Archive for April 30, 2013

Why medicine is changing

I just submitted this piece for the Colorado Medical Society magazine:

Dear Colorado Physician,
Hi.  It’s Jay, the guy from down the hall.  I am writing to you today to talk to you about how our world is changing, and why I think it is doing so.

First, none of this is going to make any sense until we face up to the fact that what we have viewed as “the normal course of business” in medicine is anything but normal.  In the history of the world, never have so many spent so much of other people’s money with so little accountability for how it was spent.  Never.  It’s been the biggest bonanza of unsupervised money in the history of the planet.  You and I, hospitals, drug companies, insurance companies, and many others have made incredible livings based on this lack of adult supervision of our spending patterns.  While we like to excuse ourselves from that list, as Walt Kelly said in Pogo, “We have met the enemy, and they is us.”  At least, partly us.

How did this happen?  Well, remember that in 1950, the sum total of the data about our practice patterns could fit into a cocktail party conversation.   With loud music on.  In the absence of the ability to judge who was doing better and who was doing worse at our gig, society did a number of things to try to help itself sleep at night.

First, they invented the malpractice suit.  By more or less randomly punishing anecdotally bad behavior, they sent the message, “We can’t tell if you’re doing a good job, but we’ll rely on your fear and guilt to regulate your behavior.  Sorry to resort to that, but it’s the best we can do right now.”  We learned to fear and loath trial attorneys.

To try to regulate our spending, the spending with no natural brake on it, they invented prospective review in insurance companies.  This was to send the message, “We can’t tell if you’re doing a good job, but we’ll rely on you giving in to hassle factor for things you don’t really want all that much, to distinguish what’s medically necessary from what’s not.  Sorry to resort to that, but it’s the best we can do right now.”  We learned to fear and loath insurance companies.

To try to regulate our quality, the quality no one could define with any specificity, they created hospital peer review and credentialing.  Good, we thought, because we control those, and so while we do punish egregious error, for the most part we go through the motions and excuse anything we can imagine having done ourselves on a bad day.  We do no root cause analysis, no systems improvement, and we wait for the same thing to happen again.  We shake our heads when it does, and wonder why so many of our peers are having bad days.

But in 2013, we are learning to tell who does a good job.


In 1965, Gordon Moore working at Fairchild Semiconductor, observed that the number of transistors on a chip was doubling every 18 months, and the cost was halving at the same time.  This meant that computing power, and therefore information, was getting cheaper at an exponential rate.   Today in 2013, Moore’s Law is still true, and information is cheaper than zero.

The cheapness of information fundamentally changes the properties of modern society.   It means that everybody’s performance can be measured, including yours, with increasing precision and accuracy.   It means data will be increasingly available to do systems analysis, and improve the safety, reliability, and efficacy of treatments and procedures.  It means that very complicated things will be modeled predictively, including things that are way more complicated than a hip replacement.  So the chances this computing power isn’t being applied to your performance as a doc?  Zero.  All the major health plans have already invested a lot of money to do exactly that.

So we have a couple of options here.   We could try to ignore this trend, and hope everyone who pays for our stuff will, too.  We can spend our time and effort trying to discredit the data that’s being used, even though similar techniques are being used to send coupons to women who are pregnant before they’ve told anyone, through their buying patterns.  Big Data is here, and it cannot be lobbied or wished away.

Or, we can use the information that health plans and others can provide to get better, and to accelerate our quest for error-free, high value care.  We can humbly accept that the smartest doc alone has no chance to do her best work without the data and analysis enabled by Moore’s Law.  And we can begin to use these data to get better at what we do at a rate unimaginable in the days before powerful computing.

I’m not here to make that choice for you, even if that were possible.  I’m here to tell you that whether you voted for this or not, it’s where we are.  The profession will never be the same, and like all loss, that is sad.  But we should recognize that the old system and its imperfect quid pro quo were driven by society’s inability to judge what it was buying from us; its need to feel safe through fear and guilt-based mechanisms; and comforting delusions about our infallibility that we secretly wanted to believe ourselves.  Today in 2013, I am confident that none of those things produced what is best for us, our patients, and our society at large.

What will you choose?  You won’t have to tell anyone.  They’ll know from the data.

April 30, 2013 at 4:44 PM Leave a comment


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