| September 11, 2012
The academic year has always represented a new beginning for me following what is supposed to be a calm and restful summer vacation that never seems to recur the way it did when I was 12, despite my eagerness for such relaxation. In any case, I couldn't help watching Apple Computer's stock price rise yet another 100 points over the summer and wondering why it did so well over the course of the last decade and why it did not do well, comparatively, in the 1980s. In both cases, there was one man in charge, moving things forward precisely as he saw fit. There were no decisions made by committees, no design groups, no focus groups…there was a single guy making decisions as to what was right and what was wrong. In the 1980s, he chose a closed system architecture that cost Apple the lead that it had over IBM in the newborn PC marketplace. In the 2000s, he chose differently. The remarkable progress that Apple made as a company was due to the decision making that only one person can make. Any group thought process would have diluted the brilliance. You might still have a good company, but you wouldn't have a great company, even if the entire group were to have been made up of equally brilliant people. And as we know, just as one person can be brilliant, one person can also be less than brilliant. In which case you would want committees, focus groups, and design groups because the overall skill set can be improved.
If we look at physicians the same way, and imagine that we all fall on a bell curve, you might think you want guidelines and protocols and teamwork, at least for the bottom half of the curve. But by applying them to everyone, you end up with regression to the mean that rules out brilliance. You'd have no one with terrible outcomes, but you'd have no one with amazing outcomes either. All physicians would be following the recipe, producing equal products of certain and specific quality. Medical school, like culinary school, would teach technique so that we could all follow the recipes correctly. But then if we're going to use that analogy, we immediately recognize that the best chefs are the ones who design their own recipes, who sometimes don't follow the rules, and who dictate the precise manner in which dishes should come together in their kitchen. We could, of course, forbid such chefs through the implementation of guidelines and protocols, licensure restrictions, and regulations, thus ensuring that a hamburger from Restaurant A is identical to a hamburger from Restaurant B, or that Dr. Smith diagnoses hypertension at precisely the same point in the physical exam review as Dr. Johnson would, for any and all patients.
Frankly, I look at physicians differently. We arrive as physicians by first being the best in high school, then the best in college, then the best at our MCATs, and so forth. If we're choosing our medical students correctly, then we've already cut off the lower half of the bell curve, and reapplying the bell curve to the remainder is illogical as the standard deviation is so small. In fact, we have greater potential for brilliance than for the absence of brilliance. But only if we're left to our own devices. Dr. Johnson might therefore decide that his patient has hypertension even though blood pressure isn't quite high enough, even though Dr. Smith is following the protocol and does not make the diagnosis, making that decision based upon observation of the gradual change in pressure noted over the past ten years, and deciding to treat it early rather than wait for the inevitable and morbidity-inducing further elevation. So the question is: do we want our new physicians to be innovative, creative, intuitive, and observant scientists? If so, they need the freedom to be scientists. We recognize that advances that come with innovation come with associated costs - an expense which might represent morbidity and mortality. Is innovation worth that risk? Without it, we wouldn't be where we are now, with the advances of the centuries behind us. I'd like to see continued innovation rather than stagnation. Obtaining that goal requires trust in ourselves and trust in our physicians. I would much prefer to see a physician who is an innovative, thoughtful, and brilliant scientist rather than a team player who follows all the rules and guidelines.
We all still have that choice. Will our children have it as well?