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   What is the role of patients in this new environment?  Some useful historical background is provided by Paul Starr.  Comparing attitudes towards advances in medical science during the Jacksonian and Progressive periods, Starr has written:

The outcome in the 20th Century was that “American faith in democratic simplicity and common sense yielded to a celebration of science and efficiency.”⁵⁴  This involved acceptance of professional authority, a “retreat from private judgment” and a “general decline of confidence in the ability of laymen to deal with their own physical and personal problems.”⁵⁵  Patients thus became increasingly dependent on licensed, expert professionals for information, judgment and skillful performance.

   Now, with the Internet, patients have become less dependent on experts for information and judgment.  Simultaneously, new technologies are lessening patient dependence on experts for performance of some medical procedures, because simple devices for diagnostic testing and monitoring are increasingly becoming available to patients.  But these devices generate detailed data that must become part of the medical record.  The record must be organized for use by the patient and multiple caregivers.   And data must be selected and analyzed in light of medical knowledge. If these problems in managing clinical information can be solved with effective tools and standards of care, then patient autonomy and independence from expert practitioners can increase by an order of magnitude.  The extent to which this new independence occurs remains to be seen.

   The patient role might evolve in either of two directions.  First, providers could become better organized to deliver patient-centered care through some form of “medical home.”  Medical homes would have responsibility for delivering and coordinating care for defined populations.  Patients would use information tools but still depend on practitioners for guidance in decision making and for coordination of care.  Information tools would reduce but not remove the information asymmetry between patients and practitioners, under this scenario, because the tools could only capture formal, explicit knowledge from medical science, not informal, tacit knowledge from concrete experience in medical practice.  Unlike patients, practitioners accumulate experiences with multiple patients encountering a given disease condition and the processes of care for that condition.  Thus patients would naturally turn to the judgments of veteran practitioners, who could draw on their past experience in navigating the processes of care on behalf of multiple similar patients.  On this view, the insight conferred by that past experience is a form of medical expertise above and beyond any specific skills in performing medical procedures.  (Indeed, the market for that expertise might constitute a new definition for primary care.)  Thus, under this scenario, patients are dependent recipients of care chosen under the guidance of the experts who provide it.

   The other direction in which the patient role might evolve would involve a basic shift of responsibility for going through the decision making process from providers to patients.  Under this scenario, patients are autonomous users of a total system of care that provides resources, experts and accountability.  Rather than being dependent on expert providers for information or judgment, patients employ expert providers when needed for delivery of specific services.  Autonomy in this scenario does not mean that patients make difficult medical decisions on their own, without involvement of others, nor does it mean that patients decide among alternatives determined by experts.  Rather, as in other areas of their lives, patients may exercise private judgment after turning to (or being confronted by) trusted parties who provide dialogue, guidance, feedback and emotional support.

   In doing so, patients would have available a transparent, orderly, reliable system of care, they would be responsible for using it, and they would be accountable for the choices and behaviors their use of the system reflects.  This second scenario is a return to the Jacksonian vision of medical science as “knowledge that could be widely and easily diffused.”  In contrast, the first scenario is rooted in the Progressive vision of medical science as too complex and inaccessible to employed without expert guidance.

   This second scenario is most applicable to chronic disease, where the economic burdens of health care are concentrated.  Imagine the patient as the driver of a car (to borrow an analogy from Norbert Wiener, who used it to illustrate the importance of feedback in complex behaviors).  No one can drive a car blindfolded by listening to directions from a passenger.  This is so even if the passenger is more knowledgeable about driving the particular vehicle or navigating the particular route.  That expertise in the passenger is no substitute for the driver’s personally receiving and responding to visual feedback while driving.  So it is in the care of chronic disease.  There can be no substitute for the patient’s taking on the responsibility to exercise private judgment.  That is, the patient must personally learn about his or her condition, consider the pros and cons of therapeutic alternatives (including personal behavior changes), choose among those alternatives in light of personal values and circumstances, act on the choice, get feedback on the results and make corrective adjustments over time.

   The patient with chronic disease cannot escape this role, for two fundamental reasons.  First, the patient, not the expert caregiver, is the one who must live with the choices made, and the patient is the one who must summon the resolve to make the behavior changes those choices may entail.  Even if a medical expert would arrive at the same choices as a well-informed patient, the patient’s relying on another to make those choices detracts from the personal involvement and commitment essential to coping with chronic disease.  Depending on another for inherently personal decision making saps motivation and self-respect.  And this dependency state shifts decision making authority away from the person, who is, in Hayek’s terms, “closest to the subject matter of the decision,” with “intimate knowledge” of the disease as uniquely experienced by that individual.

   The patient’s intimate knowledge of his or her own chronic disease is the second reason why the patient cannot escape responsibility for decision making.  The course of a chronic disease depends on numerous variables, none of which the caregiver personally experiences, most of which the caregiver does not control and some of which the caregiver is not aware.  In diabetes, for example, blood glucose levels depend on not only insulin levels but also diet, exercise, emotion, medications, infections and co-existing medical problems, among other variables.  The patient has more knowledge and control of many of these variables than the provider ever will.  Managing chronic conditions demands keeping track of these variables over time and examining them for medically significant patterns and relationships.  The provider’s expertise is limited to textbook generalizations and limited personal experience
with other patients, neither of which is sufficient to cope with detailed data and arrive at individualized decisions for the patient at hand.  Those decisions require expertise that resides only in that patient, feedback that only the patient can recognize and act on, and external tools that the patient has more time and incentive to carefully use than the provider ever will.  The patient feels what the disease and its treatments do to him or her, and can rapidly recognize correlations between those subjective symptoms and detailed data on physiological parameters.  Without any formal education, the patient is in the best position to observe these correlations.  What the patient needs beyond this personal knowledge is not the broad, sophisticated scientific understanding of a physician but rather a basic understanding of principles and data that bear specifically on choosing among the options relevant to his or her situation.  To that extent, information asymmetry exists in favor of the patient, not the expert provider.⁵⁶

   For patients to acquire the necessary understanding of their chronic conditions, decision making processes must move from Karl Popper’s World 2 to World 3, from personal recall, knowledge and judgment to highly organized records, including graphs and flowsheets for organizing objective data, plus decision support tools that bring objective knowledge to bear on this data in a usable manner, all in the hands of patients as well as providers.  Patients themselves can use decision support tools to identify options and evidence.  They can use medical records to discern their own unique patterns of response, to see what works and what doesn’t work.  And others can use these records to confront irresponsible patients with feedback on the medical consequences of their own actions or inaction.⁵⁷ External tools in World 3 thus provide concrete instruments for capitalizing upon the personal knowledge and motivation of patients, very much as the price system in a market economy capitalizes upon the personal knowledge and motivation of market participants.

   Consumers would naturally use the system of care in World 3, not expert caregivers in World 2, as the primary source of information for decision making.  The question remains, however—where do people turn for outside guidance and judgment?  Most people do not make important personal decisions based on purely private judgment.  Most people form judgments about their own needs based in part on dialogue with others.  But there is no reason for patients necessarily to choose medical experts for that dialogue.  Not all experts have the interpersonal skills or temperament to play that role effectively.  Nor do they often have a sufficiently close personal relationship with patients.  In many situations, the best source of guidance, feedback and emotional support may be other patients who are available in online communities oriented to particular diseases.

   As between the two scenarios outlined above, the first scenario is more compatible with the current medical culture, rooted in World 2.  But the second scenario is more compatible with the movement to World 3 made possible by modern information technology.  For that movement to be completed, the educational system will need to change.  If patient-consumers are to apply medical knowledge to their own medical data to manage their own health, then they as well as their caregivers need medical education.   But for consumers, medical education needs to begin in childhood.

   Every child has a natural interest in the workings of his or her own body and mind.  Every child personally experiences health care and the health care system.  Education designed to explore that personal interest and experience could involve learning by doing and learning from personal experience—elements that traditional education usually lacks.

   From their education consumers need to learn the principles, skills and attitudes required for maintenance of personal health, coping with health problems, using information tools and taking responsibility for medical decisions and health behaviors.  They need to learn about their own biological uniqueness and why it means they must take responsibility for their own health behaviors and their own care.  They need to learn why their uniqueness precludes relying uncritically on established medical knowledge, or accepting the marketing pitches of vendors, or becoming dependent on physicians to make inherently personal decisions for them.  They need to learn to interact with the health care system autonomously very much as they learn to navigate the transportation system.  They need to access and understand their own medical records, and to use software tools for applying medical knowledge to their own data.

   Consumers and caregivers alike face a medical culture not unlike the intellectual culture faced by Francis Bacon 400 years ago.  As described by Loren Eiseley, Bacon had to overcome an entrenched and stifling world view:  “The real problem was to break with the dead hand of the traditional past, to free latent intellectual talent, to arrest and touch with hope the popular mind, to carry word of that which lay beyond the scope of the isolated individual thinker …”⁵⁸  So we in medicine now must break with our past, if we are ever to control our own future.

Disclosure:  The corresponding author is the founder and a major shareholder in PKC Corporation (www.pkc.com), which develops and markets one of the information tools (knowledge coupling software) discussed in this article.  The other author is the son of the corresponding author.

Endnotes:

 ¹  The corresponding author is the original developer of these standards and tools, which are briefly described in part II.C below and presented in detail elsewhere, most recently in an unpublished manuscript entitled Medicine in Denial, which will be available on the Web in the near future.  

²  The manuscript cited in note 1 above includes references to numerous prior publications.

³  Bacon F.  Novum Organon (1620), Summary of the Second Part, Aphorisms Concerning the Interpretation of Nature and the Kingdom of Man, Aphorism No. 31 (Montague, trans., 1854); at http://history.hanover.edu/texts/Bacon/APHOR.html.  

⁴  NIH Working Group on Biomedical Computing, The Biomedical Information Science and Technology Initiative.  1999.  Available at http://www.nih.gov/about/director/060399.htm.  

⁵  Whitehead A. An Introduction to Mathematics, 1911 (American ed., Oxford Univ. Press, 1948, p. 83).  

⁶  Ibid., pp. 39-42.

⁷  Edward Gibbon, The History of the Decline and Fall of the Roman Empire, ch. IX; (Paris: Baudry’s European Library, 1840) , p. 200; available at http://books.google.com.

⁸  Grove W, Meehl P. Comparative efficiency of informal (subjective, impressionistic) and formal (mechanical, algorithmic) prediction procedures: the clinical-statistical controversy. Psychology, Public Policy and Law 1996; 2:293-323, p. 316, available at  http://www.tc.umn.edu/~pemeehl/167GroveMeehlClinstix.pdf.

 ⁹ Ibid.

¹⁰  Popper, K.  Objective Knowledge:  An Evolutionary Approach.  Oxford:  Clarendon Press, 1972 (pp. 72, 106). 

¹¹  Ibid., p. 108 (emphasis in original). 

¹²  Bacon F.  Novum Organon (1620), note 3 above, Aphorisms No. 2, No. 9.

¹³  Bacon F.  Novum Organon (1620), note 3 above, Aphorism No. 36.

¹⁴ Gaukroger S.  Francis Bacon and the Transformation of Early Modern Philosophy.  Cambridge University Press, 2001 (pp.10, 14-18); Kors A.  “The New Vision of Francis Bacon,” in Lecture 3 in The Birth of the Modern Mind:  The Intellectual History of the 17th and 18th Centuries (recorded lectures from The Teaching Company).

¹⁵  Bacon F.  Novum Organon (1620), note 3 above, Aphorisms No. 42-44.

¹⁶  Bacon F.  Novum Organon (1620), Preface to Second Part, note 3 above.

¹⁷  A popular exposition of this research is Gladwell, M.  Blink (New York:  Little Brown and Co., 2005).

¹⁸  Grove and Meehl, note 8 above.

¹⁹  Dawes R.  Rational Choice in an Uncertain World (New York:  Harcourt Brace Jovanovich, Inc. 1988), p. 143.

²⁰  Berg M.  Rationalizing Medical Work. Cambridge, MA:  MIT Press, 1997.

²¹  Ibid., p. 7.

²²  Institute of Medicine, To Err is Human (Washington, National Academy Press, 1999). p. 47 (“This report addresses primarily … errors of execution,” as distinguished from “errors of planning”).

²³  C.C. Weed.  The Philosophy, Use and Interpretation of Knowledge Couplers, PKC Corporation, 1982-2008 (p. 1), available at www.pkc.com.

²⁴  Bacon F.  Novum Organon (1620), note 3 above, Aphorism No. 47.

²⁵  Friedman M., Kuznets, S.  Income from Independent Professional Practice, 1929-1936 (National Bureau of Economic Research, 1954) (originally published in 1939), available at http://www.nber.org/books/frie54-1; Friedman, M.  Capitalism and Freedom (Chicago:  University of Chicago Press, 1962), pp. 137-60; Svorny S., Medical Licensing:  An Obstacle to Affordable, Quality Care, Cato Institute Policy Analysis No. 621, Sep. 17, 2008, available at http://www.cato.org/pubs/pas/pa-621.pdf; Kling A, Cannon M., Does the Doctor Need a Boss?, Cato Institute Briefing Paper No. 111, Jan. 13, 2009, available at http://www.cato.org/pubs/bp/bp111.pdf.  

²⁶  Dawes R.  Rational Choice in an Uncertain World (New York:  Harcourt Brace Jovanovich, Inc. 1988), p. 208.

²⁷  Ibid., p. 143 (emphasis in original).

²⁸  Blumgart H., “Medicine:  The Art and the Science,” Hippocrates Revisited, R. Bulger ed. (New York:  MEDCOM Press, 1973), p. 34.

²⁹  Nuland, S.  How We Die: Reflections on Life’s Final Chapter (New York: Alfred A. Knopf, 1994), pp. 248-49.

³⁰  Sowell T.  Knowledge and Decisions.  New York:  Basic Books, 1980, p. 26.  

³¹  F.A. Hayek, “The Use of Knowledge in Society,” American Economic Review, XXXV, No. 4, Sep. 1945, pp. 519-30 at p. 525 (emphasis added).

³²  Ibid. at 22.

³³  Ibid. at 18.

³⁴  Arrow K.  Uncertainty and the Welfare Economics of Medical Care.  American Economic Review.  1963.  LIII:941-73.  For further discussion of Arrow’s classic article in relation to Thomas Sowell’s analysis of knowledge and decision making, see , Part IV.B (pp. 5-8) of Weed LL, Weed L.  Opening the black box of clinical judgment, British Medical Journal, eBMJ Edition, Vol 319, issue 7220, 13 November 1999, available at http://bmj.bmjjournals.com/cgi/content/full/319/7220/1279/DC2.  

³⁵  Specific tools and standards of care for these purposes are described in parts IV and VI of the manuscript cited in note 1, as well as numerous prior publications cited therein.  These tools and standards have been used in clinical practice for many years.

³⁶  Herzlinger, R.  Who Killed Health Care:  America’s $2 Trillion Health Problem and the Consumer-Driven Cure (New York:  McGraw Hill, 2007), p. 185. 

  ³⁷  Knowledge and Decisions, note 30 above, pp. 10-11.

³⁸  IOM, Crossing the Quality Chasm (Washington, National Academies Press, 2001), Appendix B, Paul Plsek, “Redesigning Health Care with Insights from the Science of Complex Adaptive Systems,” pp. 326, 329. 

³⁹  IOM, Crossing the Quality Chasm, p. 69.  

⁴⁰  http://en.wikipedia.org/wiki/Double_entry_bookkeeping.

⁴¹  A company founded by the corresponding author, PKC Corporation, has developed “knowledge coupling software designed to implement this standard of care.  See www.pkc.com.

⁴²  The corresponding author originated the problem-oriented medical record standard.  

⁴³  Schattner A.  “Simple Is Beautiful:  The Neglected Power of Simple Tests.”  Arch Intern Med 164: 2198-2200 at 2199 (Nov. 8, 2004).  

⁴⁴ Groopman, J.  How Doctors Think (New York: Houghton Mifflin, 2007), pp. 193-94.

⁴⁵  Mendelson M., Murray, P.  Towards the appropriate use of diagnostic imaging, Medical Journal of Australia 2007; 187 (1): 5-6.  See  http://www.mja.com.au/public/issues/187_01_020707/men10331_fm.html.  

⁴⁶  Gottlieb, S.  Opening Pandora’s Pillbox:  Using Modern Information Tools To Improve Drug Safety.  Health Affairs, July/August 2005.  DOI 10.1377/hlthaff.24.4.938, pp. 938.  

⁴⁷  Schattner, A.  “Clinical paradigms revisited,” Medical Journal of Australia, 2006; 185 (5): 273-275, available at http://www.mja.com.au/public/issues/185_05_040906/sch10143_fm.html.  See also Dr. Schattner’s response to letters to the editor, criticizing “imaging without forethought.”  Ibid, 2006; 185 (11/12): 671-672 [Letters], available at  http://www.mja.com.au/public/issues/185_11_041206/arn11029_letters_fm-2.html.  It is remarkable that these issues are still the subject of debate.   

⁴⁸  Weed CC.  “Overview,” in Weed LL., et al., Knowledge Coupling: New Premises and New Tools for Medical Care and Education, New York: Springer-Verlag, 1991, pp. xviii-xix. 

⁴⁹  Groopman, J., How Doctors Think, note 44 above, p. 228.  Jauhar, S., “Many Doctors, Many Tests, No Rhyme or Reason,” The New York Times, March 11, 2008.  Dr. Jauhar’s essay generated remarkable commentary from many readers, both patients and caregivers, who further described the lack of “rhyme or reason” in medical services.  See  http://community.nytimes.com/article/comments/2008/03/11/health/views/11essa.html?s=1&pg=1.

⁵⁰  Congressional Budget Office.  The Long-Term Outlook for Health Care Spending, March 2008, p. 6. 

⁵¹  Bacon, F.  The Advancement of Learning, IX(1), at http://www.fullbooks.com/The-Advancement-of-Learning2.html 

⁵²  Heng, H.  The Conflict Between Complex Systems and Reductionism, JAMA 300;13: 1580-1581 (Oct. 1, 2008).  See also Wade N., A Dissenting Voice as the Genome is Sifted to Fight Disease, New York Times, Sep. 16, 2008, which states:  “the effort to nail down the genetics of most common diseases is not working. …  The common disease/common [genetic] variant idea is largely wrong.  What has happened is that a multitude of rare variants lie at the root of most common diseases ….”

⁵³  Starr P., The Social Transformation of American Medicine (New York: Basic Books, 1982), p. 140. 

⁵⁴  Ibid. 

⁵⁵  Ibid., p.  141. 

⁵⁶  For more detailed discussion of the patient’s central role, see Weed, LL, “Introduction: Scientific principles that tell us why people must manage their own health care,” in Your Health Care and How To Manage It (Essex Junction, VT:  Essex Publishing Co., Inc., 1975); Weed LL., et al., Knowledge Coupling, note 48 above; Part II of Weed LL, Weed L.  Opening the black box of clinical judgment, British Medical Journal, eBMJ Edition, Vol. 319, issue 7220, 13 November 1999, available at http://bmj.bmjjournals.com/cgi/content/full/319/7220/1279/DC2; 

⁵⁷  For two examples of this kind of interaction using problem-oriented medical records, see Dr. Ken Bartholomew’s descriptions in Knowledge Coupling (cited in the preceding note), p. 265.  

⁵⁸  Eisely, L., Francis Bacon and the Modern Dilemma (Lincoln: University of Nebraska Press 1962), p. 22.

   Medical knowledge is itself an element of the health care system.  Just as the system fails to organize health care providers for delivering patient-centered care, so it fails organize medical knowledge for solving the medical problems of unique individuals.  Instead, knowledge is organized for comprehension by the unaided minds of physicians.  Medical specialties, for example, are defined by body system, because that narrowing of focus reduces the burden of comprehension. Yet, patient problems normally implicate multiple body systems.  Similarly, because the mind more readily comprehends generalities about large populations than detailed data about individual variation, evidence-based medicine is oriented towards population-based forms of evidence that poorly describe the realities of unique individuals.  Indeed, that orientation characterizes medical knowledge in general.

   The reality is that every individual is a unique combination of resemblances to and differences from other individuals.  Medical knowledge is oriented towards the resemblances, not the differences.  All diabetics, for example, have in common some dysfunction in hormonal regulation of blood glucose levels; indeed, diabetes is defined in terms of that resemblance.  Of course, diabetics vary enormously in how the disease occurs, in the circumstances (physiological, psychological, social, economic) of its occurrence, and in the actions needed to manage the disease over time.  Some of these variations are specific to the individual, while others occur across definable subpopulations, which include broad groupings (e.g., Type I and Type II diabetics) to narrower ones (e.g., Type I diabetics with chronic renal insufficiency and cardiovascular disease).  Each individual diabetic is a unique and changing combination of some resemblances to some subpopulations, plus some variations specific to the individual.  Multiple dimensions of this uniqueness must be taken into account to manage diabetes over time.

   Medical knowledge about diabetes is oriented towards resemblances among individuals within subpopulations.  A great deal of medical knowledge about these interrelationships has been accumulated.  Much more such knowledge about diabetes remains to be discovered.  This illustrates the vital role of population-based analysis employed by scholars of evidence-based medicine.  But that role is crippled by failure to use the external tools—and corresponding standards of care—necessary to perceive and document medical realities encountered every day in diabetic patients.  Those are the very same tools and standards that caregivers and patients need for their daily functioning.  Were they consistently employed—that is, if more patient care took place in Popper’s World 3 rather than World 2—then new knowledge and errors in existing knowledge would constantly be coming to light.

   Medical knowledge long ago exceeded what the unaided mind is able to take into account or integrate with corresponding patient data (not to mention additional data about variations specific to the individual).  Were the missing standards and tools to be enforced in patient care, then the simultaneous use and development of knowledge could generate enormous synergies.  Health care cost and quality could become an arena of continuous improvement, rather than a quagmire of intractable dilemmas.

   Even now, with medical practice still mired in the status quo, science is transforming medical knowledge.  New understanding of disease at the genetic and molecular level is already making it possible to reconceive existing diagnostic entities and classifications.  These advances in medical science, however, demand a comparable transformation in medical practice.  To reiterate, more complete, organized, documented clinical observations in patient care, plus better linkages among these observations and existing knowledge of disease and therapy, would yield constant feedback on that knowledge.  There is reason to believe that we would learn how seemingly distinct disease conditions may actually be interrelated, how medical interventions that seem narrowly targeted at a specific gene or molecular pathway may actually disrupt multiple body systems, of how an individual’s phenotype may actually be more important than genotype for some diagnostic and therapeutic purposes, and how drugs and other powerful interventions sometimes may be more disruptive and less effective therapeutically than simple improvements in health behaviors.  These possibilities are reinforced by evidence that common disease conditions appear linked to many rare genetic variants among individuals rather than to a few common variants across populations.⁵²  Thus, individual heterogeneity and uniqueness, no less than patterns of resemblance across populations, must become the subject matter of medical knowledge.

> Part 5 – Patient Autonomy

         A. The domain of commerce

   Commercial enterprises, more so than research enterprises, must cope with the ongoing costs of gaining information resources and engaging in decision processes.  Although often overlooked, the economic importance of these costs, as Thomas Sowell observes, is fundamental:  

This basic problem is more difficult to solve in medical decision making than in settings (such as execution of decisions, or factory production) where the goal is to achieve uniformity of outputs by eliminating variation of inputs.   The goal of medical decision making is just the opposite, because the most important inputs come from patients.  Thus the goal is to individualize care by taking variation among patients into account.  A central difficulty in achieving this goal is that medical knowledge is usually expressed as generalizations that fit unique patients imperfectly.  Those generalizations are essential to take into account, because they capture medically important elements that different patients have in common.  Yet, these generalizations cannot properly be applied without also taking into account detailed, patient-specific data and individual preferences. 

   These disparate elements must be combined for individualized decisions, but those involved in medical decisions are not positioned to do so on their own. Caregivers cannot judge how patients’ personal preferences or values should be applied.  Nor are either patients or caregivers able to efficiently mobilize relevant general knowledge and couple that knowledge with detailed data.  Enabling them to do so should be a central task of health reform.

   A similar dilemma exists and is resolved to varying degrees in many economic contexts.  To understand how it is resolved, recall Whitehead’s principle—”civilization advances by extending the number of important operations which we can perform without thinking about them.”  F. A. Hayek observed that Whitehead’s principle has “profound significance in the social field.”  The significance is that social practices and institutions have evolved for avoiding dependence on limited personal knowledge and intellect:

   Hayek’s concern was “the price system as a mechanism for communicating information.”  He critiqued formal equilibrium analysis in economics, which assumes away the need for such a mechanism:  “there is something fundamentally wrong with an approach which habitually disregards an essential part of the phenomena with which we have to deal: the unavoidable imperfection of man’s knowledge and the consequent need for a process by which knowledge is constantly communicated and acquired” (emphasis added). He also critiqued central planning as inadequate for this purpose. The price system provides a superior alternative.  In contrast to centrally planned systems,   

   The planners of a command and control economy are unable to apply their knowledge (statistical information) effectively, Hayek argues, because they are too isolated from practical knowledge of “the particular circumstances of time and place.”  This practical knowledge “by its nature cannot enter into statistics and therefore cannot be conveyed to any central authority in statistical form. The statistics which such a central authority would have to use would have to be arrived at precisely by abstracting from minor differences between the things, … which may be very significant for the specific decision” (emphasis added).  That practical knowledge of “minor differences” is only available to the “man on the spot” who is closest to the subject matter of the decision.  “But the ‘man on the spot’ cannot decide solely on the basis of his limited but intimate knowledge of the facts of his immediate surroundings.  There still remains the problem of communicating to him such further information as he needs to fit his decisions into the whole pattern of changes in the larger economic system.”³³   The pricing system communicates information in the form of prices and quantities, which all interested parties can easily translate into personalized conclusions about affordability and availability.

   Hayek characterizes the pricing system as part of “the foundation of the civilization that we have built up.”  Such a foundation is missing from medicine.  Rather than building upon practices and institutions that have proved successful in science and commerce, medicine has remained mired in dependence on the physician intellect.  In Karl Popper’s terms, medicine has failed to move from World 2 to World 3, from the world of subjective knowledge to the world of the objective knowledge embodied in external tools.

         B. Comparing commerce and medicine

   Just as market economies need a price system to efficiently communicate basic information in terms meaningful to interested parties, so patients and caregivers need an efficient system for accessing and processing the limited, personalized information relevant to solving individual patient problems.  The difficulty presented by medicine is that personalized information is a needle in the haystack of medical knowledge and data.  Patients thus face enormous uncertainty unless and until they can access the limited information relevant to their individual problems.  Resolving this uncertainty for patients is the traditional role of physician experts.³⁴  But this role is misconceived, for four reasons.  First, physicians lack the cognitive capacity to play this role.  Second, consumer dependence on physician experts imposes high costs in money and time.  Third, transferring inherently personal medical decisions from patients to third party agents inevitably degrades the quality of those decisions.  Fourth, traditional decision making by physician experts is not susceptible to organized improvement, because clinical judgment is opaque—its cognitive inputs are undefined. 

   In many economic contexts other than health care, we take for granted that personal consumption decisions do not require costly expert advice.  In transportation, for example, one need not hire an engineer to advise on buying a car, nor an expert to drive it, nor a guide to
navigate it.  Market and regulatory forces have developed systems enabling consumers to use cars autonomously.   In medicine, however, the systems necessary for consumer autonomy are absent.  As a result, consumers are expected to rely on decisions by physician agents acting on their behalf.  But this approach is unworkable, for the four reasons just stated.  The current response to this situation among policy makers is evidence-based medicine.  But this response is futile. To paraphrase Hayek, evidence-based medicine takes the form of statistical, generalizations, isolated from practical knowledge of each patient’s particular circumstances and characteristics.  That practical knowledge is only available to those who are closest to the subject matter of the decision—the patient and caregiver.  But those parties cannot decide solely on the basis of their personal knowledge.  They also need to access broader scientific knowledge, couple that knowledge with patient-specific data, and organize the entire process over time.³⁵  In no other way can they make informed, individualized decisions.

   Regina Herzlinger makes a related point in her critique of managed care.  Managed care is a form of group purchasing.  “The Achilles heel of group purchasing,” Herzlinger observes, “is that it inhibits product differentiation.  The fundamental tenet of a market-based economy is that competition among differentiated products is much more effective in controlling costs than the clout of group purchases.”³⁶  In medicine, the power of competition among differentiated products for consumer choice has been illustrated with Medicare Part D, where costs for the first several years turned out to be 40% below projections.  This outcome appears to have resulted from Web-based software enabling consumers to enter their personal medication profiles and thus efficiently differentiate among competing drug plans in a highly individualized way, finding the most precise and cost-effective matches between their personal needs and available plan offerings of generic and brand-name drugs.  This example illustrates how tools and systems external to the mind (World 3) provide an essential foundation for a market of autonomous consumers in which producers compete effectively.  Moreover, the lack of this foundation distorts the development of differentiated products and services generated by medical science.

         3. The need for simple rules to manage complex information

   Not only consumers but caregivers are unable to cope with complexity when left to their own devices.  Both caregivers and consumers need to rely on external systems to manage information for decision making.  Moreover, they need to use these systems jointly.  These systems must therefore be simple to use for everyone involved.  Indeed, simplicity at the consumer level is characteristic of much economic activity outside of health care.  “The growing complexity of science, technology and organization does not imply either a growing knowledge or a growing need for knowledge in the general population,” as Thomas Sowell has written.  “On the contrary, the increasingly complex processes tend to lead to increasingly simple and easily understood products.  … Organizational progress parallels that in science and technology, permitting ultimate simplicity through intermediate complexity.”³⁷  From this point of view, the health care system’s impenetrable complexity is anomalous.

   Analysis by the Institute of Medicine (IOM) points in the same direction—simplicity must be built into the health care system for patients and caregivers.  The IOM points to a theoretical basis for this conclusion in scientific study of “complex adaptive systems.” Occurring in various social and natural contexts, complex adaptive systems are not built according to external, pre-conceived designs.  Rather, complex systems “can emerge from a few simple rules that are locally applied” by individual participants in the system (emphasis added).   “It is liberating to realize that the task of complex system design does not itself need to be complex.” To design an effective complex system means to “create the conditions for self-organization through simple rules under which massive and diverse experimentation can happen.”³⁸  Based on these scientific insights, the IOM has concluded that “important lessons about simple rules for complex adaptive systems can be applied to health care systems as well.   In redesigning health care, the building blocks are the simple processes that make up the work of small systems of care and their interconnections.”³⁹  The IOM proceeds to formulate “Ten Simple Rules for the 21st Century Health Care System” (pp. 70-88), but these are in reality general goals, not specific, operational rules for achieving the goals.

   What are the “simple rules” needed by the health care system?  A basic reality of health care is its information-intensive nature.  That reality suggests that simple rules for managing complex clinical information are pivotal.  Consider an analogy from the domain of commerce:  accounting rules for managing complex financial information.

   At first glance, accounting rules may seem like an unfortunate analogy.  Complexity, not simplicity, is what most of us associate with financial accounting.   Moreover, accounting rules have been powerless to prevent either the financial scandals that occurred at the beginning of this decade in cases like Enron and Worldcom, or the financial crisis occurring now near the end of the decade.  Yet, the analogy with accounting reveals much about the health care system.

   Accounting rules are indeed complex.  But that complexity exists only at the margin.  The core concepts of double-entry bookkeeping are so simple that they are taken for granted.  They apply universally, and yet allow for enormous diversity.  They help to organize the economic relationships among individuals who may or may not have any awareness of them.  First codified in Renaissance Italy 500 years ago, the core concepts of double-entry bookkeeping still provide a foundation for commerce.⁴⁰  On this foundation have been built “generally accepted accounting principles” (GAAP) in the U.S. and similar standards in other countries.  Accounting principles are generally accepted for internal use, not simply imposed as an external compliance obligation.  This general acceptance results from the order, transparency, feedback and accountability they make possible.  To secure these benefits, private sector organizations codify and refine accounting standards, governments incorporate them in regulation, and the accounting profession is employed to enforce them with periodic audits.

   The profound social and economic importance of accounting standards became obvious in cases like Enron and Worldcom, where egregious accounting violations occurred.  In the current financial crisis, financial risks have been magnified, concentrated and obscured in unprecedented ways.  Financial accounting standards then could not be relied upon to maintain order and transparency.  Thus, the scandal was that generally accepted accounting standards were violated or allowed to become ineffective.  By comparison, in health care the scandal is that generally accepted standards for managing clinical information are absent.

   If health care needs standards of care for managing clinical information, what would those standards look like?  And given the infinite variety of patients, medical problems and practice settings, how could a single set of simple standards be universally ap
plicable and useful?

   All medical care involves two problems in managing information: (1) applying general knowledge to patient-specific data (information processing), and (2) organizing the flood of data generated by complex processes of patient care over time.  Two corresponding standards of care can and should govern these activities:

• First, a combinatorial approach (as opposed to judgmental, algorithmic and probabilistic approaches) must be employed for using medical knowledge to inform selection and analysis of detailed patient data.  A combinatorial approach systematically combines multiple items of knowledge and data to identify medically significant linkages (for example, the linkage between a set of findings on the patient and a set of diagnostic or treatment possibilities).  This is a simple matching process that external tools can perform, before the exercise of judgment.⁴¹

• Second, providers and patients must jointly use external tools (medical records with a problem-oriented structure) to organize patient data over time.  The organizing principle is to rigorously follow the basic steps of orderly problem-solving:  gathering information, defining problems, formulating plans of action for each problem, executing the plans, obtaining feedback on the results, and taking corrective action in response to feedback.⁴²

   These two simple standards of care are not technical or obscure.  Instead, they embody common-sense principles of thoroughness and organization.  These are principles that everyone grasps, that minimize dependence on unstructured, subjective judgments, and that apply in all medical contexts.  That simplicity, order and unity are essential to making the health care system transparent, usable and affordable for all. 

         D. The effects of unmanageable complexity

   To reiterate, the manifold failures of quality and economy in health care arise from failure to bridge the gap between the mind’s limited capacities and the complexity of ordinary medical practice. Consider the problem of managing the use of expensive new technologies and procedures. For these advances to be used cost-effectively, two issues must be addressed.  First, they should be used only when superior to other options—which requires taking into account all available options, their applicability to the individual patient and their pros and cons for that patient.  Second, once an expensive technology or procedure is determined to be the superior option for a given patient’s circumstances, using the technology effectively may itself require taking additional detailed information into account.

   In short, managing the use of expensive technologies is fundamentally a problem of managing information—of applying extensive medical knowledge to detailed patient data.  This reality means that judging the effectiveness of imaging technologies, drugs and other costly medical interventions is context-specific.  Generalized “comparative effectiveness” studies are virtually useless.  To be useful, judgments of effectiveness must take into account all relevant factors (and filter out the irrelevant) on a case-by-case basis.  This can only occur in Popper’s World 3, using external tools to organize detailed patient data and integrate that data with comprehensive medical knowledge.

   An example is clinical imaging technologies.  Ordinarily, these technologies should not be used until first eliciting the information available from a carefully designed initial workup (history, physical and basic laboratory tests).  The initial workup for a given presenting problem can and should be designed in advance of the patient encounter.  Habitually conducting this pre-defined initial workup will sometimes elicit the information needed to solve the problem presented, or else point to further inexpensive, readily available data.⁴³ When this is not the case, when costly imaging technologies prove necessary, their effective use requires taking into account a bewildering array of factors in judging alternative tests, test protocols, test limitations and the significance of test results.  In particular, the initial workup often contains elements relevant to formulating inquiries and interpreting results.⁴⁴  The complexity is such that effective use of imaging technologies demands external guidance, which should be in electronic form, continuously updated and integrated with other information tools.⁴⁵  Caregivers need information tools to use clinical imaging tools cost-effectively no less than they need the imaging tools themselves to reveal internal organs.  In both contexts, ignoring modern technology is unacceptable.

   Another example is decisions about drug therapies.  Pharmaceutical use is fraught with complexity and peril:

 Our pharmaceutical habits today might actually make pharmacotherapy more risky than it was when all we had were herbal remedies and liquefied tree bark…. doctors today use an increasing number of drugs in combinations, and more drugs are being used more often by older people, a group that is likely to recognize fewer of the benefits of some medicines and more of their side effects. All of these trends are likely to continue to make adverse drug reactions more prevalent and profound and our efforts to mitigate them even more difficult.⁴⁶

The difficulties make it critical to weigh drug therapies against other therapeutic alternatives, to keep track of the drugs patients are already taking, to take into account the patient’s medical problems other than the problem for which the drug is prescribed, to anticipate side effects and interactions with other medical interventions, to carefully select physiological parameters for monitoring, and to meticulously collect and analyze the relevant data, including the patient’s subjective responses.  

   One would hope that economic pressures (not to mention concern for patient safety) induce practitioners to use costly technologies and risky procedures in a careful, highly selective manner.  But precisely the opposite has occurred.  Dr. Ami Schattner writes of clinical imaging technologies:  “physicians have become ‘fascinated’, ‘preoccupied’ and ‘obsessed’ with their new instruments,” which “are vigorously promoted by the large companies that supply them.”  This state of affairs is destructive at many levels:

With the increasing availability of powerful diagnostic instruments, physicians have become distanced from both their patients and the basic clinical data.  Today, tests and procedures are considered infallible and ordered in increasing numbers—often almost blindly, repeatedly and sometimes even without examining the patient.  Thus, many are redundant, inconclusive or misleading, in addition to being unnecessarily expensive.  Uncertainty, false positive findings and fear of lawsuits often beget more tests or procedures and may trigger dangerous cascades. This testing-dominated approach undermines the value of clinical skills, which tend to become underestimated, underused and finally lost.⁴⁷

   The key “clinical skills” at issue are those involved in conducting the initial workup—that is, taking a history, performing a physical exam and selecting basic laboratory tests.  The specific elements that these components should include depend on the patient’s presenting problem.  No practitioner will know what clinical observations are needed for each problem that patients might present.  Equally difficult is comprehending all the data generated by a thorough workup.

   These realities lead Dr. Schattner to argue that fully exploiting information from the patient history “mandates a closely linked and thoughtful use of large, preferably electronic, databases.”  But Dr. Schattner does not address the core issues of how and when external databases are to be used.  In traditional medical practice, the physician’s unaided mind largely determines the content of the initial patient history during the patient encounter; afterwards the physician may go to medical libraries and electronic databases for external guidance, if time permits.  This sequence is backwards.   What should happen is that before the initial workup guidance should be captured in external tools for use during the workup. In contrast to the unaided mind (Karl Popper’s World 2), the external tools (World 3) can perform rapid combinatorial analysis to select relevant data and reveal the data’s implications based on medical knowledge.  Then the practitioner and patient may supplement this objective process with additional observations suggested by their personal knowledge, experience and judgment of the practitioner who may have seen many other similar patients, and that of the patient whose intimate personal knowledge and experience of his or her own condition may reveal crucial variations from what the practitioner expects.

   The tool-driven, combinatorial approach just described contrasts sharply with the judgmental a
pproach that now prevails in medicine.  Without the necessary tools, a combinatorial approach is not practical for either provider or patient.  The patient will thus continue to rely on the apparently expert judgment of practitioners.  In turn,

    By default, practitioners act in accordance with their own interests, which may be driven by financial concerns, intellectual bias or simply convenience.  Vendors thus encounter little resistance as they market new technologies aggressively.  Reinforcing this effect are practitioner relationships:  “the current culture of medicine fosters lucrative networks of referrals and procedures but discourages critical examination of their value.”⁴⁹  Further reinforcing this effect are patients, influenced by vendor advertising, who demand the latest innovations.  Physicians are powerless to resist this pressure, because their patients will simply find other physicians who accede to patient demands.  These elements have led analysts to conclude that technological advances are a root cause of excess cost growth in health care.⁵⁰

   Technological innovation might have exactly the opposite effect if an objective, transparent, combinatorial approach to data collection and analysis were employed.  Patients and caregivers would be equipped to critically examine the value of new technologies and use them only when superior to existing alternatives in quality and cost, based on each patient’s individual needs in specific problem situations.  In that environment, innovation could be become a source of cost decreases—which is the role that technological innovation often plays in other sectors of the economy.

   For this to occur in health care, medical knowledge must be reconceived, and the patient must play a central role in the use of knowledge.  Those issues are the subject of the next two sections.

> Part 4 – Harvesting Medical Knowledge from Patient Care

                                      — Francis Bacon³

   Scientists face a wide gap between limited human capacities and the demands of effective practice.  To bridge that gap, scientists use external tools, such as measuring instruments, the microscope, the telescope, and, in recent decades, the computer.  The same is true of physicians and researchers in the applied science of medicine.  Everything from stethoscopes to advanced imaging devices, for example, make possible clinical observations that are not otherwise within human capacity.  So too, computer technology now makes possible information processing that physicians and researchers could not otherwise accomplish:   

   This statement begins by equating medical science and medical practice.  Yet, the examples given are drawn from science, not practice.  Using the computer to extract new knowledge for medical science differs from using it to apply existing knowledge for medical practice.  And, within medical practice, using the computer as a component of medical instruments to enhance the user’s physical capabilities differs from using the computer as an information tool to empower the mind for clinical decision making.

   These distinctions suggest that physicians and scientists differ fundamentally in their approach to limited human capacities.  Physicians recognize limits in their capacity for observation and data processing, but not in their capacity for applying medical knowledge.  Thus, the most advanced, costly and ubiquitous use of computer technology in modern medicine is sophisticated clinical imaging devices.  Through these devices, physicians collect detailed data and use sophisticated software to assemble the data into images of internal organs.  By comparison, physicians rarely use computer software to assemble patient data and medical knowledge into options and evidence for medical decision making.  Instead, physicians rely largely on personal intellect (“clinical judgment”) for this pivotal function.

        A. Intellect and the culture of science

   In contrast to medical practice, science has advanced by developing alternatives to unaided judgment.  These developments made possible intellectual operations that would otherwise be prohibitively laborious and prone to error.  The development of mathematics, for example, was described in these terms by Alfred North Whitehead.  He argued that confining the role of judgment facilitates development of system or method while freeing the mind for tasks where judgment is essential.  Writing of geometry before Descartes, Whitehead observed: “Every proposition has to be proved by a fresh display of ingenuity; and a science of which this is true lacks the great requisite of scientific thought, namely, method” (emphasis added).⁵  Writing of algebra, he observed that using symbols in equations “is invariably an immense simplification. … by the aid of symbolism, we can make transitions in reasoning almost mechanically by the eye, which otherwise would call into play the higher faculties of the brain.”  Writing of arithmetic, he explained the simplifying effects of notation:

   Giving these examples from mathematics, Whitehead then stated a broader principle: “It is a profoundly erroneous truism … that we should cultivate the habit of thinking about what we are doing.  The precise opposite is the case. Civilization advances by extending the number of important operations which we can perform without thinking about them.”⁶

   A prime example is the invention of writing.  The tools and techniques of writing extend our minds to past thoughts and words without our having to recall them.  Indeed, Gibbon observed that our capacity for “knowledge and reflection” depends in large part on the use of writing:

But science requires more than enhancement of personal judgment and imagination.  Also required is the simple capacity to effectively process the raw material of science—information.  For this purpose, the mind is untrustworthy.  Although its powers of instinctive judgment are impressive in some contexts, the mind is “a relatively inefficient device for noticing, selecting, categorizing, recording, retaining, retrieving and manipulating information for inferential purposes.”⁸  This reality explains why digital information technology represents a turning point in the history of science.  Scientists were quick to exploit advances in that technology as they came about in the second half of the 20th Century.

   Thus far we have discussed how tools and techniques for aiding the mind bridge the gap between human cognitive limits and the demands of science.  But we have not addressed other gaps that science must bridge:  gaps between normal human behaviors and the rigorous habits of careful investigators, between individual, subjective experience and shared, objective knowledge, between limited individual capacities and the greater capacities of social, cooperative endeavors.

   To bridge these gaps, science has developed a variety of social and technical practices.  These practices include enforcing habitual use of tools and techniques to aid the mind.  These practices also include simple standards of thoroughness and reliability.  Disciplined practices and behaviors of this kind are essential to scientific progress:

The dazzling achievements of Western post-Galilean science are attributable not to our having any better brains than Aristotle or Aquinas, but to the scientific method of accumulating objective knowledge. A very few strict rules (e.g. don’t fake data, avoid parallax in reading a dial) but mostly rough guidelines about observing, sampling, recor
ding, calculating and so forth sufficed to create this amazing social machine for producing valid knowledge. Scientists record observations at the time rather than rely on unaided memory. Precise instruments are substituted for the human eye, ear, nose and fingertips whenever these latter are unreliable. Powerful formalisms (trigonometry, calculus, probability theory, matrix algebra) are used to move from one set of numerical values to another.⁹

These practices introduce reliability, order and transparency to the raw material of science—information.  This is achieved by compensating for the variable habits and limited abilities employed in measuring, recording and manipulating information.  That compensatory function also empowers the mind’s capacities for judgment and imagination, but its first purpose is to enable trustworthy information processing.

   Scientific behaviors do more than bridge the gap between normal human behaviors and the rigorous habits that science requires.  Scientific behaviors also link the individual with other minds, bridging further gaps between individual, subjective experience and shared, objective knowledge, between limited individual capacities and the greater capacities of social, cooperative endeavors.

   This aspect of science is illuminated by Karl Popper’s distinctions among three different realms to which human thought and knowledge relate:  the world of physical objects or states (World 1), the world of mental states or conscious experiences (World 2), and the world of the objective contents of thought, residing not just in the mind but externally in books, electronic storage, works of art and elsewhere (World 3).  World 3 has objective content existing independently of the mind.  Moreover, “World 3 is autonomous:  in this world we can make theoretical discoveries in a similar way to that in which we can make geographical discoveries in World 1.”¹⁰   Popper’s view departs from traditional epistemology.  “Traditional epistemology has studied knowledge or thought in a subjective sense—in the sense of the ordinary usage of the words ‘I know’ or ‘I am thinking.'”  Popper distinguished knowledge in this subjective sense from scientific knowledge.  “While knowledge in the sense of ‘I know’ belongs to [World 2], the world of subjects, scientific knowledge belongs to [World 3], the world of objective theories, objective problems and objective arguments.”¹¹ Popper characterizes scientific knowledge in terms of theories, problems and arguments because scientific knowledge is conjectural and always potentially subject to refutation.

   By moving knowledge from World 2 to World 3, we create new opportunities to access knowledge, test it and apply it to human needs.  Moving knowledge from World 2 to World 3 thus fosters an evolutionary process of natural selection, with both errors and new knowledge coming to light.

   Consider technologies like the printing press and the computer, techniques like decimal notation, and simple practices like recording data at the time of observation instead of relying on unaided memory—they are powerful because they accelerate the movement from World 2 to World 3.  This movement is central to the culture of science.

   Remarkably, Francis Bacon envisioned these dimensions of scientific culture at its birth four hundred years ago. As the first thinker who systematically examined the mind’s role in the advancement of science, Bacon recognized that external aids to the mind are pivotal:

The unassisted hand and the understanding left to itself possess little power. Effects are produced by means of instruments and helps, which the understanding requires no less than the hand … those that are applied to the mind prompt or protect the understanding. … The sole cause and root of almost every defect in the sciences is this, that while we falsely admire and extol the powers of the human mind, we do not search for its real helps.¹² 

   Bacon reacted against academic and ecclesiastical dogma, with its static dependence on the minds of ancient authorities (Aristotle in particular) and its sterile mode of inquiry (formal, Scholastic disputation).  He became deeply skeptical of abstract thought divorced from observation and experience, writing:  “… we must bring men to particulars, and their regular series and order, and they must for a while renounce their notions and begin to form an acquaintance with things.¹³  The learning from experience by those engaged in commercial and practical activities enormously impressed Bacon.  He also witnessed a flowering of intellectual life outside the universities. He came to view science and practical learning as cumulative, collaborative activities that escape the limits of received authority and the individual mind.¹⁴

   Bacon saw a path that led away from the alchemy and astrology of his time and towards remarkable advances in science and technology over the last four hundred years.  That progress has involved a symbiotic, evolving relationship among the creative minds of individuals, tools and practices for observation and experiment, social practices for systematic feedback on received knowledge, market and non-market systems for generating, disseminating and applying advances in knowledge, and finally, in recent decades, revolutionary information technologies that empower the human mind by providing an alternative to its limited capacities.

   Analysis of the limits of the mind was central to Bacon’s philosophy.  Anticipating several currents of 20th century thought, he identified four “idols of the mind” that distort human thinking and perception:

•   universal mental limitations “inherent in human nature”;

•   each person’s disposition and acquired beliefs; each “has his own individual den or cavern, which intercepts and corrupts the light of nature”;

•   the limits of language, which “force the understanding, throw everything into confusion, and lead mankind into vain and innumerable controversies and fallacies”;

•   “various dogmas” in philosophy and the sciences, “which have become inveterate by tradition, implicit credence and neglect.”¹⁵

   Bacon understood that for both the individual and society, overcoming these idols of the mind was a difficult challenge.  “Our only remaining hope and salvation is to begin the whole labour of the mind again; not leaving it to itself, but directing it perpetually from the very first, and attaining our end as it were by mechanical aid.“¹⁶

   Some readers may dismiss this notion as a mere rationalization for “cookbook medicine.”  The reality is the opposite.  Cookbook medicine results from the weaknesses of the unaided mind.  Unwarranted variations in practice exist, because each practitioner writes a personal cookbook.  Evidence-based medicine seeks to replace that variation with uniformity, but it does so by failing to take into account the medical uniqueness of each patient.  That uniqueness can be taken into account only when scientific rigor is brought to medical practice.

         B. Intellect and the culture of medicine

   The first of Bacon’s idols of the mind—universal mental limitations “inherent in human nature”—has been studied in modern cognitive psychology for more than half a century.  Yet, this school of thought in psychology competes with another school of thought showing that the mind has impressive powers of instinctive judgment in some contexts, including medicine.¹⁷  This research suggests that external tools cannot replicate instinctive judgment or the “tacit knowledge” on which it relies.  At the same time, yet another school of thought in cognitive psychology discounts the power of both instinctive judgment and deliberate judgment (with the explicit knowledge on which it relies) as bases for expert decision making (in medicine and other fields).  This school of thought has studied two modes of combining items from a data set about an individual or group for a predictive or diagnostic purpose.  One method relies on human expert judgment based on informal contemplation and sometimes discussion with others (case conferences, for example).  The other method relies on formal, algorithmic, objective procedures (weighted sums of predictive factors, for example).   Empirical comparisons show that the latter, mechanical method is usually equal or superior to the former, judgmental method.¹⁸ “In fact, there is even evidence that when [mechanical] aids are offered, many experts attempt to improve upon these aids’ predictions—and they do worse than they would have had they “mindlessly” adhered to them.”¹⁹

   Separately from this research in cognitive psychology, clinicians have spent several decades attempting to develop software tools to replicate the deliberate judgment of highly trained and experienced physicians, using the analytical powers and explicit knowledge of pathophysiology on which they rely.  These efforts have had little impact.²⁰ That outcome is consistent with a general critique of formal, rule-based approaches to expert decision making in many fields.  In medicine this critique has been directed at clinical protocols, statistical decision analysis and computer-based tools.  As summarized in a study by Marc Berg, this critique idealizes the “art of medicine” and physician autonomy:

     This resistance to formal, rule-based approaches to decision making has been opposed, during the past two decades, by evidence-based medicine.  During that period, critics of the status quo have come to focus on the cognitive vulnerabilities first identified by Francis Bacon (although Bacon usually goes unmentioned). Galvanized by the patient safety movement, the culture of medicine is now acutely aware that epidemics of cognitive error in medicine result from the mind’s normal propensities.  But this awareness has (until recently) focused on execution of medical decisions rather than the decision making process.²²  And this awareness has not led physicians to embrace electronic information tools to aid decision making.

      Indeed, physician training, credentialing and functioning remain fundamentally unchanged—even though cognitive error in medicine is now recognized as epidemic, even though consensus has developed on the need for electronic medical records and other “health information technology,” even though health care institutions increasingly use digital technologies for storing, retrieving and communicating information, even though caregivers and patients use the Internet to gain unprecedented access to medical knowledge, and even though enormous amounts of time and money are being expended to develop networks of interoperable health information technologies among disparate systems and institutions. Despite these advances, the physician’s mind remains heavily burdened with the core function of processing information—applying comprehensive general knowledge to inform selection and analysis of patient-specific data in the clinical encounter.

   Given this state of affairs, the question arises whether scientific practice (Bacon’s concern) and medical practice differ in some way that justifies the limited use of information technology in medical decision making.  The answer is that the domains of science and medicine do indeed differ, but, rather than justifying current medical practice, the differences highlight its failure.

   Scientists and practicing physicians engage in fundamentally distinct problem solving activities, in terms of both purpose and context. First, in terms of purpose, as Chris Weed has observed²³, scientists seek to discover knowledge while practitioners seek to use established knowledge for solving more-or-less familiar problems. Although each patient is unique, many patient problems are sufficiently familiar so that established knowledge can often be applied effectively.  Unfamiliar problems may arise that are truly inconsistent with or unencompassed by established knowledge. But practicing physicians are not expected to develop new knowledge about these truly unfamiliar situations.  Instead, physicians seek to apply established knowledge as well as possible to situations that resemble prior practice.

   Second, beyond this difference in purpose, scientists and physicians act in very different contexts.  Research environments shelter scientists from difficulties that practitioners must cope with on a daily basis.  Scientists choose the problems to investigate, they have the time and resources to pursue those problems in depth, and they create controlled conditions needed to isolate and understand relevant variables.  Scientists thus work under ideal conditions for human judgment.  In contrast, practicing physicians must function without the luxuries of choice, ample time, sufficient resources and controlled conditions.  Physicians may not choose which patients they wish to care for, o
r which patient problems they wish to investigate.  Physicians may devote only limited time and financial resources to each patient, in comparison to what scientists may devote to their investigations.  And physicians have little opportunity to create controlled conditions for isolating variables of interest.  On the contrary, physicians must care for complex patients with multiple interacting variables. Each patient thus represents a unique combination of countless variables.  That individuality demands rapidly taking into account an enormous amount of medical knowledge and correspondingly detailed patient data.

   A further difference from scientific investigation is that medical practice is even more vulnerable to the universal mental weaknesses that Bacon identified and cognitive psychology has studied.  Medicine involves human situations where personal experience makes indelible impressions (for example, a physician who saves a patient’s life with a chosen therapy and then uncritically uses that therapy with other patients for whom it may not be the best option).  At the same time, medicine involves a vast body of knowledge that is at once too complex for anyone to fully comprehend and yet not complex enough to fully capture the realities of individual patients.   Practitioners, usually operating under severe time pressures, apply whatever knowledge enters the mind at the point of care.  Often that is not the precise knowledge most applicable to the unique patient but rather fragments of personal knowledge and beliefs evoked in the physician’s mind by limited data.   Francis Bacon described the psychological process involved:

   At this point some readers may respond that enforcing “evidence-based medicine” provides the “severe regulations” and “powerful authority” needed to break the hold of personal experience on judgment.  But evidence-based medicine in its present form is slow and unfit to move from the population-based generalizations of medical knowledge to “the remote and heterogeneous instances” of unique patients.  Moreover, evidence-based medicine leaves unsolved the “needle in a haystack” problem—the difficulty of coupling vast knowledge with detailed data to find the crucial combinations of details relevant to an individual patient.

   This state of affairs continues to exist in medicine in large part because of economic and legal factors.  Physicians’ legal monopoly on medical decision making has blocked forces of competition that might otherwise have brought reform long ago.  Indeed, for more than half a century, free market theorists have recognized the need to remove educational and credentialing barriers to competition in medicine.²⁵  But these barriers are entrenched. They protect the professional status quo in terms of power, money, status and self-image.  As the cognitive psychologist Robyn Dawes has observed:

States license psychologists, physicians and psychiatrists to make (lucrative) global judgments of the form “It is my opinion that …” [P]eople have great misplaced confidence in their global judgments, a confidence that is strong enough to dismiss an impressive body of research findings and to find its way into the legal system.²⁶

Denial of cognitive limitations, and reluctance to employ external tools, are not limited to medicine.  Psychologists have examined these phenomena in many fields.  Dawes explains that these phenomena reflect emotional needs:

The greatest obstacle to using [external aids] may be the difficulty of convincing ourselves that we should take precautions against ourselves … .   Most of us … seek to maximize our flexibility of judgment (and power).  The idea that a self-imposed external constraint on action can actually enhance our freedom by releasing us from internal and undesirable internal constraints is not a popular one.  …  The idea that such internal constraints can be cognitive, as well as emotional, is even less palatable.  …²⁷

   In medicine, expert judgment is idealized.  In the words of one distinguished clinician, “application of knowledge at the bedside is largely the function of the sagacity inherent in or personally developed by the individual physician.” ²⁸  Sherwin Nuland has further described this ideal of personal sagacity:  “every doctor’s measure of his own abilities … the most important ingredient in his professional self-image” is “to understand pathophysiology” and thereby “to make the diagnosis and to design and carry out the specific cure.”²⁹

   Science seeks to protect against this kind of reliance on individual cognition.  Protection against this reliance is needed in medicine even more than in science, because of the time and resource constraints and the financial influences that operate in medical practice.  In this regard, medicine resembles the domain of commerce.  This comparison is important because medicine lags far behind the domain of commerce in serving individual needs reliably and efficiently, without unnecessary use of scarce resources.

> Part 3 – Economy of Knowledge in Decision Making