Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

Bruce Spurlock bspurlock at CYNOSUREHEALTH.ORG
Wed Jan 14 16:33:37 UTC 2015


Hi folks - been watching this conversation and I¹ve included 4 slides
about the Stacey frontier concept - hopefully they¹re still attached.
Stacey brings the idea of certainty and uncertainty to decision-making
methods.  The more agreement in the action/decision and the less complex
the situation makes for use of protocolized processes.  The more
complexity and controversy surrounding the decision/action the more it is
a process that requires different methods.  Ultimately, chaos ensues at
the edge of the frontier.

The first three attached slides identify the frontier graphically using
different language but similar constructs. The last slide I made after
discussing ³focused factories² with a policy leader.  Working in HRO we
focus a great deal on the idea of ambiguity which generally addresses
emergent concepts and decision making that is more akin to complexity
theory.

But the data out of focused factories around complications from hernia
repair and cataract treatments are so impressive that I placed them in the
protocolized area of the construct.  Reducing variation is likely the most
important factor to achieving minimal failure rates.  But I also included
antibiotics for pneumonia within 6 hours which has both face validity and
modest evidence that it is appropriate therapy (high agreement) but the
ambiguity and complexity come from making the correct diagnosis in that
time frame and subsequent overuse of abx which are some of the reasons why
it is no longer reported as a core measure.

Also on the last slide is Early Goal Directed Therapy (EGDT) which when an
organization is committed to doing is not an extremely complex process but
their is growing controversy and ambiguous evidence about its effect.
Finally, chronic back pain is one of the most challenging ambulatory
conditions to manage with great ambiguity around both what to do and how
to do it.

It might be worth trying to use the Stacey frontier for a few diagnostic
challenges which really gets at not an either/or approach on how to make
diagnoses and what systems to use - social interaction with patients vs.
decision support, but the types of diagnoses that fit best into different
approaches.  There is a ton of overlap and as we learn more, develop
better decision support tools, just as we gain more certainty over
specific treatments, topics can progress towards the more protocolized
portion of the construct.

But we are likely to have failure (read ³error") regardless of the method
used, our goal should be to minimize the errors and use the most
appropriate, perhaps even combinations of appropriate methods for decision
making.

Thanks.  Bruce

Bruce Spurlock, M.D. | President & CEO | Cynosure Health Solutions
916-772-6090 (w) | 916-835-0204 (c) | bspurlock at cynosurehealth.org
www.cynosurehealth.org <http://www.cynosurehealth.org/>




On 1/14/15, 4:30 AM, "Jain, Bimal P.,M.D." <BJAIN at PARTNERS.ORG> wrote:

>If we look upon science as a method of investigation, there is little
>doubt in my mind that diagnosis is more of a science than art. The
>essential feature of science is that it is a search for testable
>explanations and once such an explanation is found by observation or
>experiment it is agreed to by everyone. For example, if I see a patient
>with dispend and suspect pulmonary embolism, I perform a chest CT
>angiogram. If this test is positive, everyone would agree my suspected
>explanation was correct.
>Clinical diagnosis is identical to the method employed by Richard
>Feynman, the great American physicist in his investigation of the
>explosion of space capsule Challenger in 1986. He carefully studied all
>available data about the explosion and suspected malfuncion of an
>O-ring,which functioned as a valve due to extreme cold weather (28
>degrees F) as the cause of explosion. He tested his explanation with his
>famous experiment performed on television in which he dipped a replica of
>rubber O-ring in a glass of ice cold water and demonstrated it to lose
>its resilience convincing everyone he was correct.
>The 'art' part in diagnosis and in other investigations occurs in
>suspecting fruitful explanations which may require creativity at times.
>
>Bimal
>
>
>Bimal P Jain MD
>Pulmonary-Critical Care
>Northshore Medical Center
>Lynn MA 01904
>
>-----Original Message-----
>From: Robert L Wears, MD, MS, PhD [mailto:wears at UFL.EDU]
>Sent: Tuesday, January 13, 2015 1:06 PM
>To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times:
>"Doctor, shut up and listen!"
>
>I like this thought -- I've often thought that the 'medicine is an art --
>no medicine is a science'
>debate is sterile and unfruitful.  In addition, assertions that 'an art'
>is involved tend to be dead ends, closing off rather than opening up
>discussion.
>
>My own thinking is closer to David's -- medicine is neither art nor
>science, but rather a craft
>-- a learned way of thinking and acting about illness and injury.  In
>that it is rougly paralle to engineering, which is also not a science,
>but rather an informed, iterative tinkering and assessing to try to make
>things better in some sense.
>
>bob
>
>
>
>On 12 Jan 2015 at 17:24, David Lawrance wrote:
>
>> The practice of clinical medicine is neither art nor science. Those
>> things are both experimental. Whatever I do is not so much that. I
>> think I'm more of a skilled technician. My skills were largely
>> learned, but not taught. I have a lot left to master even after 35
>> years of practice. I wish what I did was experimental so that I could
>> 
>
>Robert L Wears, MD, MS, PhD
>University of Florida  	Imperial College London
>wears at ufl.edu		r.wears at imperial.ac.uk
>1-904-244-4405 (ass't)  	+44 (0)791 015 2219
>The kind of thinking got us into these problems is not likely to be the
>kind of thinking that gets us out.
>                                              ---Einstein
>
>To unsubscribe from the IMPROVEDX:
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


ATTACHMENT:
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