Sunday, November 15, 2009

Medical Innovation, Health Reform, and The Counterintuitive, Irrational, Improbable, Unconventional, Unintended, and Unpredictable.

A third of the essays are portraits of “minor geniuses” — impassioned oddballs loosely connected to cultural trends.

Another third are on the hazards of statistical prediction.

The final third are about augury, about individuals rather than events. Why, he asks, is it so hard to prognosticate the performance of artists, teachers, quarterbacks, executives, serial killers and breeds of dogs?

New York Times Review of Books, “What The Dog Saw; And Other Adventures ,” by Malcolm Gladwell, November 15, 2009

Malcolm Gladwell – author is Outliers, Blink, The Tipping Point, and What The Dog Saw – is my favorite non-fiction writer. I suppose the reason why is that he defies conventional logic. I suppose I like his writings because they fit my own counterintuitive views:

• that most medical innovations comes from impassioned, creative, tinkering, doctors on the ground seeking pragmatic solutions rather than from purposefully managed large institutions or individual doctors following evidence-based protocols;

• that doctors at the point of care know better what to do from their own intuition and what they know of the patient before than from predictive modeling databases.

• that doctors generally do what they think is best for the patient rather than what is best for their wallet;

• that prognoses and effectiveness are unpredictable and cannot always be foreseen statistically.

• that everything in health reform in a government regulated system is obvious and that universal coverage will improve the health of the nation and can be reduced to zero in a complex managed system .

• that the expectations of doctors and patients from what they know and read of medical science, and what society and malpractice lawyers expect, is more important factor in decreasing costs than data on comparative cost effectiveness.

• that American culture - its faults, its violence, its freedoms, its attitudes towards opportunity and outcomes, and its skepticism toward Big Government – are far more important in determining the nation health than sweeping reforms.

• that incremental pragmatic reforms from the bottom-up over time that fit the nation’s culture will be more important and far less expensive than sweeping reforms from above.

Conventional wisdom from Washington would have us believe we can force the system to be more productive , tax our way to efficiency, simplify medical forms, end fee-for-service, bundle and capitates services, innovate through government demonstration projects, manage completion, lower costs through public plans, compare, control, and dictte treatments, negotiate drug prices, and extend coverage before we control costs.

Malcolm Gladwell and I might beg to differ.


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