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April 02, 2009

Learning from Gawande

It’s now less than a week since the casually overheard portion of an NPR radio interview made me aware of Harvard surgeon Atul Gawande, who happens to be one of two Harvard physicians writing regularly for the New Yorker. Ironically, both became regular contributors to the magazine in 1998; but although I’d read several articles by Jerome Groopman, and only two written recently by Gawande, I’m quite confident I’ve detected critical differences between them.

For one thing, Gawande is not only considerably younger, he also writes analytically about a variety of social issues in ways that make him unique and have little to do with his calling as a surgeon. Indeed, his early career was distinguished by the great aptitude he displayed for social issues. Despite interruptions to pursue them before and during medical school and again during his surgical training, the medical skills he ultimately displayed placed him, almost at once, in a position to practice surgery close to a well established academic pinnacle. That he still finds enough time to pursue his interest in broader social issues and write about them so clearly and in depth, has convinced me he’s a genuine medical polymath, someone with a lot to offer today’s world.

My first evidence was this week’s New Yorker article on the cruelty of American prisons. Our increasing reliance on incarceration, particularly as enhanced by punitive solitary confinement, is an issue which, much like our relentless punishment of those using cannabis for any reason (and especially for medical purposes), can be thought of as both institutionalized injustice and needless cruelty. Nevertheless, as Gawande points out in Hellhole, even tentative efforts at reform from within “the system” of incarceration have been so politically unpopular that those making them have been forced to desist. It was that nugget of information that led me to hope Gawande might be a guru from whom I could learn other helpful truths.

I didn’t have long to wait; his penetrating analysis of several national health systems in developed nations had just been published in January; not only does it comport with my own knowledge of those systems, it added to it. More importantly, it provided me with a concept that may turn out to be one of those disarmingly simple key insights with the power to change the world, at least for a little while.

That concept is Path Dependence; an idea that seems seems to have arisen among those primarily concerned with Economic system analysis and has been around long enough that its exact provenance has already been hopelessly confused. In any event, it doesn’t seem io have been comprehensively applied to either biological systems or their evolution.

Briefly stated, Path Dependence, as applied to Economics, is the notion that the developmental trajectories of new products competing for market share are already constrained by conditions that existed when they were first conceived, and are then shaped by new conditions that develop over time. The examples referred to in most iterations of PD are repetitive: the VCR versus Betamax and QWERTY versus Dvorak keyboards. The usual conclusion is that what might now appear to have been a better design often didn’t win out in the marketplace for good reasons that can only be understood in retrospect, and with enough specific information.

Current definitions of PD turned up on several Google searches were not nearly as informative as the one I was able to derive from Gawande’s invocation of the concept in his comparison of modern national health plans as they had evolved in Britain, France, Canada, and other nations, with the hodgepodge non-system now failing so expensively in the United States.

This is all I have time for now. I plan to return to both Atul Gawande’s writing and the pivotal concept of Path Development at my earliest opportunity.

Doctor Tom

Posted by tjeffo at April 2, 2009 04:53 PM

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