In 2005 Wendell Berry wrote an essay called “Local Knowledge in the Age of Information” in which he articulated several themes germane to the challenge facing medical organizations in 2020. He was particularly interested in farmers and the agricultural/industrial complex, but his words seem applicable to medical care as well.
“Insofar as the center is utterly dependent upon the periphery, its ignorance of the periphery is not natural or necessary, but is merely dangerous. The danger is increased when this ignorance protects itself by contempt for the people who know…Furthermore the danger increases as the periphery is enlarged...
The general complacency about such matters seems to rest on the assumption that science can serve as a secure connection between land and people, designing beneficent means and methods of land use and assuring the quality and purity of our food. But we cannot escape the or ignore the evidence that this assumption is false.”
In the 1980’s academic centers discovered unexplained geographic variation such as between Boston and New Haven in use of hospital services. Boston spent $300 million more annually than New Haven on a per capita basis, most of which was explained by discretionary admissions in medical illness. It was implicit that both could not be right, although both could be wrong. It was also clear the additional spending did not result in measurable improvement in population health, so most efforts in the years since have been designed to reduce variation and its associated “waste.” There have been, in my view, three primary efforts: patient safety, quality improvement, and utilization management.
The patient safety effort has shown the value of checklists and proven bundles of steps to improve patient outcomes, particularly for procedures. Its utility in general medical problems has not been as satisfactory and the “pathway” movement has generally stalled. We reviewed the uneven impact of the quality movement in the recent article called Quality Improvement 3.0. There have been a few successes, but with limited impact on variation and little success in defining optimum steps. Utilization management mostly consisted of efforts by insurance companies to erect bureaucratic barriers, known as hassle factors by the clinicians, designed to discourage “thoughtless” ordering. I suspect the cost of creating the hassles is about the same as the money saved by discouraging/denying the expensive procedure. “Tiering” the price structure has had similar effects. All three of these efforts, though, could be thought of as efforts by the “center” to control behavior on the “periphery.”
These efforts have been contemporaneous with the rise of the large medical organization, which also needs to “control” from the center what is going on in the periphery, meaning on the ward and in the clinic. Most consider including their clinicians in organizational decision-making, but few have found effective ways to do this for all but a few issues. And, unfortunately, the ignorance, if not outright disdain, of the center for the periphery has increased in many organizations.
The periphery, in this case practicing clinicians, know they are being ignored. There are a lot of articles discussing recalcitrant clinicians who don’t apply evidence like the experts would want, clinician burnout, and persistent “waste,” and problems with the electronic health records, all of which can be seen generally as resistance by the periphery to being ignored by the center. But what if the periphery knows something the center does not? Some years ago, Medicaid tried to control expenditures by limiting beneficiaries to five prescriptions monthly. I dutifully went through the lists trying to simplify hypertension and diabetes management (and thyroid hormone) only to find out the patients wanted me to refill their arthritis medication, their benzodiazepine, their proton pump inhibitor, and their Viagra. So, I knew early on the effort was doomed to fail, but no one was available to talk to about what else we might do and there was no way for clinicians to collectively report their common experience.
Berry also noted the issue and recommended conversation, as opposed to communication.
“Communication, as we have learned from our experience with the media, goes one way, from the center outward to the periphery. But a conversation goes two ways; in a conversation the communication goes back and forth. A conversation, unlike a “communication,” cannot be prepared ahead of time, and it is changed as it goes along by what is said. Nobody beginning a conversation can know how it will end. And there is always the possibility that a conversation, bringing its participants under one another’s influence, will change them, possibly for the better.”
I used to conduct “open-mike” sessions between medical directors and the corporate organization and frequently would start with no agenda. Many corporate staff found these sessions terrifying, because there was no way to prepare. The doctors took to them like ducks to water, because they were comfortable engaging in discussions and expressing their views. As moderator, I usually found the comments to be insightful, particularly if we were addressing a problem the junior directors had not encountered before. I did not observe much effort from the staff to enter into these discussions, or conversations, and only occasionally did it reduce their distrust of the doctors.
Real improvement in health care does not require us to stop what we have been doing, but we need to realize the limits of the methods. We should continue to standardize and streamline that which should be standardized, particularly procedures, and we should continue to use the tools of CQI to help us improve outcomes where we can. But we also need to realize variation is multifactorial—some of it is the clinician, some of it is the patient, and some of it is a complex social interaction between the two with the local system. I suggest we need to decide how much variation is acceptable rather than strive to eliminate it. Perhaps we should suggest 60% standard to 40% variation as the right ratio, at least at the beginning. But we need to start by having more conversations to find out what tacit knowledge clinicians have that should inform implementation decisions.
15 September 2020
 Berry W. Local Knowledge in the Age of Information. Reprinted in American Conservatism: Reclaiming an Intellectual Tradition. Ed. by A. J. Bacevich. (New York: Library of America, 2020,) pp. 481-492.
 Wennberg JE, Freeman JL, Culp WJ. Are Hospital Services Rationed in New Haven or Over-utilized in Boston? Lancet 1987;329(23May):1185-1189. doi.org/10.1016/S0140-6736(87)92152-0.
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