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Wednesday, July 28, 2010

Wikileaks, Military reports, and office notes

There was an interesting Op-Ed piece in the WSJ on the military reports leaked to the public through Wikileaks by Noah Shachtman. He describes the difference between what was recorded in these reports and what actually happened.

The vast difference between what actually happened at the Moba Khan compound in Helmand province and what the report says happened there should give caution to those who think they can discover the capital-T truth about the Afghanistan conflict through the Wikileaks war logs.
It should also give pause to those officers in military headquarters who rely on these updates. The military has a problem in how it talks to itself. These reports—ultra-compressed and focused solely on the bombs-and-bullets part of the war—are a symptom of that shaky reporting system.
He went on to say:

That's not to say Echo company hid the truth. It's that these reports from a harried commander at the farthest edge of the war zone are by nature clipped, compressed, clunky and incomplete. But they also made their way up the chain of command. At the Marines' provincial headquarters at Camp Leatherneck, this was one of the primary methods by which officers were kept apprised of Echo company's actions: number of rockets fired, number of enemies killed, number of bombs dropped. Next report.

In a counterinsurgency, such metrics often matter least. A counterinsurgency is a contest for the loyalties of the people. Munitions expenditures and body counts are, at most, tangentially relevant. More important is insurgent motivation, the mood of the local shopkeeper, and the local farmer's ability to bring his crops to market.
 I was struck by the how this sounded like the documentation we use in medicine. Not that anyone is shooting at us but like the soldiers, our primary job is not documentation and the documentation we do is under harried conditions. We record objective information which tends to be both objective and recordable, although often irrelevant to actual good medical decision making. It increasingly is serving as the basis for metrics to assess quality and safety, and decisions regarding allocation of scarce resources. Where the military fails to capture information crucial to the local shopkeeper or farmer, in medicine we tend to overlook information which is important to our patients.

While the military does a stellar job at assembling data to target its enemies and rearm its troops, it still has problems processing this other kind of information, which is the most crucial to the war effort. Even the top U.S. intelligence officer there thinks so. "Having focused the overwhelming majority of its collection efforts and analytical brainpower on insurgent groups," wrote Maj. Gen Michael Flynn in a report earlier this year, "the vast intelligence apparatus is unable to answer fundamental questions about the environment in which U.S. and allied forces operate and the people they seek to persuade."
Any time a signal gets compressed, information is lost. Think about the difference in sound quality between a live rock show and an MP3. Think about a news report of a political rally, and the feeling of actually being there.
In health care, what information we record tends to be similarly compressed and what is documented is primarily what is needed to justify the bill and stay out of legal trouble. We have serious troubles using medical records to talk to ourselves. Medical records are generally next to useless as communication tools and the electronic medical record is not improving this aspect of communication.  It is the body counts all over again.

1 comment:

  1. Chauncey McHargue M.D.July 31, 2010 at 10:42 PM

    There are even broader analogies here to the military ops/medical practice information-intelligence-decision making loop. First and foremost I don't think this editorial gives sufficient due to the fact that the fragmentary information conveyed in the field is received and assessed by professionals with identical backgrounds generally with the requirement that those higher up receiving the information have been in similar front line situations. The need for detail in a tactical situation is not crucial. Similarly in medicine when I'm dealing with a serious acute problem I trust that the resident is providing a cogent synopsis of what I need to know to render advice, make a therapeutic decision or simply affirm his or her decision making and tell them to carry on.

    Secondly, as with medicine, when your troops are too few and spread too thin, and often burdened with non-essential tasks keeping them from the front lines, you tend to deal with the most immediate and acute threats. "No better friend, no worse enemy" is the informal Marine Corps motto and if not being shot at then providing medical care to the indigenous population, rebuilding infrastructure, etc. is an operational task and facilitates combat operations by generating local support. But that is hard to accomplish if you have not secured the area you wish to establish such support and that takes manpower. In the first two years of medical school we are taught to approach the patient from a wholistic perspective considering the social, familial, psychological and other aspects of their disease beyond their physical illness. Then we hit the wards where we are under fire from day one to manage physical illness and the consequences of not doing that well for patients, and your career, may be profound. Add the burden of non-essential tasks to meet regulatory, reimbursement and medico-legal requirements and learn how that EMR systems works, and resignation or cynicism sets in among students and residents forming a lifelong perspective on just what medicine is really about. Determining what is of value is dictated by many factors extrinsic to the actual healing of patients, and the first thing to go in a rational physician's calculus of value is anything beyond a patient's immediate problem and meeting the minimal requirements of those extrinsic demands.