Every now and then I chance upon an article that articulates something I have known and used, but have not formulated clearly. Such was the paper by Schwarze and Taylor called “Managing Uncertainty—Harnessing the Power of Scenario Planning.” The authors note physicians often address the issue of clinical uncertainty by citing statistics to patients and families as if they somehow made it easier for them to decide what they wanted. We all know, of course, that for the patient the outcome is all or none, not 70%, and patients tend to assume they will be the fortunate ones when the odds are steep.
According to these authors scenario planning became popular with economists who were trying to forecast economic conditions when oil prices surged in the 1970’s. Scenario planning has been a staple of war planners though, for more than a century. Even today I am sure there are large studies that have been done contemplating military responses to scenarios ranging from a major land war in Europe, or a conflict with North Korea, to a brush-fire war in Central America. The basic notion in these scenario-planning situations is to make a set of assumptions and then follow them out to see what is likely to result. Of course, it is best if you do this for several sets of assumptions rather than just one.
“A scenario should be realistic and accessible to patients; it must span the distance between their personal story and the realm of health and illness. Well-constructed scenarios manage complexity by prioritizing the deepest concerns and values of the decision-maker. This personalization helps patients create new perceptions about how their illness might progress and the implications for daily life. By exposing obstacles, scenarios promote the strategic thinking that is essential in considering treatments for complex health problems.”
I do think some physicians engage in scenario planning with their patients, particularly in complex situations. I estimate I do this with about 10% of my patients in any given time. A couple of recent patients come to mind. The first is a woman who is undergoing palliative chemotherapy for metastatic cancer. Chemotherapy given several years ago led to kidney damage and now she is progressing toward end-stage. I could have simply told her about dialysis and let it go at that, but instead I asked her what her goals were. She answered, “To be in my right mind and at home until I die.” This allowed me to start exploring questions about when or whether dialysis might be appropriate. She was anxious and brought her father into the conversation, and was back this week with her daughter to talk about it some more. I still don’t know what her decision will be, but I have tried to put the decision in terms of things that might help and those that might impair her chances of being sentient and at home when she dies. Of course, the conversation is exhausting for me, and not adequately compensated by the current payment system. There is not cost-savings to share with me if she opts for the less aggressive course. Of course, neither is the oncologist, who has obviously made it clear that her disease is incurable even while he administers palliative chemotherapy.
Another recent example was a patient referred for what amounted to a second opinion about her progressive kidney disease. After visiting a few minutes, I asked her what she understood about her disease and she said, “I know I am NOT going on dialysis. I knew someone who did it and it seemed terrible to me.” I asked her to let me give her my take on the issues, but assured her I was not going to argue with her about her decision. After giving my standard counseling, including what I call my sermon, she said, “I did not now that much about it.” Having gotten past her original statement, we were then able to explore what her issues were and they turned out to hinge on “I don’t want to be a burden on my husband. I don’t want him to have to spend all of his time taking care of me.” In this case, we could move beyond her fear and begin to consider decision-making in the context of her goals. Since this was her first visit, and the issue is not urgent, I don’t know what she will end up doing. Here again, the time investment and expenditure of emotional energy on my part was substantially greater than needed to capture the maximum billable charge for the evaluation.
If other physicians do something similar, then we have another way to think about how physicians and managers can communicate. Consider a senior hospital leader trying to figure out what the current debates in the U. S. Senate mean for next year’s bottom line, independent of what is or is not enacted as legislation. The degree of uncertainty is high right now, and unlikely to get better anytime soon. What if physicians and administrators got together and thought about different likely scenarios for healthcare businesses five years out. Having done this in terms of dialysis units, I can say that some outcomes are more likely and there are some common elements to all scenarios. For instance, all of my scenarios assume two things: we will be paid less for current services in the future and the bureaucratic burden (and costs) will continue to rise exponentially. We can certainly plan our business with these assumptions in mind and then adjust to the “facts” as we go forward.
I am sure there are some organizations that do this sort of thinking, but I find what usually happens is tactical, not strategic. We have meetings to talk about developing a new program or competing in a new clinical area, but we don’t think about it in the context of where we need to be five or ten years down the road. Since we don’t really have either a strategic vision other than something vanilla—“to be the best provider” or “the provider of choice” for our area—we haven’t done scenario planning to think about how we would get there. Think about it. Is your organization doing strategic AND tactical planning, or just tactical planning? Maybe this is an area where physician experience in dealing with complex and uncertain situations can help.
27 July 2017
 Schwarze ML, Taylor LJ. Managing Uncertainty—Harnessing the Power of Scenario Planning. N Engl J Med 2017;377(3):206-208. doi. 10.1056/NEJM/Mp1704149.
 The sermon includes two points. First, whether dialysis is a good idea or not depends on having a positive reason for doing it. Second, I am comfortable with a conditional agreement that says if you can walk, talk, and make your own decisions about things, dialysis is reasonable. But if you get to the point where I need to talk to your family about going to the nursing home you say: “No thanks,” I am comfortable with that decision. (I then get into a discussion about decision-making at the end of life, including advance directives, living wills and durable power of attorney for healthcare. I almost always recommend they pursue the latter, since it is impossible to spell out all the contingencies in advance.
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