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Sunday, April 21, 2013

It is just too complex to be managed manually

I spoke to my daughter tonight. She is in nursing school and has almost finished up her first clinical rotation on a floor dealing with gunshot wounds and abdominal surgery. What she has been surprised by is how chaotic the environment is. After the rigorous didactic prelude, clinical care does not quite jive with any of the  pre-clinical work. There are too many tasks for any given nurse to handle. There are huge opportunities for error. No one seems to be in charge.

I have made the same observations and during my 30+ years of dwelling in a variety of clinical contexts, I see the chaos only becoming more obvious. Medicine has become much more complex during those 30 years. Our options have expanded and so has our ambitions. With each additional choice the complexity grows not in an additive fashion but in a geometric fashion.

Atul Gawande has written about this, focusing on acute care and hospital based settings. However, this explosion in complexity is every bit as evident in the ambulatory environment. In some sense it may be worse since most of our interventions happen in a much less controlled environment which provides less consistent feedback for patients and providers alike.

I am reminded of a quote from Thomas Sowell in his book "The Quest for Cosmic Justice", where he notes:
Unfortunately, the inherent scarcity of resources means that all of the evils that are preventable seriatum are not preventable simultaneously
Each of us tries to practice in a seriatum world and by the nature of how practice has evolved, we make every attempt to focus on pathology in our specific arena of specialty. It is our way to make our practice world manageable. However it tends to create the illusion that  increasingly complex approaches are desirable since their deployments appear to be possible, at least in the short term and when viewed in isolation. Those deploying them in isolation do not see the web of interconnected and complex problems, but only the simple series of events which they feel obligated to address in order to make a particular intervention. Elements or occurrences which may develop outside of this are viewed as being "not my job".

This leads to even more complexity which drives those practicing into greater focus on even narrowing areas of expertise and ownership of responsibility. It is a cycle which results in greater and greater complexity and less and less integration of care.

I am reminded to a host of other industries where control of complex systems have been moved out of human hands. Airline pilots increasingly are managers of computer systems with fly airplanes. Manufacturing has moved from human controls to computer controls as well as use of robots to replace human labor. In each of these environments it was recognized that the human mind is not the ideal tool to manage huge amounts of information.

In health care, we have not formally come to recognize this but informally those involved have recognized this long ago. Individually, practitioners have realized this and their individual responses to being placed in unmanageable situations has resulted in improvement of their individual circumstances and worsening of the care delivery system in general. Their individual practice lives become more manageable as the general practice environment becomes more complex and chaotic. No villains here; only the wrong incentives.

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