I'd love to discuss this topic in more detail with anyone who is interested. It is currently a topic of my guest blog on www.cognitive-edge.com
Since Flexner in 1910, we have followed a "Scientific Management" approach to medicine. Truth is, we had to, as there was so much quackery involved in medicine and medical education at that time. We used a reductionist methodology to solve the complicated areas of medicine and healthcare. There was quite a bit. However, the "wicked problems", to use complexity theory jargon, remained. Our mistake was attempting to use the same reductionist principles in dealing with problems of finance, access and lifestyle choices. It's not so much that numbers are not our friends, its that numbers do not supply the answers. "Evidence based medicine" is an extension of the reductionist methodology. It works great for complicated problems in medicine. It is useless for complex problems, and an attempt at employing it only makes the complex problems worse. Is the cost/access/quality conundrum better or worse now than 15 years ago? I would say it is WORSE because we have treated the problem as complicated, attempted to impose order in an emergently-ordered system and failed to recognize inflection points for change. As Porter and Teisberg have so eloquently stated in "Redefining Health Care: Creating Value-Based Competition on Results", our well-meaning tinkering has exacerbated the problem and pushed us to the brink of chaos. If things progress along the same trajectory, we will be off the cliff shortly. There is an extensive body of academic thought on this subject. Google "Paul Plsek", "Sholum Glouberman" "Mark Quirk" and "Trisha Greenhalgh" for peer-reviewed articles. Medicine is a combination of metacognition and intuition. Reductionist thinking fails both. The proof, of course, is in the results. www.plexusinstitute.org describes the ONLY studies that have shown a reduction in MRSA, the scourge of the modern hospital. It has not been reduced through process, but through "positive deviance". The answer, in my humble opinion, is not an either/or approach to process and starting point--like Avedis Donabedian, I believe both are important. Evidence-based medicine is needed in SOME areas, but in others, it will lead to an intellectual tyranny and analysis paralysis. The key is knowing where, and when, to make the shift. The exclusive application of population-based studies to individual patient care is only satisfactory to the newly-minted physician, and will never be satisfactory to the patient. I myself was in the situation of having had an anaphylactic reaction to a blood transfusion, only to have the blood bank pathologist tell me it should not have happened, and he wanted to repeat the process. I told him to take a flying leap, especially since pre-treating me with steroids (outside the "evidence-based" protocol) solved the problem. Population studies alone would be viable if every patient had the same starting point. We have not advanced enough to identify all the characteristics of those starting points. "Outcome" is an emergent characteristic, and is almost impossible to exactly duplicate. It can be approximated, but the degree to which it is approximated is an intersection of that metacognition and intuition. Both are "capabilities", not skills, that can be learned but cannot be taught. If health care was easy, why would we have such a mess on our hands? The truth is we need people like you, people who understand Complex Adaptive Systems, to become involved in the debate and demand that those in the position to make decisions wake up and listen to us. My "zwei Groeschen" Russ #3 On Jan 19, 2010, at 7:41 PM, Douglas Roberts wrote: > > > On Tue, Jan 19, 2010 at 6:13 PM, Pamela McCorduck <[email protected]> wrote: > > On Jan 19, 2010, at 7:15 PM, Miles Parker wrote: > > > > It was surprising to me to find the extent to which just basic traditional > statistical techniques have not made it into health care practice until quite > recently. Is it a stretch to imagine that part of the reluctance of doctors > to embrace the kinds of techniques used in other fields could be in part due > to an inherent (if unstated and poorly realized) conviction that these > systems have emergent properties? > > Maybe they don't think numbers are their friends. > > That just doesn't add up. > > > > ============================================================ > FRIAM Applied Complexity Group listserv > Meets Fridays 9a-11:30 at cafe at St. John's College > lectures, archives, unsubscribe, maps at http://www.friam.org > > > > -- > Doug Roberts > [email protected] > [email protected] > 505-455-7333 - Office > 505-670-8195 - Cell > ============================================================ > FRIAM Applied Complexity Group listserv > Meets Fridays 9a-11:30 at cafe at St. John's College > lectures, archives, unsubscribe, maps at http://www.friam.org
============================================================ FRIAM Applied Complexity Group listserv Meets Fridays 9a-11:30 at cafe at St. John's College lectures, archives, unsubscribe, maps at http://www.friam.org
