sends the message on to the brain.  Therein lies the production of neurotransmitters (serotonin, dopamine, GABA), generating immune responses, altering mood, decision-making, and energy distribution.  In systems language, the Gut is a driver node, an initiating force that can reorganize downstream processes, from sleep quality to immune resilience.

The Processor Role: Utilizing the microbiome or microbes, this committee member changes the chemical state of the Gut by adding (changing the ratio of good and bad), killing (reducing the number of bad) microbiota or microbes.  The Gut processes raw inputs from food, toxins, and even psychological stress and translates them into meaningful signals. It serves as both a decoder and a translator in the system, much like a data team converts raw numbers into actionable insights.

The Contributor Role: This committee member’s responsibility is to generate usable energy through digestion and absorption literally. It takes in external resources, breaks them down, and redistributes them to the system.  In systems terms, it is the operations department, the machinery that ensures resources are converted into usable forms and allocated efficiently.

The Executioner’s Role: A biological executioner refers to a type of cell or organism that plays a role in programmed cell death, also known as apoptosis, a natural process that eliminates unwanted or damaged cells in multicellular organisms.  At times, we may use antibiotics to facilitate this function. Biological executioners are often involved in signaling pathways that trigger apoptosis or an immune response by targeting and destroying infected or cancerous cells. As is the case with many systems, the Gut utilizes the executioner in its need to rid itself of dysfunction in the bodily system.

Exit Manager/Garbage Sorter Role: This committee member decides what stays in the Gut and what is expelled. The Gut acts as both a filter and an eliminator, separating nutrients from waste.

Sorting: Like a recycling plant, the Gut distinguishes absorbable nutrients from indigestible or harmful substances.

Detoxification: It works in conjunction with the liver, bile, and microbiome to neutralize toxins and pathogens.

Clearing Space: Waste removal prevents toxicity, inflammation, and system breakdown, making elimination as crucial as absorption.

Just as many other systems rely on various departments to separate valuable resources from unnecessary materials, the Gut’s functions mirror roles such as quality control, waste management, and risk assessment. The “Exit Manager” resembles a compliance officer who ensures only beneficial elements are processed further, while harmful or non-essential items are effectively removed to maintain overall health and operational efficiency. Collaboration between departments, with the Gut working with the liver and microbiome, reflects teamwork across units to safeguard wellbeing and productivity.

Without this function, the system gets “clogged,” and a buildup of waste products can destabilize every other organ and process.

Instigator/Generator/Assimilator Role: The Gut acts as a key communication center, connecting the nervous, immune, and endocrine systems.  It works like a hub, keeping body “departments” in sync:

Nervous system → messaging and quick response

Immune system → protection

Endocrine system → hormone control and adaptation

It does not just reflect the system; it drives it.  It creates fuel, initiates the change, and integrates the new into the existing.

Similar to the coordination office in other systems, it avoids isolation and ensures all parts share information. The Instigator/Generator/Assimilator role functions as a chief of staff or central coordination office, facilitating collaboration, promoting information sharing, and maintaining alignment. In all systems, this function prevents stagnation, powers growth, and ensures new elements become part of the whole rather than destabilizing it.

Together, these six roles show the Gut as both mirror and motor:

• A mirror reflecting the health of the entire system.
• A motor, generating energy, driving change, and keeping processes in motion.

Healthy biological systems require not only intake and generation, but also filtering, integration, and elimination. The Gut teaches us that survival and renewal are inseparable: you cannot grow without also clearing space.

Instigator/Generator/Assimilator Role: The Gut acts as a key communication center, connecting the nervous, immune, and endocrine systems.  It works like a hub, keeping body “departments” in sync:

Nervous system → messaging and quick response

Immune system → protection

Endocrine system → hormone control and adaptation

It does not just reflect the system; it drives it.  It creates fuel, initiates the change, and integrates the new into the existing.

Similar to the coordination office in other systems, it avoids isolation and ensures all parts share information. The Instigator/Generator/Assimilator role functions as a chief of staff or central coordination office, facilitating collaboration, promoting information sharing, and maintaining alignment. In all systems, this function prevents stagnation, powers growth, and ensures new elements become part of the whole rather than destabilizing it.

Together, these six roles show the Gut as both mirror and motor:

• A mirror reflecting the health of the entire system.
• A motor, generating energy, driving change, and keeping processes in motion.

Healthy biological systems require not only intake and generation, but also filtering, integration, and elimination. The Gut teaches us that survival and renewal are inseparable: you cannot grow without also clearing space. Perhaps Caroline needs a bit more clearing or space in her Gut. The healthcare system that is treating her ineffectively might also have to clear itself of outmoded mental models.

Culture and Climate

The assimilative process of an organization’s “Gut” is found in the Culture of the organization. The Climate of the organization represents the current state of the organization’s Gut. The culture of an organization is equivalent to an individual’s personality or character. One’s personality is established early in life (or inherited) and is very hard to change later in life. The “culture” of one’s Gut is measured by one’s ongoing capacity to effectively process the food coming into one’s body.

If we rarely have an “upset stomach,” experience diarrhea or constipation, and need few Tums to counter an “acidy” feel and few pro-biotic supplements to ensure a fully operating Gut, then the culture of our Gut can be considered gastroenterologically ”strong.” Signs of a weak Gut include nondigested particles in the stool, frequent diarrhea or constipation, bloating, abdominal pain, and heart burn. Much as in the case of personality, a strong or weak Gut often seem to remain with us for extended periods of time. For some of us, the Gut is our friend and aid to our strong health; for others, the Gut is often the enemy and a barrier to strong health.

When considering the Gut of an organization, we can similarly examine the extent to which the daily activities, expectations, and narratives of the organization enable and reinforce a positive sense of this organization’s “health.” Emphasis is placed on the organization’s accomplishments and its future. As noted by Edgar Schein (Schein, 1992), organizational culture provides a comprehensive framework for the generation and interpretation of the underlying beliefs, values, and practices that pervade an organization. Identification of an organization’s culture requires assessment of the artifacts (rituals, narratives, etc.) and behaviors operating in the organization, espoused values that are frequently articulated by members of the organization, and underlying assumptions regarding the impact of specific behaviors on the functioning of the organization. The “guts” of an organization might be on display with the observation of these operations.

The climate of an organization is equivalent to an individual’s mood at any one moment in time. The mood can shift based on changing in one biological condition (allostasis and somatic template) and one’s psychosocial environmental conditions (Polystasis and psychosocial template). Climate can be measured by: (1) the acidity and Ph Balance (morale) of the organization and (2) the proportion of good and bad bacteria (“good” and “bad” employees/contributing and blocking behaviors (force field analysis).

At the organizational level, the climate of an organization is determined by such temporary factors as formal (and informal) news about the current status of the organization (market share, level of productivity, customer satisfaction reports), an inspiring motivational speech made by a leader of the organization, or the shifting status of a rival organization. The “mood” of those working in and with the organization will change with shifts in the news.

Polystatic adjustments are made based on the anticipated impact of this news on an employee’s or stakeholder’s status. Organization climate can be measured with employee morale assessments, and indirectly with rates of employee sick leave and daily levels of productivity or quality of service being offered. The “guts” of an organization does change from day to day, and even from hour to hour–especially in an environment that is filled with the VUCA-Plus conditions we consider in some depth later in the book.

Assimilation and Accommodation in Balance

The Gut we have just portrayed is both one of stability (culture) and change (climate). At both a physiological and organizational level, the Gut is operating like Goldilocks: there can be too much assimilation and too much accommodation. Too much accommodation leads to toxicity. There is too much bad bacteria and/or not enough good bacteria (dysbiosis). The dysbiosis, in turn, creates a “leaky” Gut. The lining of the Gut becomes permeable. Toxicity leads into the GI tract, which leads into the bloodstream.

In an organizational setting, too much accommodation results in too many new entities from the outside environment to process and adjust to. We can introduce additional warriors in the organization (those fighting for the good cause). These are the probiotics.

We may change the product or service we are delivering within the organization. However, this doesn’t change the toxicity. The disease remains even with a change in the “character” of the organization. The toxic Gut remains in place. The culture remains in place even with a temporary change in climate brought about by new leaders, changing polices, or new compensation systems.

Assimilation in an organization’s Gut can be aligned (destructively) with our search for Serenity in place of VUCA-Plus (Bergquist, 2025). There is “no bad news.”  Everything is aligned with some long-established values and purposes. More constructively and appreciatively, members of an organization can search for what is authentically positive within their organization. Embracing an appreciative perspective, members of the organization can identify, celebrate, and learn from that which is operating in a successful manner in their organization (Cooperrider and Whitley, 2005). While the Gut works toward parasympathetic activation at a physiological level, it works toward a “legitimate” climate of appreciation, safety, and agility at an organizational level.

Direct and Indirect/Integrative Functions

If the Gut serves as both a mirror and a motor, then how might these two functions show up in the way an organization is structured?  The motor (instigator) in an organization is represented in direct services. These direct services include the organization’s production functions and/or the customer services that it provides. The mirror (indicator) in an organization is represented in the indirect/integrative services of the organization. These services include functions such as HR functions, planning, institutional planning, and training. The direct services may change in a relatively easy manner (tied to the Climate); the indirect/integrative services are much harder to change (tied to the Culture)

The balance between instigators (direct services) and indicators (indirect/integrative services) is critical.  As Lawrence and Lorsch noted many years ago, the ratio of direct to indirect services tends to change over time and as an organization increases in size (Lawrence and Lorsch, 1967). In “youth,” we propose that the organization’s Gut primarily provides direct (instigating) services. The indirect (indicator) services are secondary or fully integrated with the direct services. Those owning or running a small business or operating a small clinic do everything. They are both the boss and “dishwasher.” Similarly, when we are teenagers and even younger, there is nothing that stops our energy and our dedication to leading a full, purposeful life. There is no need (nor time) for a doctor or physical therapist.

As we individually grow older, a greater proportion of our bodily functions is devoted to simply holding us together. We become less “efficient” in our bodily functioning. The number of our body mass index grows. We spend a greater proportion of our time at the doctor’s office and at physical therapy than at work. Caroline might have to look forward to even more health-related challenges as her body becomes less efficient and more vulnerable to illness and injury.

We propose that a similar change in our Gut occurs over time. We may have fewer instigating initiatives in the Gut as we grow older. At the very least, we are likely to find our Gut growing “weaker.” More attention must be paid to alleviating these weakened conditions. The integrative, indirect services operating in our organization’s Gut would similarly require more attention. The direct services are more likely to become a bit “cranky” as the organization becomes more vulnerable to stagnation and routine. We must devote more resources to holding the organization together. Our attention is directed toward matters of morale, equity, and mission, more than to matters related to just keeping up with the demands for products or services that are present when our organization is young and prosperous.

Central Organizer or Self-Organization

We conclude this foray into consideration of organizational guts by posing a challenge: Is our organizational Gut a central organizer? Or is this function served by our Brain? Perhaps the central organization takes place as an alliance between Gut and Brain. It is even more likely, as we have often mentioned in this book, that there is no central organizer. Our body may be self-organizing.

As we have noted, complex adaptive systems are self-organizing. Given this observation, we have to ask: Is there an organizing Gut? Does the brain ever rule?  Or is the human biological system self-organizing without a central organizing entity?  Perhaps, like flocks of birds and swarms of fish, each sector of our body and mind is influenced by their “neighbor.” This neighbor could be a nearby organ (such as the close location between the amygdala and hippocampus) or an organ that is closely connected by neural pathways (such as the neural links between many parts of the Gut and Brain).

The Dysfunctional Organizational Gut

Given this overview and consideration of the way in which organizations might be considered to have a Gut, we are ready to consider the nature and status of an “organizational gut” that might be operating in contemporary healthcare systems.

Our integument or our intestines are actually connected to each other; however, there are no connections in our health system. It’s disjointed. It would be as if part of the bowel has been resected and no one sutured it up. So, a lot of spillage happens. We can imagine people in a health care system flowing through this broken system. That means people are spilling out all over the place in different locations because they think they’re going through a system. However, they’re actually only entering into some very potentially profitable sections that are quite ordained with great powers.

As we have already suggested, the “Gut” of the health care system is an interesting metaphor. Jeremy Fish has previously used a castle metaphor for healthcare, where there are several doors. Many of these doors are gated and secured, so no one can enter. And then you have the garage door, which is the emergency room where everybody gets a garage door opener. Patients can just go in there, but they think now they’ve entered the integument or the inner workings. Yet often, using the metaphor of the Gut, they are vomited out of the emergency room without having gotten much help.

Jeremy’s castle operates as a digital system, with operations being clearly specified. While his castle is more of a mechanical metaphor, the Gut metaphor is oozy. It’s organic. It’s messy. It’s not tidy. The Gut operates as an analogical system with a bit more of this and a bit less of that. As a sloppy system, the Gut can be both helpful and harmful, much as antibiotics may help one part of the system but create havoc in another part of the system (especially the Gut). Are there solutions inside healthcare that work for one small element of it, but do plain havoc on the central processing system? An antibiotic-like organizational intervention would mean that there is an indiscriminate attack. Something that’s actually very healthy is being destroyed. What would be an example of attacking something in healthcare that’s actually quite healthy?

Fee-for-Service

An easy example of the dysfunctional attack is fee-for-service payment. Fee-for-service works really well at times. You do something, you get paid. But it also then hurts, because suddenly, it drives more widgets rather than health. So, you’re buying sick care, and you’re buying sick widgets rather than creating health. This is an example of one part helping and one part hurting. Fee-for-service financing really hurts primary care and a lot of direct clinical care, because it creates an incentive for primary care doing more rather than better.

There’s outstanding evidence that of all the things in healthcare, the only thing that’s been shown to improve life expectancy and quality of life, is the amount of primary care that’s delivered in a community. We can assume that primary care is a good thing. However, in many parts of the United States, health care critics have been trying to dismiss primary care for quite a long time. There are advanced practitioners who are dismissive of primary care.  It’s important that primary care not be dismissed. We have to recognize we’re doing real damage when we introduce something like fee-for-service that can disrupt the provision of primary care services.

The Gut’s Product: Source of Disgust and Discard

We would note that the Gut’s product is a really embarrassing part of the body. It’s taboo to talk about it. It’s not something we talk about in polite company, but we’re realizing more and more how important the Gut is as the second brain. As a mirror and motor. As a seat of intuition. As a part of our body that communicates frequently with the first brain. That controls many aspects of our health—psychological, emotional, and physical. Yet the Gut and its byproduct is “disgusting,” foul-smelling, and nothing more than that which is disposable.

The noted psychiatrist, Harry Stack Sullivan (1953), proposed that the really fascinating thing for children is not sexuality. The truly fascinating things are feces. For little children, this is warm stuff that comes out of our own bodies. It is kind of interesting. It is something that they have created. “Wow, I want to play with it.” But then someone declares, “Don’t touch that. Go over to that toilet and get rid of it and never look at it again. It smells horrible.” So, what’s discarded in the healthcare system? Are some things (and events) treated like feces? Don’t touch them. Don’t talk about them.

Don’t talk about feces. They smell bad. So, we just ignore them, and we don’t want to deal with them. Jesus had an interesting metaphor and scatological sense of humor. It’s not what goes into a person, but what comes out of them. That’s taboo. That’s hideous. That was his joke. He really meant hateful speech. But he told it as a joke. Jesus’s insights might have been offered as a joke; however, it’s interesting that in healthcare, we have denigrated the end products of the gastrointestinal tract, and we’ve denigrated the bacteria. We turned them into enemies. Perhaps, we have also turned the organizational Gut (as a transformational subsystem) and its product (information) into an enemy that is to be dismissed or challenged.

We can add to the metaphor of the Gut operating in the healthcare system. Fee-for-service may be like Go-Lightly (a major laxative) for the healthcare system? It makes everything go faster, but that doesn’t necessarily improve the health of the patient unless they need surgery and need their bowels completely evacuated. We all have had the opportunity to take a little bottle of Go Lightly or some other powerful laxative. As a resident, we joke that it really should be called Go-Heavily because that’s really what happens.  Fee-for-service is a Go-Heavy laxative. It makes everything turn into productivity. The product then becomes the euphemistic bowel movement. There is only the ejection of an end product rather than some improvement of the preceding process. Fee-for-service has nothing to do with the quality of the experience being transmitted rapidly through the system.

Disposable Entities

It is interesting to note that the metaphor of the Gut in healthcare systems pulls us to a focus on the primary product of the Gut, this being feces. This pull might be justified, given the importance of feces as indicators of health. There is an important thing that many primary care doctors do when engaging in well-child checks with kids. They train their child-patient to always look at their poop. This is counter to what most people are educated to do: Don’t look at your feces! The question to be asked is: How can you not look at the feces? It’s going to be the thing that you most need to look at every day for the rest of your life, because it will tell you a lot about what’s going on. What kid doesn’t love that assignment?

This reminds Gay Teurman of sitting on a metabolic ground round of folks in the USA who are in her field:

We had a poop expert doc. She collects and analyzes fecal matter. Before she is doing a brain scan or doing any of the questionnaires, she looks at the poop. As she declared: That which is discarded is of great value.

What we throw out defines what we keep and value. That’s why so many sociologists say: “If you want to understand the values of a society, look at the garbage. Look at what is being thrown away, what is devalued, and you’re going to gain more insight”. Bill Bergquist offers his own observation:

While traveling on a train from San Francisco to Sacramento, or on an East Coast train, going down the corridor through New Jersey to Washington, D.C., I love to sit by the window and look at what’s at the side of the railroad tracks. The stuff that’s being thrown away says so much about our society. It’s the “shit” that’s telling us what is non-valued and what is valued.

It seems that the output of our Gut contains valuable information, whether this information is transmitted through our Vagus Nerve or through our much less “valued” excrement.

Feces, Shame, Anxiety and Treatment

We can take our exploration of feces to an even deeper level. We’ve known for years that the Gut is the second brain, although there’s been a lot of disconnect in terms of looking at the health of the Gut. How do you determine the health of the Gut, and what is leaking into the system? The Gut’s lining is permeable, like it might be in healthcare. You know, we’ve got a lot of things seeping into the constitutional house that we live in, and what are those things? Are they toxic? Are they good? All of this is true. Some things are serviceable, some things are helpful, and some things need to be excreted, but there’s also the other component from a neurological perspective that provides important information. As our primary care doctors have concluded, this other component is our poop.

It is indeed unfortunate that we have culturally overlaid many negative features on excrement, whether it has to do with coming out the end of our colon, or coming out of our pores (sweat and other body “odors”). As a culture, we are intent on shedding and ridding ourselves of toxins; however, there’s a mental health component that concerns shame. If we’ve got toxic innards, then how could our neurobiology not be toxic in some way? Meaning, our interpretive function is not working as it’s intended to work. It seems that sweat and tears, as well as feces, are sources of shame. We are ashamed of our sweat, we’re ashamed of our tears, and we’re ashamed of our feces.

Perhaps negative impressions are assigned to our feces, tears and sweat because each of these vehicles for bodily elimination is associated with a deep source of shame for each of us. This source is Anxiety. We painfully know that Anxiety accompanies Sorrow. We weep because of our sorrow and often sweat because of our anxiety. What about Caroline? With all of the deaths and dissertations in her life, is she weeping through the many maladies in her life? Does she find relief by addressing her sorrow rather than (or in addition to) her maladies?

Even our feces are associated with anxiety. One of the items on the MMPI (a widely used psychological inventory) concerns whether your bowel movements are tarry. This item is included because if you have tarry bowel movements, it’s because you have sustained levels of anxiety. Feces, shame and anxiety have had a long and complex relationship. For instances, during the 60s, it was fashionable in California to journey to the Russian River in order to participate in the colonic clinics. The clinics focused on the bowels. The goal was to be able to return to the Bay Area with a clean bowel after a weekend of selected colonics. The directors of this clinic would take a look at your stool and then devise a special program of directed enemas to give you a fresh start from a bowel perspective. Obviously, like the primary care doctors who are educating their child-patients, those attending these clinics had some appreciation for their feces or were trying to connect bowel health with overall health.

Furthermore, if you look back to 19th century, the most popular treatment were cayenne pepper enemas. You really got a “treatment” there, and it was less dangerous than all the other poisonous things doctors were giving people. For instance, it was popular for women to swallow worm parasites to keep themselves thin. So, using pathological means to cleanse the bowel was probably happening in health care, too. Historically, it goes way back to Galen and Hippocrates. They were big fans of looking at excrement as a way of measuring health. During Elizabethan England, and at the time of royal revolutions, they had a special physician who always attended the king. Part of what they needed to do every day was look at the bowel movement. These physicians figured out the state of health of their monarch (or possibility of poisoning) based on their inspection of the bowel movement.

We are now moving forward with more sophistication about the Gut and its products; however, as just noted, it’s not that the Gut has been an ignored part of health for thousands of years. It isn’t that people have always ignored the Gut and its product as an indicator of health. There’s a long historical and medical tradition of paying attention to the function of the Gut. Our appreciation has been getting better during the past couple of decades. We are beginning to more clearly understand the functioning of the Gut.

If you ever have the misfortune of watching commercials in between the segments of CNN, and if you don’t skip over them, there’s a whole bunch of commercials now promoting healthy bowel movements on a daily basis. Women in the ads grab their stomachs and take this product. They then go out with their friends to have a nice jog in the park because they’ve taken an effective product that restores the balance of their bowels. Many “true believers” accept the premise that having a healthy, regular, satisfying bowel movement is one of the keys to happiness. At some level there is awareness that digestive biology is informing neurobiology, and vice versa. We have long known that they are connected, but sometimes over the past century we have forgotten or ignored this connection. Could this relate to Dr. Bloor’s own search for greater understanding of the complex processes of health and illness?

Enemas and the Health Care System

So, like Steven Bloor, we are beginning to appreciate our Gut. However, we still often treat it rather badly. We stuff it with Tums or with a probiotic. And we flush it out with an Enema. Are we just as bad in managing our organizational Gut? What might be the equivalent of an Enema in organizations—and especially in health care organizations? It might be the length of stay in a hospital. Do we try to get patients ejected out of the hospital more quickly. Is this an Enema-like flushing out. Or do we just sort of pull patients out? Are we in the business of rushing people out?

Bill Bergquist reflects on his experience as it relates to the matter of admissions and discharge from hospitals.  He once interned in a mental hospital that was associated with the two hospitals on which One Flew Over the Cuckoo’s Nest was based. The finances of his VA hospital were such that they needed to get people out of the hospital. They needed to have a high percentage of successful treatments. So, they were pumping these men out of the hospital and sending them off to work sites. It was Oregon, so many of the existing patients went to work for very low pay at lumber processing plants, cutting the incoming tree trunks into construction-grade lumber.

When the patient population got too low at the hospital, the staff were instructed, in essence, not to heal people: “We need to retain our patients here in the VA. We need to keep them around for a while because we need the beds to be filled.” It’s interesting to note that that whole issue of what was to be “pooped” out of the VA hospital was based on fee for service– much as we have identified. There was the critical matter in this mental hospital about how to declare someone “mentally healthy”. This declaration was based more on the economics of the system than on anything concerning the person’s Gut or Brain.

We are again focusing on the mechanics of the Gut rather than other components of the health care system. Gay Teurman has commented on referrals and communication between parts of the health system. These processes seem to be analogous to the operations of the Gut, which is very neuroactive. It is an endocrine-based, and chemically oriented part of the body. Operating like a dis-eased Gut, our contemporary healthcare system has lost its ability to communicate with itself.

Health care is filled with different, isolated proprietary electronic health records. Neither the clinician nor the patient owns their own data. The data is owned by the proprietary EHR company, whether that’s Epic or Cerner. Physicians may send a patient to a health psychologist. She may try to communicate with the physician. Maybe the communique gets back into the physician’s record. Maybe it doesn’t. There’s pseudo-protection of privacy issues. This protection is hampering communication rather than facilitating this communication.

Beyond the Gut

There are many other levels of our healthcare system that have nothing to do with what’s inside the Gut. They have nothing to do with communication done by the Gut with the rest of the second brain. For instance, there is the endocrine organ. It has microbiota. It has chemicals that come in and chemicals that go out.  This is another major piece of what we have lost in healthcare. The barriers of communication are damaging this other work that healthcare professionals and institutions need to do. They can’t readily move information or coordinate healing processes between the various places and between the people who do the healing. And we would add communication with the faith community.

In contemporary healthcare, we have focused on another part of the system. We are obsessed with the mechanical utility of technology. A robotic surgeon is a super cool thing on which we’re going to spend millions, if not billions of dollars. So, the surgeon can be on Mars and take your appendix out. Wouldn’t that be cool? There’s just a huge amount of energy that goes into that aspect of almost superhuman tech. There is a joke told to residents. The ENT doctor can get rid of the earwax, but they’ll use their laser beam to put the Mona Lisa in there—given what they’re charging. They might as well be creating a work of art instead of just using a saline syringe and getting $10, like the family doctors who do the same thing. Technology is used as a part of what makes things so expensive. Because who knows how much you can charge once a robot’s doing what a human used to do. Should Dr. Bloor add this concern to his growing malaise regarding the provision of medical services?

Intuition, Communication, Catharsis and the Gut

The challenge of technology brings us back to the multiple functions served by the Gut and other bodily agencies associated with the Gut. While there are many tangible functions that we have already identified regarding the Committee of the Gut, there are some less-tangible functions including intuition, communication, absorption, and protection. We conclude this chapter with brief reflections on these often-elusive functions.

Intuition and Communication

Many men tend to say: “That’s what my Gut says.” Whereas a woman might say: “That’s my intuition.” People who are in between might say either one. But there are certain ways that we trust our Gut. We believe in our Gut, and yet we’re oftentimes dissociated from our Gut. We might ask what the sources are of this powerful intuitive function. These sources have to do with communication between the Gut and other parts of our body.

We lean on our Gut to tell every part of our body what is occurring. The Vagus nerve plays a critical role. This nerve is really the communication conduit to assist the peripheral nervous system or the autonomic nervous system in its regulation. This regulation, in turn, directly affects our heart, of course, our Gut, of course, and our neurobiological responses to whatever external stimuli we’re exposed to. And that lays on top of epigenetics and history, and a blunt force trauma, emotional trauma. So, these central organs, the Gut and the Vagus Nerve, relating to the heart and the brain, are so important in terms of how that communication flow happens.

Their critical communication and interaction are not unlike what must optimally occur in a healthcare system. Some central hubs have to be regarded as the centers of communication. They are required if we are to consider all facets involved in someone’s life. Sometimes it’s hard to get mental health to communicate with medical, and sometimes it’s hard for those in mental health to get medical to communicate with them. There are all of these highway blockages in that communication channel. This is very much like what happens as we age. The same blockages occur in the healthcare system. There are efficiencies. However, sometimes those efficiencies, such as technologies, lead to less and less efficient or less protective patient care. But who’s looking at that?

Absorption and Protection

The Gut is an interface. Its job is not only to communicate, but also to protect and absorb. There’s an immune system right beyond the absorptive center. The function of the Gut is maintained by the health of the milieu inside the Gut. And what’s put into the Gut is so incredibly important. The health of the Gut is determined by the diversity of the bacteria in the Gut. So, there is the critical interplay between what people put into their Gut, how it is going through the system, and the system’s absorption.

There is a Salus-P3 opportunity to interact with the health of the people by reviewing what they’re putting in their mouths. What are they eating, and what is the environment like in which they are living? Gut health and population health operate in very similar ways. Many people in health care may be missing that similarity. Just to throw in a couple of facts. 90% of the serotonin in the brain comes from the Gut. Most of the dopamine is from the Gut. Most of the norepinephrine is from the Gut. It travels via the Vagus nerve, which activates the parasympathetic system. This system, in turn, slows down the heart, relaxes us, and is important in the digestion and slowing of the GI tract, making it work together.  Absorption, protection, and coordination walk hand in hand.

Conclusions

In this chapter, we have ranged from the Vagus nerve to immune systems, and from feces and shame to Go Lightly and Enemas. We have considered both the nurturing of a microbiome and procedures that quickly begin a cleansing of the Gut. Over the years, clinicians have used cayenne pepper. They have used coffee. They have used all sorts of things to wrongly clean bacteria out of the Gut and decrease the bacterial count. They have wanted to start over again without realizing that real health is based on what you put into the Gut and that the Gut is doing fine without our clumsy meddling. We now know that our Gut is modifiable and is quickly adaptive to changing conditions in its own gastro-environment. Dynamic changes and health improvement are dependent on how our Gut is treated, and the feedback that our Gut provides to our brain. We must carefully tend to that abundant garden made up of the microbiome of our Gut.

What then do we do about the insights we have gathered into the Gut as it operates in our body and metaphorically as it operates in our healthcare system? First, it is important to note that the bodily Gut and organizational Gut might not just provide an interesting bridge and metaphor. Those who have studied complex systems identify something called Fractals, which are structures and dynamics that repeatedly operate at different levels of any system. The structure of a pine tree, for instance, is replicated in each of its branches and even in each of its needles. Complexity theorists often declare that “Mother Nature” is very efficient (or perhaps a bit “lazy”). She finds things that work in nature and replicates them again and again.

We see something like a Fractal operating in many organizations. Members of the organization become skillful in addressing certain kinds of problems. As a result, they will create new problems that closely resemble the existing ones. These can then readily be solved. For instance, human relations departments often stir up their own human relations problems, and nurses often do a great job of creating their own internal healthcare issues. The HR folks spend time working on their own internal HR issues, while the nurses diligently seek to heal the healthcare damage done in their own department

Perhaps this is the case with the Gut. Its multiple functions in the body might be replicated in the functions provided by a Gut-like system in healthcare organizations. If one of the functions of a healthcare team is to treat their patient’s dis-eased or dysfunctional Guts, then they might be producing (and then try to heal) their dysfunctional organizational Gut. Could Steven Bloor transfer his disappointment with healthcare delivery to an active role in bringing about improvement in this delivery?

At the heart of the matter is conversation and change. The matter of a dysfunctional organizational Gut, like that of a patient’s dysfunctional Gut, must be addressed openly. While products of the Gut might be distasteful for some people (whether this product be feces or fee-for-service), they must be incorporated into all discussions regarding the health of a patient or the health of a healthcare system. You have to make it a conversation before you can hold on to it and expect change.

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Chapter Four

Salus Perspectives, Policies and Practices

Often, nobody’s looking at their Gut or their constitution based on all things, biological, mental, and neurobiological challenges. The system is clogged with information and actions that do not relate to one another. Nothing is synthesizing (digesting) this information, coordinating these actions, or addressing the outcomes (products) of this dysfunctional system.

It seems that the Gut serves many functions and operates as both a mirror that provides information to other parts of our body and as a motor that generates the energy to drive our body. Furthermore, our Gut is both an Assimilator that converts food to energy and an accommodator that acknowledges shifts in the body’s status (“gut feel”). In many ways, our Gut operates like a committee that meets diverse needs in our body and coordinates these needs.

Viewed from a systemic perspective, the Gut is not a passive organ but a self-organizing center.

We have identified six members of the committee. There are undoubtedly additional functions. However, our preliminary list should provide us with a vivid image of the many functions being served by our Gut.

Healthy biological systems require not only intake and generation, but also filtering, integration, and elimination. The Gut teaches us that survival and renewal are inseparable: you cannot grow without also clearing space.

The assimilative process of an organization’s “Gut” is found in the Culture of the organization. The Climate of the organization represents the current state of the organization’s Gut.

In an organizational setting, too much accommodation results in too many new entities from the outside environment to process and adjust to. We can introduce additional warriors in the organization (those fighting for the good cause). The introduction of probiotics. We may change the product or service we are delivering in the organization. However, this doesn’t change the toxicity. The disease remains even with a change in the “character” of the organization. The toxic Gut remains in place. The culture remains in place even with a temporary change in climate brought about by new leaders, changing polices, or new compensation systems.

Is our organizational Gut a central organizer? Or is this function served by our Brain? Perhaps the central organization takes place as an alliance between Gut and Brain. It is even more likely that there is no central organizer. Our body may be self-organizing.

Our integument or our intestines are actually connected to each other; however, there are no connections in our health system. It’s disjointed. It would be as if part of the bowel had been resected and no one sutured it up. So, a lot of spillage happens. We can imagine people in a health care system flowing through this broken system.

It is indeed unfortunate that we have culturally overlaid many negative features on excrement, whether it has to do with coming out the end of our colon, or coming out of our pores (sweat and other body “odors”). Perhaps negative impressions are assigned to our feces, tears, and sweat because each of these vehicles for bodily elimination is associated with a deep source of shame for each of us. This source is Anxiety.

The Gut is an interface. Its job is not only to communicate, but also to protect and absorb. There’s an immune system right beyond the absorptive center. The function of the Gut is maintained by the health of the milieu inside the Gut.