Emergent Networks: Physicians to Follow Psychologists

Emergent Networks: Physicians to Follow Psychologists
James Brody · 04/19/03 at 2:31 PM ET

Preachers, teachers, best friends, counselors, hair dressers, massagers, and chiropractors practice psychology. Human instinct, after all, is for quiet reason, physical assurance, and sometimes money from a cooperative source regardless of whatever that source calls itself. (Words can vary, the actions that carry them may not.) Any hooker or cafe waitress understands these things. So do their customers.

The adaptive quality of psychology (fun to do, learned easily, and performed by nearly every human) limits its exclusivity and, therefore, its market price. After all, psychology never established an essential set of skills that come only with training in psychology.

There's a second problem, one that now gives irony to physicians' coming demise: psychologists attempted to provide a cheaper alternative to the offerings from physicians (especially psychiatrists, the most dubious of specialties after chiropractic) while becoming symbiotes of medical organizations. Psychologists offered a different, less secret collection of beliefs but one also represented, for money of course, to be part of corporate health care rather than to remain an expression of evolutionary common sense. We billed health care, we sought hospital admission and treatment privileges, and strive now for authority to write prescriptions.

The modern practice of psychology dispersed as nurse practitioners, social workers, and addictions counselors now treat the depressions, impulses, distractibilities, and addictions once claimed by psychologists. The irony? Nurse practitioners now pose a similar threat to physicians. Nurses and the rest of us who seek health care will soon benefit from technology that extends nursing knowledge and competitive dominance.

The Problem Knowledge Coupler
Chris Gaither (What your doctor doesn't know could kill you, Boston Globe Magazine, July 14, 2002, 12-26) told of the Problem Knowledge Coupler (PKC) that consists of a comfortable chair and a patient who communicates with an extensive data base by answering an hour's questions on a touch-sensitive screen. PKC immediatelhy lists the 1-15 different possible diagnoses and the appropriate tests to distinguish between them.
There is interesting history behind the PKC, an invention of Lawrence L. Weed. Weed gave us the "problem oriented record" (POR) several decades ago when he noticed that medical goals and progress notes were both illegible but, when readable, also incoherent. Weed recommended that progress in the patient was to be recorded under the headings of goal, Subjective impressions, Objective data, summary Assessment, and Prognosis.

SOAP notes, spread by federal surveyors, invaded health care. (I remember well the growth of client records at an infamous residential facility from 3 pages in a manila folder to dual volumes, measuring 6 or more inches thick and requiring college-level staff to feed the chart and to supervise others who also fed the chart instead of the residents.) The POR made charts more objective and easier to evaluate than client care, federal money followed surveyor opinions and, thus, social agencies spent a LOT of money on charting.

Weed eventually noticed that the SOAP format did not improve patient care. Goals were pursued but the wrong goals. Or goals had little to do with patient recovery. Weed, a stubborn Vermonter, struck again and this time with greater accuracy than he did with the POR. His point: physicians over diagnose their favorite ailments and do not consider the 3-12 other possible causes that may lead to the same constellation of complaints from a patient. Paul Meehl found the same phenomenon for psychologists 40 years ago. Individual clinicians have favorite important things that they see but at the cost of not seeing other important things. Every parent exhibits the same kind of bias when watching their child.

Weed's and Meehl's observations do not surprise network analysts. First, hubs emerge in biological systems and in human concepts but networks of diagnostic preferences may not match those evolved by germs and viruses. Second, the variation between patients is apt to exceed the variation in the clinician's labels. Third, clinicians may see a cluster of symptoms no matter if most of them arise from genes, parents, teachers, or diet that are extraneous to the root cause(s) of discomfort.

Implication: a lot of medicine depended on placebos. A pediatrician once commented that he wanted to be the last doctor "to see the patient before he got well." There was also ancient wisdom in Army medics who ordered "Take an APC (asprin)" to complaints at sick call: turn off the complaint, return the soldier to KP, and let their body heal itself. Similarly, patients in civilian life often feel cheated if the physician charges for an office visit but writes no prescription. Imagine: visit the doc and hear from him or her: "I don't know what's wrong with you but you won't die from it, pay my wife at the desk $40."

Physicians, according to Gauthier, hate Weed's idea: PKC is now being evaluated by the Department of Defense. I'm confident that PKC will pass its empirical tests, I'm also confident that physicians will prevent its immediate large-scale use. Older preachers resist evolution, older adults resist the ideas of teens, and older rhesus were more skeptical when Imo first washed potatoes. Evolutionary primate systems will also conspire against immediate application of the PKC: we like to be touched by a healer regardless of whether that healer knows anything.

There are periodic reminders that we have not lost our evolutionary heritage. Dunbar, for example, estimated 150 as the magic number for the size of social group that we track in regiments, church memberships, and extended families. It also reflects the number of students managed by educational teams in many public schools. We should not be surprised that a Philadelphia physician collects advance payment of $2000 from each of his patients and gives in return, weekend access, unlimited contact, and membership in a restricted pool of customers (true story!). If the doc enrolls 150 patients for $2000 each, he earns $300,000 per year, has time for golf on Wednesdays, and still gets his fill of a personal integration with his patients. (Patients like his idea and he also could use the PKC.)

Economics will eventually do, however, to physicians in organized health care what it has already done to other health professionals. Physicians already have limits and quotas on the length of time they see a patient and the number of patients they see each day. Some of them also countersign orders written by a nurse and for patients about whom the physician may have more limited information than usual. It will take a generation before the healers find other things to do. I hope they don't take their demotion too much to heart. It happened to psychologists.

Copyright, 2003, James Brody, all rights reserved.

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