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Saturday, July 21, 2012

Failure of our intuition

I colleague of mine sent me a link to a Medical Grand Rounds at Emory University dating back to 1971. I recorded a presentation made by a Dr. Lawrence Weed, who is credited with the conception of the problem oriented medical record. The presentation is well worth listening to. For those who do not want to listen to the hour long video (highly entertaining as it might be), he has written a follow up in the British Journal of Medicine almost 30 years later which eloquently states his case -

What I was struck with is how relevant his presentation is today. It is almost as though the concepts presented had been completely forgotten in the interval of time since 1971. I was trained ostensibly on the problem oriented medical record but it was never presented in the cogent way that Dr. Weed presents it in this 1971 video. It never quite sunk in, at least in medical school. I basically forgot any lessons that I may have been exposed to and it is only much later in life that I have begun to think about the purpose of the medical record. Thus, I have taken my own medical journey and oddly enough, I have ended up in place very similar to where Dr. Weed was encouraging his medical colleagues to travel back in 1971.  

Dr. Weed recognized early on that what was then the current practice of medicine was fundamentally flawed, not because its practitioners were any more flawed than people involved in other endeavors,  but because they were equally flawed. Progress in human systems is facilitated when success is not strictly dependent upon the activities of extraordinary people, but instead is made when systems are created which make things happen independent of the input of of such people. They work when ordinary flawed people are involved. 

What Dr. Weed posits (and I believe he is spot on),  is that contemporary medicine combines the use of global snap judgments by physicians with few mechanisms in place which feed back to inform them when they are wrong. He sees the fundamental problem as being an information problem. Information is not systematically collected, organized, or evaluated as part of decision making and assessment of success or failure. When medicine was dealing with hard outcomes which occurred rapidly after interventions, this was not an issue. Success was measured by patient living or dying in short order. 

Much of medicine is not blessed with such unambiguous outcomes now. Even short term measures of life and death may not be particularly relevant to the overall measurement of success or failure. Fulfilling human goals as a provider of health care is much more nuanced now and our tools to assess success or failure are not up to the task. To make matters worse, we are oblivious to how inadequate they are and the basic concepts of measurement and feedback are not at all embedded in how we think and what we value. Intuition is great as long as you have the tools in place to determine if your intuitions are deceiving you. 

Why has so little progress been made? I believe much of the blame can be assigned to the payment structure which over the past 60 years has become focused on doing discrete things to patients with timelines of success measured by getting paid and getting patients out of the hospital. It has had a bias toward action, whether effective or not, whether harmful or not. It is important to do something, preferably something for which you will get paid. Why bother with rigorous information collection and evaluation when its most likely effect will be to disrupt your revenue stream. 

There is widespread recognition that this model is broken and needs to be fixed. However, fixing this is no trivial undertaking and suffers from some of the same problems as the practice of medicine itself. How can we know what is working? It depends upon what you can measure and at this point the most measurable of element is money. Even that is not so easy. Is success measured by spending less or by cutting the rate of growth? From a microeconomics perspective,  systems which save money b doing less may find themselves in financial duress in the short term.  In the long term, there will undoubtedly be cuts but how can we determine whether cuts are too draconian when we are not so clear how to measure outcomes and whether our interventions actually add value to patients? 

We are at a cross roads and continuing on the present path is not a long term option unless you are content to bankrupt the nation. The insights needed to identify the best path forward will be created by information which guides us by defining what that we do that provides the most value at the least cost. Our intuition has failed us in this domain and it is time to get new tools.

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