Healer, Heal Thy Guidelines!

I found my way over to an interesting blog written by one Joseph Paduda on Managed Care. A number of his posts were interesting, but I was most captivated by this one on the limits of guidelines. This is a topic, as a healthcare marketer, that always catches my attention, because health guidelines cause an essential challenge: namely, that the guidelines can only be improved upon if physicians ignore them.

What I had always assumed, and what Paduda calls into question, is that guidelines are based on the best science of the day. He puts it as follows:

A recent study may well give you pause - the key finding is rather alarming - many guidelines are NOT based on solid research, but on work that is kindly described as rather more superficial.

Published in the Archives of Internal Medicine, the research found "More than half of the current recommendations of the IDSA (Infectious Diseases Society of America) are based on level III evidence [expert opinion] only." [emphasis added]

Paduda goes on to note that many guidelines are based on good science, but encourages people to be vigilant in asking about the basis of guidelines they come across.

And while that may be good advice for the healthcare professional, or even a well-informed lay person, most patients aren't going to be able to debate the merits of particular guidelines with their doctor, or, more importantly, their insurer.

This bothers me immensely, because care decisions are going to be further centralized in the coming years (probably whether or not Obamacare is repealed, by the way), and the centralizers are going to lean on guidelines to cut costs and standardize care. This seems highly likely to slow the adoption of medical innovation. So never mind that slavish conformity to guidelines limits the opportunities for smart individual physicians to come up with better approaches to care, many of those guidelines may not be worth the glossy medical journal paper they're printed on. Not comforting.

On Condemnation

200 Years ago, the idea of slavery had many defenders: it was seen as biblically endorsed, blacks were assumed to be inferior, and it was the basis for an entrenched economic system. A combination of high and low rationales made it seem like a permanent feature of our society. Today, anyone who would endorse anything that bears the faintest resemblence to slavery would be hounded out of public life.

This evident truth occurred to me when reading a recent post by Ta-Nehisi Coates, titled, "On Improvement". He talks about some of the flaws inherent in humanity, and whether we can ever wash away the dark spots on our collective soul. He starts, innocently enough, by speculating on why we so enjoy football:

Have we created institutions which look unseemly, but actually are addressing some deeply-felt need? In relation to football, what if we--as humans--have a need to vent aggression, even if only vicariously? And what if we do this through other people who will be richly rewarded for their sacrifice, but will also suffer tremendously?

He goes on to speculate why some people persist in holding seemingly ludicrous beliefs and seeking out sources of information that reinforce them, for example those who cling to the 'Obama-is-a-Muslim' theory. He then concludes:

I confess that I have not fully worked this out, yet. I guess I'm just wondering the extent to which we've crafted our own chains. How much of this is just who we are? How much of it can be improved and reformed?

Coates doesn't touch on what I would consider the most obvious explanation: that our sinful human nature constantly tempts us down crooked paths that make us feel good, or make our lives easier, or help us avoid standing out from the crowd. To return to slavery, think about the ways that institution rewarded southern whites 200 years ago:

1) It enriched them. (we could probably stop right there, but wait, there's more!)
2) It gave them absolute power over someone else.
3) It helped them fit in, by not condemning something the richest, most important members of their community were all doing.
4) It gave them a clearly defined sense of the enemy (both the slaves and, perhaps more importantly, northern whites who were butting in.)
5) It provided a clear social hierarchy, and ensured they would never be at the bottom of it. (This is why, I'd guess, so many poor whites who owned no or few slaves were so adamantly against abolition, and explains some of the nostalgia for the Confederacy that still exists.)

I'm sure I could go on, but the point is that slavery was deeply embedded in the psyches and the relationships of the people in the southern states, and thus required major the application of powerful forces to tear it out.

Now, the interesting thing is that I could build similar lists for social causes championed today by both the left and the right. Does not abortion give the woman absolute power over the unborn child? Does not condemnation of gay marriage clearly define the enemy for conservatives? The question is whether as a society we will ever come to see abortion-on-demand or denying gay couples the right to marry in the same way we now regard slavery: that is, as a stain, something abhorrent.

One final thought. If it is true that societal ills have their root in human sinfulness, then we can expect changes in social structures, technology, and government to change what evils we tolerate, but not that some evil will be tolerated by large swaths of what we generally call decent people. An example: in the 1960's, television brought images of the civil rights struggle into every American home, making it impossible for people to ignore the plight of blacks the way they had for a century. At the same time, the contraceptive pill and improved surgical techniques made it possible, for the first time, for women to seperate sex from childbirth. Both technological changes created the impetus for major social changes: I would argue one for the better and one for the worse. One could imagine, say, a technology that allowed a fetus to develop in an artificial uterus after a few months of pregnancy, along with increased concerns about population declines in western nations, to change the societal calculus again.

A society's morals are not static, nor should we assume blindly that all changes are for the better. But we should hold out hope that we can learn an improve. Often, the sign of our progress is marked by those old practices which are now so widely condemned that (we hope) they will never curse us again.

The Incentive to Mediocrity

In my last post, I argued that greatness is increasingly unlikely to occur when society rewards talent so lavishly in its embryonic state. I would like to examine the issue from another perspective: is there, in fact, an incentive in modern life to be mediocre?

Throughout most of history, luxury was exceedingly rare, and only those at the pinnacle of power (think kings, dukes and the like) could harness sufficient economic resources to have it. This changed with the industrial revolution to some degree, but the real shift came with the advent of electricity and broadcast technology, which allowed for the first time most people to consume entertainment regularly. The advent of commercial air travel then allowed the non-elite to consume experiences (going to a beach in the winter, seeing exotic places or great art) with some regularity. After this, you no longer had to be a king to receive the best society has to offer, just moderatly wealthy: the top 1% of US households bring in more than $350,000 a year, which will pay for a very nice home, luxurious travel, and a damned big television.

So the incentives, perhaps, start to change for people. Is it worth it to kill yourself for your art, your science, your political platform, if you can achieve recognition and wealth without going quite that far? For those without genius-level talent, a great effort is necessary just to get to that elite level, and they will work extremely hard if they want all the perks of modern life. But the most gifted can achieve great success without supreme exertion: these are the people who 'make it look easy.'

I admit there is no proof to back up my idle theorizing, but the nature of modern luxury seems to offer at least a partial explanation for why society has produced so few truly great individuals in the post-WWII era.

On Being First

I am reading World Without End, sequel to Pillars of the Earth: both books are about medieval England, and the assortment of craftsman, priests, nobles and visionaries that either impede or advance the efforts to build, respectively, a bridge and a cathedral in the fictional town of Kingsbridge. Along the way, the characters kill, make love, go on journeys, try to ruin each other, and do all the other things characters do to fill out two 800+ page popular novels.

But what really interests me is the way the author, Ken Follett, captures the nature of how progress is made. Both books are driven by characters who solve seemingly intractable problems through intellect and force of will, doing things no one else in their community could have imagined.

But the interesting thing is that many of the solutions they come up with seem, to the modern reader, clever but not particularly ingenious. One example: in World Without End, the main character builds the foundation of a bridge by driving stakes around the area where the pillars will go, then filling the gaps between rows of stakes with clay to block the water. Clever? Absolutely. But not revolutionary, at least not to modern minds, even though few if any of Follett's readers have done anything similar.

What you realize upon relfection is that it doesn't seem so revolutionary because you know similar things are done all the time. You might have to reason out how to do it, but you know it can be done. It is much harder to ask yourself, about something that has never been imagined before (at least, as far as you know), "Can this be done?" Follett's characters win us over because they are always asking that question, and overcoming the obstacles in between them and their goals.

Being first to do anything is hard, especially in hard times like these when the easiest thing to do is play it safe and wait for things to improve. But human progress is the accumulation of knowledge gained as people try something first, and then a lot of other people applying that hard-earned knowledge to their situations. In any walk of life, there is the possibility to try the untried, and perhaps to prosper by doing something totally new.