Necessary Ignorance

3 stoogesOne of the smartest men I knew had a grade 3 education.

He followed politics and current events. He toyed with bookish pastors who dropped by to convert him. He could build a house, fix a car, grow and store anything edible, and much more.

He embodied Heinlein’s vision:

A human being should be able to change a diaper, plan an invasion, butcher a hog, conn a ship, design a building, write a sonnet, balance accounts, build a wall, set a bone, comfort the dying, take orders, give orders, cooperate, act alone, solve equations, analyze a new problem, pitch manure, program a computer, cook a tasty meal, fight efficiently, die gallantly.

Specialization is for insects.

Never Enough Measurement

We discussed measurement in Medicine is Relationship, Not Quality Metrics.  It sparked a thoughtful guest post: It’s Not a Choice, Good Quality Requires Relationships and Measurement.

Measurement hogs the microphone in healthcare. Anyone who questions measurement gets labeled a Luddite. They must favour ignorance, or anarchy.

Before we dismiss the Luddites, listen to their question:

Can we trust our capacity to measure everything we need to make great decisions?

Each day, 320,000 patient visits produce millions of data points in Ontario. In one day.

Measurement starts to look like a teacup scooped from an ocean of information.

Those who question the role of measurement want more information, not less. They do not disagree with measurement per se.

Necessary Ignorance

The economist Hayek said that everyone has a necessary and irremediable ignorance.

Rational decision-making demands knowledge of available and relevant facts.

But it is impossible to know all the ‘millions of facts, which in their entirety are not known to anybody,’ Hayek said.

Hayek believed we make better decisions using widely dispersed fragments of knowledge, not better quality knowledge for a few smart controllers.

( Ref. T. Sowell, A Conflict of Visions: Ideological Origins of Political Struggles).

Brilliant Elites vs Ignorant Plebes

“How much measurement do we need?”

Heretics question the primacy of measurements in decision-making. Spreadsheets and scatter-plots leave too much unmeasured.

No one is smart enough to control a whole industry using primarily measurement and audit. We need the billions of data points from all patient care decisions.

Millions of decisions made every day offer a better source of information. Front line doctors and patients possess and create information with every choice they make.

A small group of elites will never know this ocean of information, no matter how big their brains are.

We all want a great healthcare system. True greatness comes when system leaders embrace their necessary ignorance.

Certainly, keep measuring. But we should put more trust in the unmeasurable information guiding patient care at the front lines.

Doctors and patients are uneducated in policy and politics. But they are not stupid. Perhaps we should listen to them. Let them make more decisions using information that system planners will never know.

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Medical Malaise

depressed docDoctors love to talk. If you give them a chance, and show that you actually care, doctors have a great deal to say.

One doctor seemed to capture what so many others are saying. She gave permission to share the following email:

I feel it setting in with myself and my gp colleagues……..

this long drawn out affair with our contract and cuts is taking its toil…….

I fear another announcement about cuts is about to come……

we all feel powerless, helpless and I think many are getting disengaged from the fight with the government because it just seems to fall on deaf ears and yet they go on their merry way to fund this and that with no accountability of the public purse.

I could not work today- way too tired to be an effective doc-

provided an e consult for a patient with post partum depression- up north with likely very little services of this kind to help her effectively- this was all my brain could do

More Than Charts and Lab Tests

I think about my last three patients who died from cancer. Each one had the same look, at the end of their last office visit. They each said goodbye with their eyes.

Medicine transcends billing and audits, regulation and charting, guidelines and research. It touches people. It exists in a space between two people: the doctor and his/her patient.

The transcendent quality of care requires a special kind of person to handle it with enough gentleness to nurture, enough detachment to act.

Doctors do not train to fight. They train to care. Years of government attacks teach doctors to think differently. In subtle ways, prolonged disparagement undermines the medical character needed to serve patients.

Does government understand this? They play loose with a fragile resource.

A medical student described studying medicine in an air of animosity and how it flavours her whole education.  Her article laid blame where it belonged, with government.

But in a followup comment, she complained about her teachers (gated). How dare they mention the destruction caused by the Ontario government in front of “vulnerable” students! 

In the same way, outside observers lecture doctors on how best to talk with government. They scold doctors for expressing their feelings.

A person who acts obsequiously toward someone important in order to gain advantage.

Medical Malaise

Demoralized doctors do not give great care. Patients get the best care from fulfilled, respected, supported doctors.

Of course, doctors take responsibility for their own morale. But worrying about bank loans creates a big distraction from patient care.

Cuts to medical services reduce the amount of care available for patients. That’s the most obvious, practical impact. The deeper, emotional impact affects patients even more.

Government cannot act illegally, with repeated unilateral legislated cuts, and expect physician attitudes to remain unchanged. Attitudes impact patients.

The government settled quickly with all the other public employees. Yet it refuses to talk with doctors, except to discuss more cuts.

Doctors want to talk, to work out an agreement, while there’s still time to fix the medical malaise.

photo credit: When Doctors Get Depressed (NYTimes)

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Tsunami Bomb in Ontario Health

Whitby protestDesperate times call for desperate measures.

In WWII, Professor Thomas Leech worked on a new weapon: a tsunami bomb, an explosion designed to cause a natural disaster.

Experts gave up on it in 1945. Premier Wynne may have succeeded with Ontario healthcare.

Tsunami Bomb

A Tsunami bomb is an explosive charge that starts a wave big enough to kill a few hundred thousand people. It crushes the enemy with disregard for citizen casualties.

Premier Wynne unilaterally legislated cuts to spending on medical services, despite patients waiting up to 2 years for some services (e.g. joint replacement).

She made cuts for 2014 and 2015, last spring.

She cut again in Oct 2015, and has promised to make even more cuts at year end.

Her cuts come after the Liberals made a 5% unilateral cut in spring 2012.

Doctors ‘did their part’ by agreeing to a 0.5% cut per year for 2 years starting in 2012.

Wynne kept the 0.5% annual cut ongoing on top of all her other cuts.

Some experts believe that nuclear explosions could create Professor Leach’s disaster. Tsunamis cannot be stopped. They result from deep imbalance in powerful structures in the earth. All we can do is clean up the mess.

In Windsor, a protest formed over funding cuts.

An 11,000 member Facebook group popped up over a few days in October to protest cuts to care. They have a website now.

Spontaneous groups of doctors come together to protest at by-elections, like this one in Whitby:

Whitby protest


At some point, Premier Wynne will try to come back, to fix her healthcare mess. She needs peace in her 3rd year to woo voters back in time for re-election. By then, healthcare will look like a tsunami clean-up. It will be too late.


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