Schon and Gawande

The family got back Saturday evening from a week of R&R in Door County. The week itself was a lot of fun but the drive is a bit on the long side for me – my knees especially don’t like sitting in a car for the almost eight hours we were in route. So there was a need to recover from the travel. While the rest of the family hunkered down to watch some junkie movie I tuned into the Olympics. The women’s marathon had just started. I watched for about 45 minutes, after some jockeying at the front of the pack the runner from Romania made a sustained push and broke well ahead of the other runners. (She ultimately won.) Soon afterwards I nodded off. When I awoke, after I’m not sure how long, the men’s 100 meter final was just getting underway. The announcers seemingly anticipated the result – Usain Bolt obliterated the field, setting a new world record while relaxing and showing off before reaching the finish line. Bolt is the fastest man alive which, in spite of his obvious talent, comes as a bit of a surprise since he is so tall, 6’5”, and usually tall people have trouble getting out of the starting blocks so are more adept at longer races. (The 100 meters is a sidebar for Bolt. His prime race is the 200 meters.)

I thought back to the first Olympics I watched on TV, the 1968 Games in Mexico City, when I was thirteen, a regular reader of Sports Illustrated, and Track and Field was showcased (on Wild World of Sports and perhaps other programming) quite apart from the Olympics and the Olympic Trials. There is some parallel between Bolt and Tommie Smith, who most readers will remember did the Black Power salute (along with John Carlos) while on the victory stand after having won the Gold medal in the 200 meters. People may not recall, however, that Smith at full stride was the fastest person alive back in 1968, faster than Jim Hines the Gold medal winner in the 100 meters. But Smith, almost as tall as Bolt, was slow out of the starting blocks and hence didn’t run the 100. (The other candidate for fastest man alive was Bullet Bob Hayes, though I only saw him in football uniform for the Dallas Cowboys, never as a track star.) Of course it’s not possible, but I wonder how Smith and Bolt would do head to head in the 200 meters and I wonder as well why we see world record times continue to fall in these races. I found this rather interesting interview with Lee Evans (a contemporary of Tommie Smith, Gold Medal winner in the 400 meters, and subsequently a track coach, the interview is in the middle of the page under the subheading Running Vagabond) where he argues that especially in the U.S training is less strenuous nowadays and the athletes substitute weight lifting and supplements for calisthenics and more traditional conditioning. The modern approach may produce more spectacular results in the top performers, particularly sprinters, even if it is worse for stamina, though I don’t really know how to test that proposition.

* * * * *

The comparing of current developments with things I know from my past is a recurrent theme for me. I do it in all sorts of areas. And, as above, I will do it in the rest of this post. Thanks to a recommendation from Gardner Campbell a good chunk of my reading while on vacation was Better by Atul Gawande. I had seen Gawande in this interview with Macarthur Fellows from the Charlie Rose show. And I had read a couple of his opinion pieces in the New York Times, such as this one, which seemed sensible and well written, so I was well disposed to Gardner’s recommendation. Indeed, it struck a chord in me. Gawande’s core hypothesis, something that Gardner quotes and I excerpt below, rings a familiar bell.

Arriving at meaningful solutions is an inevitably slow and difficult process. Nonetheless, what I saw was: better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.

The combination of these factors I would term “intelligent guessing.” It is neither trial and error nor is it direct application of known research results. It is a different, though perhaps hybrid animal. One might try to define it more precisely, but that’s already been done. The Reflective Practitioner, by Donald Schon, something I read more than ten years ago, is an elegant argument and a complete epistemology about how professionals make real world decisions. The approach is meant to work across fields. Though Schon doesn’t write about Medicine specifically (he does write about psychiatry as one of his examples) his approach carries over in a straightforward manner to Medicine and to other professions as well (like teaching and learning). So somewhere in the middle of Better I started to ask myself about what is in it apart from the interesting stories of particular patients and the novel treatments their doctors devised, certainly good reading in and of themselves, that is value add over the Reflective Practitioner in terms of describing what is going on with professional practice. I have a few answers to that.

But before I get to them, let me pick on the two chapters in Better that I found the least satisfying. I do want to embrace much of what Gawande preaches; it makes for a very good agenda for learning technologists. But I want to do so in a critical way so I don’t want to merely echo what Gardner has already written. Then too, I didn’t know how to bring out these negative reactions after a complete endorsement of Gawande’s main themes. So I though it better to get to those reactions first.

There is a chapter on Capital Punishment and what, if any, role doctors should play in administering the death penalty. The rest of the book can be read by omitting that chapter without skipping a beat on the argument. I can only guess why it is there – Gawande feels a need to confront the ethical dimensions of being a doctor – and on that level I’m sympathetic because I feel that same need in the realm of learning technology. But the conclusion he came up with makes no sense to me whatsoever. The core issues are these. Doctors’ raison d’etre is to preserve life, improve health, and maintain the well being of their patients. Any behavior that departs from these norms is antithetical to the doctors’ core mission. The State, however, has found Capital Punishment acceptable in light of certain crimes, subject only to the provisions of the Eighth Amendment to the Constitution, which prohibits cruel and unusual punishment. Gawande’s conclusion, he does discuss and has interviewed some doctors who have actively participated in carrying out executions, is that doctors should not be involved in administering the death penalty. He does not seem to feel a need to take a stronger position, to wit that doctors should openly argue against the death penalty because administering it is inherently cruel and unusual. Nor does he argue that doctors should be part of the administration because that would make the punishment humane. Rather he clings to a middle ground that to me has no footing and, I might add, it seemed to me that doctors would be abdicating responsibility if they collectively behaved according to Gawande’s argument. As I said, the rest of the book can be fruitfully read by ignoring that chapter, or one can come back to it after the rest of the book has been finished.

The subsequent chapter, titled On Fighting, makes an argument that doctors should always fight for the health and welfare of their patients. Fine. He does recognize that there are possibly cases where the doctors view shout not ultimately prevail. The patient’s perspective can serve as a trump card. And he gives as example a teenaged cancer patient who forgoes an invasive and low probability of success treatment, dying peacefully soon thereafter, because the patient had already been through the ringer. Enough is enough. In this chapter Gawande tries to personalize the patient’s point of view by talking about the severe skin problems his own daughter has gone through and the impact of that on her and the family. But Gawande lumps together two groups of patients into a single category, those who are near the end of life, regardless of their age and hence regardless of their prospects of a good life should their medical problems be cured. He thus ignores the intergenerational income transfer issues that Larry Kotlikoff raises, issues that are inherent in the “Fighting” approach. And on a more personal level, since I’m going through this now with my mom, he ignores the issue of dementia (Alzheimer’s) and whether Fighting continues to make sense once the patient’s mental capacities have been severely diminished. Here I mean Fighting about general health problems, say removal of a skin cancer, not Fighting about restoring the mental capacity to its earlier state. The issue is if the latter is likely not possible, how much of the former should be done from the patient’s perspective or, since the patient likely can’t work this through given the mental state, from the perspective of the immediate family or those with medical power of attorney. Gawande doesn’t touch this issue. It’s a tough one. I would have liked to see some of that moral clarity arguing either side of it – Fighting is still right in this case or no, this is time to give up the ghost. Moral clarity would be very helpful. When I discuss this issue with my wife or my siblings, I’m prone to mumble.

* * * * *

Let me turn to Better’s value add. First, consider this passage from Daniel Pink’s book A Whole New Mind…. Celebrate Your Amateurness. The admonition is essentially the same as Gawande’s core theme, but the labeling is different. The labeling matters. Gawande makes clear the behavior is not outside the role of the professional. It is the core of what makes the professional excellent. Gawande does a more or less complete sociology of intelligent guessing; he shows that not all doctors do it but those who are most successful with their patients do. Moreover, he is able to carefully distinguish between the intelligent guessing that is an outgrowth of practice from research, the type we think of happens in labs or in carefully monitored clinical trials, the source most of us think is responsible for improvement in medical outcomes. Gawande argues to the contrary that it is diligent application of intelligent guessing rather than research that is the primary cause.

This leads to the next area where Gawande adds to Schon. The quintessential reflective practitioner is perhaps Sherlock Holmes. His solving of cases by careful attention to detail and putting the pieces together are acts of genius. The rest of us couldn’t do it. But did Conan Doyle’s fictional detective advance the state of criminology in the process? Did his solution of any particular puzzling case help the rest of us with cases we’re trying to understand? Schon’s depiction of the reflective practice is in this sense like a depiction of Holmes, with the one exception that Schon argues much of it can be learned, through an apprentice model of some sort. Of course, Schon’s focus is not on how the field advances so much as to how expert practitioners operate. Gawande has a different focus. His title is a double entendre. Making the patient better is, of course, the doctor’s imperative. Making the medical profession better is the mystery he wants to explain. Gawande makes clear that there is a double edged nature to reflective practice. It solves the problem at hand but it also adds to the stock of knowledge of approaches that might be used to help other patients.

Gawande’s third contribution is bringing a scientist’s sensibilities to what is essentially a humanist’s undertaking. And it is here that Medicine may be somewhat special, though as Gardner notes in his post it does make us wonder whether we could come up with meaningful performance metrics (I take a modest stab below) to do similar comparison’s in teaching and learning that Gawande reports in his book. At various places he talks about survival rates, the well being of newborn babies, the efficiency with which lungs respire, each of which is a sensible and quantifiable performance measure, so comparison across approaches can be made. The scientist wants to know whether intelligent guessing works. The only convincing evidence for Gawande is that it creates improvement in accord with such performance measures. Gawande’s book is full of these sorts of demonstrations. But this is not proof a la hypothesis testing in controlled experiments. Indeed, the point is that controlled experiments are too slow and won’t produce needed answers in situ. One necessarily needs ad hoc solutions, but solutions that make sense and stand a decent chance of being right. Given that, there should be evidence of the post hoc variety to speak to whether the approach really trumps a more conservative one, applying only what has already been proven via clinical trials. Personally, I don’t need that sort of evidence in thinking about my own teaching. I’m already there. But in trying to convince other teachers to embrace an approach founded in intelligent guessing, as this Educause Quarterly piece argues, having that sort of evidence would be hugely helpful. The anecdotes are fine but the numbers are very useful too.

So with that in mind here is my first stab at creating an index of class function (not individual student function) that instructors might score their classes on, perhaps on a session by session basis, or if done online on a week by week basis. Mimicking the Apgar scoring system for newborns, each item gets from zero to two points. There are five items so a top score is ten points. Scores well below the maximum are fodder for the instructor to consider possible improvements in the teaching approach.

· There is lively discussion with lots of back and forth.

· There is diversity of input with all students participating in the discussion.

· Students don’t just ask questions or voice opinions but also respond to the questions and opinions of other students.

· The discussion produces a transfer of an idea that was previously presented to a scenario that had not been previously analyzed.

· The discussion produces a synthesis of ideas and this synthesis emerges from the students themselves rather than from the instructor.

One might also envision doing a similar such index for small group function and have the students in the group score themselves. Obviously there is some subjectivity in doing the actual scoring (as there is in judging events like gymnastics at the Olympics) and knowing that might prompt a diligent instructor to write a line or two to explain the rating. Perhaps the ratings could be shared with the class – after all it is not an individual performance thing – and maybe that would help the students see what their role in the class should be and also to get them to reflect on how class function might improve. Could we implement something like this? I don’t know. Gawande’s book is an inspiration to try.

Let me now turn to two issues that are not in Gawande’s book or are there in a tangential way, but seem like next steps. The first is how to transfer learning that has occurred from an intelligent guessing approach to others who were not initially involved but who would benefit from the knowledge. In the chapter on India, Gawande does talk about the doctors, overwhelmed with work, nevertheless making time in the afternoon for a Chai to share stories and have some down time from the grind. Undoubtedly peer networking of this sort is a good vehicle for transfer. It clearly solves the problem of whether those who need to learn find the information credible and it prevents having to reinvent the wheel every time, but scale-wise perhaps it is limited. And, indeed, in the chapter on cystic fibrosis treatment Gawande makes clear that such transfer doesn’t happen well in the profession as a whole and consequently there is substantial difference in performance from one center to the next. So I wonder if Gawande is looking for other possible transfer mechanisms. Perhaps as I’ve suggested here (read these three posts from the bottom up) that like open source development there should be a center, embodied in a particular and perhaps charismatic individual, whose primary job is to facilitate transfer of this sort of knowledge. This is an area where learning technology might lead Medicine and it is an argument for why the person performing this center function should be a faculty member rather than a staff person.

The other issue is about who is doing the intelligent guessing. With the exception of the first chapter where the focus is on epidemiologists (who I take it are PhD’s not MD’s), all of the characters in the book who engage in the heroic solving of medical problems in place through this intelligent guessing/reflective practice approach are doctors. In particular, there is no section where nurses are the heroes doing this sort of problem solving. The question is why. I will speculate about the possible answer. One alternative is that this simply reflects Gawande’s center of gravity. He is a doctor so his focus is on other doctors. Some nurses do engage in this reflective practice and produce substantive improvements. It’s simply that there is no chapter on that sort of activity.

Another possibility, however, is that there is much less of the activity on the nurse side compared to the doctor side, relative to their respective numbers, because of the hierarchical relationships that exist in Medicine. Indeed, even with the doctor side, it may be that only certain doctors spend a lot of their effort in this sort of intelligent guessing behavior. Here I speculate based on those instructors I’ve seen who do this in their teaching. They tend to be senior, don’t have to worry about achieving tenure, feel a certain dissatisfaction with how their classes are going, and then once having started down the path find the journey self-reinforcing. Teaching and learning would benefit if other instructors similarly traveled down these paths, but the other instructors are not so disposed.

If this is true, the question emerges then at an institutional level if there are structural changes that could be put in place to change the mindset of the individual instructors – for example an open embrace of experimentation in the classroom. Likewise in Medicine one might ask what structural changes would encourage more of the participants to engage in a systematic program of intelligent guessing. My belief is that hierarchy discourages it. Can we move to flatter structures and still preserve the essence of what we do?

Let me close with the following observation. Sometimes we learn important lessons for our field by looking outside the field, where similar lessons have already been learned. Better is a great book for educators precisely for that reason. And it’s a really good read to boot.