Re: Applications in Medicine

[Judith Rosen <***>]

Tom Staiger wrote:
> <x-tad-smaller>As I mentioned in the prior post, I've been trying to come up with a practical application for Rosen's ideas in patient care.  In Anticipatory Systems I recalled reading that the likelihood of a system failing increased with a greater discrepancy between the system's behaviors and its models of what was actually occurring or about to occur.   Any suggestions for a better design of an anticipatory system in the realm of patient care would be most welcome. </x-tad-smaller>
>

I would love to help in that effort. However, unless you are talking about a single practice, where you have total policy control, the situation is pretty dire. In terms of hospitals, medical schools, and the AMA... I suspect it would involve far more than a few applications. It requires a complete redesign of the system and, more than that, a redesign of the thought process about the system. 

I have, unfortunately, had rather more involvement with medical facilities than anyone would want over the past 8 years or so. First with Dad, when the diabetic side effects (predominantly neuropathies and kidney involvement), and then when Kyrie' was born and immediately went into the NICU... things aren't as acute anymore, but we still have a whole tribe, a team (a gaggle, a herd, a school [fish], a business [ferrets], a murder [crows]...) of doctors and nurses and specialists and therapists... And I can tell you from my own direct observations that there is nothing anticipatory about the design of hospitals and other medical systems in terms of patient care. If there is any anticipatory design process involved at all, it is from a very different mindset with very few of the actual needs of the patients taken into account. The only requirement of the patients' that seems to be considered at all is the technical aspect of "patient care"; the technological capability for diagnostic tests and surgical intervention. Aside from that, it seems to be entirely motivated by a need for efficiency, and that term seems to be defined as a synonym of "expediency." Time and money are the two commodities that seem to be prime motivating factors in every medical system or hierarchy that I've been involved in. It has only been in individual practices or individual cases (such as a single specialist) within a larger hospital or other medical system that I've found exceptions to this otherwise uniformly unpleasant experience.

The patient as "object" is the first mistake. I see this as the natural consequences of the reductionistic approach in science. As soon as one goes into an emergency department or is admitted to the hospital, there is a process of complete depersonalization that one is ferried through. One ends up, in short order, dressed in an undignified costume with a series of numbers assigned to one's care, and the chart is what medical personnel are most concerned with-- not the person the chart is supposed to refer to. I have seen so many instances of errors in the chart, I can't even count them all. And once something is written down on the chart, forget about reality! "It is written, therefore it is so" seems to be the prevailing attitude of all concerned. It's a damned meat grinder. I have argued until I'm ready to strangle someone, on both my father's behalf and then on my daughter's, over stuff in the chart that was incorrect, which they wanted to then use as a basis for prescribing some sort of treatment! ARG!

Hospital as business is the second (fatal?) mistake, because the business attitude is often "How to make the most amount of money in the least amount of time with the lowest overhead expenses" or some variation on that theme. This is the very same attitude that is killing post-secondary education. Students at universities and patients in hospitals both become "something to be processed" by the system, whereby the most processing in the least amount of time with the lowest possible overhead expenses is the way to maximize the business potential of the system.

This attitude is precisely why my father took early retirement to get out of Academia. The attitude at the university was that a professor with three PhD students wasn't as valuable as a professor who taught classes of 500. The urge to count things is, apparently, overwhelming in the financial acCOUNTING department mindset. "Time is money," after all.

Hmmm... I seem to be ranting. 

Sorry. I guess I have a lot of deep irritation on this subject built up from the hard times of the past 6 to 8 years, or so!

In any case, to put patient care as the prime focus of medical systems in an anticipatory model would, I hope I've managed to point out, require a return to square one for a complete redesign. Just as there is no way to make a system "more complex" by adding stuff to it, there is no way to salvage what currently exists of the organization of medical systems around a new paradigm. The facility would be salvageable but the organizational type has to be jettisoned. Mind you, that's my own personal opinion. 

Judith

Web address: http://www.rosen-enterprises.com
BioTheory: An electronic journal of general science based on the Relational (Rosennean) Complexity Paradigm
On Oct 18, 2005, at 7:35 PM, Tom Staiger wrote:

> <x-tad-smaller>David,  I've attached a Word version of this paper if you have questions that aren't addressed in my comments below. Again, be aware that the study described was designed to evaluate an agreement instrument and doesn't refer to anticipatory systems directly. </x-tad-smaller>
>  
> <x-tad-smaller>As I mentioned in the prior post, I've been trying to come up with a practical application for Rosen's ideas in patient care.  In Anticipatory Systems I recalled reading that the likelihood of a system failing increased with a greater discrepancy between the system's behaviors and its models of what was actually occurring or about to occur.  My thought was that both a patient and a physician are formulating models (of sorts) or representations of what they think is causing problems for the patient and of what is likely to happen to the patient.  My hypothesis would be that disagreements between the patient's and the physicians representation of what was wrong with the patient are a marker for either a missed diagnosis, an incorrect prognosis, communication problems, or unrealistic expectations.</x-tad-smaller>
>  
> <x-tad-smaller>If patient-physician disagreement is sometimes a marker for a missed diagnosis, an incorrect prognosis (or some other problem with the patient's care), and physicians could learn, through training or feedback, to recognize and act on these disagreements, they might be able to improve certain future patient outcomes.   While I don't think this is necessarily the best possible example of an anticipatory system (in the sense of a system in which its behavior in the present is influenced in part by the system's models of the future) it seems to me to have some of the characteristics of one and a way to provide an example of how the present could be entailed by something other than recursive, mechanistic processes.   (A related set of examples that I see in reviewing  events in our medical center is that adverse events are not infrequently preceded by disagreements between physicians and nursing staff, families, and/or patients.Whether such disagreements occur more often before an adverse event than in other circumstances would potentially be an interesting study.) What do others think of this as an example of a sort of an intentionally designed anticipatory system?  Any suggestions for a better design of an anticipatory system in the realm of patient care would be most welcome. </x-tad-smaller>
>  
> <x-tad-smaller>I'm glad to be part of a motley crew. Best wishes,</x-tad-smaller>
>  
> <x-tad-smaller>Tom</x-tad-smaller>
>