Blog | Monday, September 8, 2014

Unintended consequences--we need to think like chess masters

After 12 years of blogging, I wonder if I should have titled this blog “unintended consequences”. So many rants focus on the unintended consequences that follow from health care policies.

The aphorism (falsely attributed to Samuel Johnson) states “the road to hell is paved with good intentions”.

Too often our policy makers, be they bureaucrats in government, insurance company managers or guideline creators, think like a chess beginner. They see the problem, and take the obvious solution. As H.L Mencken did say, “For every complex problem there is an answer that is clear, simple, and wrong.”

Chess masters consider a move and then do a mental pre-mortem analysis, predicting in their minds what the implications of the move are. Where will we be after that and several more moves?

Too often in health care, as well as other policy areas, we ignore the unintended consequences of premature solutions. Too often we hear the excuse that there was a good reason for the policy.

As examples, first consider the 4 hour rule for antibiotics in pneumonia patients. Any hospitalist or infectious disease expert could have predicted the unintended consequences, yet Medicare adopted the rule that led to much unnecessary antibiotic use.

Consider the VA appointment scandal. If we give bonuses to administrators for decreasing appointment waiting times, and do not provide moneys for adequate primary care physicians, we will stimulate dishonesty in some administrators. This outcome is sad, but predictable.

In Great Britain, they had a performance measure that rewarded shorter waits for appointments. This indicator improved, but continuity decreased. Duh?

Resource-based relative value units provide a great example of this naiveté. The original New England Journal of Medicine paper is a classic left brain economic analysis that totally ignores the possibility (which became the reality) of the difficult of assigning fair relative values.

Policy wonks are too quick to embrace these new solutions to a problem. They rarely think about what the policy would induce. They are lousy chess players. They do not look ahead.

Unfortunately, I do not see a solution for this problem. We fail to remember Mencken’s admonishment. We act too often without careful consideration of all the expected and unexpected consequences. Unfortunately, too many of the unintended consequences are predictable, if we would just take time to think.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.