Check Lists and Decision Trees versus Spontaneity and Imagination

The task of health care reform in 21st century America is to decrease per-capita cost of care and to increase the quality of care delivered to patients. It’s complicated.  A famous Rand study concluded that Americans only receive 55% of the care that science dictates. Patients intuitively believe that more health care is always beneficial. Medicare reformers would like to do comparative effectiveness research so that CMS and private insurers could wind up paying only for therapy that actually works. Some estimate that 30% of all care delivered in the United States is waste.  What some call waste, others label revenue, and Atul Gawande becomes famous for identifying waste/revenue in McAllen, Texas (http://bit.ly/ENlli).

Neuroscience tells us that the smartest human can only keep track of seven variables at one time, and physicians tell us that diagnosis and treatment of a complicated patient can involve as many as 100 such variables.  Computers are good at cataloging, organizing, and retrieving information, but physicians are not yet routinely utilizing them at the point of care.  Computers are also good at allowing us to analyze large data sets and learn from experience.   Patients yearn for the warmth and caring of a doctor who really knows and cares about them. Behavioral economics pioneered by Amos Tversky and Daniel Kahneman taught us that human brains are designed with inherent biases that make us less than rational decision-makers.  We now know that human physicians and patients suffer from biases such as Pygmalion complex, confirmation bias, focusing illusion, incorrectly weighing initial numbers, and being more impressed with single cases than conclusions based on large data sets (http://bit.ly/49q4Uy).

So how do we decrease per-capita cost and increase quality?  Thomas Goetz and Atul Gawande have written two new books that attempt to address the essential question.  Goetz’s The Decision Tree is not out yet, but one can get a pretty good idea about his approach from a Wired Magazine article (http://bit.ly/6hQ9gw) and from a Website that is already available (http://bit.ly/7HkIA8).  According to Goetz, each of us should participate in the data revolution and plug in personal health information from genetic testing, iPhone applications, lab tests, running journals, and other sources of relevant data into decision trees.  A decision tree has four components that can help us overcome our inherent biases and capture the wealth of personal health information:  input, process, decision, and end result.

In the Wired article, Goetz gives three powerful examples.  Should Teri Smieja have preemptive surgery to protect against cancer?  Should Frank Kozik give up smoking? How should my Twitter buddy, @accarmichael, deal with her chronic pain which has been difficult to diagnose and treat?  I especially liked the case of Frank Kozik whose inherent biases made the abstract risk of getting cancer not powerful enough to quit smoking.  But when his dentist told him smoking related gum disease was going to make his teeth fall out, he was motivated to stop (http://bit.ly/6hQ9gw).

Atul Gawande’s The Checklist Manifesto (New York: Metropolitan, 2009) argues that a simple checklist approach can help us deal with the complexity of caring for patients by “making sure we apply the knowledge we have consistently and correctly.”  The same reasoning is behind the use of evidence-based medicine guidelines that ICSI produces (http://www.icsi.org) and protocol-driven care that has made Brent James and Intermountain Health Care famous and influential (http://bit.ly/7gVcVS).   It is hard to argue with this approach when one considers that a five-point checklist implemented at Johns Hopkins Hospital prevented 43 central line infections and eight deaths over 27 months.  A similar approach in Michigan ICUs decreased such infections by 66 percent within three months and saved more than 1,500 lives over a year and a half.

Why do doctors oppose checklists?  A survey of medical providers at eight hospitals about a Gawande checklist that cut surgical deaths in half revealed that 20 percent thought it was hard to use and did not improve safety.  However, 93 percent said they would want the checklist used if they were the patient undergoing the surgical procedure.  This is a great example of the confirmation bias at work in real life.  We have an inherent bias to discount contradictory data and so we continue to believe what we believe in the face of disturbing evidence.  The overconfidence bias is also probably at work here with the surgical teams who are impressed with their past successes and fail to be sufficiently self-critical.

Two book reviews of The Checklist Manifesto put their finger on drawbacks I felt when reading this important book about how to deal with the complexity of modern medicine.  Philip K. Howard in the Wall Street Journal review disagrees with Gawande that checklists are always “an unalloyed benefit.”  Howard also is not convinced that Gawande’s story of the Wal-Mart manager who drove a bulldozer through her ruined store to retrieve supplies for Katrina victims supports the use of checklists.  “Giving someone the authority to use her judgment means relying on individual creativity and improvisation – the opposite of a checklist (http://bit.ly/7sbiC3).”  Sandeep Jauhar in the New York Times Book Review also chides Gawande on “almost no discussion of the unintended consequences of checklists” such as overuse of antibiotics in emergency rooms tied to a pneumonia checklist (http://bit.ly/5kHBHS).

Most of us would also like to take Gawande to task for making us so jealous.  He is better looking, younger, skinnier, a regular New Yorker contributor, read by President Obama, a skilled practicing surgeon at Harvard, and a better writer than me. My knowledge of the behavioral economics concepts of maximizers and satisficers should allow me to deal with such jealousy by realizing that I will be much happier if I do not compare myself to others.  There, I feel better and I have made a full disclosure of my inherent bias against Atul Gawande.

This whole topic of the tension between Checklists and Decision Trees and Imagination and Spontaneity is also the subject in a way of Jerome Groopman’s “Health Care: Who Knows Best?” in the current issue of the New York Review of Books (http://bit.ly/7QFS9X). Groopman identifies Peter Orszag, director of the Ofice of Management and Budget, as the advocate for protocol/checklist/decision tree approach.  He writes that Orszag stated, “To alter providers’ behavior, it is probably necessary to combine comparative effectiveness research with aggressive promulgation of standards and changes in financial and other incentives.”

Groopman contrasts this approach with Cass Sunstein who works in the Obama White House overseeing regulatory affairs. Sunstein who co-authored the book Nudge: Improving Decisions About Health, Wealth, and Happiness believes that inertia causes us to make unwise decisions about our wellness and health.  He advocates using default options as nudges in service of libertarian paternalism.  Groopman explains this concept by writing: “For example, to promote a healthy diet among teenagers, broccoli and carrots would be presented at eye level in the cafeteria and would be easily available, while it would take considerable effort for students to locate junk food, thereby nudging them into accepting a healthier diet. But all choices should be ‘libertarian’ – people should be free to opt out of ‘undesirable arrangements if they want to do so.’”  Groopman wonders who will carry the day with the President on health care reform.

We need checklists and decision trees to make sure that American patients get more than 55% of indicated care.  We need imagination and spontaneity because we are human and because not all situations and not all patients follow protocols.   We need to understand how our brain is designed with inherent biases that make rational decision-making dicey.   It is all rather complicated, isn’t it?

Dr. Kent Bottles is President of ICSI. This post first appeared on the ICSI Health Care Blog.

5 replies »

  1. I am in a medical specialty deemed rather “intellectual”. I think that creativity/spontaneity is usually overrated and often cited by doctors who do idiosyncratic nonsense – and this occasionally includes academic physicians who committ similar acts of nonsense based on hobby interpretation of complex, barely explored biochemical/pharmacological processes.
    The problem, as hell MD pointed out, is the inaccurate application of checklists, resulting in incredible paperwork that makes the chart hard to read. To reduce a mysterious patient to “chest pain”, “TIA” etc. protocol creates inappropriate simplification which puts the patient on the road to mismanagement.

  2. So the writer is unable to advance the conversation. But, he was reasonably witty while he dithered.

  3. Protocols and check lists are also ways to start care without a doctor. We have some of that in our ED, with the nurses frequently putting a square peg in a round hole because they get in trouble with administration if they don’t. For example: 28 y/o with cough, fever and CHEST PAIN; nurse starts chest pain protocol. Doctor tells them to take Tylenol.
    Protocols and checklists are resisted by doctors because they are not written by doctors or initiated by doctors, yet we are responsible for the final outcome.
    Checklists are great if you are doing the same thing over and over. Patients are very subtly different, one from the other. They are a little like your GPS: route guidance will begin when you get to the route. There is plenty of zigs and zags before you get there.
    Good doctors are those who get good outcomes, obviously. The bias of a good doctor is not the average in the studies mentioned. Then there are the bad doctors (in some opinions) whose patients love them fiercely and go to them for years. Are they bad for their patients? The patients think not.
    There are too many variables to start calling balls and strikes which translate to dollars.
    Then there are the docs who take care of sicker patients. We have a strong regional oncology group. They are excellant. We also have two excellant and busy nephrology groups. Their patients are sicker and have a higher mortality rate, which skews the stats for our hospital.
    Most reasonable doctors are all for more science and the intelligent use of technology. Just remember that the doctor’s time is the most expensive time in the exam room (a fact which really pisses off nurses). The more time I spend at a computer or at a dictophone or on the phone the more it costs per patient, in the long run.

  4. I would like to thank Kent Bottles for questioning traditional wonk wisdom – namely, that if we systematically adopt enough protocols, check lists, best practices, and comparative effectiveness results, all will be well.
    I am amazed superior minds – like those possessed by the Atul Gawandes, Barack Obamas, and Peter Orszags in the world of eclectic pragmatism – would fall for the arguments of dogmatic electronic simplicity.
    As Alfred North Whitehead, the English philosopher said, “ Seek simplicity, but distrust it. “ I agree with Kent,”We need imagination and spontaneity because we are human and because not all situations and not all patients follow protocols.” Life’s too complicated for computers to explain.
    To conclude,
    Good for you, my fellow pathologist, Doctor Kent Bottles,
    Head of the Institute for Clinical Systems Improvement,
    For questioning the wisdom of applying full system throttles,
    For doubting aspects of the checklist and protocol movement.
    We need more, not less, imagination and spontaneity.
    We need more creative and flexible human noodling,
    And less dependency on computer homogeneity,
    And less deification of impersonal googling.