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Sunday, February 3, 2013

Are entering into a post-truth age of medicine?

I read an interesting essay by Ronald Bailey at Reason.com entitled "Do we live in a Post-Truth Era?" (http://www.washingtonpost.com/wp-dyn/content/article/2009/01/26/AR2009012601850.html)


I have to admit I was initially perplexed by such a title, but I read the essay nonetheless. Bailey touches upon the work of Horst Rittel and Melvin Webber who forty years ago made a very insightful distinction between lame and wicked social problems. This is work which I have previously highlighted almost four years ago. (//georgiacontrarian.blogspot.com/2009/06/health-care-super-wicked-problem.html) Wicked problems often involve high stakes domains such as health care. It does not get much more high stakes than life or death, health or sickness, function or dysfunction. However, because there are no right or wrong solutions to wicked problems, only potentially better or worse approaches (and even those distinctions are murky depending upon the outcomes measured and the time points examined), addressing wicked problems is invariably fraught with contention and disagreements, most of which can never be settled by finding the "truth".


Recent history is replete with examples where people and groups takes sides on particular issues, obtaining funding from like minded foundations (or the government), and hiring their own form of expert mercenaries. These efforts are generally not devoted to find any form of truth but instead are directed to affirm what they already believe. As Bailey notes in his essay:



Progressives who believe that corporations are unfairly denying workers a living wage can point to research by analysts at Institute for Research on Labor and Employment to argue that higher minimum wages do not increase unemployment. Free marketeers can turn to the Employment Policies Institute for evidence that boosting minimum wages increases unemployment among the youthful and poor. The pro-immigrant Migration Policy Institute can report that Washington "spends more on its immigration enforcement agencies than on all its other principal criminal federal law enforcement agencies combined." The Center for Immigration Studies, which favors strict immigration enforcement, can denounce the study as "bogus" and "riddled with false statements, cherry-picked statistics, and inappropriate comparisons." Climatologists at the University of Alabama in Huntsville can assert that the atmosphere "has not warmed noticeably since the major El NiƱo of 1997–98—giving us about a decade and a half of generally stable temperatures." Researchers associated with the Potsdam Institute for Climate Impact Research can report that the warming rate has been "steady" since 1979.

Bailey cites another recent essay "Wicked Polarization" by Michael Shellenberger and Ted Nordhaus, also worth reading. In this piece the authors also draw upon Rittel and Webber's original work noting:
The result, Rittel and Webber suggested, was neither the end of ideology nor the end of expertise but rather the continuation of ideological battles on new, more expert terrain. Criminologists might agree that the crime rate had gone up or down but would disagree over whether crime is caused by poverty, racism, the prohibition of drugs, the weakening of traditional moral values, or too few police officers. Any and all of those arguments can be supported empirically. With crime, as with so many other issues, myriad overlapping influences confound simplistic efforts to define causality.

I was struck by the how applicable their observations are to the world of medicine and health care. Health care is absolutely riddled with wicked problems. No other realm is so populated by experts touting the latest truth de jour. Does mammography, PSA tests, or total body skin exams benefit patients? What about treatment of hyperlipidemia or modest hypertension? What about the usefulness of high imaging, cardiac stents, anti-depressant use, to raise but a few. The answers you receive will depend upon what experts you ask what what biases they have, what end points you look at, and in whom you examine these measures. It also depends upon what patients ultimately want from the industry we designate at "health care", which is increasingly integrated into every other industry and service which address human needs and wants. It appears very unlikely that data in the form of outcomes research and and experts will provide unambiguous answers. You need only to look at the controversy triggered by the US Preventative Services Task force in 2009 by their recommendations regarding screening mammography.

I have to admit that up to this point I viewed finding truth in medicine as difficult but possible, limited only by the ability to collect sufficient information on enough individuals over time. I viewed these challenges as perhaps unlikely to be accomplished but essentially possible. I am not so sure anymore and I now suspect that we can never get to actual "truth" in regards to many of the issues we are grappling with in health care. I now have begun to believe that we are entering into a post truth age in medicine.
The challenge we face is how to adapt to such a world. Shellenberger and Nordhaus note:
The problem is not that we are in a post-truth age but rather that we have not learned to adapt to it. Perhaps a good place to begin is by recognizing our own biases, perspectives, and agendas and attempting to hold them more lightly.

One of the major limits to adapting is the increasingly partisan nature of the environment where these issues are addressed. Nowhere is this any more apparent than in the world of health care. Disagreements in the marketplace are settled by consumer choices and these decisions are immediately constrained by resources which are available to individuals or voluntary associations. This provides a reasonable stopping mechanism when addressing a wicked problem, providing at least some assurance that resources will no longer be directed to a particular problem or problems when the investment has reached a point of diminishing returns. When one appeals to people free to invest or spend their personal resources and it does not really matter how partisan the disagreements might be. However, move these issues into the political realm and unlike the market based world, the end game results in a more difficult environment to have expression of individual preferences.

As health care financing has moved more and more into the public realm and the sums of money involved have become more and more staggering, the discussions have become hyper-polarized and partisan, and our prospects of reaching any form of truth ever more remote. Furthermore, as the financing of public goods is less and less immediately constrained by financial resources through the illusory magic of borrowing from future generations of yet to be born, spending on wicked problems, particularly health care wicked problems, runs the real risk of consuming our entire economy. Such wasteful diversion of resources is less likely to happen if private entities are responsible for making such investment decision. When private entities make bad investment decisions they tend to quickly disappear. The same can be said for governments but the time lines may be be very much prolonged and the impacts of failure much worse.


Then how do we adapt to a post-truth age in health care? I don't really know the answer to that question but I suspect that it depends upon who (or what) controls resources which are directed at wicked problems and whether decisions to allocate resources are made at the local (individual) levels via individual decisions or are made via governmental entities through political processes. Stay tuned for more...

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