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Monday, May 31, 2010

Is the practice of medicine best done as an individual or group activity

I am reading David Sloan Wilson's "Evolution for Everyone". I first heard of him through a lecture I found on iTunes University which prompted me to buy his book. It is well worth reading. One of the basic tenants of the book is that one of the key developments in human evolution was the development of tools which furthered human cooperation. These included both physical traits such as highly visible eyes with stark contrast between iris and sclera, personality traits, and cultural norms which favor group v. personal accomplishments.

I happen to practice medicine in an academic health care setting. Academic success and promotion are predicated almost exclusively upon personal accomplishments. The hard currencies recognition are "my papers' or "my grants". Outside of scholarly activities, the clinical metrics are also very individually based. The sad truth in the clinical realm is that clinical excellence simply does not exist by any measurable metric. Yes, when the president of the University has a friend or family member who needs the best care, everyone knows who they should see, likely a solid if not stellar clinician not otherwise recognized. Those within the clinical realm are otherwise recognized by individual metrics of gross billings or RVUs. There are not other measurements which might assess how well they facilitate the functioning of those around them.

The model is pretty clear. Measure and reward on the basis of individual accomplishment and hope that this translates into success at the level of the group. This is simply wishful thinking. As David Sloan Wilson points out, virtually all moral codes throughout the world are successful because they value behaviors which further the ends of groups as opposed to individuals.  In particular, physicians view themselves as a world apart. We attempt to select for extraordinary intellect and assumes that this will translate into some sort of higher moral judgement. However, the feedback on the individual metrics is persistent and consistent while the feedback on the group success is virtually non-existent.

In my environment, at least I am surrounded by colleagues and trainees, although not always when I may benefit from their insights and input. When evaluating a patient in a time constrained context,  inputs from other physicians, trainees, and staff would likely improve the quality of diagnostic assessments. In very elegant studies of group v. individual decision making using a "twenty question" model of analysis, he found that stellar individual performers almost never translated into outstanding group performance. Furthermore, those participating as individuals found it less gratifying than those participating in groups. Yet, I see the practice of medicine as increasingly being practiced in isolated ambulatory settings as solitary endeavors, whose success is measured by tabulation of measurable but irrelevant metrics.

Einstein is to have said that:
If I had an hour to solve a problem and my life depended on it
I would use the first 55 minutes to formulate the right question
because as soon as I have identified the right question
I can solve the problem in less than five minute
 Humans as a whole have triumphed because we have acquired the tools and inclination for cooperative activities. Within medicine, we have adopted a culture and metrics which value and overwhelmingly reward individual accomplishments which further individual ends alone, many of which are irrelevant or destructive to success of the whole. We in academic medicine who have been placed in the position of training future clinicians and scientists and modeling behaviors they can and should emulate. I maintain that we are making a fundamental error by doing this within a culture which explicitly values individual achievement and self promotion above everything else.

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