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Sunday, December 18, 2016

Uncertainty and how problems and solutions are framed

I would like to direct my readers to a recent piece published in the NEJM entitled "Tolerating Uncertainty" (NEJM). The issue identified and the article has implications well beyond the delivery of health care. We humans love certainty and hate ambiguity. Until recently, medicine didn't really have to address uncertainty since our roles were fairly straight forward. We measured our successes and failures based upon a hard endpoint: were are patient dead or alive within days or at most weeks after we were asked to evaluate and intervene. Because of our successes, the dead or alive bar is no longer the primary goal of our efforts. Simply finding that our patients did not die after we touched them is not adequate to justify our efforts. 

Our metrics and particularly timelines to measure successes or failures have changed dramatically. Our endpoints may be measured years or even decades into the future and that creates all sorts of problems. We are not so good at predicting the future and the longer we try to look out, the more uncertainty we need to face. Some view this problem of prediction as a problem which can be addressed with the application of enough data and enough technology. However, I believe that uncertainty will always be with us and the longer we attempt to peer into the future, the more inherent uncertainty we will need to acknowledge. 

I find myself explaining this to patients every day. People come to me in various states if ill health and it is my role to evaluate their circumstances and provide them with options in terms of intervention. In each case, decisions are made in terms of doing something based upon trying to peer into the future and estimating whether any given course of action is likely or unlikely to leave them better off. For any given decision, there is always a possibility of catastrophe, whether the decision is to act or not act. There are no certain outcomes, just ones we estimate to be more likely to be generate better or worse outcomes. There are always trade offs involved and it is always about probabilities, not certainties. 

The trade off reality is not limited to health care. While there may be uncertainty regarding which particular trade offs will come into play, there is absolute certainty regarding the inherent existence of trade offs. Thus, the blindness to the presence of both uncertainty and required trade offs influences how humans address problems, both current and future. I see this particular problem poisoning thoughtful exchanges in all realms which are potentially contentious, which is basically everything. 

I would like to highlight how the desire for certainty and the blindness to trade offs has totally poisoned any discussion regarding climate science. I am listening to a Great Courses audio course given by Dr. Robert Hazen of George Mason University entitled "The origin and Evolution of Earth". The basic premise of the course is that the geosphere and the biosphere have been interacting for literally billions of years and that life on earth has changed the earth in fundamental ways. These life driven changes have preceded human existence, again by billions of years and have resulted in the modification of rocks and minerals, makeup of the atmosphere, and changes in climate. The earth has varied in the past from being covered with ice to tropical environments at the poles, all without any human intervention. We are only now recognizing this to be the case.  We are also now recognizing that like life forms which preceded us on earth, we are influencing our environment. All of life on earth past and present and future have and will do the same, no matter what we as humans do.

This has set off alarm bells among certain groups on the basis that any change which we might be driving could have catastrophic consequences, and they could. Like we have observed in health care, any time we act we might create serious problems. We also observe that when we act in attempts to prevent one outcome, we can also create unintended problems. It is that trade off thing. However, the discussions regarding climate change and possible outcomes rarely are framed with trade offs involved. How likely are the catastrophic outcomes to happen if we continue pursuing our current courses? Who will these outcomes preferentially affect? Similarly, if we intervene and apply some sort of carbon (energy) restrictive approach, what are the trade offs involved? Who will these outcomes preferentially affect and will these people be different from those affected if we do not change?

Like interventions for disease states which may occur in the future, we need to think about whether we will leave most people better off if we apply any particular intervention. There is often no right or wrong answer but only interventions which are believed to be more likely to leave people better off at a given point in time. Our current knowledge about climate change is that the climate is changing as it has been for billions of years. There is no surprise here. That humans may be altering the climate should also not come as any surprise. Our ancestors back to single cell oxygen producing organisms have been doing the same back to the great oxidation event. The questions are:

1. Are we actually screwing things up to the point of likely catastrophe?
2. Do we have any real idea that we can change our actions such that we are likely to move toward better outcomes? 
3. Specifically, what do the trade offs look like regarding following our current course and any alternative courses?  

We haven't any real clue as to the answers to these questions. As far as I am concerned the predictions made regarding what is going to happen 50-100 years into the future regarding highly complex and poorly understood systems are crazy. In the same sense that we crave certainty in medicine and will be disappointed because there are things which are unknowable until they happen, our world will also not yield to the desires for certainty that we may have. We are just humans, not gods. To think we can predict where chaotic systems will take us in an extended time frame and select interventions which will leave humanity and the earth better off represents arrogance and hubris. 

Our desires and attempts to scientifically change the future have yielded all sorts of Utopian nightmares, whether that be Scientific Socialism and mass murder, or eugenics and mass murder. My experience in the health care realm has taught me that we can always make things worse and create new problems. It is an experience which I believe has provided me with a broader understanding of the world outside of medicine as well. We are not inherently better off when we act than when we do not. 

Best intentions and unintended consequences

I read a story from the New York Times today (Cuban tourism) about an unintended effect of the surge of tourism on the lives of ordinary Cubans. It seems that the Cuban government failed to anticipate the flood of new tourists (3.5 million last year). One might think that in a normally operating economy these arrivals would result in some sort of positive effect on the island economy, with all of the external currency injected into the economy. However, that was not the case.

What happened is that in order to meet the needs of the visitors, goods (especially food) normally which met the needs of ordinary Cubans were diverted to feed the visitors. Cuban citizens were left with empty shelves and soaring prices. The response of the Cuban government was both predictable and maladaptive. The government placed price controls on basic staples which served to make the price on paper affordable but in reality made the unavailable to the average Cuban citizen.

There is an irony here. I suspect that those individuals now most likely drawn to Cuban travel are ones who have an element of good Samaritan motivation.  And yet, the immediate effect has been to make the lives of ordinary Cubans worse, at least in the short term. The market for supplying the tourism sector with what now are luxury goods is giving at least some Cubans an opportunity to better their lives, but not without more unintended consequences. The Times article describes the activities of Leticia Alvarez Canada, a nurse who gave up her job to sell snacks from a cart and increased her income by 10-fold. This does not bode well for health care delivery.

It seems that the tourists who visit Cuba are likely unintentionally undermining the very system they likely hold sympathy for. In contrast, the staunch anti-Castro elements which have successfully lobbied to keep Cuba isolated for more than five decades may very well have helped create an environment of isolation which was necessary to perpetuate the regime.