Monday, March 30, 2015

The Gut and The Computer: Subjectivity and Objectivity

Subjectivity and objectivity commit a series of assaults on each other during a human life out of which first one suffers a the worse beating.

Andre Breton (1896-1966), Nadja (1928)

I once had a neurosurgeon friend, Erich Wisiol. He had uncanny knack for spotting patients with brain tumors. How did he do it? After spending time with a patient, Erich claimed he could “smell” a tumor, which is another way of saying he had the human intuition to perceive subjective patterns of symptoms and signs and behavior indicating the patient had a tumor.

This type of intuitive skill is based on something called “perception learning.” If you see enough of something you can perceive what it is without thinking. It becomes automatic. In medicine, you can apply perceptional training to removing gallbladders through a laporascope to reading cardiograms, to identifying rashes, to interpreting biopsies, to unraveling what data means (Benedict Carey, “Learning to See Data,” New York Times , March 29, 2015.

In this computer age, subjectivity is taking a beating. Reformers tell us you can’t trust your gut. You can only trust data and objective algorithms, But there’s a problem. “The problem today is that biological data are often abstracted into the digital domain, says John Greally, director of Einstein’s Center for Epigenomics, “ and we need some way to capture the gestalt, to develop an instinct for what’s important”. In other words to train human intuition to perceive patterns in the digital universe. In the words of Benedict Carey, science reporter of the New York Times, “ The information is all there, great expanding mountain ranges of it. What is lacking is the tracker’s instinct for picking up the trail, the human gut feelings for where to start looking to find patterns and meaning.”

But subjective learning, meaning learning based on person perception or knowledge or time spend with patients, is coming back in style. In Seattle, a medical group called Iora, which as 140 employees in 11 practices , has just raised $28 million in its third round of venture financing. Its secret? More time subjective spend with patients. Most primary care doctors have 2000 patients. The typical Iora doctor cares for only 1000 for a monthly fee. Iora primary care approach is longer hours, more support staff, and additional funding with more upfront time understanding the patient’s problems through daily huddles of the staff, and as a result, driving down total spending, through prevention and fewer hospitalizations. Iora’s model does not include deductibles or co-pays and welcomes more patient communications through visits, emails, and phone calls. (Margot Sanger-Katz, “A Starbucks for Medicine, “ New York Times, March 28, 2015). Iora’s leaders believe their model will prove profitable on a large scale and will attract further venture capital to facilitate expansion.

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