Does the Wisdom of Crowds Rival the Wisdom of Your Doctor?

Two pieces in Sunday’s paper got me to thinking.  The first, in the Sunday Globe Magazine was by Douglas S. Brown,  Vice President at UMass Memorial Health Care in Worchester, MA.  This interesting piece resonated with me in that it speaks of how the U.S. healthcare system, at all levels, has displayed arrogance and disinterest when faced with the reality that we provide low value healthcare compared to most other industrialized countries.

There is lots there that we could debate, but one passage in particular struck me as it relates to the adoption of connected health.  Brown cites a 2008 safety alert* on physician attitudes toward working with patients and other healthcare workers, noting that “reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions” sends an unmistakable message: I am better than you. Who are you to question me?

The second piece was in the Sunday New York Times Business Section, by Natasha Singer, entitled “When Patients Meet Online, Are There Side Effects?”.  Singer writes about two Internet-based efforts in healthcare that are truly disruptive. I admire them both greatly.

One is and the other is  The controversy that Singer writes about is the tradeoff that patients make when they join communities like Patientslikeme, where consumers share personal information so that others can compare and learn together.  Of course, Patientslikeme has been transparent from the very beginning, stating that they reserve the right to offer participants’ private health information (in aggregate and deidentified) to outside firms as market research.  This is not unique in the world of social networking, but somehow when applied to the very private world of health information, it raises concerns in some individual’s eyes.  My interest, however, is in the very notion that two communities (I’m sure there are others) like this can be successful despite any perceived risk that personal health information will make it into the wrong hands.  To me, this indicates a frustration level with the health care status quo that should be listened to.

I’d like to tie these two together by pondering why Patientslikeme and Curetogether got started.

I’ve heard both founders (Jamie Heywood of Patientslikeme and Alexandra Carmichael of Curetogether) speak about their disenchantment with the health care system as offered. In both cases, the question being posed is whether the wisdom of crowds is more powerful that the wisdom of your physician. I expect that if we physicians were listening more attentively for for clues that patients feel they aren’t being heard as opposed to complaining about returning calls and pages or griping about those who question our authority, neither of these founders would have felt the need to create their respective firms.   My gut tells me that the right answer is somewhere in the middle.

Patients live with their illness all day long, 365 days a year, and if they are careful observers, they will know infinitely more detail about their illness than their physician. The physician adds context, by way of expertise from domain level training, experience and judgement.

Really this is not a new debate.  I’m paraphrasing but the revered diagnostician Sir William Osler was known to counsel medical students, “Listen to the patient.   He’s trying to tell you what the diagnosis is.” We went through a phase in healthcare where we trained a generation of physicians who paid more attention to the imaging, lab tests, ecg’s, etc., than the patient history. It’s no wonder we’ve got patients wondering if  they can do a better job on their own.

Connected health will compound this challenge.  By way of example, lets look at blood pressure.  Hypertension is currently managed based on a handful of readings taken in the doctor’s office 2-4 times a year.  When we’ve explored Not surprisingly, then, physicians react in a variety of ways to the concept of frequent (anywhere from 3 per week to 3 per day) home blood pressure readings stored in a log to be used for clinical decision making.

On the one hand, my colleague, Dr. Richard Grant, is amongst the most progressive in that he’s designed a study to ask the question of whether patients who take home blood pressure readings, when armed with a series of algorithms, can make their own medication adjustments. On the other end of the spectrum, I hear from some doctors, “please don’t give my patients home blood pressure units.  It will only result in confusion on their part about which readings are meaningful and more calls to me. I don’t have the time to answer all of their questions.”

That comment brings me back to Douglas Brown’s article.  How can we possibly have twisted our professional thinking to believe that fewer data points are better in solving a clinical problem?  It is direct evidence of the hubris that Brown refers to.

Still, there is a role for domain experts to guide thinking around healthcare. This is why I get so many requests from investors to look at new healthcare start ups. It is also why all healthcare companies have medical director positions.  There is something unique and valuable about a physician’s training and perspective.

So what is the answer?  Would communities like Patientslikeme and Curetogether be more powerful if they had physician involvement? Would we even need them if we healthcare providers took a generous dose of humility?

What do you think?