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Saturday, December 15, 2012

The Pain of the Hedgehog

In today's Wall Street Journal, there was a very interesting article focusing on Dr. Russel Portenoy. (Portenoy)  Dr. Portenoy was a instrumental driver of a movement in medicine to address the under treatment of pain. I remember this movement at or near its inception and have to admit it made sense to me at the time and for the most part, it still resonates, although mostly as it relates to acute pain.


Early in his career Dr. Portenoy had a big idea. He noted that opiates were extremely effective in the management of pain in patients affected with cancer. He envisioned that these drugs could be used in a much broader clinical context to treat chronic pain in patients who did not have cancer. He was very smart, and very articulate and these elements mixed with his passion for for what her believed in catapulted his agenda to the front and center of medicine and the public. He changed how medicine was practiced.

He was a hedgehog. Isaiah Berlin in his essay the "Hedgehog and the Fox" borrowed from the Greek Archilocus, to divide thinkers into two categories, hedgehogs and foxes. Hedgehogs believe single defining ideas while foxes draw on a much larger set of experiences and hold more skepticism that we can place as much stock in any single idea. Hedgehogs are much better positioned to move the needle on any given issue. They are better advocates because they tend not to be distracted by anything, including evidence which fails to support their big idea.

Dr. Pourtnoy overcame resistance to wider use of opiates using his powers of persuasion to convince skeptics that the dangers of opiate use were overstated. He believed at the time that the evidence did not support the concerns which had long limited their use. While he may have correct that the evidence did not support the dangers, his hedgehog biases also blinded him to the lack of evidence supporting their safe long term use. He confused strong belief with strong evidence. To his credit, he now appears to have recognized that his efforts have resulted in substantial unintended consequences and he would not have pursued the same agenda if he knew at the movement's inception what he now know now.

The world needs both hedgehogs and foxes. Too many foxes and no one will pursue big and bold ideas. However, too many hedgehogs results in too many big gambles. Furthermore, it also makes a difference where the hedgehogs and foxes reside.


Within our world, we have people who are early adopters and others who are late adopters. That mix is great for creating "unfragile" entities. Early adopter can hit it big or can go down in flames. Late adopters can be so conservative that they relegate themselves to oblivion or they can serve as a reservoir to repopulate after the early adopters have done something crazy. It works because you have diverse groups hedging their bets in lots of different ways.

However, put a hedgehog in a position of authority and in charge of some entity which can compel others to uniformly embrace big ideas and you remove that diversity of response. In the world of pain management, the hedgehogs captured the power of medical licensing boards and used coercive tools to push their big idea.

I have to admit I have my hedgehog tendencies, particularly relating to the deployment of data and data tools in medicine. It is my big idea (although do not take that to mean I conceived this). I think big ideas are fine as long as they are pursued within a particular framework. First, if at all possible, big ideas need to be pushed out within an environment where people have the right to decline them. No matter how good the idea sounds, it is desirable to have cadres of people who are free to reject them and exercise that freedom, even if they appear to be stupid at the time. Second, big ideas should be deployed in an environment which has feedback loops already in place. The concepts of improvement and  progress are meaningless if there are no mechanisms in place to define where you started from and where you ended up. Finally, understanding success or failure, improvement, and unintended consequences often requires a time frame which is beyond the attention span of individuals or individual human lifetimes. What appears to be success after a few months or years, can translate into disaster after a few decades.

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