Gorillas in Our Midst

By Kim Bellard, August 13, 2013

There’s a well-known psychology experiment in which participants were asked to keep track of how many times a basketball was being passed in front of them, only to have a (fake) gorilla stroll in front of them.  Surprisingly, about half of the participants were so focused on their task that they were totally oblivious to the gorilla’s presence.  Researchers call this “inattentional blindness,” and we now have some evidence that it happens even to trained health care professionals as well.

Researcher Trafton Drew recently published results of a study in which he and his colleagues placed an image of a gorilla – I swear, I am not making this up! -- in one of a series of slides radiologists were reviewing for cancer nodules.  Amazingly, 83% of the radiologists failed to detect the image, even though it was 48 times larger than the typical nodule they were looking for and eye tracking indicated the radiologists had looked directly at the image.  They weren’t looking for gorillas and, as a result, did not see them. 

“Inattentional blindness” seems to me an apt description of how those of us in the health care field tend to look at health care.  It’s the old “if the only tool you have is a hammer, then everything looks like a nail” syndrome and it may help account for why our health system is so dysfunctional.  Health care has a lot of hammers and we sure do like to use them.

Take health insurance.  Health insurers are notoriously low rated when it comes to consumer trust, and it’s no wonder: consumers don’t understand their product.  Recent research by George Lowenstein of CMU indicate that only 14% of consumers understand four basic terms – deductible, copay, coinsurance, and out-of-pocket maximum – and only 11% could estimate their cost for a hospital stay given all the applicable data. 

I worked a long time in the health insurance industry and like to think I’d do well on Dr. Lowenstein’s tests, but when it comes down to reading all the fine print from different companies I suspect I’d not know how to evaluate them either.  We’ve simply made coverage too complicated, and if anyone thinks the new health insurance marketplaces will solve this problem, then I suggest they think again. 

It’s all well and good that ACA dictates which preventive services are covered at 100%, what “essential benefits” are, and how much different levels of plans must pay out, but none of that is making health insurance understandable to the average consumer.  We’re so busy debating things like high deductible plans versus first dollar plans, single payor versus competing private plans that we ignore the real problem: not only don’t consumers understand the product but, even worse, the product fails to help them be healthy.

Or take hospitals.  Let’s say you were very sick but had no idea what a hospital was.  Your friend tells you they are where sick people go to get better.  As a result, they’re full of sick people; in fact, it’s more likely than not that you’ll have to share a room with some sick stranger.  All those sick people means lots of germs; the official statistic is that one in 20 patients will pick up an infection during their stay (which is almost certainly understated) and that about 100,000 will die from those each year (which hopefully is overstated).  Part of the problem is that hospitals can’t even do a good job of getting their employees to do simple hygiene tasks like washing their hands. 

When you arrive, you’ll have to fill out lots of forms, giving them information that you no doubt have already given to other health care professionals.  The hospital will expect you to wear a flimsy gown that affords no dignity, and stick a wristband on you like you are a piece of merchandise, which is supposed to lessen the chance that they’ll, say, remove one of your limbs or a kidney by mistake.  An array of different hospital personnel will keep interrupting you for a variety of tests, procedures, and other tasks, virtually none of which you’ll have much advance warning of when to expect and which will make sleeping or resting very difficult.  You’ll spend most of your time in the hospital waiting around, but don’t expect much in the way of good distractions: the food is bland at best and terrible at worst, and the entertainment options on the television might have been state-of-the-art for 1970’s cable. 

Don’t bother trying to find out what anything is going to cost; no one can tell you until long after the fact, and then you’ll be shocked at how expensive everything is – at prices that would make even the most hardened Pentagon procurement officer blanch.  Oh, and there’s a one in five chance that you’ll have to be readmitted within 30 days, either because you didn’t really get better during your stay or because something else bad happened to you when you were there. 

If you learned all this for the first time, you might think twice about being admitted.

Hospitals have been around in some form for centuries, but they didn’t really start turning into these impersonal behemoths until federal money started pouring in after World War II, first with Hill-Burton funds and then with the introduction of Medicare and Medicaid.  The trend has accelerated in recent years.  Hospital buildings have often grown very complex due to repeated expansion and renovation, to the point that visitors need color coded maps just to try to get around.  The equipment in the hospitals, down to the beds themselves, has grown equally complex – and expensive.   Hospitals can certainly help patients in ways that would have been unimaginable even twenty or thirty years ago, but I doubt there are many people who could assert that the hospital experience has improved.

It’s not that smart people aren’t thinking about this.  Take, for example, Patient Room 2020, led by design firm NXT Health in conjunction with Clemson’s Healthcare + Architecture Program, and funded by the Department of Defense.  They’re reimagining what patient rooms should look like and work, and have come up with some cool design changes (see, for example, more pictures in Wired’s article).  As Wired said, it’s like the Apple Store meets Tron (although I think I’d have chosen a better sci-fi movie – or at least one that had a medical facility in it). 

The trouble is, they’re not seeing the metaphorical gorilla.  It’s the concept of the hospital that we’re not seeing properly.  It’s sort of like Windows 8 – some impressive engineering that provides expanded capabilities, but at the end of the day still a kludge trying to maintain an approach that is quickly becoming bypassed by newer ones. 

To carry the analogy further, hospitals and health insurers would surely be the mainframes of the health system, with outpatient clinics and surgical centers perhaps the desktops.  Physician offices and perhaps physical therapy offices might be considered the laptops.  In this analogy – where are the equivalents of tablets and smartphones, and where are the “apps” that make using the system easier?  Again, I mean these as an analogy, not literally, to illustrate that we’re just not doing a good job of rethinking the system.

Just look at all the artificial distinctions that have ossified in our health system: allopathic versus osteopathic (or chiropractic); “Western” versus alternative medicine; primary care versus specialty versus subspecialty; dental versus vision versus medical; workers compensation health coverage versus “commercial” health insurance; state by state licensing of health care professionals and insurance.  I could go on and on, but it’s clear that there are a lot of gorillas that we’re missing with our inattentional blindness. 

For example, a recent study found that one in ten Americans now take an antidepressant.  The problem is, nearly two-thirds of them don’t meet the criteria for depression and probably shouldn’t be taking the prescription.  Both the patients and the prescribing physicians are guilty of going for the medication fix because that’s what they’ve been conditioned to look for.

We need to go back to first principles.  What are the structures we need to encourage and incent consumers to focus more on good health?  What are the types of professionals and support systems that can assist them in that ongoing journey?  How do we better identify when health issues turn into medical problems, and apply the “least necessary” resources to them?  How do we keep the patient in the center even as care becomes more complex?  How much should consumers be expected to pay towards their own health, and how do we want to finance those costs?  Answering these questions from first principles would be monumentally hard, but right now there are not many people even trying.

We’re so busy seeing tests/procedures/pills/payment that we’re missing, not the gorilla, but the patient.