How to lower the high cost of medicine

Kahnemann – because our thinking is often limited by the fallacy  - what you see is all there is, and that our confidence in our opinions is determined, not the quality of evidence, but by the coherence of the story we construct in our heads, there is “The illusion of validity”.  Some of our most important beliefs have no evidence.   The coherence of the constructed story tends to parallel our confidence , but not its validity.

An example of this is shown by studies of stock picking skill in which few are able to beat the market for any prolonged period.   Persisting differences in ability are how we confirm skill.  Experts, using the recognition primed decision model, can be reliable in a regular predictable environment that can be learned with practice.  See Gladwell’s book ,”Blink”

Kahnemann then goes on to discuss Paul Meehl, a psychologists from U. of Minnesota.   He wrote a book called Clinical vs. Statistical Prediction: a Theoretical analysis and a Review of the Evidence.  The bottom line is that experts are inferior to algorithms in making predictions.    This is because experts try to be clever and they make summary judgments.  His conclusion is that to maximize predictive accuracy final decisions should be left to formulas.  Kahnemann says, “ Whenever people have enough data to build a model it will better than most people.”

These do not need to be complicated.  Robyn Dawes article “The Robust Beauty of Improper Linear Models in Decision Making” demonstrates that an even weight model of predictors has equal validity to a multiple regression.   Simple examples:  Marital stability= frequency of lovemaking – frequency of quarrels or Virginia Apgar’s newborn assessment scores.

In his E-myth, Book Gerber discusses the franchise prototype rules, which are: 1. The prototype will provide value.  Using algorithms in medicine will lead to the best possible result.  Even if the algorithm is just equal to the expert, the algorithm is less costly.  2. People with the lowest possible level of skill will operate the model.  If expertise is only used where it adds value this will lead to significant cost savings.  3. The model creates order.  4. The model is documented in a manual.  5. The model provides predictable service. 6.  The model utilizes a uniform color and dress and facilities code. 

Anesthesia is an area where much of this has been adopted.  The field has been protocolled and now nurse anesthetists are used.   The future is evidence based diagnosis and treatment protocols by less skilled practitioners with proper tools and training.   Highly skilled people will be needed to make the algorithms and monitor outcomes.