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Is healthcare getting better? It’s something of a paradox

It constantly feels in healthcare that any snapshot in time is one of moving forward and backward and nowhere all at the same time.

There was a recent article in Business Insider that described different kinds of paradoxes. According to Dictionary.com, a paradox is defined as a statement or proposition that seems self-contradictory or absurd but in reality expresses a possible truth.

The Business Insider article, entitled 15 paradoxes that will make your head explode, was written by Andy Kiersz and Gus Lubin, and featured this as the first paradox:

To go anywhere, you must go halfway first, and then you must go half of the remaining distance, and half of the remaining distance, and so forth to infinity: Thus, motion is impossible.

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The dichotomy paradox has been attributed to ancient Greek philosopher Zeno, and it was supposedly created as a proof that the universe is singular and that change, including motion, is impossible (as posited by Zeno’s teacher, Parmenides).

People have intuitively rejected this paradox for years.

From a mathematical perspective, the solution — formalized in the 19th century — is to accept that one-half plus one-quarter plus one-eighth plus one-sixteenth and so on … adds up to one. This is similar to saying that 0.999… equals 1.

But this theoretical solution doesn’t actually answer how an object can reach its destination. The solution to that question is more complex and still murky, relying on 20th-century theories about matter, time, and space not being infinitely divisible.

And while reading this did not make my head explode (yet), it did make me think about a discussion I was engaged in last week while I was on a panel at the Cavendish Global Health Impact Forum held in conjunction with the 2015 Cleveland Clinic Medical Innovation Summit.

The panel was organized by the great guys at Sage Growth Partners and moderated by Sage’s CEO Don McDaniel. Don focused the panel on the “industrialization” of healthcare, by which he meant the move to change the field from local craft businesses to scalable delivery enterprise, and similar topics. We had a lively discussion and then Don closed by asking each person on the panel if he/she was hopeful about the healthcare industry’s ability to incorporate innovation to transform into a better industry overall. By “better” I believe Don was getting at a variety of things in healthcare delivery, including efficiency, consumer-friendliness, physician-satisfaction, cost-effectiveness and quality of outcome for value paid.

Here’s the connection to that dichotomy paradox I opened with: As I thought about whether I was optimistic or pessimistic (hopeful or not hopeful) it occurred to me that the healthcare system is definitely trying to move itself forward. I think that every stakeholder in the system has recognized that things must change and that we must create motion towards a new model. But we move so incrementally and the distance always seems to be just a little further away. Getting all the way to “a great healthcare system,” however defined, seems impossible most of the time. There is always another distance to cover and, while we may get seemingly closer, the gap to nirvana is ever-present and seems to shrink by the smallest discernible amounts. Getting caught up in this spin cycle made it hard for me to decide how to answer Don’s question: was I or wasn’t I hopeful?

As I sat there collecting my thoughts before answering out loud, I also meandered my way into what is known as the arrow paradox, a phenomenon to which I could not have given a name until I read the Business Insider article where this appears as the 2nd entry. The arrow paradox is this:

In any instant, a moving object is indistinguishable from a nonmoving object: Thus motion is impossible.

This is called the arrow paradox, and it’s another of Zeno’s arguments against motion. The issue here is that in a single instant of time, zero seconds pass, and so zero motion happens. Zeno argued that if time were made up of instants, the fact that motion doesn’t happen in any particular instant would mean motion doesn’t happen.

As with the dichotomy paradox, the arrow paradox actually hints at modern understandings of quantum mechanics. In his book “Reflections on Relativity,” Kevin Brown notes that in the context of special relativity, an object in motion is different from an object at rest. Relativity requires that objects moving at different speeds will appear different to outside observers and will themselves have different perceptions of the world around them.

Truthfully, nothing could fit the healthcare system better than this concept. It constantly feels in healthcare that any snapshot in time is one of moving forward and backward and nowhere all at the same time.  Clearly healthcare is moving, but we are moving so slowly in some quarters that there appears to be no movement at all in the short term. To get past the arrow dichotomy, one has to think about the optimism/pessimism question in terms of time; the real question needs to be: are you optimistic about the healthcare’s ability to get better in the next 5 years? 10 years? While one is still on the right side of the grass? Before global warming wins? Because if you look at healthcare at any moment in time, it seems to be standing still, or at least advancing and regressing in almost equal ways. One can only hope that the advancements move a little faster than the regressions.

An example: I read an Modern Health article this week that over 450 hospitals and counting, have settled with the US Justice Department for more than $250 million as part of a years-long, nationwide investigation into the suspected overuse of implantable cardiac devices (ICDs). My first response was: there those hospitals go again, over-treating for revenue. But a full read of the article reveals something far more complex. According to the article:

…The rules say the devices cannot be implanted within 40 days of a heart attack or 90 days of bypass surgery or angioplasty, but many doctors have chosen to implant them in such circumstances anyway– leading to the investigation.

The investigation, however, has also ignited criticism from physicians who argue that Medicare’s coverage rules for the devices conflict with other medical guidelines.

The purpose of making physicians wait either 40 or 90 days before implanting the devices in patients who’ve had heart attacks or bypass/angioplasty, respectively, is to give the heart a chance to improve on its own, according to the Justice Department. If a patient’s heart improves enough, the device may not be necessary.

But medical professionals say the Medicare coverage guidelines are at odds with clinical guidelines developed by medical societies.

In other words, doctors and their professional societies whose guidelines hospitals follow  (ACC, AHA, etc.) are saying that the 2005 CMS rule about when to implant ICDs is ancient history  when compared with more recent clinical guidelines written after gathering far more clinical evidence of the risk/reward to patients of having faster ICD implantation. The good news: CMS saved a bunch of money by reducing the number of ICDs implanted. The bad news: many patients may have suffered as a result. The good news: physicians are paying attention to evidence-based guidelines and trying to do the right thing. The bad news: their hospitals are getting punished for it. Welcome to the arrow paradox. At some point the CMS regulation and the clinical guidelines may start to align, but it’s so “two steps forward, one step back” that it’s hard to tell when we are actually moving.

So here was my answer to the “are you hopeful about healthcare system’s ability to transform itself for the better” question. I said yes in the long term, no in the short term. Yes in the specific, no in the aggregate sense. My feelings are so complicated about this issue.

63586 I see many great examples of better ways to do things and better things getting done: better delivery system improvements, better uses of data to create evidence-based decision-making and personalization, better drugs and devices that help individual people heal faster and at a greater value for money spent, better patient engagement and greater clinician awareness of the importance of kindness and respect.

And at the same time I still see plenty of the opposite, lots of mixed messages, profoundly entrenched negative interests, inertia and glacial speed when it comes to innovation, technology for technology’s sake, people who are immune to caring about their own health, doctors who are immune to being kind, industry self-interest that trumps advancement. The whole gamut of crap from the sublime to the ridiculous is ever-present.

That’s why the dichotomy paradox and the arrow paradox so perfectly define the situation. We can keep inching closer but the distance never seems to close. At any snapshot in time, we seem to move in all directions simultaneously, and thus have no movement. One can only hope that the math on these works out better than our pal Zeno would suggest.  By taking the long view, we like to think that good wins out over evil, that right vanquishes wrong, that evolution is a positive force and not a negative one (don’t get me started on the whole topic of why some people don’t believe in evolution).

So I’m going to go with that: It’s getting better and cause for optimism, just maybe not today specifically. I like to think of my perspective as positive cynicism–my self-created buzzword for being a pessimistic optimist. Perhaps I have invented a new paradox in and of itself—one that uniquely fits the healthcare paradigm.

Photo: Flickr user Shelly Tee

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