🤔 Uni-disciplinary thinking and the future of healthcare
The time for staying in your lane is over
Tyler Cowen has a beef with epidemiologists.
For anyone who’s been following his excellent Marginal Revolution blog the past few weeks, you’ll know that he has been talking to a lot of epidemiologists, and has found their advice — indeed their whole mode of thinking — somewhat lacking.
They are thinking only about the epidemiology, and not about sociology, political will, and economics. Their models of the coronavirus disease too often don’t take these factors into account, and their response to any suggestion that they should, is to throw their hands up and say, in effect, “I’m just an epidemiologist.”
In a May 15th post, Cowen wrote:
Let’s say it’s 1990, and you are proposing an ambitious privatization plan to an Eastern bloc county, and your plan assumes that the enacting government is able to stay on a non-corrupt path the entire time.
While your plan probably is better than communism, it probably is not a very good plan. A better plan would take sustainability and political realities into account, and indeed many societies did come up with better plans, for instance the Poland plan was better than the Russia plan.
It would not do to announce “I am just an economist, I do not do politics.”
He adds:
If a public health person presents what is “only an estimate of public health and public health alone” to policymakers, I view it as like the economist in 1990 who won’t consider politics. Someone else should have the job. Right now public health, politics, and economics all interact to a significant extent.
And if you present only one of those disciplines to a policymaker, you will likely confuse and mislead that policymaker, because he/she cannot do the required backward unthreading of the advice into its uni-dimensional component. You have simply served up a biased model, and rather than trying to identify and explain the bias you are simply saying “ask someone else about the bias.”
Uni-disciplinary thinking
Healthcare is rife with this kind of uni-disciplinary thinking.
Ever heard of hospital silos? That’s a bunch of highly educated, very smart scientists and doctors all staying in their lane, failing to consider that what happens in other parts of the hospital might have some effect on them, their work, and their patients’ health.
I’ve watched physicians suggest that what happens outside the hospital is largely out of their control, and therefore outside of their responsibility, and I’ve also watched physicians highlight their attention to things outside the hospital as if it were a major innovation in healthcare (Sadly, that actually does represent innovation in healthcare).
The opioid epidemic is a worthy example. I’ve written about the extensive lengths undertaken by Johnson & Johnson to convince doctors to prescribe more and more opioids, even if their efficacy wasn’t exactly backed by the science. But what the opioid crisis really taught doctors is that what happens outside their office, hospital, or department really does affect what happens inside.
Last year, working for US Acute Care Solutions, I wrote about a nurse named Ariana Sampson who had launched a program to give opioid patients buprenorphine inside the ER — an idea she said met with a fair amount of institutional, bureaucratic, and cultural resistance. Ariana was involved in numerous activities outside the ER, including advocacy work, speaking, and her participation in organizations like California Bridge.
She understood that making her patients better would involve politics, culture shift, societal attention, and yes, a new drug administered inside the ER, where her colleagues weren’t used to administering it. She was a multi-disciplinary thinker, and that made her a better clinician.
A doctor’s role and purpose
Like the opioid crisis, the coronavirus pandemic has made clear that what happens outside the walls of the hospital is very much the doctor’s concern, from just-in-time supply chains which exacerbated equipment shortages, to the politics and sociology of asking an entire world to shut down, social distance, and #StayHome.
The pandemic has also shaken a core assumption of doctors in the United States: that their profession was immune to economic shock. That’s an unsettling place to be.
A physician colleague of mine recently recounted in a Medium post a conversation he had with his critical care chief:
“There is a lack of certainty out there,” he told me. “Coronavirus is exposing a lot of people, and what it’s exposing is that a lot of people have stories that they tell themselves about who they are that get to be exposed as false. Meaning a lot of clinicians are a lot less certain about their role as clinicians, their role as people, and their purpose.”
Perhaps one’s role and purpose are not things a doctor often thinks about, or has to think about. After all, their purpose is perfectly clear — to take care of patients, to do no harm, and all that noble stuff they said at the medical school graduation ceremony.
But I wonder if anything can prepare a clinician to triage who deserves a ventilator when only a handful are available, or to make the kinds of decisions about the value of a human life that doctors in Northern Italy had to in March, or that doctors in NYC had to in April. Or give comfort to the dying when their family cannot be there with them. Or choose between staying home and not going to work, or risking their entire family’s health by going to a hospital take care of patients every day.
Those are questions for which we need ethics and philosophy in addition to medicine. They are questions our society has asked doctors to handle even if they were not prepared.
All models are wrong
As for the epidemiological models: all models are wrong, but some are useful. Well, to be useful they need to account for human sociology, political will, economics, and even certain ethical, moral problems (which are the same as societal problems).
For example: if and when we get a vaccine, how will it be distributed? Will we prioritize at risk populations, or will it simply flow to those who can pay, or who have the right insurance?
Epidemiologists can no longer content themselves with throwing up their hands and saying, “I’m just a doctor.”
We need doctors and healthcare leaders generally who think beyond the walls of their offices and hospitals — far beyond. They need to think into the homes and minds of patients and also into the halls of Congress and to the ballot box. They will be doing as Marc Andreessen counseled and building something new: a new technology, a new model, a new way to communicate.
And they will not fool themselves that leaving other disciplines to other specialists (medical or otherwise) is the prudent choice, either for their business or their patients.