Breaking Healthcare's "Monoculture of Thought"

I read a phrase recently that I can't get out of my head: "monoculture of thought."  It wasn't said about healthcare, nor was it said by someone in healthcare, but I keep thinking it is a pretty good description of healthcare.

Image: Steve Lipofsky

The quote comes from Jessica Powell, in an interview with Farhad Manjoo for The New York Times.   Ms. Powell is a former Google executive who has written a novel that is a not-so-thinly-disguised portrait of life in Silicon Valley, where, as Mr. Manjoo puts it: "A lack of diversity is not just one of several issues for Silicon Valley to fix, but is instead the keystone problem."

Or, as Ms.Powell told him: "It’s a monoculture of thought, and that’s a real problem."

Lack of diversity has also been identified as an issue for healthcare, although it has usually been focused on the fact that, historically, most physicians were men.  That continues to be true, with women only making up about a third of active physicians (although women make up almost half of medical school graduates).  It has not only been a man's profession, it's been a white man's profession, with African-Americans and Hispanics still underrepresented.   
  
We've also come to realize that health and healthcare are not blind: clinical trials need more diversity, women's health is often shortchanged,  and we have deep-rooted racial and ethnic disparities.   

All of those are real problems for healthcare, and must be addressed, but, like Ms. Powell, I want to talk about the monoculture of thought.

We don't think much of our healthcare system, and for good reason.  It costs too much, it leaves too many people without access to care and/or financial protection, too much of what is done is of questionable value, and we don't end up any healthier or living longer than those in other countries.  

Despite all that, we want more of the same.  We want more physicians, more hospitals, more drugs, more health insurance, and plenty more technology.  We want what we have now, just better somehow.  We've fallen prey to healthcare's Stockholm Syndrome. 

That's healthcare's monoculture of thought problem.  

Here are some examples:

1.  We think we know how to educate physicians:  A new study found that there is no correlation between how highly regarded physicians' medical schools are and their patients' outcomes.  It takes longer to get trained as a physician in the U.S. than in many other countries, without a clear positive impact on patients of those extra years.  Heck, after over a hundred years we still can't decide between allopathic and osteopathic medicine.  

We can't even agree on how to do ongoing certification of physicians.  

2.  We think physicians always use best practices: We like to think that physicians base their treatments based on the best available evidence, right?  In fact, too often physicians base their clinical decisions based on how they were trained, where they practice, and what they've always done -- even when the evidence would suggest different decisions.  

The Dartmouth Atlas has been preaching this for decades, and organizations like the Lown Institute, Choosing Wisely, and The NNT Group have echoed the need for evidence-based medicine, with little discernible impact.

Source: Bipartisan Policy Center

3. We think health care brings health: See the doctor.  Get a prescription.  Have those screenings.   Go through that test or procedure.  Use the ER.  In short, we think that the healthcare system is the answer to our health.  That is wrong.  We spend most of our health dollar on health care, but most of what impacts our health happens outside the healthcare system.  

A small percent of us need a lot of healthcare, and cost a lot of money, but most of us don't, and our health investments might be better spent elsewhere.

4.  We think patient data belongs to everyone but the patient.  We've been talking about the value of sharing patient data for decades, and significantly moved the needle on how much of that data is digital, but we're still struggling with interoperability of patient data.  

Too much of patient data is trapped within physician practices, within health systems, and/or within EHR vendors.  Too much of the data is supposedly "de-identified" and then sold to third parties, without getting patient consent, ensuring true anonymity, or including patients in its economic value.   What should be an asset of the patient ends up being an asset for everyone else.  

5.  We think technology will be the solution to our problems.  We wanted electronic records; we got them, to no one's delight.  We wanted m-health/e-health/digital health, and we're getting it, but with all that connectivity and all that new data, we're not sure what is useful, how we'll use it, or whether it will result in making us healthier -- or just more worried.  We see the future value of genomics, but our ability to test is far outpacing our ability to understand, much less use, the information we can gather.  

Technology will be a crucial part of healthcare's future, but it will support the reforms we need, not bring them about.  We need to start with better understanding of what makes us healthy and how to motivate us towards the right behaviors.  We need to more rigorously track what "works," and who makes it work best.  And we need to revamp how and what we finance.     

None of these problems are unknown.  None are being ignored.  But way too little progress is being made on any of them. 
  

There is a well-known expression: "if your only tool is a hammer, then every problem looks like a nail."  Healthcare has a lot of people with a lot of hammers, only they're stethoscopes, scalpels, MRIs, chemotherapies, and the like.  They're buildings and offices that need to get filled.  Too many health problems are seen as nails, needing those medical hammers.    

That's the monoculture of thought in healthcare. 

Most healthcare experts scoff at the various outsiders who are showing interest in healthcare.  It's too complicated, it's too unique, they warn.  Maybe.  But I'm increasingly of the belief that it is only from outside of healthcare that we'll get the new ideas and the new approaches that healthcare needs -- and that those ideas and those approaches won't look like or easily fit in with what we have now.   

Want to bet on which monoculture of thought changes first -- Silicon Valley or healthcare?