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Sunday, April 28, 2013

The power of self correcting systems: why feedback is essential for the creation of enduring entities

I remember when I was a trainee at the NIH seeing two brothers from South America with a rare disorder. They were born with the absence of nerve fibers allowing them to feel pain. They were young adults, having survived chuldhood..sort of. They had no fingers, toes, lips, or nose. They were missing a key system that provided them with critical feedback in real time and as a consequence, their physical structure became seriously degraded.

Pain of some sort is a crucial element of any system or entity which aspires to be enduring. There will always be places where we should not go and activities which we should not undertake.  A world without pain (or at least without sufficient pain) would be a world without necessary feedback. It would be a very dangerous and undesirable place.

We have examples of where particular individuals have ended up operating in niches where they have received insufficient feedback of the negative variety and ultimately ended up in very bad places. A recent article in the NYT described the rise and fall of the career of Dr. Dietrik Stapel ("The Mind of a Con Man"). The article, written by YUDHIJIT BHATTACHARJEE, describes a Dutch social scientist who fabricated data over the span of two decades. As noted in my previous blog, the Roman playwright  Terence noted, “One easily believes what one earnestly hopes for”, and by all accounts, Dr. Stapel's work tended to cater to the belief systems of the social sciences world.

Science is supposed to be self correcting and I guess if one thinks about the time in the geologic sense, Dr. Stapel's career and the errors he has created were discovered fairly quickly. However, my question is how many Stapels are out there fabricating data and remaining undiscovered. Stapel's problem may have been he to was too successful and ambitious.

In medicine and biomedical research, we have had our share of con artists. John Darsee had a meteoric rise as a resident and cardiovascular researcher at Emory University in the late 1970's, landing him a Harvard faculty position. When his work was scrutinized, evidence of falsification of data went back over 15 years and at least at three different institutions. Feedback to Darsee was almost all positive, based upon his remarkable (and unrealistic) productivity, viewed with an uncritical eye. Despite what the phone commercials may say, more is not always better.

One of the problems with feedback is that measurement tools available fall back upon simple and measurable things; almost always money. Take for example two more contemporary individuals; Bernie Madoff and Dr. Midei. In the case of the former, he was clearly a scam artist who thought he could get away with fraud forever. What people focused on were Madoff's rates of return and they assumed he was a genius. As it turned out he was a crook. Madoff's feedback was almost all positive until it was not. One must think he woudl have some sense that he could not keep this up forever. However, I suspect that he did not have a good sense of just how long a human lifetime is and that it is longer than he could keep dancing and deceiving.

In the case of the latter (Dr. Midei) , it is more nuanced but provides perhaps an even better justification for improved feedback loops in medicine. Dr. Midei was a celebrated interventionalist cardiologist until he fell afoul of Medicare. I previously blogged on him (Radio-fence-principle).  In an excellent article in Forbes (Mark Midei Can't Get a Job Taking Blood Pressure At A Walmart - Larry Husten), one gets perhaps a more sympathetic view of Dr. Midei. The article touches upon the peer review process, which was actually set up by Midei at St. Joseph's Hospital. Here was a process by which physicians like Midei could garner feedback.
I asked Midei about stories I had heard from a cardiologist who had attended the conferences who said “he could never see the lesions before a stent went down the coronary artery.” Midei responded that it was “regrettable that that comment wasn’t raised at the conference, that’s what the conference is for. There were many times when controversial issues were raised.”

I asked Midei about the issue in another way, if he understood that it may have been extremely difficult, given Midei’s power and position, for colleagues to criticize his work. ”I get it and I know how you get around it, which is randomized, blinded review.” But, he pointed out, prior to his case this type of review was never performed. “Nobody else did it at the time.” He added: “they all do it now.”
The article touches upon the broader environment which Midei was embedded in. The author goes on to note:
I asked Midei whether, in response to the overwhelming amount of positive feedback he had received over many years, from his colleagues, the hospital, and the medical community, it was possible that he might have developed the feeling that, godlike, he could do no wrong, and that almost anyone could benefit from his procedures. But, he said, “they’re not accusing me of pushing the bounds of intervention, they’re accusing me of exploitation of patients. But that’s not me, that’s just not in my DNA.”
With this answer I’m not sure Midei really responded to my question, but he did answer it somewhat obliquely a moment later, agreeing that the standard of practice had changed over time: “I know what the standard is now, and it’s different from what it was then. Even in 2009 after the appropriateness criteria were published my practice had changed.”
At this point he made an important concession: “so it’s impossible for me to look back at some of these cases and say” that they would all be justified today. “It’s possible that things look different today than they did then.”
But Midei insists on a key point: he is very confident that his standards were “no different” than the standards at St. Joseph’s and other hospitals. 
While the excuse that "everyone else was doing this" should not be an excuse, it does underscore the broader feedback loop environment sending signals to individuals such as Midei. The signals he received were essentially all positive until they were not.  Dan Areily's work underscores a basic human tendency to stretch the truth and we have to understand that there exists a spectrum of individuals. We all have an element of con artist in us. For us to thrive, we need environments which provide us with consistent and timely feedback when we have pushed the envelope. It may seem painful at the time but it does not approach the pain we will experience in its absence.

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