There are two fundamentally different ways of thinking about complex social systems: the economic approach and the engineering approach.
The social engineer sees society as disorganized, unplanned and inefficient. Wherever he looks, he sees underperforming people in flawed organizations producing imperfect goods and services. The solution? Let experts study the problem, discover what should be produced and how to produce it, and then follow their advice.
In medicine, the engineering approach results in what many call “cookbook medicine.” This means that in treating patients with various symptoms, doctors must follow guidelines or protocols and they must record each step along the way. Cookbook medicine is the opposite of personalized medicine — an approach which aims to tailor the therapy to the characteristics of the patient, including her genetic makeup.
Before criticizing it, let me say something good about the “cookbook” approach. I think a doctor would be foolish to ignore protocols. Being aware of how other professionals have treated conditions and what outcomes they have experienced is part of being on top of what is happening in the medical profession in general and the doctor’s specialty in particular.
In MinuteClinics and in other walk-in primary care retail clinics around the country, nurses are doing a superb job of following computerized protocols. In fact they seem to follow best practices better than traditional primary care doctors. They also seem to pretty good at recognizing when a patient’s condition is outside their area of expertise and referring that patient to a specialist or to an emergency room for more complex treatment.
But things will go wrong if the cookbook becomes a master rather than a servant; if it becomes a book of orders rather than a book of suggestions; and if complying with endless checklists takes valuable time away from patient care. Yet that is exactly what is happening in American medicine.
I’m gonna cry,
Cry, cry, cry.