Physicians on the Assembly Line

The role of the physician in our evolving medical system is the subject of many studies, articles and angst on the part of the physician community.   In an article this week in the New York Times, about the efforts by a group of physicians in Oregon to unionize, the physicians involved discuss how their creative assessment and problem solving skills are brought to bear in even the most mundane cases.  Dr. Rajeev Alexander, one of the physicians involved is quoted as saying, “Real life is all about the narrative.  It’s sitting down and talking about bowel movements with a 79 year old woman for 45 minutes.  It’s not that interesting but that’s where it happens.”  Dr. Alexander may start out believing the source of this elderly woman’s constipation is related to dehydration, often the most common cause when elderly people have to be brought to the hospital due to bowel problems, however he is following the best medical approach by spending time to first determine that the problem is not something less common, and then trying to also determine factors that may contribute to the dehydration.  He brings a cognitive approach rather than a strictly reflexive approach.  However his approach from a pure resource management point of view may not be seen as efficient, hence the disagreements that led to the physician group forming a union. 

The system clearly needs to be more efficient.  We must be both customized and thoughtful for each patient, and also recognize that much of medicine is the same from patient to patient.  We must build more efficiency into the system.  Is the best way to do this by taking the traditional leadership role of physicians in patient care and making them into unionized workers?  In that same article, Dr. Brittany Ellison, another member of the physician group says, “We’re trained to be leaders but they treat us like assembly line workers.  You need that time with the patient where his wife is ratting on him.”  Is the best way to accomplish this by making the role of the physician be more of a follower – of algorithms, of management incentives, and of organizational goals, than a leader for their individual patient?  Should they be judged on population effect, efficiency and data capture rather than their work of caring for the individual?

While I have an MBA from Northwestern University and twenty-five years of experience working on the business side of the health care industry, I do not believe the answer lies in money, bonus programs or physician incentives.  I have found, that while physicians are people and want to make money and earn incentives, they are driven more by their own sense of commitment to their patients and their own sense of professionalism.  Dr. Robert Wachter, chief of the division of family medicine at the University of California, San Francisco in that same article states, “If at the end of the year, 10 percent of your salary is at risk based on whether you have consistently clean hands, what patients say about you, readmission rates, that can be OK. The counterargument is that you could screw things up by tying everything to financial incentives.  You stomp on their intrinsic motivation.”

Appealing to that intrinsic motivation is critical for the individual patient interactions that make up that data.  The goal when I or the professionals who work with me at Accolade, help people through the health care system is to find ways to bring out the best in people by finding ways to use the internal motivation of both doctor and patient.  We help people find the right clinicians for the problems they have and help them communicate with their doctors, nurses, and other health professionals in such a way so as to bring out the best in their clinician. 

Maybe we have to rethink the role of the doctor.  Perhaps we need to reserve the use of the doctor as a true leader and always team them with another professional who can spend more time filling in the blanks for them.  We have experiments going on around the country which are as varied as having nurse practitioners be the front lines for most patient interactions, to having scribes be with doctors to free them from the data capture duties that they have.  At Accolade we have pioneered a new profession of Health Assistant to assist patient and doctor with the life context issues, emotions and clinical decisions that patients must make (which specialty to see for my problem, what questions should I ask the doctor, how can I balance my life responsibilities with my compliance needs).  A Health Assistant who is part of a team led by a creative problem-solving physician could make the physician more efficient and allow for more access to the system.   Whatever the solutions that are developed, it should not be to make the physician into an assembly line worker.  

“Strangers at the Bedside” and the Internet Economy

In my last post, I wrote about information systems and health care and the challenge of finding and treating the “black swans” which often separates superior medical care from  barely adequate or even bad medical care.  I define barely adequate care as care that inadvertently takes advantage of the body’s tendency to heal itself and represents a doctor and /or nurse being more lucky than smart.  The movement from medicine being an art, a science and a profession to also being a business is today tied to an economy which is rapidly changing as the Internet economy becomes a major factor in our lives and therefore in health care. 

But first, I must pursue some personal history.  In my education and development both as a physician and as a healthcare systems expert, certain books were formative, having a dramatic impact on my thinking.  One such book was “Strangers at the Bedside” by David J. Rothman.  Professor Rothman is a historian by training however he holds the post of the Bernard Schoenberg Professor of Social Medicine and Director of the Center for the Study of Society and Medicine at Columbia University.  To make this personal story more complex, Bernard Schoenberg for whom Professor Rothman’s academic post is named, was a professor of mine at Columbia when I was in medical school and was someone who taught me to look at the social and emotional context that each patient brought with them to the doctor-patient encounter. 

In his book, David Rothman describes the changing dynamic in social and ethical issues in medicine, especially in those issues involving clinical research, end-of-life, and other bioethical dilemmas such as choosing patients for transplants with limited access to donor organs.  He discusses the arrival of sociologists, ethicists, theologians and others trained in the humanities into these decisions that previously were the purview of only the treating physician.  In a future post I plan to write more about David Rothman’s words now twenty-five years after he wrote them.  He does not write about the business people, the management experts and the information technology engineers and their entry into the bedside dynamic yet those may be the more important “strangers at the bedside” in today’s world.

As medicine, health care delivery systems, and health information technology progress, the industry must be informed by more than medical facts and prospective.  Thomas Friedman’s 1999 book entitled “The Lexus and the Olive Tree” in which he describes the drivers behind globalization has nothing to do with health care.  In that book, which came only eight years after David Rothman’s book, Friedman talks of a changing world and speaks about the democratization effect that globalization could have on technology, finance and information.  I remember reading his book when it was first published and believing, somewhat naively perhaps, that he had left out the democratization of health care in his formulation.  I believed that through the internet and through the free movement of health and medical information, health care which is far too important to be left only to doctors, as David Rothman points out so elegantly, was going to undergo a revolution for the better by making the mystery of medicine – the guild aspect of the medical profession – fall to the wayside of an informed, democratized public. 

I was too optimistic.  I minimized the profound complexity of medical care and the fact that people, for the most part, access medical care only episodically and focus on their life issues before focusing on their health issues.  I left out the spiritual dimension of care that is a necessary part of medicine and has been written about so eloquently by people such as Daniel Sulmasy, who wrote another of my formative books, “The Healer’s Calling.”

I also missed the nature of an Internet economy and the tendency towards monopoly that often defines the best Internet companies.  A recent article in The New Yorker by Om Malik entitled, “In Silicon Valley Now, It’s Almost Always Winner Takes All” cogently presented the reasons for this monopolistic tendency to prevail in this “democratized” world.  As Malik writes, “In the course of nearly two decades closely following (and writing about) Silicon Valley, I have seen products and markets go through three distinct phases.  The first is when there is a new idea, product, service, or technology dreamed up by a clever person or group of people.  For a brief while, that idea becomes popular, which leads to the emergence of dozens of imitators, funded in part by the venture community.  Most of those companies die.  When the dust settles, there are one or two or three players left standing.  Rarely do you end up with true competition.” 

Malik writes about the Network effect, often called Metcalfe’s Law after Bob Metcalfe inventor of The Ethernet, which occurs when the value of a product or service goes up with the number of people using it.  It creates a loop of algorithms, infrastructure, money and data and that leads to a winner-take-all approach.  This is especially recognized by the investors who provide the capital for these new companies.  The investor community and the public markets take large risks to predict the next monopolies and in this Internet economy, punish anything less than a monopoly or a duopoly since according to Malik’s cogent analysis, most of those companies die. 

What happens when this winner-take-all type of economy meets health care?  In some ways we have a direct example with Epic Systems which now supplies the hospital software that holds 54% of the US population’s health records.  It is a marvelous system designed by engineers and hospital administrators and is masterful at capturing data for billing purposes and for inventory purposes.  Physicians will tell you it can divert their focus from the patients and while it does make accessing records when not at the bedside easier, it does not tell the patient’s story – their life context and emotional struggles with illness that are critical to good care, in the way it must.  Competition is being shut out because, as Metcalfe’s Law suggests, the more EPIC is the standard and the more data they have, the more monopolistic they can become.  There is an old joke told in the early days of computing (and I am old enough to remember).  It goes, “How many Microsoft engineers does it take to change a light bulb?”  The answer – “None because Bill Gates declared that darkness is the standard.”  Will we define a health care standard that removes the human aspects from care even though those elements are arguably the most important?

Perhaps a good example that is not in health care and not even in the Internet is the story of agribusiness in the United States.  In the food business, four companies control over 60% of grain production.  This came about from a starting point of an America whose food came almost entirely from family farms.  It occurred because the Internet realities of algorithms, infrastructure, money and data have their counterpoints in food production, in land, infrastructure, money and logistics.  The more you control land, infrastructure and logistics, the more money you can raise and the more you can increase control of the market. On the positive side, this has led to more efficient use of farmland, more availability of food to the market on a year round basis, and more consistency in preventing food borne illness.  On the negative side, we have been subject to monopolistic tendencies by these companies, leading to episodic need for lawsuits and regulatory action, a loss of family farms and the communities they supported, and a loss of the unique aspects of local food that can lead to healthier more varied diets.  We have traded efficiency and the positive of availability for a loss of flavor (for those of us who value that), loss of varied nutritional sources, and perhaps potential environmental damage as well (I will let those discussions occur elsewhere).  Management and finance prioritized over dedication and even love of the land and the amazing variety of food the land produces have driven this tendency. 

I now watch the froth of Internet health companies being pursued and funded by venture capitalists and the hope being put into information technology in health care by both government and investors.  I welcome the creativity and the new approaches but wish those to be driven by a desire to improve the care for each unique patient as well as the desire to foster efficiency.  I for one remain enamored of a democratization of health care and repeat a line I wrote earlier in this post and have been saying for years, that health care is too important to be left to doctors and nurses.  However, health care is also too important to leave out doctors and nurses.  It is too important to leave health care only to the management experts and the information system engineers.  Health professionals train and take oaths and have experience that gives them a special voice in protecting the personal aspects of medical care. 

David Rothman states that while “the physicians are alert to numbers and findings from random clinical trials carry critical authority” they also recognize that no two patients are alike and that medicine is inherently uncertain.  Clinicians value experience highly as they realize that only through experience do professionals understand the management of that inherent uncertainty and how individuals can vary from the clinical trials.   Experienced clinicians understand, as I discussed in my last blog, the importance of always looking for the unexpected.  We as patients – and we are all patients at one point or another – should also value that knowledge and experience and always hope to have doctors and nurses, who use technology and who respect our ability to find information for ourselves on the Internet and from other sources.  We should also demand that the technology support health professionals treating us all as the potential “black swan” – the unexpected disease or circumstance and not as a data point in an Internet algorithm or on a balance sheet.  I believe that can only occur if experienced caring clinicians are involved in the development of this new world of the health care Internet economy and ironically do not end up as the new strangers at the bedside.

Information Systems, Good Medicine and the Search for Black Swans

Many years ago, when I was in medical school, learning the art of the physical exam, I was taught that the exam should always be done in the same order each time, starting with the skin, moving to the head and then working your way down, leaving the rectal exam and the exam of the genitalia for last (more for the comfort and the dignity of the patient).  It was drilled into me that it must always be done from the right side of the bed or exam table.  That consistency and discipline in performing the physical exam the same way each time was considered a critical element of good medicine. 

While the idea of a physical exam in general may be seen quaint and outdated in our era of telemedicine, scans, apps that can monitor bodily functions and other imaging technology, the discipline of the physical exam and even the emotional impact of that exam is hardly outdated.  Abraham Verghese, the esteemed author, physician and educator has written and spoken about the importance of the physical exam in both a ted med talk and in the medical literature and his words are worth reviewing.  Verghese emphasizes the ritual part of the physical exam, and the importance it holds in bonding the physician and the patient.  He writes,

“…….the ritual of the bedside examination involves two people meeting in a special place (the hospital or clinic) wearing ritualized garments (patient gowns and white coats for the doctors) and with ritualized instruments, and most importantly, the patient undresses and allows the doctor to touch them.  Disrobing and touching in any other context would be assault, but not part of this ritual which dates back to antiquity.”

 

He goes on to say,

“We propose that if the ritual is short changed, if it is done in a cursory fashion, if it is not done with skill and consideration, if its sacredness seems to be violated, then the transformation (which in this case is the formation of the doctor-patient bond, the beginning of a therapeutic partnership and the healing process) does not take place.”

His words reflect the way a good physical exam helps form the basis for the doctor-patient relationship.  However that is not what I will choose to dwell on in this post.  Rather I want to discuss the ritual itself.  The very rote and disciplined way the examination is done each and every time a physician, especially an internist or family physician sees a patient. 

Back in medical school, I was taught to perform the exam very precisely each time for a simple reason.  I was told that if I did the exam the same way each time, it would make it more likely for me to notice anomalies.  I would notice something that was not like the thousands of other exams I had done.  In many ways, medicine is extremely repetitive.  Because of this repetitive nature of practice, it is very easy for physicians (and nurse practitioners) to go on auto pilot – to become reflexive in their actions instead of remaining cognitive with every patient and through every exam.  At the same time, high quality medicine is all about finding the needle in the haystack: noticing the unusual exam finding that might suggest an illness that could turn into tragedy.  In order to find that “black swan” (defined as an unpredictable or unforeseen event or diagnosis, typically with extreme consequences) one must sift through thousands of exams that are very usual and very common.  One must feel a lot of normal livers and listen to many normal hearts to find the one that is indicative of a disease.  It is so easy not to notice!  It is so easy to take shortcuts and not go through the discipline of the exam. 

The result can be a missed diagnosis and ironically a more expensive evaluation, as unfocused diagnostic evaluation often called shotgun medicine, requires numerous tests which are unnecessary if instead the exam is thorough.  An example is the 50 year old patient who comes in with chest pain.  On the basis of that history and a lax approach to the physical exam a cardiac evaluation would be done which could include stress tests, and even cardiac catheterization.   If one however does a physical exam and notes that the pain is in one dermatome (an area of the skin supplied by nerves from one spinal root) and that small vesicles can be seen, the diagnosis of shingles is made and no further evaluation is needed. 

I sat once on an airplane next to a psychologist.  He told me that he had been an airline pilot and had developed a psychological test to see if prospective pilots would be good in the cockpit. He left the pilot’s seat to develop this test as he felt his ability to improve airline safety would be greater in promoting widespread use of the test than in his flying planes.  The key to being a good pilot was to be highly intelligent but not too intellectual.  You had to do the same things every time you took off and landed.  On each take-off, you had to make a decision as to whether to abort the take off and it had to be a conscious decision.  You could not allow your mind to wander (in his definition an intellectual is one whose mind does wander) or have the take-off become so reflexive that you don’t notice small differences from the normal take-off.  It seemed to me that the similarities to medicine, especially primary care medicine, were apparent and so it also seemed to Dr. Atul Gawande.

  

Atul Gawande noticed the use of checklists in the cockpit of an airplane and it led to his writing “The Checklist Manifesto” which advocated for checklists in medicine, similar to the checklists in aeronautics.  In a real sense, Dr. Gawande was only harkening back to the medical school truism of finding ways to do repetitive tasks, such as the physical exam, in such a way that that steps in the processes were not missed and  abnormalities were more easily noticed.  Checklists are a way to highlight deviations from the norm and to ensure that we do everything in medicine in a disciplined way.

However, as we started to computerize our routines, and started to monitor them using modern information technology including EHRs and other electronic tools, we may have lost our way a bit.  The goal of routine leading to more easily noticing deviations from the norm took second place to pure efficiency and blind adherence to protocol.  The idea of the best doctors being those who were complete even compulsive and who found the black swans was replaced by the idea that the best doctor was the one who could prove adherence by having all the computer fields filled and prove efficiency by doing so most quickly. 

Computers allow us to copy and paste and pre-populate fields for the sake of efficiency.  If we do the same exam each time and nine times out of ten the exam is normal, doesn’t it make sense to just prepopulate the normal exam and doctors can then change the results as needed?  However having the areas prepopulated does collide with one of the secrets of medicine, namely that doctors are people and they work towards incentives and towards the path of least resistance as other people do.  When you have a computer record field that is prepopulated, and you don’t think something will be abnormal, and you have a waiting room full of patients, you tend, as a person, to just accept the prepopulated answer and skip the actual exam component.  By doing so, your organization (and more and more physicians are employees of larger organizations) will receive higher reimbursement for a more intensive exam because it is documented that more was done on the exam.  The physician will get a higher report card grade, leading to a better bonus because they did more complete exams or so the computer says. 

By the same logic, in the hospital setting, in which multiple physicians and nurses all having different roles and responsibilities may see a single patient, the ability to copy and paste someone else’s exam since it is likely to be the same as yours, is not seen as dishonesty or poor medicine, only as a way to be more efficient and more productive.    The fact that it removes an internal quality check and that each health professional may notice something missed by another is not factored into the development of the system.  If someone is sick enough to require hospital level care it only makes sense to have multiple checks in place to guard against mistakes that could cost someone their life. 

As an example: for one patient, the head, eyes, ears, nose and throat exam (HEENT) was presumably done because it was pre-populated.   In reality the physician skipped actually preforming that part of the exam.   The patient being seen had known Irritable Bowel Syndrome and came in with constipation and abdominal pain that was not very different from when seen during the previous visit.  The rationale was that the HEENT exam was bound to the unchanged from the previous visit.  But this time could have been different and the good doctor, would have either changed the pre-populated fields to reflect the head was not examined, jeopardizing his or her own job evaluation by the health care organization, or actually done the potentially unnecessary part of the exam, lengthening the appointment in such a way as to either not have time to focus on the problem at hand or run late in the clinic and hurt his or her service evaluation, also harming the job evaluation. 

This is not a problem with the information technology.  These tools can help us achieve and monitor the exam routines I learned more than 40 years ago.   What is missing is the proper design of these systems to support those noble goals of finding the black swans and focusing further testing and therapeutics, rather than the simpler goals of efficiency and adherence to a norm.  Missing from our currently designed systems are the aspects of human engineering that understand how patients, physicians, nurses and therapists really work and think.  We cannot afford to ignore the need for constant diligence to find something unexpected – something unusual that will make the health professional stop and think and perhaps save someone’s life.  It is not an impossible challenge.  It can be done and must be done for the promise of information technology in medicine to truly be met.  

Technology, the Triple Aim, and the Three Laws of Robotics

The triple aim of health care (improve the patient experience, improve population health and lower per capita cost) remains the driving force in health policy since Donald Berwick, Thomas Nolan and John Whittington first described it in Health Affairs in 2008.  Information technology is now being used in ways unimagined in the past to drive the triple aim, often with less success than had been anticipated.  The challenge has been and continues to be, using information technology effectively while maintaining the aspects of medical care that require the human touch.  The real challenge is how to harness the power of the computer in what must remain a caring pursuit. 

It is clear that our quest to incorporate computers into medical care and perhaps even direct medical care, risks losing the essence of medicine – the humanism and caring tradition that should be paramount.  I have written before in an earlier post of my own experience in the hospital and the fact that I felt ignored as the staff worked diligently to address the need to answer the computer’s demands (My Recent Hospital Stay and the Care of the Computer).   Yet I know that our ability to properly use information technologies will help improve medical care.  The real question is, and will be, will the health care system effectively use technology to improve care and foster the humanism inherent in care or will the technology itself define a new system which is driven only off the zeal for efficiency and the best science of disease, but which leaves the hands-on humanistic and spiritual tradition of medicine in the dustbin of history. 

When I was in college, in the late 1960s, early 1970s, I had a friend who was getting a degree in the early field of computer engineering and programming.  He was a strange sort of guy who used to rail about the evils of computers.  He would talk about how they were actually imbued with malign intentions and evil spirits.  When asked why then he wanted to go into computer science, he would answer that someone had to control them in order to defeat the evil that was inherent in them.  In today’s world, and especially in today’s world of computers in medicine, I wonder if he wasn’t on to something. 

Certainly in popular culture the ideas of computers having an evil dimension and even dominating humans is examined both by those at the cutting edge of science and by those in the arts.  Physicist Steven Hawking has been one of the more vocal scientists who have warned of the risk that computers, via the use of artificial intelligence, could, “spell the end of the human race.”  Bill Gates and Elon Musk have also voiced their concerns in calling for more research on the potential for computers to learn to “think” for themselves and evolve themselves and where this could potentially lead including the possibility of information technology controlling human action.  As recently as June of this year, Steve Wozniak, co-founder of Apple, created media buzz by declaring that in the future, humans will be the pets of computers.   Science fiction has explored this concept for many years, with Isaac Asimov inventing the “Three Laws of Robotics” which aimed to protect mankind from the control of machines.  He then proceeded to build stories to show the inadequacy of the three laws in protecting humans and humanity.    As written by Asimov the three laws are:

“A robot may not injure a human being, or, through inaction, allow a human being to come to harm.  A robot must obey orders given it by human beings except where such orders would conflict with the First Law.  A robot must protect its own existence as long as such protection does not conflict with the First or Second Law. 

The laws all stress the need to help men and women however Asimov’s stories show the reality of unintended consequences when good intentions can cause bad even evil results.  The reality is that when human arrogance believes that control can be total over the world around us (including the technology we create) the results often can prove us wrong in painful ways.  In medical care, this may prove to be especially dangerous as the results are highly personal and could be life-threatening.  Medicine is filled with low probability, high consequence events and information technology is invariably designed for populations, rather than the black swans – the unpredictable, rare but high impact event that can radically affect a person’s life.  Our systems approaches to date have also not taken into account the values, beliefs and social structures that we all live under. 

While the three laws of robotics do not directly address the same issues as the triple aim, the idea that certain hard wired goals, or laws can address all eventualities, and all permutations, is similar.  Both the triple aim and the three laws of robotics are inherently good: however any laws developed by man that are ultimately taken as holy writ and hard wired into computer systems, can be interpreted in such a way as to create pain for individuals.  In medicine, one of the dangers of technology being programmed to address certain components of the triple aim is that while service and quality are implied in the first aim, it is not stated clearly who defines either service or quality.  More and more we have studies that show that the “system” definitions as determined by those who design and run the health care organizations are different than physician and nurse definitions which are different than patient definitions.  A certain decision algorithm, being driven by information technology, may not support the goals of population health and lower per capita cost but, due to the unusual nature of the disease and of the patient’s psychosocial situation, may help that person in need. 

David Shaywitz, one of the best thinkers in health care and a blogger for Forbes, recently wrote a short blog entitled, “First, We Devalued Doctors; Now, Technology Struggles to Replace Them” in which he describes  the challenge of trying to have technology drive personalized medicine which depends so much on knowing the psychosocial dynamics of each person being treated.  He writes, “I realized there was something that seemed a little sad about the idea of developing extensive market analytics and fancy digital engagement tools to simulate what the best doctors have done for years – deeply know their patients and suggest treatments informed by this understanding.”

I agree.  It is sad that society may be abdicating the sacred trust of knowing the person to a computer rather than to a caring professional.  But it is not too late to change the new paradigm being written.  We can effectively find a way to control the computer and use the capabilities inherent in that technology to augment the humanism of the professional helping those who are in need.  We can prevent a purely technological approach to the triple aim going the way of the three laws of robotics in literature and being the fodder for tragic stories of individual pain.  It will take new information technology and new approaches that are carefully designed to foster humanism, as defined by the patient and the family.  Caring can be improved if we learn how to use information technology in a way that supports and helps our professionals focus more on understanding each patient as a unique individual and not just a set of pathologies.    My strange friend from forty years ago had confidence that he could fight the inherent evil of computers and I too am confident that we take harness the power of technology to improve the professionals’ ability to care for patients.

Apps, Attention, and Obesity

At one point in my career, since I have a strong background in nutrition (I am a Fellow of the American College of Nutrition and was board certified in clinical nutrition) I thought I would make my fortune by writing the ultimate diet book.  It was really very simple.  On each page I would print the following message:

EAT LESS AND EXERCISE MORE

Of course that was many years ago and now the current version of my book is achieved by creating the ultimate weight loss app.  The many apps that have appeared are as equally effective as my book concept would have been.  Or so it seems in a very nice study this month in the journal Obesity.  The Duke team, one of the best in the country in treating obesity, investigated whether apps on a cell phone helped young obese adults lose weight.  The answer was no.  In their words, “this behavioral intervention did not lead to significant weight loss relative to control at any trial time point.” 

In some ways, this is not surprising.  Shlomo Benartzi, author of the book, “The Smarter Screen” and a professor and co-chair of the Behavioral Decision-Making Group at UCLA’s Anderson School of Management, makes the point that computer screens, or cell phone screens are “changing the way we think making us more impulsive and reactive.”  For behavior change to occur especially when it comes to overeating, becoming more impulsive is not likely to drive a successful strategy.  He notes, that “people think faster on screens, and this can lead us to become more reliant on our instinctive responses and initial impressions, even when they are misleading and incorrect.”  So while the app may tell you that you are eating too much, it is unlikely to drive behavior to make you eat less impulsively. 

I can have multiple apps on my cellphone, to manage my diet, my activity, my sleep, my heart rate, my medications, and my medical records.  Many of these apps are based on the theory that people just need more information about what they are doing and how they are doing it in order to change.  The most elegant apps (technologically) also send messages to your doctor or to a nurse if you or your numbers are out of line.  However the question is whether all these fragmented sources of personal information actually help us to modify our behaviors. 

This focus on making it simple to keep track and give us feedback on our own activities appears on face value to have some benefit.  We can potentially be able to keep records and “share” the information with the doctor or a nurse who can then intervene.  However it also can create information overload for both the person who owns the device and the health professional expected to intervene on the basis of the information.  Benartzi points out the experience from the VA Health System which has wonderful alarms within its medical records which doctors routinely ignore because there are too many alarms and too little time and attention.  It turns out that too much information – too many alarms – leads to a “scarcity of attention” – a term used by Benartzi – and that scarcity is amplified in our screen based world.

Benartzi compares our new use of apps and computer screens to Adam Smith’s treatise “The Wealth of Nations” written in the early stages of the Industrial Revolution.   He writes, “While Smith associated scarcity with a lack of material resources – during the Industrial Revolution, people needed more coal and wood and land – the most important scarcities of the information age are psychological, and caused by our new abundance of information. “ 

When I was a health consultant, advising the Fortune 100 companies on the health programs they put in place for their employees, I would often point out that they were spending huge sums of money on multiple health programs which ranged from weight loss, to stress management to disease management to pharmacy management, each with their own separate information and interventions for their employees and the employee’s families.  I would then tell them that the only thing that they were actually achieving was confusing the hell out of the same people they were trying to influence and whose behavior they were trying to change.   While at that time I admittedly did not know all the decision science behind my consulting point, it turns out that what was obvious to me has now been proved experimentally in numerous studies. 

In the world of apps, it is hard to have a full picture of the person trying to make the behavior change.  Life circumstances may make good diet and exercise virtually impossible due to competing priorities, financial and time constraints, and emotional factors.  It is virtually impossible for an app alone to address these points that are unique to each individual and that are often constantly changing. 

In the article on cell phone weight loss apps, the Duke team makes the point that behavioral change principles are often absent in the app based commercial obesity products.  Current obesity treatment guidelines recognize the need to evaluate optimal frequency and duration of contact on an individual basis which is hard to design into a pure app solution.  They conclude that you need a combined approach that may require “the scalability of mobile technology, the social support of personal coaching, adaptive intervention design and more personally tailored approaches.”

Apps and technology do have a role.  However their role is in making already effective programs and approaches scalable, easy and consistent.  They are facilitators of solutions rather than independent solutions.  Part of our challenge, is how to use these powerful tools, in conjunction with people and other support and operational processes to truly help people to lose weight, control their blood pressure, take their medications and maybe even just enjoy their lives more. 

The apps alone, in providing information, will be hard pressed to address the psychological and life factors that require the personally tailored approaches the Duke authors in the article speak about.  In many ways, our challenge for the foreseeable future is how to harness the power of technology in the search for the more individualized approaches that address people’s health, their life situations, their psyche, and even their spirit in the quest to improve their lives.  

What Patients Value in Everyday Medical Decisions

Mary comes in to see her physician, who she has known for five years, clearly worried.  The trust between them is excellent.  Mary is 42 years old, works as a waitress and has struggled with Metabolic Syndrome.  It is hard to manage the high blood pressure, high cholesterol and the need to maintain a healthy regimen of diet and exercise when you are sometimes working two shifts, trying to manage two teenage daughters and have a husband who is a truck driver and is gone much of the time.  The partnership between Dr. Sheila Jones and Mary has been excellent through the years and that relationship has led to control of Mary’s blood pressure and lipid levels even while the ability to eat well and exercise is limited due to life getting in the way. 

Today’s visit is different.  Mary is frightened because two people she works with have been diagnosed with breast cancer, and another third friend has also just started chemotherapy for breast cancer diagnosed three months earlier.  She knows that none of them are direct relatives, and that she does not feel any lumps when she examines herself, however she wants to be screened.  Dr. Jones sits and talks with her, telling her of the data that shows little to no benefit to screening before age 45 or 50.  Dr. Jones knows that the American Cancer Society guidelines do say that women over 45 should be screened and women ages 40 – 45 who wish to have a screening mammography should be able to do so.  However the US Preventive Services Task Force (USPSTF) says that screening should start at age 50 and the healthplan follows those stricter guidelines.  The screening mammogram may not be paid for since Mary has no medical risk factors, only inordinate fear.  Mary cannot afford to pay for a screening mammography from her own pocket as money is very tight. 

Dr. Jones knows that, statistically, the test will offer no benefit.  For Dr. Jones, ordering the screening mammography will be a mark against her on the scorecard that the healthplan keeps and may impact her income and even more importantly, her reputation as the scorecard is available publically. Dr. Jones talks to Mary and tries to dissuade her from having any test but Mary is not to be moved.  She wants the test or will try to go elsewhere to get it done even if that means switching doctors which she does not want to do.  Mary needs the relationship with Dr. Jones to be strong as her Metabolic Syndrome successes to date may be compromised by a breakdown in trust and a transition to a new doctor. 

 Dr. Jones thinks through her options.  She can call the healthplan medical director who may help her by making an exception however the healthplan medical director is told very clearly that his job is to communicate and obtain complex medical information that may not be reflected in the claims data, and not to go against the medical policy of the plan.  The healthplan lawyers are fearful that making decisions against medical policy sets legal precedent and may be used as evidence that they are not consistent in their fiduciary decision making.  Trying to work through that system can be a nightmare.  Or Dr. Jones can order the mammogram, not as a screening test but as a diagnostic test – a “rule-out” breast cancer.  She can say that she feels something on physical exam even though she does not.  It will maintain trust with Mary and will allow Dr. Jones to continue to be seen as her advocate.  It will also save time when she has twenty patients to see that day.  Dr. Jones tells herself there is a small risk that a false positive will be seen on the mammogram that will require more testing, perhaps even biopsy but there is also an extremely small chance the mammography will show a true positive that was unsuspected!  We are dealing with statistical probabilities after all.  Yes it involves telling a small lie and having something paid for by the healthplan that should not be paid for however how much more will it cost the plan if Mary’s Metabolic Syndrome was totally out of control due to her losing Dr. Jones as a trusted physician and she ended up with full blown diabetes, heart disease and all the complications. 

I present this as a dilemma and I admit for some, it is not a dilemma at all.  Many believe that the doctor must base all their decisions on the medical guidelines, deny the test and move on to the next patient. Dr. Barron Lerner, a professor of medical ethics at NYU Medical Center recently wrote an article in the Washington Post asking why the American Cancer Society took so long to “ignore evidence about early detection” when they recently increased their the screening age from 40 to 45 in breast cancer screening guidelines. He writes, “in an era of cost containment, we need to prioritize payment for proven interventions.”   However we are also in an era of trying to determine what the patient values not only what medical protocol says.   

In an article in JAMA Lynn, McKethan and Jha discuss the challenge that, as their title states it, “Value-Based Payments Require Valuing What Matters to Patients.”  They make the point that we must ask patients what they value and then deliver on those priorities.  However we must acknowledge that patients often value reassurance and family concerns over the strictly medical.   They are often more influenced by friends and family than they are by statistics and expert opinions.  In Mary’s case, she wants reassurance and wants to know that her life balance will not be upended.  She sees her friends struggling with all aspects of their lives as they deal with this potentially deadly disease.  They approach her about caring for their children if they die.  She must know that is not about to happen to her and she wants that test. 

In the JAMA article, the authors say “serious, life-altering and ultimately life-ending chronic conditions, often in old-age, pose a particular challenge for the health-care system because traditional professional standards may not effectively address what an individual most wants.”  I take issue with that emphasis.  I believe that often the most difficult issues are the more mundane, everyday issues that physicians and nurses encounter in the outpatient setting in the course of their daily practices.   Just like the metaphorical flap of a butterfly wing in Brazil (as described by Lorenz in chaos theory), that may change the course of a tornado in Texas, these small interactions with patients everyday may have in aggregate much greater effect than the issues of the patient dying of end stage disease.

The real challenge then is how to build these shades of grey decisions into systems of care.  These decisions involve people’s lives and not only their diseases, and occur between doctor, nurse, therapist and patient every day.  How can we make them work for both populations and for individuals?  Ultimately we must build health care processes and value based payments that respect the biomedical protocols as well as the humanistic, emotional, social and financial concerns that drive people’s lives.  We must build this for everyday medicine and not just intensive care and end-of-life medicine in order to maintain people’s trust in health care and solve our healthcare cost problems.  

Is Bad Data Better Than No Data?

We are now in the era of “big data” which, we are told, will answer questions we could never answer and also identify individuals before they are sick so we can intervene and prevent their illnesses and their problems.  It is exciting, earth shattering and the subject of more articles, blog posts and conferences than one can shake a stick at.  However is it true?  Can “big data” or little data for that matter really lead us to salvation (medically speaking at least). 

Forgive me for the religious association however it often seems as though people are taking the pronouncements from the medical data gurus as being holy writ from God.  That bothers me a bit because fundamentally being a monotheist I do tend to think that we mere mortals are not godlike in our perfection, even if we are physicians and even if we are the even godlier than physicians, health policy experts.  There is an old joke about a good man dying and going to heaven.  In heaven he is shown around by one of the angels who take him to the dining hall where a line of happy people are patiently waiting their turn to pick up their food for the day.  He then sees one of the heavenly beings wearing a white coat with a stethoscope in a pocket cut into line.  He asks the angel who that is and the angel says, “Oh that is just God – sometimes he thinks he is a doctor.”  Since we are not godlike in our analyses, we must better understand what all this data means, and whether bad data is better than no data.  Ultimately we need to know how to use data to help those in need.  That is the essence of medicine – helping those in need.     

I speak as a physician and a health data expert who has helped health care organizations, government and large corporations design programs based on the populations they serve.   The work I do is data based and thus I must understand the strength and limitations of data.  I know that data can potentially be used to positively impact the use of precious health care resources and the care a patient receives.  At the same time, in my professional role, I am often the skeptic, challenging those people who claim the data holds magical powers.  Thus I enjoyed the article by Dr. Saurabh Jha in the Health Care Blog entitled, “Quality of Skepticism and Skepticism of Quality.” It was his section on bad data being better than no data that inspired this post.  He makes the point, and I admit it is a point I make all the time, that perfection is the enemy of good but does not stop there as many do. Dr. Jha understands the limitations and that while perfection is the enemy of good, sometimes data analytics do not even achieve the standard of good.   

What then is this data we are talking about?  All data depends on some information, being put into the right format to translate into the binary code that computers understand.  When people speak of big data, at this point in time, they are mainly speaking of claims databases which take billing codes from insurance claims and assume that they accurately reflect the care that is being rendered.  Billing codes are financial tools that drive payment and are used by providers to maximize their revenues (there are courses and consultants that constantly try to help people adjust codes to do just that) and are used by insurance companies to minimize payments.  That results in a game with only passing interest in accurately reflecting what is going on between a doctor and a patient.  With electronic medical records, the hope is that we will obtain more accurate information on what is really happening.  The funny part is that the most popular and widespread EMR gained its market dominance by being able to help hospitals maximize their revenues by capturing all services and materials for accounting and billing purposes, not by accurately telling the clinical story.

Saul Weiner and Alan Schwartz, who I have spoken about in previous posts, have looked at whether medical records actually reflect what happens in an interaction between doctor and patient and have found, by comparing tape recorded encounters, and using standardized actor patients, that the record does not!  Thus even the data inputs from a medical record, considered to be much stronger than the claims records have serious flaws. They point out in their research that the medical records leave out the emotions, competing priorities, financial concerns, spiritual beliefs and other aspects of being human that have a major impact on the care rendered.  They call this contextualized care and have found the ability to understand the person and not only the disease is much more important in driving quality care than the purely bio-medical issues. 

Data tends to suffer from observational bias, sometimes called the “streetlight effect” from a joke that scientists like to tell.  Late at night, a police officer finds a drunken man crawling around on his hands and knees under a streetlight. The drunken man tells the officer he’s looking for his wallet. When the officer asks if he’s sure this is where he dropped the wallet, the man replies that he thinks he more likely dropped it across the street. “Then why are you looking over here?” the befuddled officer asks. Because the light’s better here, explains the drunken man.  We tend to look at these big databases, designed and optimized for financial purposes, because the light is better, even though the answers, the insights, are more likely found in data ‘across the street’ where it is not captured. 

But advances are being made.  Lab data is now included in some databases.  Pharmacy information, which used to be separate, is now incorporated.  Methods using word search and mining audio databases of phone calls between providers, patients, and insurers are starting to be used with some potential effectiveness.   However the databases, on a sheer numbers basis, are still overwhelmingly claims or EMR based, both of which are designed for financial and not clinical purposes. 

All this brings me back to the question which titles this post.  Is bad data better than no data?  I do not have a hard and fast answer.  Bad data can push you to make bad decisions and when the data is big, the bad decisions can really be whoppers.  Big data used to identify individuals is especially prone to mistakes as the variability in people is far greater than can be seen from the financially based data in the databases.  The danger is that we assume that the data is correct.  We assume it to be useful.  Dr Jha takes exception to this and says, “The burden is on proponents of the metrics to prove their usefulness.”  Currently that is not the case and the burden is on those who question the usefulness.  That does need to change and to be tempered by the medical tradition of skepticism. 

    

None of this is to suggest that the use of data be abandoned.  Perfection is the enemy of the good.  Let’s just understand what we are looking at, what the limitations are, and stop using even good data as if it is perfect.  We need to take a breath and study the use of data to evaluate its effectiveness rather than assume that all answers lie in those numbers.