Sunday, March 31, 2013

Questioning, Listening and True Learning

“If men learn this, it will implant forgetfulness in their souls; they will cease to exercise memory because they rely on that which is written, calling things to remembrance no longer from within themselves, but by means of external marks. What you have discovered is a recipe not for memory, but for reminder. And it is no true wisdom that you offer your disciples, but only its semblance, for by telling them of many things without teaching them you will make them seem to know much, while for the most part they know nothing, and as men filled, not with wisdom, but with the conceit of wisdom, they will be a burden to their fellows.”
Plato, Phaedrus

This week, I sat down with my family for the traditional Passover Seder with the reading of the Haggadah and the ongoing questions and discussions that are the central part of the evening.  The feast of freedom, as one Haggadah calls it, is based on questions as being free means being able to question everything without fear.  The written word of the prayers and the story of the exodus from Egypt, while important, are not as important as that interactive dialogue that ensues and that is expected and even mandated by the holiday.  Each section is designed to elicit conversations, questions, and thoughts that lead to the participants gaining intrinsic knowledge.  This is in keeping with Plato’s contention that merely reading is not a way to impart knowledge.  True knowledge must come through dialogue and creating an internal understanding of the topic at hand.  I have found this to be particularly true in health care and in endeavors to help people obtain quality care from our health care system. 
The first step in internal understanding as Plato understood is to ask a question and then listen to and hear the answer.  Each year at our family Seder, it starts with the four questions asked by the youngest in the home.  My grandchildren, age 7 and 5, are asked (and were asked as soon as they could talk) to form their own questions at that section and throughout the Seder in addition to the standard four questions.  Everyone at the table is encouraged to ask questions.  The questions themselves are always more important than the answers as the questions allow a discussion to start: a back and forth of the type that is more likely to produce learning and understanding.  Isidor Rabi, who won the Nobel Prize in physics, was once asked why he became a scientist.  He answered, “My mother made me a scientist without ever intending it.  Every other Jewish mother in Brooklyn would ask her child after school: ‘Did you learn anything today?’  But not my mother.  She always asked me a different question.  ‘Izzy’, she would say, ‘Did you ask a good question today?’  That difference – asking good questions – made me become a scientist.”
Plato, in writing his dialogues, often presented Socrates as a questioner.  Our understanding of Socrates is through these dialogues written by Plato.  Plato and Socrates believed that just reading something, rather than discussing something, could not lead to true learning and could instead lead to an intellectual laziness which would produce people who “for the most part they know nothing, and as men filled, not with wisdom, but with the conceit of wisdom”.  Plato tried to recreate that give and take by writing as dialogues.  Implicit then in this approach to questions leading to dialogue is the assumption that after the question is asked, there must be true hearing of the answers, if only to be able to formulate the next question! 

That resultant listening is really an exercise in interpretation and then in testing that interpretation with yet another question.  Thus the iterative nature of a good clinical interview is really no different than a Socratic dialogue or a discussion elicited by a question at a Seder table.  Plato and Socrates believed that only in such a manner could learning occur and Professor Rabi believed that only in that matter could unique, creative scientific inquiry truly occur.  In medicine and law, that tradition of asking question and then eliciting discussion, dialogue, and research, is at the heart of education and training.  It is believed that intrinsic learning occurs in the iterative nature of the teacher and the student having such a “dialogue” on the topic and situation at hand. 

The goals of using such a system of questions followed by dialogue in health care are to create a better understanding between a care giver, a care supporter, the person in need and often the family in need.  That understanding then leads to better, more personalized care for that unique individual.  It allows for intrinsic learning for the patient who needs to do certain things, whether it is to take certain medications, stay on a diet, or follow through on therapy.
Currently, there are those who believe that technology can make this dialogue unnecessary.  A professional forming a relationship with a person in need is believed to be too costly and even wasteful when powerful big data, interactive Internet tools and apps that are with us wherever we go can be used instead.  Engaging in dialogue is believed to be too expensive and too difficult.  Yet we should share the same fears in this era as Socrates and Plato did in their era: the fear that we will not achieve intrinsic learning, either on the part of the care giver or of the patient by the mere reading of an Internet page or the use of an app.  We still need those dialogues that lead to true relationships in order to create the intrinsic understanding that leads to action on the part of people who are patients living their lives with their families, their work, and their friends.  The technology is welcome but only if used to foster the dialogues and to assist in the development of the relationships that are at the heart of good practice and good care. 

Thus asking the right questions, truly hearing the answers and using that as a starting point for dialogue are crucial steps in creating good quality care.  That may not win any Nobel prizes or lead to the entirety of Western philosophical thought; however for me, as a dedicated health professional, it is an art that we should continue to foster and not allow to be lost in the excitement over technological solutions.  

Sunday, March 17, 2013

Health Care, Big Data, and Black Swans

The movement towards using “big data” in health care has the ability to vastly improve the way medicine is practiced.  The term “big data” is used to describe large databases processed by powerful processors analyzing and recognizing trends and patterns that would not otherwise be apparent.    Today, research into the use of big data is centered on the analysis of the human genome and the resultant individual variation of disease and response to therapy, and in the use of health insurance and electronic medical record data to find patterns of care in order to potentially improve quality and lower costs. 

The genomic research is moving from the description of the genome into the more practical application in the treatment of disease.  The goal is to create “personalized” medical care based on each individual’s specific genetic makeup.    The most obvious use is the application of genomic knowledge to define specific sensitivities to certain drugs for certain illnesses so that the medications can be customized on the basis of this individual data. 

As complex as these two areas are, it should come as no surprise that they don’t yet meet or coordinate.   We are too early in their development.  We do not yet know how to combine a “big data” approach to populations to the “big data” of the individual.  When dealing with populations, individual variations of the type that we try to define with “personalized” genomic based care, is often just “noise’ in the statistical system of the population.  So the trend towards personalized care may be contrary to the trend towards evidence based care based on large databases. 

Both of these somewhat different approaches also leave out an entire domain of the complex business of treating individual patients.  We may not be asking some of the most important questions.  All of these applications are focused on services or encounters, costs and biology.  There is no focus in either a genomic approach or an encounter, claims approach on people as complex, multifaceted individuals who are living social lives in the context of their own emotions, beliefs, economics, and values.  People are complex and that complexity is only partly related to their biology and their claims records.  

Perhaps we need to ask what defines good medical care as another starting point.  The hallmark of a superb diagnostician, is the one who can recognize and look for black swans.  Nassim Nicholas Taleb, who is a distinguished professor of risk engineering at New York University and the author of the book, “The Black Swan: The Impact of the Highly Improbable” is someone who has studied risk and chance in finance for much of his professional life.  He defines a black swan as an event, positive or negative, that is deemed improbable yet causes massive consequences.   In medicine, these events can have death or chronic disability as the consequence.  For me and my family, I want a doctor who will always be thinking about potential black swans while also minimizing the risk of sending me on diagnostic wild goose chases (to mix bird related metaphors).  I wonder if systems that are too focused on the best practice protocols, developing the evidence based medicine, will have that ability that we see in the truly expert, experienced clinician or if the best practice protocols will actually punish that sort of thoughtful, experienced based approach by seeing it as being inefficient and not in keeping with the evidence that supports the bulk of medical care. 

The hallmark of a master clinician is one who customizes the decisions, in partnership with his or her patient, taking all the data, including the social, emotional, financial, and spiritual into account in managing the problem at hand and in managing the potential for future problems.   I also worry that we don’t have databases that reflect the real reasons people get better or not.  The master clinician asks the right questions and listens for the answers with a skill that currently no computer can match.  Does the patient have the family support that is needed to deal with illness?  Can the patient afford the right diets?  Does their religious belief create a social network of support and a psychological framework to allow someone to deal with their physical condition in a way that fosters healing?  Are they worried about other family members and that is leading to their spending less time caring for themselves?  Do they lack basic shelter?  While this may also suggest the need for yet a third domain of big data we also have to be concerned with the moral implications that this third type of data may bring.  The loss of privacy and the ability to misuse data such as this is great.
So I hope that we make good use of the big data systems that we are now building but I also hope that we never let these systems become a new type of electronic care giver that ignores all of the important elements that we are not, and perhaps never will, capture.  Let’s also hope that these efforts at big data and evidence based protocols do not lead to our ignoring the possibilities of those black swans in medicine that can devastate people and families. 

Most of all, let’s make sure that in any system of care, we always ask the right questions to help us understand the people behind the illness and to truly hear their answers.  We will always need to find, as Professor Taleb puts it, the “bird droppings” of the black swan so we don’t miss the illness that can be a catastrophe.  

Sunday, March 3, 2013

The Doctor, the Pilot and the Dog

There is an old joke told among people in aviation.  The joke is that the airplane cockpit of the future will have a pilot and a dog.  The pilot is there to feed the dog and the dog is there to bite the pilot if he tries to touch anything.  The idea behind this is that the airplane of the future, carrying hundreds of people, will be fully automated and be safer than planes are today and that the pilot, will not only be unnecessary but potentially dangerous to those on board.  Of course that joke does not acknowledge that computers may shut down or need to be overridden.  Presumably in the cockpit of the future a Captain Chesley Sullenberger will not be needed to land a plane with no working engines on the Hudson River and safely get all of his passengers out without any deaths.  As a passenger however, I would be reassured to see “Sulley” or someone like him up there in the cockpit no matter how good the systems were.
Human beings are at least as complex as airplanes yet we now see a belief, most eloquently voiced by the brilliant businessman and venture capitalist, Vinod Khosla, the founder of Sun Microsystems (the link to download Mr. Khosla’s full statement is attached) that can be read to suggest that the doctor’s office of the future will be staffed by a doctor (but probably a nurse since doctors are too costly) and a dog.  His thesis is that 80% of what is now done by a physician will, in the future be done by technology.  As one reads his thoughts on this, two of his assumptions became apparent to me.  One is that he believes that the diagnosis of disease and the defining of treatment plans is a bigger part of medical practice, especially primary care medical practice, than it really is.  The second is that he has great faith in the ability of systems to consider non-medical factors such as a person’s beliefs, values, social situation, financial situation and psychological makeup that may affect diagnostics and therapeutics.  I wonder.  The reality of practice is that 80% of doctors’ visits are driven by fear and social isolation rather than diagnosable disease.  The reality of therapeutics is that the diagnosis and treatment plan are only a small step in the march towards cure which depends as much on the non-medical factors and the physician and nurse ability to understand and impact those non-medical factors as it does on the science of disease. 

Mr. Khosla’s contention is that much of the knowledge that is now driving specific diagnostic approach and the outline of treatment steps will be and should be facilitated by technology.  That is absolutely true. All he says of the promise of technological systems to process medical inputs such as blood pressure, pulse, weight, lab data and certain pieces of history to create a better health care experience for all also is true.  However if our current approaches to laws, rules, regulations, and health systems are based totally on Khosla’s faulty assumptions of the nature of medical practice rather than on practice realities, then we may create a system that is not as individualized and not as attuned to the inherent uncertainty that comes with people as social, spiritual and psychological animals, as good medicine should be.  I worry that if we build a health system that is based on this already accepted assumption that technology and guidelines will fix all of our health care woes we will end up with a dehumanized system that creates an entire new set of problems.   In our zeal to improve what we acknowledge to be broken in health care, we may minimize the danger of a system that is based purely on technology, rules and algorithms.

A recent case in California that David Shaywitz wrote about in his Forbes blog is a good case in point.  A nurse in an extended care facility did not perform CPR on a patient because it was against institutional policy for her to do so.  Instead of seeing a person in need, this nurse, who is presumably trained in CPR and trained to recognize someone having a cardiac arrest, followed the institutional policy instead of doing the right thing for that patient.  This is an example of procedure trumping patient care and trumping empathy and thought.   One can make the argument, as Khosla does, that our current systems and protocols are primitive and they will improve over time and they would, in the future, not allow this to happen.  However even in the best of systems, the danger of relying on expert systems, and even requiring their use, is that fear of overriding the system can take precedent over the need to help. 

The recent entry of electronic medical records is another case in point.  The EMR has allowed for medical guidelines to be built into the medical record and that is a strong plus when combined with an ability to catch and prevent certain errors that may result in danger to patients.  However it has also fragmented the information needed by a health professional so that trying to navigate a medical record to get a quick understanding of a patient sitting before you has become even more of a nightmare than it was with a paper record.  It also requires sometimes time consuming and complex data entry by the care giver.  I have accompanied friends to emergency rooms only to watch the doctor pay more attention to data entry and following the algorithm than to the patient in need.  Bad information can also become so embedded by a system that encourages “copy and paste” and standardized wording instead of independent thoughtful analysis that incorrect diagnoses and histories become impossible to change. 

So I sit here and only hope that I always have my and my family’s care directed by me and my family working in partnership with a caring health professional, usually a doctor, who uses technology but never allows it to overtake his or her own judgment, knowledge and empathy.  I will always prefer a captain in the cockpit of an airplane and a caring physician by my side.