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Thompson: Learning from Others I

Healthcare Wouldn’t it be great to read in the New York Times Magazine that the education reformer’s "approach obviously involves some realpolitik. Since his fellow doctors teachers have so much clinical autonomy in the classroom, (the reformer) has little choice but to woo them. ... ‘He knows that the minute he says "I’m right, and you must do this" he loses everybody but the true believers.’ (He) is appealing to the idealistic side of doctors teachers - the flame, he calls it - that helped persuade their predecessors to adopt scientific methods [or their educational equivalent] a century ago. ... It would be a mistake, however, to see the deferential approach as solely political. ... Many medical teaching and learning questions still have no data-proven answer. Many never will ... Sometimes, intuition is the only good tool a doctor teacher has."

Public schools might obtain the "virtuous cycle of innovation, success, and expansion" made possible by evidence-based reforms if we could repudiate data-driven, NCLB-type accountability, and Dr. Brent James shows the way.

As with the famed Pronovost checklist, James uses measurement to counter the "pitfalls of intuition," to create protocols that are "the default" practice (while providing an override option), to adjust and reflect on practice, and ultimately to produce better outcomes based on "‘shared decision’ models." In contrast to top down educational "reformers," who fearlessly reject the practical judgements of practitioners, James respects the debate over the merits of metrics versus intuition in tracking outcomes and adjusting care. While admitting that he may be too soft on his fellow professionals who are not giving the best care, James seeks to win them over with "a combination of flattery, deference, and, finally, evidence. ‘We never name names.’"

My favorite part of the story was the debate between doctors like Jerome Groopman, who "argues that evidence-based medicine is useful in only a limited number of run-of-the-mill situations" versus advocates of "the Obama administration’s plan to tie Medicare payments to so-called quality metrics." Cognitive research indicates that intuitive diagnosis (as in the case of teaching) is more reliable "when people have a lot of relevant feedback" (as in the classroom). "Systems analysis" is less reliable when a disease has multiple effects, acts differently with different people, or must make sense of complex situations in diverse environments (as in teaching and learning in the urban classroom). While recognizing that the "instincts" of doctors (and educators) can lead them astray, evidence-based decision-making can promote reflections on mistakes, and make professionals more self-aware.

As the NYT Magazine reported, the health care debate had "too many moving parts," and "the scattershot nature of American medicine" (which encourages too much testing and treatments) has defied top down reform efforts. Government policy can play a role, but when improvements have occurred, "much of the impetus came from inside the professions. Doctors helped change the other doctors."

Ironically, the obstacle faced by medical reformers may be the key to success because "Doctors have a degree of professional autonomy that is probably unmatched outside of academia. And that is how we like it. ... Our fictional doctor heroes, from Marcus Welby to House, are iconoclasts who don’t go by the book. They rely on intuition ..." So when doctors questioned a protocol or a benchmark, reformers had to respect those concerns, and subject their own models to evidence-based revisions. This helped them learn that "‘Quality improvement is a process, not an event. ... it works by finding variation and drawing attention to it. ... And, well-done quality improvement is not punitive; it’s educational.’"

Had educators shown the self-regard of doctors, we would have been doing educational "reformers" a favor by forcing them to listen. The lose lose model of data-driven accountability could have never been imposed on a profession that showed more self-respect.


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