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Judith Rosen wrote:
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.
I would agree that an optimal
system would benefit from a redesign around a new paradigm. FYI, similar
concerns to yours have been expressed by Don Berwick, head of the Institute for
Healthcare Improvement, an organization that has been quite influential in
trying to promote quality improvement in healthcare. Dr. Berwick was one
of the contributing authors to "Crossing the Quality Chasm" an Institute
of Medicine publication that followed "To Err is Human" a publication which
received lots of attention in the public and healthcare press with regard to its
estimates of deaths due to medical errors. One of the recommendations in
"Crossing..." is that "purchasers, health care organizations, clinicians, and
patients should work together to redesign healthcare processes in accordance
with the following rules:
1. Care based on continuous healing
relationships
2. Customization based on patient needs and
values
3. Patient as the source of
control
4. Shared knowledge and free flow of
information
5. Evidenced-based
decisions
6. Safety as a system
property
7. The need for
tranparency
8. Anticipation of
needs
We clearly have a long way to go in
redesigning our systems in accord with those rules. I don't think our
current system can be financially sustained for too many more years,
so other factors may also force our society to re-think and redesign how we
provide healthcare.
Tom
----- Original Message -----
Sent: Wednesday, October 19, 2005 5:46
AM
Subject: Re: Applications in
Medicine
Tom Staiger wrote:
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.
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:
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.
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.
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.
I'm
glad to be part of a motley crew. Best wishes,
Tom
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