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Sunday, July 29, 2012

Not all bad outcomes need to be addressed with fundamental changes

Our lives are punctuated by dramatic episodes of, both dramatically positive and dramatically negative. The recent episode in Aurora, Colorado fit this description. The details are incomplete but the story follows a familiar thread. A young man, suffers a life set back and responds by killing or injuring many others in a public place. The fall out is predictable in that there is an immediate desire to assign blame and find a quick fix so as to make it impossible for this to happen again. In the lexicon og patient safety world, the should be a "never" event.

The problem is that in order to assign blame in any sort of functional way, one needs to understand actual causality and in order to understand causality, one needs to live in a world where one can predict events with some degree of accuracy. The world is not such a place. Granted, one can define a profile for who might commit such an act but there are tens of thousands if not hundreds of thousands (if not millions) of people who could be made to fit the profile. You can take about restricting access to the materials which are possibly dangerous and could be leveraged by such individuals. Again, such efforts can be undone by bright and perversely motivated human beings, of which there appears to be no shortage.

This reality then begs the question, "What to do when our lives are punctuated by spectacular events, either good or bad?" We don't think much of it when someone's life is randomly affected by some event is a positive way. Someone who has been living on life's edge who wins a $100 million lotto is lifted out of poverty. This is a random event but hardly should serve as an example to guide us on how to create incentive structures to help guide others out of such life circumstances? It would be wholly unwise to use this an a guiding principle to re-engineer law and society to improve overall welfare.

Similarly, when we observe spectacular bad outcomes, it may not be wise to respond based upon the assumption that the outcome is a result a something being fundamentally broken. The tragedy of such responses is that they often occur because our outrage as an immediate aftermath of the events creates the incentive to do something quickly, before we can possibly understand what happened. These responses are also predicated on the assumption that we must do something because we can't possibly make things worse or create new problems, an assumption which is often tragically wrong.

We witness natural disasters such as fires or floods. Prominent politicians showboat by doing dramatic fly-overs and legislators do what they do, passing new laws. The net effect is they create the illusion that the state can domesticate nature and insulate people from such events. Often the laws they pass and the regulations that follow actually make the situation worse. They create federal flood insurance that prompts people to build in flood plains. They create financial backstop rules that prompt people to take greater financial risks.

Risk is an inevitable element of human existence. Risk comes as a consequence of our inherent inability to predict the future. This is both a good and bad thing. The positive element of our inability to make predictions is that the future holds a promise of being better than the past. It also hold a promise of being worse. The range of possibilities from spectacularly good to spectacularly bad is driven by the actions of individuals, acting alone or in groups, following well tread paths or trying paths that are new, different, and possibly risky.

We have made such strides in the past two centuries regarding the improvement of human existence (although their deployments have been spotty) that we have developed a skewed view of the where we have come from and what expectations are possible. In the developed world, life expectancies have soared and yet, we act as though our world and life styles are vastly inferior to our ancestors who on average lived decades less than we do today.  The almost universal response to any new "crisis", which occur on an almost daily basis, is that we need more rules, more laws, and a greater role for the state in forcing people and non-state entities to do things is an increasingly constrained way. This path is driven by the assumption that the world is perfectible, if only enough rules made by smart people could be put into place. There will never be a shortage of bad events which happen which can serve as a constant  driver of this trend. It can and should be resisted. 

This thinking also makes its way into the practice of medicine. What we do and how we react is driven by spectacular anecdote more often than we are likely to admit. We talk about defensive medicine being driven the medico-legal environment but my perception is that the medico part came first and the legal response came later. We are taught from a very early stage in our careers that often vague clinical circumstances are to be viewed with great concern. These vague circumstances (e.g. -fever and rash, headache to name just a few) share certain characteristics. They are likely very common but their actual prevalence is unknown. The clinical characteristics of those with dangerous disease overlap almost entirely with those with banal disease. There is no way to consistently separate out the two groups with any reasonable precision.

In the same way that bad outcomes in the non-health care realm drive the adoption of new practices and rules, a similar set of events tend to play out in medicine. A single patient who develops a bad outcome after presenting with a non-specific complaint may result in wholesale changes in how patients are managed. This may result in huge changes in how scarce resources are allocated, which tests are done, and which treatments are deployed. Similar to the responses described above to natural and financial calamities, all of this is predicated on the assumption that more is always better and interventions, which may turn out to be useless, can be deployed at zero cost and without unintended consequences.

As people spend more and more money in the health care realm, we within the health care industry have a vested interest in promoting our crafts as being very powerful and impactful. It is very difficult to respond to the public when bad things happen with the message that events are beyond our control, even if that were the case and we were wiling to admit it. Such admissions may prompt the public to invest their resources in other realms where they perceive a better rate of return. That potentially would be unwise, unless in fact the public's investments in other things actually yielded better returns than an investment in health care. Perish the thought.

We share certain similarities with those within the political sphere in that we can leverage any bad outcomes to our advantage, preying upon the fears of the public and claiming that an investment in our industry is a useful approach to limiting the chances of similar bad outcomes  in the future. There is no question that we will have an almost unlimited set of opportunities to harness for our marketing advantage. However, should we reflect for at least a moment as to we should take advantage of the opportunities that the world will afford us? When we push to respond to spectacular anecdote, is the world better off? Does investment in health care result in the best return for the public or are there better places to put those resources?


  1. I agree with the basic points that the rush to regulation is inappropriate, and that regulators can do intentional or unintentional harm by manipulation or application of regulations. And yes, sometimes the regulators do more harm than would have come about in the absence of regulation. And it is indeed unfortunate that much of the population does not understand the nature of risk and prefers "definite answers" to many questions.

    I take issue with a couple of points:
    (1) "Granted, one can define a profile for who might commit such an act but there are tens of thousands if not hundreds of thousands (if not millions) of people who could be made to fit the profile. You can take about restricting access to the materials which are possibly dangerous and could be leveraged by such individuals. Again, such efforts can be undone by bright and perversely motivated human beings, of which there appears to be no shortage."
    For the particular issue of firearms, there is a simple solution that does not require implementation of "profiling" that could be nefariously manipulated. Access to firearms could be restricted for *everyone*. The United States is in a small minority of "Western" societies that allows the public access to such weapons, and it is not clear that any benefit derives from it.

    (2) "A young man, with less than optimal social skills, suffers a life set back and responds by killing or injuring many others in a public place." This cavalier characterization of the individual's mental illness is like calling someone with a glioblastoma multiforme a "person with a neural problem", or someone in catastrophic adrenal crisis a "person with an endocrine problem" or someone with recessive dystrophic epidermolysis bullosa a "person with a skin problem." While the extent of his mental illness does not mitigate the massacre that he perpetrated, I think it's important not to minimize the severity of any individual's circumstance or illness.

  2. The gun control issue is not so simple. There is the small issue of a constitutional amendment which protects the right to bear arms and the inability to control contraband such as illegal arms which can cross borders. Furthermore, troubled young men (and women) use other more destructive and ubiquitous technologies such as explosives to wreak havoc.

    The glioblastoma analogy is off base. You have the arrow going in the wrong direction. I do suspect that many of GM sufferer may initially present with neurological symptoms such as a headache but to act as if everyone with a headache should be treated as though they had a brain tumor is folly, even if in the rare person it turns out to be the case. The situation in Colorado is terrible and tragic but to initiate stupid policy in response only magnifies the tragedy.

  3. My "simple solution" comment was misinterpreted to mean that the solution would be simple to legislate. I only meant that the solution would be simple in concept when compared to the easily corrupted and difficult to implement "profiling" that you discussed. While the constitutional issue is significant (and certainly difficult to overcome), the personal right of an individual to have firearms was only recently (in 2008) identified by the Supreme Court (District of Columbia v. Heller). It was a narrow 5-4 decision, but nonetheless remains law. I was simply stating my own opinion that such a right should be outweighed by the horrible loss of life that has occurred (which is essentially what at least one of the dissenting arguments in that case held). At this point, you are correct that outlawing personal possession of firearms would require a constitutional amendment or a decision by the Supreme Court to overturn Heller (both indeed difficult). As for your point that troubled young men and women can use other more destructive and ubiquitous technologies such as explosives, I'm not sure that this is correct. I don't have hard data on this, but guns seem far more ubiquitous to me than explosives. I have (in some states) seen guns for sale at Wal-Mart. I have never seen explosives for sale anywhere. And while explosives can be made from readily obtained material such as fertilizer, we do not see (in the US or in countries that forbid the possession for firearms) significant use of this method. While it's certainly true that people with malevolent intentions can find other ways to realize their goals, it is not unreasonable to make it more difficult for them to do so. From a statistical standpoint, it would likely mean fewer heratbroken families and ruined lives.

    It seems that my point about GBM was also misunderstood, although in this case I'm having difficulty understanding how. No argument was made about assuming that people with headaches have GBM; no arrows were drawn (or shot). I *certainly* did not say or even imply that people with common mild symptoms should be assumed to have rare fatal conditions. All I said was that I find it inappropriate for anyone (especially a physician) to cavalierly describe someone with a known serious illness in a dismissive fashion. In this sense, the analogies were appropriate. I gave examples of other serious illnesses being described in a dismissive fashion. There was no implication that "stupid" policies should be implemented. In fact, I explicitly agreed with you at the beginning of my response that the regulations being advocated in the current environment are not well-founded.

    I would add that the horse is somewhat out of the barn here. Federal legislation barring gun ownership by certain categories of mentally ill patients has been around for decades. In 2007, Congress attempted to make it "easier" for federal agencies to obtain information about potential gun buyers from state authorities. The implementation of this law has been quite uneven, varying significantly by state. This may be sufficient proof for your that this type of legislation is ineffective.

  4. Thank you for your engagement and comments. I am not prepared to weigh in on the merits of gun control legislation. I hold no strong views on this and do not believe that we will see any broad implementation of national gun control legislation in our lifetimes. I have read viewpoints on both sides and I am not able to discern whether gun control is either possible or desirable. If you have a desire to write a guest blog on this site, consider this an invitation.

    It was not my intention to trivialize the tragic events in Colorado. It was only my intention to highlight that the events leading up to the tragedy were not particularly extraordinary or unique. I believe that the exceptional nature of this young man could only be identified after the event, not before.

    My world view which shapes my actions is that the world can be dangerous and unpredictable and similarly people exhibit the same elements. Bad events happen and some are essentially unavoidable. As Richard Epstein wrote in Simple Rules for a Complex World, bad outcomes are compatible with good systems (paraphrased).

  5. Thank you for the invitation. I will give it some thought, but I doubt that I would have the readership to justify the investment of effort.

    My point about the Colorado shooter is that this is in fact not the case that the events leading up to the tragedy were not particularly extraordinary or unique. While I agree with your overall thesis that bad events happen and some are essentially unavoidable, that was not the case here. A truly extraordinary event that could have led to the discovery of the exceptional nature of this young man occurred before the event. His psychiatrist notified the local police about her concerns that he may be dangerous to others. While a casual observer may have viewed him as " A young man, with less than optimal social skills, suffers a life set back (sic)," law enforcement was made aware of the potential for grave harm by someone bound to confidentiality except under the rarest of circumstances. While the details remain unclear, this case is not a good example of the overall point.

  6. We will never know since no one acted ahead of time. You might want to consider the date of the blog and the date that the information regarding the psychiatrist became public. I wrote it before any of the information relating to his psychiatrist became public and I have not been following the story closely since. I really was not aware of all that has transpired subsequently and given those events, I must admit that you are correct that the language I used trivialized the event. It has been removed since it serves as a distraction from the real message.

    I thought the story from CBS news ( reveals the vagaries of these scenarios:

    "Chief Deputy District Attorney Karen Pearson asked Fenton what information she wanted from police, but Brady objected and the judge barred the question.

    When asked on the stand Thursday if she reported Holmes, who was studying neuroscience at the university's medical campus, as a "threat to harm," she said she did not."

    We will ultimately find out what she told the CU campus police and there will be no end to Monday morning quarterbacking. I wonder whether the fact that he dropped out of school placed him in some sort of jurisdictional limbo.

    While I feel terrible for the victims, I also feel for the psychiatrist. For a psychiatrist, predicting dangerousness is almost impossible and this situation will haunt her for the rest of her life.