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    Monday, March 08, 2010

    Kneel at the Altar of Your God

    Yesterday I was reading an article at The Reinvigorated Programmer (hat tip to my brother for the link) about the changes in computer programming and coming to grips (or not) with them. The writer laments the metamorphosis of programming away from a creationary enterprise.

    Today, I mostly paste libraries together. ... Is that programming? Really? Yes, it takes taste and discernment and experience to do well; but it doesn’t require brilliance and it doesn’t excite. It’s not what we dreamed of as fourteen-year-olds and trained for as eighteen-year-olds. It doesn’t get the juices flowing. It’s not making.

    How universal is this desire to create? It drives humanity, and has since the beginning. Adam & Eve got kicked out of the Garden of Eden and started creating our race. The Pharaohs of Egypt built huge pyramids to remind us of their power. America boasts of creating an environment (government and economy) that fosters creation of products and ideas.

    EBM not only takes the individuality out of case management, but stifles innovation
    Medicine is the same. To some extent each of us, definitely myself, got into medicine to help others. Put another way, we wanted to create health from sickness. Surgeons say "a chance to cut is a chance to cure," but it could also be said "...a chance to create a new, healthy patient." 80% of physicians are still in private practice instead of large, academic settings because - in part - we enjoy creating that medical practice. We enjoy hiring our nurses, finding our own building, being our own boss. We enjoy creating a relationship with our patients.

    Quoted in the article is Don Knuth, from Peter Siebel's book Coding at Work:

    There’s the change that I’m really worried about: that the way a lot of programming goes today isn’t any fun because it’s just plugging in magic incantations — combine somebody else’s software and start it up. It doesn’t have much creativity. I’m worried that it’s becoming too boring because you don’t have a chance to do anything much new. Your kick comes out of seeing fun results coming out of the machine, but not the kind of kick that I always got by creating something new.

    ...The problem is that coding isn’t fun if all you can do is call things out of a library, if you can’t write the library yourself. If the job of coding is just to be finding the right combination of parameters, that does fairly obvious things, then who’d want to go into that as a career?

    The current trend of Evidence-based Medicine (EBM) is the mirror of Don Knuth's antagonist. We are taught in medical school and Continuing Medical Education (CME) seminars that we must practice EBM. Medicare has adopted it as measures of quality and tied it to repayment. for example, hospitals are rated by Medicare according to how fast a heart attack patient gets to angioplasty once arriving at the ER.

    This isn't a bad thing. When numerous studies show that mortality improves when a patient gets to the cath lab in under 60 minutes, who will argue with saving lives?

    But the problem with implementing EBM on a systems level vs a personal level, is that the physician becomes the cog in a machine.

    In an article on insurance companies using EBM to determine care, it says,

    Under EBM, medical treatment decisions are made primarily using guidelines from existing literature rather than a doctor's own expert opinion. Advocates of the practice say such guidelines limit variation in physician practice thereby improving quality of care.

    But critics dismiss a reliance on such standardized treatment protocols as "cookbook medicine" and argue that EBM not only takes the individuality out of case management, but stifles innovation by removing insurance companies' obligation to pay for treatments they may deem "experimental."

    And so the problems are two-fold for physicians:
    1. The adoption of systems-wide EBM results in elaborate flow charts and checklists that impart a feeling of "cookbook medicine" on the viewer. For a physician this negates the creator feeling. As this pervades the profession, would-be physicians who understand this will follow that creator feeling to other professions & medicine will lose a valuable part of its talent pool.
    2. Without individuality, the decision-maker leaves the physician-patient relationship. A third-party insurance company who stands to gain from denying care, interprets the literature and decides whether a procedure is necessary or not. More physicians will leave when they feel their position usurped by these companies, and the talent base of medicine is further eroded.

    It’s not what we dreamed of as fourteen-year-olds and trained for as eighteen-year-olds. It doesn’t get the juices flowing. It’s not making
    Plus, it's bad for patients. Last month I was learning ultrasounds in a high-risk Ob/Gyn office. One morning an Indian woman arrived for a scan due to previously seen IUGR (her baby wasn't growing). However, the family were immigrants, and mother was small. Talking about this with my attending, she remarked that the growth charts we used were standardized among middle-class Caucasian New Englanders. Totally inapplicable to the patient before us. In Britain, they've determined that many IUGR babies are normal when plotted on curves specific to that ethnicity. The same would be true with this woman's child. However, we as physicians couldn't make that decision because too many third parties would look at us not following up this baby's weight as bad medicine because it didn't follow EBM. So, she was here to get a second scan, wasting her time and money.

    Let's see EBM for what it is -- a wealth of accumulated human knowledge that elucidates the generally best way or an individual physician to practice medicine. Following it is the right thing to do. But let's not kneel at the altar of EBM. You go to medical school, and establish a practice, and cultivate relationships with your patients so that you can have the knowledge-base and intuition tailored to your patients so you can understand when the rule and when the exception is applicable. It's at that point we physicians step back from connecting libraries into a program and start to create again.

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