Disconnected Attention Points

(Image from Free Digital Photos)

A few days ago a friend got a hip replacement. Her surgery had been put off three times. About 1 in every 10 people in the UK is currently on a waiting list for health care, so delays were not surprising.

She’s home now. Yesterday I visited. No matter how carefully we prepare for something like this major operation, something always turns up that isn’t quite the way it needs to be during recuperation. I set up what she needed. Then, wearing my FFP3 face mask, I sat at the other end of the living room.

She told me about her surgery. She’s delighted. She is in less pain now, after such a big operation, than she was before going into the hospital.

But this is only part of a much bigger picture with her health. She told the whole story about how and when things began to go wrong.

Our conversation went all over the place. Family patterns that indicate how much of her trouble is probably inherited. Osteoarthritis. Bone loss and how bone gets built, destroyed and rebuilt. The immune system. Gut microbiome involvement in things that don’t seem like they ought to be related. Chromosomal DNA versus mitochondrial genetics (which come entirely from the mother).

She mined the trove of information I absorbed when I was a volunteer sysop in an online forum for people with chronic illnesses, my habit of reading scientific material and my inclination to try to understand and troubleshoot systems.

We didn’t solve anything, but it felt like we made a start on a challenging jigsaw puzzle.

She said she wishes she could get a doctor to look at her health that way. Each doctor only pays attention to the element of her health that fits their area of interest. The orthopedists only care about bones. The gastroenterologist only cares about her extremely narrow dietary tolerance, and only to record it rather than address it. Nobody looks at her immune system, which is in an uproar echoed by a daughter’s autoimmune disease. Problems in her spine are recorded in her chart, but she has no idea what she might be able to do to keep them from getting to a level where they impede her activities and require intervention.

Finding a doctor who is willing and able to grapple with bafflingly complex, persistent health problems that affect much of the body would be hard in the USA, even with plenty of insurance and money. Health care is more oriented toward quickly diagnosing, treating and discharging patients. I remember when health insurers began requiring doctors to specify a diagnostic code before even running any diagnostic tests. That is when American medical care began to become so bizarrely dominated by pursuit of profit and so keen to push patients out the door as soon as possible.

In the NHS after more than a decade of strangulation of the service, there is no place for patients like our friend. Doctors need to see patient after patient in 10 minute appointments, make quick decisions, issue immediate medication or treatment prescriptions and chop the waiting list as fast as they can. There is only enough time to deal with one small thing per appointment. Nobody has the time or resources to apply systems thinking to a case like hers.

She got a new hip. Everything else wrong with her, some of which may have contributed to needing a new hip, is still wrong. Disconnected care points aren’t what she needs, but that’s what she can get.

It would be better if her care could be better connected, approached as a matter of improving her systems instead of patching a crisis at a time. Thinking that way is much harder than having each doctor look only at their area of expertise and not collaborate with the others. Real life isn’t like an episode of House or Gray’s Anatomy.

Health care certainly isn’t the only field where this happens. I see it in other fields all the time.

There is a place for efficiency, an assembly line that deals with simple problems expeditiously. But there are aberrations in every field. The efficient mechanism for handling the ordinary always needs a way to recognize whatever needs a deeper, slower, more intensive effort and arrange for that to be done where it is needed. Not doing so just leaves the complex problems to become bigger and more difficult. In terms of money, it makes the complex problems ultimately cost more to solve than they would have if we dealt with them when we first saw them.

It’s true for health care. It’s true for information technology. It’s true for buildings, bridges, ships, farms, waterways, climate change, outbreaks… practically everything.

Maybe someday that will fully sink in.