Category Archives: complex systems

Death of Expertise and the Birth of Alternative Facts

O's fact: "This is a cool pig's head." A's alternative fact: "This is disgusting!" My fact: "Looks like the pig is done, and we are eating well tonight!"
O’s fact: “This is a cool pig’s head.”
A’s alternative fact: “This is disgusting!”
My fact: “Looks like the pig is done, and we are eating well tonight!”

I was recently pointed to an essay on the perception that our country faces a “Death of Expertise.”. The scary part is the article was written in 2014. As we now seem to live in a world of facts and alternate facts, I am becoming more and more aware how limited our perceptions are when it comes to our ability to discern actual reality. The lines blur, and worse the titles we use to convey a sense of expertise are often cheapened by those who benefit from “alternative facts.”

As a patient advisor to the American Board of Internal Medicine, I find this article on the Death of Expertise relevant as we begin to embrace patient centered care. We are looking at the impacts of the patient becoming a partner in their healthcare rather than a subject upon whom the art of medicine is employed to better their health. It’s interesting to me because I find myself frequently commenting to the doctors there is no way most patients know enough to really understand the impacts of a treatment on their health as a whole. We know what we experience, and we tend to assume what did not happen could/would never have happened to us. Many have little or no understanding of likelihoods, especially rare ones. Our minds are not primed to understand such information. As a result, preventative care can be a very hard sell, and it takes only a little bit of fear mongering to send us down an anti-vaccination route.

Of course, our body is a complex system (note: different from a complicated system that it also is). We are still learning the down stream implications of many of the things we do to and with our bodies. I recently gave a presentation to doctors, insurers, regulators and patients on patient generated data and how we can use it. It is “big data,” a term very few understand. Big data is simply data collected from many sources, collected for different purposes and then used as if one data set. We can use it to assert a position or confirm a position, and we are already doing both. We are just in the infancy of understanding how best to use the huge trove of information, and one of the challenges is pulling in most uninformed perspectives into something useful.

The ability to gleam and present such insights is where I predict the next generation of experts will arrive. The best of them will be able to sift out the trash to present and stay current with the overall trends. The hard part is recognizing the limits of our knowledge. The Dunning-Kruger effect is real, and ironically one mentioned at the last board meeting. When it comes to medicine, we have the added frustration coming from double complex system issues around both the complex system that is our health and the overlapping yet distinctly separate complex system that is our emotions about our health and healthcare.

Still, we are coming a long way at a fast pace. As our traditional study based medicine is either directed or confirmed by huge amounts of data, our knowledge is refined faster than ever. Heck at the last meeting, the doctors were talking about the study in Stroke showing an increase in strokes and dementia for people who drink one or more diet soda a day. It was mind breaking to them, and they were shocked by my only mild surprise. I told them I stopped drinking coke zero because my headaches were worse, and when I switched back to regular coke I looked at other patients’ info. I was far from alone across neurological conditions to note worsening symptoms on diet sodas. As a result, I was less surprised than they at a link between diet sodas and neurological issues. My knowledge was not based on a formal study, and I would never present it as fact. However, a smarter person could have made the connection and presented a decent level of proof from expanding the small amount of research I did, and they could present something I would believe as much as my doctor telling me. However, I need the doctor to tell me which of the millions of “facts” and “alternative facts” available to me are most likely to help me feel better and live the life I want to live better. Alas, I do not have the base to make such distinctions well.

That is why I need a doctor. What’s more, that is why I need the term doctor to convey a level of current expertise. It is why I endorse the idea of a body of “experts” who can set a minimum bar to be called an expert in their field. Note that is what the American Board of Internal Medicine is. It is a group of doctors (experts) who say to be accredited with them, a doctor must know X.


For When the Map Fails

I was trying to conceptualize why it might be that lesions on parts of our brain thought to control a certain function within our nervous system sometimes have no immediate impact on the particular function.  I have long explained it to people as our nervous system being like a giant road system with signals traveling along our nerves to their destination.  A pot hole on a road may make it totally impassible or merely feel like a bump to the big rig traveling over it at 65mph.  In a similar vein, the road being impassible may be big problem if it is on a major highway, or it might just mean taking another almost equally fast route through the neighborhood.  Without knowledge of the severity or the equivalence of alternatives, determining the impact is difficult.  At least this is how I have always pictured and explained the relationship between my MS with roughly a dozen and a half lesions and my moderately good functioning thus far.  While I think this conceptualization normally adequate, I think it is likely an attempt to make a complex system into a complicated one.
A complicated system is one where there are many relationships, but they can pretty much be tracked/mapped.  For example, if the light is red, all traffic should stop.  If there are 20 lights between work and home, it will take me getting a green light 20 times to get home.  That’s 20 different relationships between my movement and the lights.  I shouldn’t be able to get home faster than the time it takes to complete each of those requirements.  One can add in a few other requirements like if my car has a flat, it will take me another 20 minutes to change the tire.  One can add more relationships, and the equation becomes more complicated, but the system isn’t a complex system.
A complex system is one where there are so many interrelationships between variables such that the overall function of the system is not easily discernible from the parts.  The whole is greater than the parts.  If we were to look at the entire brain, would we be able to say this part of the brain tells my fingers to type, and this part says to love my wife?  Without those parts, could the brain still tell my fingers to type and me to love my wife?  Perhaps the real problem with the road map is the attempt to assign a function of the entire system to a part.  If so, the complex nature of the nervous system rather than the complicated road map model could be the reason I have thus far been lucky to have so few and comparatively mild symptoms thus far.

Of course, this says little from any predictive standpoint.  I still have no way to know if tomorrow will have the proverbial straw that broke the camel’s back moment.  It may be the day I can’t see or walk, but isn’t this true for everyone whether they have MS or not?  As I ponder our nervous system, I can appreciate the need for belief.  It’s easy to get caught up believing we understand.  Physics went hundreds of years on Newton’s laws because they agreed with what we observe.  However, there is a whole layer of reality underneath when we start studying the atom.  Likewise, I tend to think the road map model adequate for 99 percent of what I have experienced with MS thus far, but for the other 1 percent I think I shall henceforth just attribute the difference to the complexity of the mind body relationship.


Perhaps the complex model rather than the complicated model is what is missing in our understanding of why MS has the impacts it does.  Perhaps this is why MRI’s looking for lesions or brain atrophy seem to give relevant information but may be only giving one part of a complex story.  I still go back to us not knowing the right questions, and I think more and more this is likely the result of incomplete conceptual models for our nervous system.

Funny parenting note of the week:
When O acted out this weekend, he had to go to the corner.  In the corner, he was continuing to try and get attention.  For some reason, he thought sing/shouting, “I am so sexy.  That’s why they make condoms.” over and over would get him out of the corner.  We did what we usually do which is to ignore him, but both J and I were hiding our laughter on the inside.  Where the heck, do 6 year olds get this stuff?
Frustrating part of the week for me:
Both kids were misbehaving today to the point where I feel like I was screamed at 75% of the time between 6:30 am and 8:30 pm.  On one hand, I am happy to be more fit so I still have the energy to go all day, but wow.  Walking the dogs tonight was my favorite part of a very very long day, the second in a row like it.

After reading the annual report from my high school, I am reminded, “Rursus incipiemus nunc et semper.”   – Always we begin again.

Tomorrow is another day in another week. One of my goals remains to always grow in understanding.

Along those lines, here is a Monday morning riddle: When does removing one from seven not leave six?