Believing is seeing. (Next!).

KEY CONCEPTS

* Questioning our Assumptions

* Slow Spread of Ideas

* Opening the Mind

* Asking "What If...?"

* Seeing the Alternatives

In archaeology, the question, "Who first settled the Americas?" had a settled answer: the Clovis people, flooding across the Bering Straits land bridge some 11,500 years ago, down an ice-free corridor in Western Canada, fanning out across the continent and all the way to the tip of South America. For a long time, no one seemed to find evidence of any earlier peoples in the Americas. But new discoveries have called this ruling paradigm into question. Now it seems that there may have been earlier migrations from other areas, down different paths. These findings moved Albert Goodyear, PhD, a University of South Carolina archaeologist, to go back to the "Topper" site that he had excavated near the Savannah River. There, right below his excavation, he discovered what are likely traces of a pre-Clovis people. He explained, "I had stopped a little below the Clovis stratum. You don't look for what you don't believe in."

La Guardia International Airport, New York, midnight, National Car Rental counter. I'm on my way to a conference in Hartford, Connecticut, some three hours away by car. The woman at the counter asks to see my driver's license. Of course, I had thought to bring my wallet. No problem. Had I thought to check whether my license had expired on my recent birthday? No. You don't look for what you don't expect. Suddenly the trip was far more difficult and expensive.

Why had this idea languished?

Months before the Connecticut trip, I had read a fascinating paper by the other presenter for the program. Here was a concept, I thought, that used the new technologies to revolutionize the ways in which we deal with the flood of medical information that is coming our way. It would reduce variation, medical mistakes, and missed diagnoses. It would likely reduce costs and increase quality. It could greatly ease the daily work of doctors, and put the patient more at the center of medical decision-making. It could be used in many ways to streamline and improve clinical practice.

But I became puzzled as I read the paper in greater detail. According to his bio, the author was an imminent physician who, in the course of a long career, had taught at a number of our most illustrious centers of medical research. He was apparently still in great reputation, since he had been invited to write lead articles within the past year for both the New England Journal of Medicine and the British Medical Journal. Yet, from citations he gave to earlier articles of his, it was clear that this was not a new idea. Though he had refined the concept over the years, he had actually published the core idea nearly two decades ago. What happened? Why had this idea languished for so long?

In my travels over the next months, I mentioned this paper to a number of physicians and health care consultants. Almost all of them had heard of the concept and the author. They raised specific, serious objections to the idea--objections that, if true, would render the idea useless.

So I looked forward to meeting the author. During the question-and-answer session, I presented each of the objections that I had heard. Each turned out to be untrue, in a way that could be clearly demonstrated and that would be obvious to anyone who tried the technique even once.

New ideas slow to spread

I have been writing about the future of health care since pterodactyls roamed the skies, and I have seen this scenario countless times: Useful, well-demonstrated, well-vetted ideas in clinical practice, disease management, health care management, ideas that would save lives, save money, and make life better for the patient, simply ignored, dismissed as radical, as completely unfounded, dangerous, and without merit. The attacks on the proponents of these ideas can be vicious and personal. But worse than the attacks is the simple indifference.

When I write or speak about the future of health care, and paint idealized images of what clinical practice and health management could look like in a decade or so, 90 percent of the techniques and tools that I put in the picture are already available--they are just not being used.

If this were the toy industry, these new ideas would spread like prairie fires. If this were Silicon Valley, or the retail coffee industry, or the office furniture industry, we would be hungering for these new ideas, trying them out, letting them evolve, working out the bugs, desperate to be better, to do better for our customers.

But this is medicine. We have to be careful. Indeed we do--estimates of the number of people in the U.S. who die from medical mistakes every year run from 98,000 to 180,000. (1) We owe these people and their families something more than more of the same.

Why are new ideas so slow to spread in medicine and health care? Because believing is seeing. We do not look for something we don't believe in. In fact, we do not even see a thing if we don't believe in it. We have dedicated ourselves so powerfully to medicine, to health care as we know it, that we often do not even see any alternatives.

Try on this metaphor: The mind as train. Might be a powerful train. Might be a bullet train, a Shinkansen, a Train Grande Vitesse. But it still is a train, running on parallel rails, There are decisions now and then, switches, sidings, this way to Leon, that way to Grenoble. But the engineer can never take off across country, or try a back road if the main road is slow. If you block the track, the train must stop.

Trains have rails because they go faster and can carry more weight that way. But the rails limit where they can go. We make our rails with our training, education, experience, choices. Soon we cannot even imagine a different route, another mode of transport. When someone suggests crossing the river five miles sooner, or going to the airport, or anchoring in the bay, we don't even listen, because they seem mad, because we know for a fact that these tracks don't go there.

Now try on this metaphor: The mind as all-terrain vehicle. Go where you want to go. Imagine anything. Work it out, in full confidence that you can find your way back.

What do you really know?

Our arrogance gets in our way. We are overly impressed with what we feel we know--as individuals, as an industry, as professions within that industry. Most of what is true about the body, about health and disease and how to manage it, is unknown. Out of what is known, I am ignorant of the majority. The doubling rate of medical knowledge is now five years and falling. No one can possibly keep up with all of it. Of what I do know, probably the majority is false--outdated, poorly understood, based on faulty assumptions. The same is likely true of what you know, if you are honest with yourself.

Understanding how little I actually know is the most valuable thing I can know. It frees the imagination. It lets me leave the tracks.

"The test of a first-rate intelligence," F. Scott Fitzgerald once proposed, "is the ability to hold two opposed Ideas in the mind at the same time, and still retain the ability to function." Obviously we need to trust what we feel we know, or we have no map with which to navigate our everyday practice. But navigating daily practice and our way into the future are two quite different things. To many in health care, the 90s seemed like a time of rapid, tumultuous changes. Yet all that happened was a swapping of ownership chairs, some downsizings, some re-namings of things, some hassles on the periphery. We changed nothing that is fundamental.

A combination of factors makes it likely that, in the coming decade or two, we will change almost everything that is fundamental about health care and medicine. In a time of such rapid change, we desperately need to root out and question our deep assumptions and beliefs, to get off the tracks laid down by training and experience and ask questions we have never asked before.

We need to ask, "What if...?"

Reference

(1.) 98,000: National Institutes of Health, press release, November 29, 1999; 180,000: Leape, L. Error In medicine. JAMA 1994;272:1851.

Joe Flower is Principal of What If.., in Larkspur, California. He has written about change in health care for over a decade. Author of hundreds of articles, he is a Contributing Editor for the Healthcare Forum Journal and New Scientist, a system host of The Well Computer Conference, and a faculty member of HealthOnline, If any of the ideas presented in this column resonate with your experience, drop Joe a line at The Physician Executive, or at [e-mail] on the Internet.