Friday, April 17, 2009

Micromanagement: Medicine and Education

A few months ago, I commented on a New York Times article bemoaning efforts to micromanage medical care -- medicine by the numbers:

A few days ago, Wall Street Journal published a similar article, arguing that good medical care requires considerable discretion on the part of doctors and that micromanaging is destructive.
Groopman, Jerome and Pamela Hartzband. 2009. "Why 'Quality' Care Is Dangerous: The Growing Number of Rigid Protocols Meant to Guide Doctors Have Perverse Consequences." Wall Street Journal (8 April): p. A 13.

Yesterday's New York Times informed its readers that the Obama administration is going to continue the No Child Left Behind nonsense of the Bush administration.

While tens of thousands are getting fired and schools are cutting back vital programs, mandating multiple-choice tests will somehow save public education. Of course, the schools that cannot afford teachers who have to lay out money for tests and to waste valuable teaching time teaching toward the test.

My own university is asking us to us provide some sort of quantitative measure of our success in educating students. Because we teach a broader mix of subjects, we are not faced a cookie cutter approach as extreme as K-12, education. The demand is that we devise our own metric. Are economics students to demonstrate the quality of their education by regurgitating market fundamentalism?

Wouldn't it be nice if finance and other forms of business were held to strict standards?


Anonymous said...

Great, more nonsensical "quality" programs! But no one, I mean no one, in any of these programs understands the shortcomings of Utilitarianism.

God help us now.

Robert D Feinman said...

1. On medicine: establishing a series of best practices guidelines has been shown to improve outcomes. This does not remove the discretionary function from doctors. It is also not micro-managing.

One of the problems in the US is that doctors don't get much objective data on what works. Drug companies, for example, publish reports which support the granting of approval for a new drug. Once approved a drug can be used "off label" and there is no formal mechanism for reporting how well it serves. In fact if the results aren't all that good the drug company will refrain from doing a formal study.

2. On education: NCLB was created explicitly to weaken the credibility of public education and teacher's unions. It contains such mathematically impossible requirements as the need for schools to show improvements in performance continuously. Where do you go if you students are already performing at the highest level?

It depends upon the favored myth of the moment that teachers are the biggest factor in educational outcome. This, despite, 50 years of data which show that socio-economic status has the highest correlation with achievement. Bringing people out of poverty and despair is a multi-generational task, while bashing teachers can be done right now.

It is hard to fathom why Obama has fallen for this hokum. Arne Duncan is widely seen as an educational fraud just as was Rod Paige. At least Duncan hasn't been accused of falsifying the records (yet) as Paige did.

In NYC Bloomberg and Klein have also been shown up as their touted gains have been mostly illusory. What they did succeed in doing was replacing a community-based governance system with an autocratic and unaccountable one.

The problems is not with incompetent teachers, if anything working conditions are so poor that schools have a hard time holding on to staff. Something like 50% of new teachers leave within three years.

Every generation points to the deterioration of youth as the imminent cause for the failure of society. This allows the autocrats to suggest that they be put in charge to "fix" things. It didn't work in Socrates' time and it still doesn't.

John Dewey explained how to provide the type of education that people need to perform their role as citizens in a democracy. That's why the autocrats are opposed - people that can think for themselves are not easily (mis)led.

Jack said...

You leave nothing more to say other than you've said it all and hit the nail squarely on its head. I would only add that in addition to socio-economic circumstances a good out come in education requires that enough money be spent, in an effective manner, to provide quality texts, a clean and well structured physical plant and intelligent and well educated teachers. That is an expensive proposition. Compare what upper crust neighborhoods spend vs inner city and the differences become more apparent. No one is complaining about the out comes of schools in Great Neck or other such areas.

Michael Perelman said...

I agree with Robert, except with some reservation on medicine. Orzag was interviewed on NPR, explaining how to save money on medical care. He was saying that much care is ineffective & that by just eliminating unnecessary care we could keep health care costs in line.

I agree that unnecessary care is unnecessary, but I want to know who defines unnecessary and how.

Robert D Feinman said...

If you really want to get into the depths of the health care thicket I suggest reading this blog:

The author is a reporter specializing in health care and the site is supported by the Century Foundation.

High cost has many causes (as does sub-optimal treatment). But the field gets addressed like the three blind men and the elephant. Each partisan picks the aspect that they dislike the most and attributes too much of the problem to this factor.

Drugs are too expensive. Hospital stays are too expensive. Specialists are too expensive. There is a building boom in health care facilities. Too much is spent on futile end of life treatment. There is over treatment and under treatment. There are too many layers of middlemen.

I could go on.

Obviously since other countries are doing better the problems are not insurmountable from a technical point of view. So it all comes down to whose ox gets gored.