Of Cognitive Science, Political Correctness, and EHRs

September 15, 2015

A continuing discussion on philosophical books which will enhance critical thinking and communication skills - in healthcare and in life.

This article continues my discussion of books worth reading to enhance one’s critical thinking and communication skills. The discussion begins with political correctness (PC) -the revenge of the minority. The minority can’t change what people think, but it can create a climate in which the majority (with the exception of "the Donald" and his ilk) are reluctant to say what they really think. So for example, when someone like George Bush wants to do something that is not PC, they use the magician’s trick of indirection. They reframe the "incorrect" thing so that it will seem to glow with an aura of "correctness." Want to grant more logging rights" Call it Health Forests. Want to grant offshore drilling rights? Create the "U.S. Ocean Action Plan."

Since the introduction of Medicare, the feds have had an insatiable appetite for healthcare data. Healthcare reform upped the data requirement but by then the notion of physicians entering data into the hospital information system had become politically incorrect, especially from the physician’s point of view. The government’s solution was to reframe data collection as something warm and fuzzy like "Health Forests." This was done in two steps.

First, the hospital information system (HIS) was reframed as the "electronic health record' -same warts but covered with lipstick. Second, data entry was disguised by focusing on meaningful use. Who wouldn't want meaningful use? If an EHR contains meaningful information and if it allows meaningful things to be done with that information (and if it does not add hours to the workday) this would be a good thing. If, on the other hand, only some of the stored material is meaningful, then only that portion can be used in meaningful ways. This raises three questions: Of the material stored in an EHR, which portions are meaningful? Can the meaningful portions be identified and used effectively?  What is meaning?  Answering this question opens the door to the others.

Meaning is the product of cognitive activity. Phenomena (objects and events), like trees falling in the (healthy) forest, don't mean anything until they are perceived and evaluated by a person. Phenomena do not have an inherent, obvious, universal meaning.  What they mean to an individual is dependent on their knowledge, experience, cultural background, language, and how their brain functions. The meaning of any perceived phenomenon is also influenced by the context in which it was observed. Altering the context will alter the perceived meaning. Data, without context, can't possibly be meaningful. Anyone who thinks that it is has supplied a context doesn't realize it.

Those who study cognitive science, theory of mind and behavioral economics, have learned a great deal about how the brain sorts out what it perceives and how it attempts to present a coherent story to the conscious mind. Understanding how things work puts you in a position to be their master, rather than their slave.

Several books provide insights on the cognitive process. Daniel Kahneman won a Nobel Prize for his work on cognitive biases and the differences between rapid, subconscious information processing and slow, thoughtful deliberation. His work is summarized in "Thinking Fast and Slow." It's engaging and you may be surprised by what you learn about your own biases and decision-making processes.

Two other books in this vein are "Predictably Irrational" by Dan Ariely and "Nudge" by Richard Thaler and Cass Sunstein. Ariely describes a number of common fallacies and biases that affect us as we attempt to make decisions. Thaler and Sunstein discuss "active engineering of choice" -position the choice that you would like people to make as the one that involves the least effort, or perhaps no effort. Because of the work involved, most employers that offer 401k plans have changed them from opt-in, which very few did, to opt-out, which very few do. This concept can be applied in healthcare when there are decisions to be made and you believe that one (or some) choice would be best for the patient.

A final book that is worth reading has a tangential relationship to cognitive science. It is "Chaos" by James Gleick. It's important because much of our reasoning and most of what Kahneman's "Fast System" does is based on notions of predictability that "just ain't so." Medicine is profoundly unpredictable, much of what we think we know is wrong and we don’t know what we don't know. As a result, it is tempting but impossible to predict and choreograph the future. Assuming otherwise, as EHRs and practice guidelines do, is a recipe for failure –and we have had, and continue to have, an overabundance of failure.