Thursday, July 28, 2011

Genesis (Of The Statistical Medievalist)

It may seem strange to the reader that this post details the genesis of The Statistical Medievalist but I take as my model for this unorthodox temporal sequencing, as well as explicitly stealing the posts title from Have Gun Will Travel, my all time favorite TV series. In Episode 1 of the 6th and final season entitled Genesis, it is revealed how Paladin was transformed from a man with 'feet of clay' into a heroic champion for hire.

So along those lines, and in keeping with the spirit of the 'Knight Without Armour' it seems to be the right time to describe the genesis of The Statistical Medievalist.

Having been trained in medicine at the end of the last century, at a time when the medieval Guild system was in authority and in near complete control of the education of medical professionals, I am very much intellectually rooted in the times of the mage, the maven, and the master guildsman. However, in the pursuit of the science of medicine, and as someone with an undergraduate major in Mathematics, I have always been drawn to the meta-theoretic areas of medicine, i.e., the theory of medical practice including as I have said in introduction to the blog, biostatistics.

These then have been the two enduring lines of thought and exploration that I have traversed over my entire medical career. In this way, going back to my idolization of Paladin, I know what is too live in two worlds, such as he does in San Francisco (Dandified and Elegant Man of Letters) or the Gun For Hire (Solitary Warrior in pursuit of justice for his client).

In my own case, those worlds are the intellectual pursuit of mathematical truth, insight, or rigor in decision making existing in dynamic tension with the need for immediate and often dramatic action in pursuit of the best outcome for my 'client' usually with action being impelled with incomplete knowledge and understanding.

Thus, while I treasure the medieval values and power of the Medical Education Guild system, I find I must embrace fully and without contradiction the necessity to balance the medieval logical world view best epitomized by Aristotelian Syllogistic logic in contradistinction to the multi-valued 'fuzzy' logical systems of thought inherent in the modern quantum views of reality and implicit in the use of statistical methodologies for analysis of medical therapies.

Furthermore in another but related sense, I am attracted to the medieval view of medicine as I  live through the transformation of my profession. No longer am I a Master Guildsman who owns a unique job shop, I am being transformed into a well compensated technician laboring in an implicit medical assembly line in which statistical defined outputs and control limits are valued more than the unique outcomes of the individual patient. To better define and understand these transformational forces I would reference you gentle reader to the following graphic which illustrates the so-called Product-Process Matrix, a fundamental tool for understanding Process Architectures.

I had the experience of working as a Consulting Cardiologist at the now defunct Internal Medicine Branch of the Aeromedical Consultation Service at the USAF School of Aerospace Medicine, a job in which on a busy week, I would exhaustively evaluate, consul, and more often than not perform heart catheterizations on 4 active duty military aviators. Thus,  I understand at a visceral level the medieval job-shop practice environment. These 'clients' were all worth up to or more than $12 million dollars per copy to the USA military with respect to costs to replace them at the most important time in their careers, i.e., Major to Colonel ranks. Therefore, a highly individualized process was appropriate to their needs as well as the needs of the US military.

However, I also had the contemporaneous experience of working in an Urgent Care Clinic, in which on the heaviest day of my practice in that environment I evaluated, counseled, and treated (together with my 'team') 80 patient's in 16 hours of operations. This aberrancy was fueled by the need of the clinic to meet throughput demands driven by cash flow considerations. The 'on the hoof' value of the 'clients' was hard to judge, but certainly no one had invested multi-10's of millions of dollars in their training and upkeep. Their issues were usually more mundane than that of my military aviators, but honestly was there any humanistic justification for an almost 200:1 disparity in face time with your doctor?

It is in this sense of Medieval that I find my truest sense of despair with the transformation of my guild into a humanistically irrelevant set of processes designed to separate 'clients' or their 'payors' from the maximum amount of wealth with the minimal cost or thought possible.

And so it is in this other, darker, blacker, but more realistic sense that I am the Statistical Medievalist, an obsolescent guild master fighting a delaying but ultimately hopeless rear-guard action against relentless opponents wielding a metaphorical mace, statistical control theory.

The awful truth of statistical control theory, is that perfection lies at the 'golden' mean.  In this sense, mean-ing the greatest return for the least investment of gold. Immodestly as someone who believes he is operating well above the upper control limit, I know that those process improvement forces designed to move practitioners from below the lower control limit into the mean, must by the laws of statistics and reality also force me to drop below the upper control limit into the range of the average (meaning in my world view, thoughtless) practitioner.

So in conclusion and to be amplified at a later date, recall the talismanic power of  TANSTAAFL! 


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