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WSJ: The Rise and Fall of Math in Russia
http://online.wsj.com/article/SB10001424052748703740004574513870490836470.html#printMode Russia's Conquering Zeros
The strength of post-Soviet math stems from decades of lonely productivity
By MASHA GESSEN
Moscow
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It may be no accident that, while some of the best American mathematical minds worked to solve one of the century's hardest problems—the Poincaré Conjecture—it was a Russian mathematician working in Russia who, early in this decade, finally triumphed.
Decades before, in the Soviet Union, math placed a premium on logic and consistency in a culture that thrived on rhetoric and fear; it required highly specialized knowledge to understand; and, worst of all, mathematics lay claim to singular and knowable truths—when the regime had staked its own legitimacy on its own singular truth. All this made mathematicians suspect. Still, math escaped the purges, show trials and rule by decree that decimated other Soviet sciences.
Three factors saved math. First, Russian math happened to be uncommonly strong right when it might have suffered the most, in the 1930s. Second, math proved too obscure for the sort of meddling Joseph Stalin most liked to exercise: It was simply too difficult to ignite a passionate debate about something as inaccessible as the objective nature of natural numbers (although just such a campaign was attempted). And third, at a critical moment math proved immensely useful to the state.
Three weeks after Nazi Germany invaded the Soviet Union in June 1941, the Soviet air force had been bombed out of existence. The Russian military set about retrofitting civilian airplanes for use as bombers. The problem was, the civilian airplanes were much slower than the military ones, rendering moot everything the military knew about aim.
What was needed was a small army of mathematicians to recalculate speeds and distances to let the air force hit its targets.
The greatest Russian mathematician of the 20th century, Andrei Kolmogorov, led a classroom of students, armed with adding machines, in recalculating the Red Army's bombing and artillery tables. Then he set about creating a new system of statistical control and prediction for the Soviet military.
iStockphotoFollowing the war, the Soviets invested heavily in high-tech military research, building over 40 cities where scientists and mathematicians worked in secret. The urgency of the mobilization recalled the Manhattan Project—only much bigger and lasting much longer. Estimates of the number of people engaged in the Soviet arms effort in the second half of the century range up to 12 million people, with a couple million of them employed by military-research institutions.
These jobs spelled nearly total scientific isolation: For defense employees, any contact with foreigners would be considered treasonous rather than simply suspect. In addition, research towns provided comfortably cloistered social environments but no possibility for outside intellectual contact. The Soviet Union managed to hide some of its best mathematical minds away in plain sight.
In the years following Stalin's death in 1953, the Iron Curtain began to open a tiny crack—not quite enough to facilitate much-needed conversation with non-Soviet mathematicians but enough to show off some of Soviet mathematics' proudest achievements.
By the 1970s, a Soviet math establishment had taken shape. A totalitarian system within a totalitarian system, it provided its members not only with work and money but also with apartments, food, and transportation. It determined where they lived and when, where, and how they traveled for work or pleasure. To those in the fold, it was a controlling and strict but caring mother: Her children were undeniably privileged.
Even for members of the math establishment, though, there were always too few good apartments, too many people wanting to travel to a conference. So it was a vicious, back-stabbing little world, shaped by intrigue, denunciations and unfair competition.
Then there were those who could never join the establishment: those who happened to be born Jewish or female, those who had had the wrong advisers at university or those who could not force themselves to join the Party. For these people, "the most they could hope for was being able to defend their doctoral dissertation at some institute in Minsk, if they could secure connections there," says Sergei Gelfand, publisher of the American Mathematical Society—who also happens to be the son of one of Russia's top 20th-century mathematicians, Israel Gelfand, a student of Mr. Kolmogorov. Some Western mathematicians, Sergei Gelfand adds, "even came for an extended stay because they realized there were a lot of talented people. This was unofficial mathematics."
Math Stars
Besides Grigory Perelman and the Poincaré Conjecture, there are numerous other famous math solvers, and there are still problems to solve.
Andrew Wiles (1953-)
This Princeton mathematician resolved the most famous problem in numbers—Fermat's Last Theorem—in 1995.Leonhard Euler (1707–1783)
A Swiss mathematician who made so many contributions, particularly in the early foundations of calculus, that it gets hard to keep track of all that's named for him.Kurt Gödel (1906–1978)
This Austrian logician demonstrated that any reasonably powerful system of math contains true statements that can't be proven.The Riemann Hypothesis
To the enduring befuddlement of mathematicians, prime numbers—numbers divisible only by themselves and 1—exhibit no pattern at all: 2, 3, 5, 7, 11, 13 are the first few. They aren't evenly spaced but get scarcer the further out you go. No formula can tell you what the next one will be. In 1859, the German mathematician Bernhard Riemann discovered that a function—known now as the Riemann zeta function (expressed in the graphic above)—appeared to give signposts to where primes lie in the great field of numbers. It provided some order to the mystery. Riemann conjectured that these key signposts—"zeros" of the function—all lie on a single straight line out to infinity, that none are flung off in strange places. In the 150 years since, no one has proved his hypothesis. To a mathematician, the hypothesis looks like this: All non-trivial zeros of the Riemann zeta function have a real part equal to ½.--Charles Forelle
One such visitor was Dusa McDuff, then a British algebraist and now a professor emerita at the State University of New York at Stony Brook. She studied with the older Mr. Gelfand for six months, and credits this experience to opening her eyes both to what mathematics really is: "It was a wonderful education... Gelfand amazed me by talking of mathematics as though it were poetry."
In the mathematical counterculture, math "was almost a hobby," recalls Sergei Gelfand. "So you could spend your time doing things that would not be useful to anyone for the nearest decade." Mathematicians called it "math for math's sake." There was no material reward in this—no tenure, no money, no apartments, no foreign travel; all they stood to gain was the respect of their peers.
Math not only held out the promise of intellectual work without state interference (if also without its support) but also something found nowhere else in late-Soviet society: a knowable singular truth. "If I had been free to choose any profession, I would have become a literary critic," says Georgii Shabat, a well-known Moscow mathematician. "But I wanted to work, not spend my life fighting the censors." The search for that truth could take long years—but in the late Soviet Union, time seemed to stand still.
When it all collapsed, the state stopped investing in math and holding its mathematicians hostage. It's hard to say which of these two factors did more to send Russian mathematicians to the West, primarily the U.S., but leave they did, in what was probably one of the biggest outflows of brainpower the world has ever known. Even the older Mr. Gelfand moved to the U.S. and taught at Rutgers University for nearly 20 years, almost until his death in October at the age of 96. The flow is probably unstoppable by now: A promising graduate student in Moscow or St. Petersburg, unable to find a suitable academic adviser at home, is most likely to follow the trail to the U.S.
But the math culture they find in America, while less back-stabbing than that of the Soviet math establishment, is far from the meritocratic ideal that Russia's unofficial math world had taught them to expect. American math culture has intellectual rigor but also suffers from allegations of favoritism, small-time competitiveness, occasional plagiarism scandals, as well as the usual tenure battles, funding pressures and administrative chores that characterize American academic life. This culture offers the kinds of opportunities for professional communication that a Soviet mathematician could hardly have dreamed of, but it doesn't foster the sort of luxurious, timeless creative work that was typical of the Soviet math counterculture.
For example, the American model may not be able to produce a breakthrough like the proof of the Poincaré Conjecture, carried out by the St. Petersburg mathematician Grigory Perelman.
Mr. Perelman came to the United States as a young postdoctoral student in the early 1990s and immediately decided that America was math heaven; he wrote home demanding that his mother and his younger sister, a budding mathematician, move here. But three years later, when his postdoc hiatus was over and he was faced with the pressures of securing an academic position, he returned home, disillusioned.
In St. Petersburg he went on the (admittedly modest) payroll of the math research institute, where he showed up infrequently and generally kept to himself for almost seven years, one of the greatest mathematical discoveries of at least the last hundred years. It's all but impossible to imagine an American institution that could have provided Mr. Perelman with this kind of near-solitary existence, free of teaching and publishing obligations.
After posting his proof on the Web, Mr. Perelman traveled to the U.S. in the spring of 2003, to lecture at a couple of East Coast universities. He was immediately showered with offers of professorial appointments and research money, and, by all accounts, he found these offers gravely insulting, as he believes the monetization of achievement is the ultimate insult to mathematics. So profound was his disappointment with the rewards he was offered that, I believe, it contributed a great deal to his subsequent decision to quit mathematics altogether, along with the people who practice it. (He now lives with his mother on the outskirts of St. Petersburg.)
A child of the Soviet math counterculture, he still held a singular truth to be self-evident: Math as it ought to be practiced, math as the ultimate flight of the imagination, is something money can't buy.
Masha Gessen's latest book is "Perfect Rigor: A Genius and the Mathematical Breakthrough of the Century," a story of Grigory Perelman and the Poincaré Conjecture. She lives in Moscow and is the author of three previous books.
NYT: How to Make Health Care Better or the Debate Between Empiricism and Intuition in Health Care
http://www.nytimes.com/2009/11/08/magazine/08Healthcare-t.html?_r=1&ref=magazine&pagewanted=print Making Health Care Better
I.
During one of our first conversations, Brent James told me a story that you wouldn’t necessarily expect to hear from a doctor. For most of human history, James explained, doctors have done more harm than good. Their treatments consisted of inducing vomiting or diarrhea and, most common of all, bleeding their patients. James, who is the chief quality officer at Intermountain Healthcare, a network of hospitals and clinics in Utah and Idaho that President Obama and others have described as a model for health reform, then rattled off a list of history books that told the fuller story. Sure enough, these books recount that from the time of Hippocrates into the 19th century, medicine made scant progress. “The amount of death and disease would be less,” Jacob Bigelow, a prominent doctor, said in 1835, “if all disease were left to itself.”
Yet patients continued to go to doctors, and many continued to put great in faith in medicine. They did so in part because they had no good alternative and in part because, as James put it, they wanted a spiritual counselor with whom they could talk about their health. But there was something else, too. There was a strong intuitive logic behind those old treatments; they seemed to be ridding the body of its ills. They made a lot more sense on their face than the abstract theories about germs and viruses that began to appear in the late 19th century.
So the victory of those theories would require a struggle. The doctors and scientists who tried to overturn centuries of intuitive wisdom were often met with scorn. Hippocrates himself wrote that a physician’s judgment mattered more than any external measurement, and the practice of medicine was long organized accordingly.
In the end, of course, the theories about germs and viruses won out. They had the advantage of being correct, and doctors — haltingly and skeptically, but eventually — embraced them. “Medicine adopted the scientific method,” James said as we were sitting in his Salt Lake City office, which looks out onto the Utah State Capitol Building and the Wasatch Mountains. “It transformed medicine, and it’s easy to make the case.” Diphtheria, mumps, measles and polio were conquered, and pneumonia and heart attacks became far less deadly. In 1910, life expectancy at birth in the United States was less than 50 years, and it had not risen much for centuries, James noted. Life expectancy today is 78 years.
But there is one important way in which medicine never quite adopted the scientific method. The explosion of medical research over the last century has produced a dizzying number of treatments for different ailments. For someone with heart disease, there is bypass surgery, stenting or simply drugs and behavior changes. For a man with early-stage prostate cancer, there is surgery, radiation, proton-beam therapy or so-called watchful waiting. To enter mainstream use, any such treatment typically needs to clear a high bar. It will be subject to randomized trials, statistical-significance tests, the peer-review process of academic journals and the scrutiny of government regulators. Yet once a treatment enters the mainstream — once we know whether it works in certain situations — science is largely left behind. The next questions — when to use it and on which patients — become matters of judgment, not measurement. The decision is, once again, left to a doctor’s informed intuition.
“There are some real advantages to that,” James says, “and in some ways there are some real disadvantages too.” The human mind can sometimes do a better job of piecing together amorphous bits of information — diagnosing a disease, for example — than even the most powerful computer. On the other hand, human beings can also be unduly influenced by just a few experiences, like the treatment of an especially memorable patient. As a result, different doctors frequently end up coming up with different answers to the same question. Cardiologists in Davenport, Iowa, are quick to insert stents; cardiologists in Iowa City and Sioux City are not. They can’t both be right. Some people with heart disease are getting the best treatment, and some are not. The same is true of debilitating back pain, various cancers and even pregnancy.
The health care debate of 2009 has had so many moving parts that it has sometimes seemed impossible to follow. The crisis behind the debate, though, is about one thing above all: the scattershot nature of American medicine. The fee-for-service payment system — combined with our own instincts as patients — encourages ever more testing and treatments. We’re not sure which ones make a difference, but we keep on getting them, and costs keep rising. Millions of people cannot afford insurance as a result. Millions more have had their incomes pinched by rising insurance premiums. Medicare is on a long-term path to insolvency. The American health care system is vastly more expensive than any other country’s, but our results are not vastly better.
Any bill that Congress passes this year is unlikely to fix these problems. The lobbying groups for drug companies, device makers, insurers, doctors and hospitals have succeeded, so far, in keeping big, systemic changes out of the bills. And yet the modern history of medicine — the story that James tells — nonetheless offers reason for optimism. Medicine has changed before, after all. When it did, government policy played a role. But much of the impetus came from inside the profession. Doctors helped change other doctors.
For the past decade or so, a loose group of reformers has been trying to do precisely this. They have been trying to figure out how to improve health care while also holding down the growth in costs. The group includes Dr. John Wennberg and his protégés at Dartmouth, whose research about geographic variation in care has received a lot of attention lately, as well as Dr. Mark McClellan, who ran Medicare in the Bush administration, and Dr. Donald Berwick, a Boston pediatrician who has become a leading advocate for patient safety. These reformers tend to be an optimistic bunch. It’s probably a necessary trait for anyone trying to overturn an entrenched status quo. When I have asked them whether they have any hope that medicine will change, they have tended to say yes. When I have asked them whether anybody has already begun to succeed, they have tended to mention the same name: Brent James.
II.
ON A RECENT Wednesday morning, about 25 students gathered in a conference room in downtown Salt Lake City. The students were doctors and hospital executives who came to Utah to be taught by James. His four-month course is called the Advanced Training Program, and it is a combination of statistical methods and management theory applied to the practice of medicine. “I’ve wanted to go for years,” Janet Porter, the chief operating officer of the Dana-Farber Cancer Institute in Boston, told me later. For anybody interested in improving the quality of health care, she said, the program is the equivalent of Harvard.
At the front of the room stood James, a 58-year-old surgeon by training who speaks with the clipped accent of an Idaho native and likes to make his points by telling stories. On more than one occasion, including this one, I watched him pour himself a Diet Coke and then leave it untouched as he jumped from one illustrative tale to another. On this morning, he was telling the class the story of Intermountain Healthcare.
In the late 1980s, a pulmonologist at Intermountain named Alan Morris received a research grant to study whether a new approach to ventilator care could help treat a condition called acute respiratory distress syndrome. The condition, which is known as ARDS, kills thousands of Americans each year, many of them young men. (It can be a complication of swine flu.) As Morris thought about the research, he became concerned that the trial might be undermined by the fact that doctors would set ventilators at different levels for similar patients. He knew that he himself sometimes did so. Given all the things that the pulmonologists were trying to manage, it seemed they just could not set the ventilator consistently.
Working with James, Morris began to write a protocol for treating ARDS. Some of the recommendations were based on solid evidence. Many were educated guesses. The final document ran to 50 pages and was left at the patients’ bedsides in loose-leaf binders. Morris’s colleagues were naturally wary of it. “I thought there wasn’t anybody better in the world at twiddling the knobs than I was,” Jim Orme, a critical-care doctor, told me later, “so I was skeptical that any protocol generated by a group of people could do better.” Morris helped overcome this skepticism in part by inviting his colleagues to depart from the protocol whenever they wanted. He was merely giving them a set of defaults, which, he emphasized, were for the sake of a research trial.
The crucial thing about the protocol was that it reduced the variation in what the doctors did. That, in turn, allowed Morris and James to isolate the aspects of treatment that made a difference. There was no way to do that when the doctors were treating patients in dozens of different ways. James has a provocative way of describing his method to doctors: “Guys, it’s more important that you do it the same way than what you think is the right way.”
While the pulmonologists were working off of the protocol, Intermountain’s computerized records system was tracking patient outcomes. A pulmonology team met each week to talk about the outcomes and to rewrite the protocol when it seemed to be wrong. In the first few months, the team made dozens of changes. Just as the pulmonologists predicted, the initial protocol was deeply flawed. But it seemed to be successful anyway. One widely circulated national study overseen by doctors at Massachusetts General Hospital had found an ARDS survival rate of about 10 percent. For those in Intermountain’s study, the rate was 40 percent.
All along, Morris has been reluctant to give the protocol credit for the increase. As he explained to me, Intermountain’s trial differed from the earlier study in any number of ways. Still, his once-skeptical colleagues were impressed. Orme said that the gap in survival was eye-opening for him and others. James was thrilled not only by the results but also by the fact that the doctors managed to put together such a complex set of clinical guidelines.
In the years since the ARDS study, one Intermountain department after another has embarked on a similar project. By now, the hospital has gone through the exercise for 50 clinical conditions, accounting for more than half of Intermountain’s patients. For each, a committee made up of doctors, nurses and administrators has tried to identify variation and then figure out which treatments have not been working.
The committee members are drawn from Intermountain’s network of 23 hospitals and dozens of clinics in Utah and Idaho. These doctors and nurses can then spread the gospel of the protocol, and their words are far more influential than any printed document. Whenever possible, the guidelines are also embedded in the hospital’s computer system. Doctors and nurses are presented with a default choice — how much of a given drug to prescribe, for example — and have the option of overriding it. Most important, the electronic records system allows both committees and doctors to track patient outcomes. Doctors with consistently poor results can expect to be pulled aside for a collegial conversation with a supervisor about what they might be doing wrong. Doctors with the best results can expect to be asked what they are doing right. Doctors in many areas are also eligible for bonuses of up to about $2,500 a year if their outcomes are good.
Tracking outcomes and adjusting care, however, is rarely easy or clear-cut. Among many other things, the committees have to decide how to balance Intermountain’s internal evidence with published studies that are both more scientific and potentially less relevant. By any definition, the exercise depends on human judgment. At one primary-care meeting I attended, Dr. Scott Lindley said he had heard complaints from doctors who thought the committee made a mistake by setting the goal for hemoglobin A1c levels — a common measure of blood sugar in diabetes patients — at 8. If an obese person came in at 13 and the medical team reduced the level to 9, wasn’t that a success? An 8 might be too ambitious a benchmark, Lindley said. “Some literature shows 9 is better,” he noted.
In response, Dr. Michael Visick, another committee member, pointed out that nobody was being punished for having patients with hemoglobin levels above 8. Doctors were simply asked to take a second look at those patients. And the only reason the committee set a benchmark was that data had shown the percentage of patients with a level above 8 was rising, Visick said. That was a sign that Intermountain’s diabetes care might be slipping. Lindley seemed to accept the explanation. Still, he added with a tone of mild sarcasm that he was sure his colleagues would “just go away happy” when he conveyed the explanation to them.
James’s answer to such skepticism — and there is a lot of it, especially beyond Intermountain — is to show results. Intermountain has reduced the number of preterm deliveries, as well as the number of babies who must spend time in the neonatal-intensive-care unit. So-called adverse drug events, which include overdoses and allergic reactions, were cut in half in the mid-1990s. A protocol for dealing with one broad category of pneumonia cut its mortality rate by 40 percent over several years. The death rate for coronary-bypass surgery was cut to 1.5 percent, from the national average of about 3 percent. Medicare data on heart-failure and pneumonia patients show that Intermountain has significantly lower-than-average readmission rates. In all, James estimates that the changes have saved thousands of lives a year across Intermountain’s network. Outside experts consider that estimate to be fair.
Wennberg, the Dartmouth researcher, argues that Intermountain is fundamentally different from other oft-cited models of high-quality, lower-cost care, like the Mayo Clinic and the Cleveland Clinic. These places, including Intermountain, share certain traits, like having a large number of doctors who receive fixed salaries rather than being paid piecemeal for each treatment. Partly as a result, these hospitals do fewer tests, treatments and operations than other hospitals and still get excellent results. What sets Intermountain apart, Wennberg says, is that it is also making a rigorous effort to analyze and improve bedside care.
“It’s the best model in the country of how you can actually change health care,” Wennberg told me. I heard nearly the same argument from Anthony Staines, a health scholar and hospital regulator in Switzerland who recently completed a study of some of the world’s most-admired hospitals. “Intermountain was really the only system where there was evidence of improvement in a majority of departments,” Staines said.
Among James’s biggest points of pride is his growing, if still small, group of imitators. Thirty-five hospitals have set up in-house versions of his course, usually run by one of his former students. “Everybody is trying to systemically improve value and quality,” says Dr. John Mendelsohn, the president of the University of Texas M.D. Anderson Cancer Center in Houston, which started its course in 2005. “But at Intermountain they have worked out the operational system and the culture to do it.” Based on the success of the Anderson program, the University of Texas has required all the other branches of its medical system to start their own courses.
Viewed across the entire health care system, however, the pace of change is extremely slow. The journal Health Affairs will soon publish a survey of the chairmen of more than 700 hospitals. Its main message is that many hospitals are not even aware of what they do well and what they don’t. The physicians who conducted the survey, Ashish Jha and Arnold Epstein, gave the chairmen a list of issues — including financial performance, organizational strategy and the quality of health care — and asked them to name their board’s two top priorities. Roughly half did not name the quality of care. Yet the chairmen said they believed that the care at their hospitals was above average. Even at those hospitals that Medicare data suggest are among the worst in the country, 58 percent of the chairmen said they thought their hospital was above average. Not a single one said the hospital was below average.
“Brent is the future,” says Lucian Leape, a professor of public health at Harvard and a former surgeon. “But how long are you willing to wait? It may take 100 years.”
III.
WHEN JAMES WAS growing up on a cattle ranch in Blackfoot, Idaho, as the oldest son in a family of six children, he spent a fair amount of time on a tractor. Sometimes he would have nothing to do but wait for a ditch to fill up with water. So he brought along a calculus textbook. “I’m one of the relatively rare subset of people that finds math fun,” James said. “Just thinking about it was fun. It’s how my brain is wired.” He liked the elegance of mathematics, and he also liked that it could describe the workings of the world. Numbers could tell stories. Like many number lovers who don’t want to do pure, abstract math, James decided to be an academic physicist. He enrolled at the University of Utah and spent his time there working on high-energy physics and the relatively new field of computer science.
“One day, we’re in the lab and we’re working away, and we had a postdoc there,” James recalled. “We had a little conversation, and he said I was an idiot for going to into physics.” The postdoc explained that there was “a line 200 people long for any university faculty position.” After checking around, James decided that the postdoc was right, and he began looking for another field that offered both fascinating research questions and decent career prospects. Medicine seemed as if it might be the answer. He applied to the University of Utah’s medical school and was accepted
James enjoyed treating patients more than he expected, and he became a cancer surgeon. But research remained his main interest. After his residency, he did a fellowship at the National Cancer Institute, outside Washington, and then took a job at the American College of Surgeons, helping to oversee its cancer research. One of his projects involved studying variation in how oncologists determined cancer stages and then treated patients.
Eventually he joined the faculty at the Harvard School of Public Health. While in Boston, he and his wife divorced, which made him want to be closer to his family out West. Salt Lake City was especially appealing because James is an observant Mormon. In 1986, he was hired by Intermountain as the director of medical research and continuing medical education. At the time, Intermountain was one of the few medical systems with electronic patient records.
The job gave James his first real chance to put his research into practice. He was no longer working where so many other reformers do, in an academic department or government agency. He was working for a hospital. But being in the real world also created a problem for him. He could not simply tell Intermountain’s doctors what to do, no matter how much research he brought to bear. Doctors have a degree of professional autonomy that is probably unmatched outside academia. And that is how we like it. We think of our doctors as wise men and women who can combine knowledge and instinct to land on just the right treatment. Our fictional doctor heroes, from Marcus Welby to House, are iconoclasts who don’t go by the book. They rely on intuition, and intuition is indeed a powerful thing, be it in medicine or other parts of life.
Everyone has had the experience of being able to read someone’s face or voice — to know his or her mood — without knowing how. Then there are the stories of firefighters who have rushed out of a burning building shortly before it collapses. Gary Klein, a cognitive psychologist and researcher, collects examples like these, and one of the most powerful involves a paramedic who, at a family gathering, told her father-in-law that he needed to go the hospital. He said he felt fine. She prevailed on him. The next day, he was undergoing heart-bypass surgery. Like the firefighters and the face readers, the paramedic could not explain her reasoning. She did not know how she knew what she knew. When she was interviewed later, she said that she must have been tipped off by the kind of paleness and swelling that she had seen dozens of times before.
Stories like this one are deeply appealing. They allow us to feel that we are tuned into the mysterious logic of life. Indeed, in many ways we are. The human mind can store huge amounts of knowledge. Intuition is not simply belief; it springs from this knowledge. A doctor making an intuitive diagnosis is doing so on the basis of thousands of hours spent treating patients. The problem, however, is that the mind is not particularly good at sorting through this knowledge and weighing different parts appropriately. We give too much weight to information that confirms our suspicions or that is highly memorable.
Behavioral researchers have come to believe that there is a clear pattern to when intuition works and when it doesn’t. “Intuitive diagnosis is reliable when people have a lot of relevant feedback,” says Daniel Kahneman, a Nobel laureate in economics who recently collaborated on a project about intuition with Klein. People need a great deal of experience, and the feedback from these experiences — whether a treatment is working, say — needs to come quickly and to be clear. “But,” Kahneman adds, “people are very often willing to make intuitive diagnoses even when they’re very likely to be wrong.” When doctors have been asked to estimate the likelihood of a treatment succeeding based on experience, for example, they give wildly divergent answers. Medicine is full of such examples.
James is a voracious consumer of social science, and he likes to frame these issues with opposing concepts: pattern matching and rate estimation. Pattern matching refers to intuition at its best. It is what people can do in those few areas in which they have had vast experience and clear feedback. Rate estimation is a task that people usually do not perform well but that happens to make up a great deal of modern medicine. “When a person says, ‘In my experience,’ what’s actually happening is you’re being dominated by one or two recent cases that you can recall or by some distant case that was either particularly good or particularly bad,” James says. “My first goal for Intermountain is that anytime a physician or nurse says, ‘In my experience’ when they’re talking to a patient, they mean, ‘In my measured experience.’ ”
IV.
TWO YEARS AGO, Jerome Groopman, the Harvard doctor and New Yorker writer, published a book called “How Doctors Think.” It would seem in many ways to be the kind of book that James and the other medical reformers would love. Groopman tells a series of stories about misdiagnosis and uses academic research, including Kahneman’s, to explain how intuition could lead doctors astray. But Groopman comes to a very different conclusion than the reformers do. In the book and his subsequent writings, he lays out the central challenge to what might be called the Intermountain way.
He argues that evidence-based medicine is useful in only a limited number of run-of-the-mill situations, like distinguishing between strep throat and a simple sore throat. “Human beings are not uniform in their biology,” wrote Groopman and Pamela Hartzband, a Harvard endocrinologist (and Groopman’s wife), in a Wall Street Journal op-ed article criticizing the Obama administration’s plans to tie Medicare payments to so-called quality metrics. “A disease with many effects on multiple organs, like diabetes, acts differently in different people.” Groopman and Hartzband mentioned a handful of studies in which protocols had led to outcomes that were no better, or even worse, than what doctors had previously been doing. A couple of the studies dealt with the regulation of blood sugar in diabetics, the same issue that came up in the primary-care meeting I attended at Intermountain.
To Groopman, a fundamental problem with “systems analysis,” as he calls it, is that it discourages doctors from considering a wide-enough array of possible treatments. He also worries that if doctors are judged based on how well they follow a protocol, they may follow it even when they are correctly skeptical of it. Groopman says that the proper solution to misdiagnosis instead lies with individual doctors. If they are taught the ways in which their instincts can lead them astray, and if they reflect on their previous mistakes, they can avoid some of the pitfalls of intuition. They can become more self-aware.
This debate between intuition and empiricism is as old as Plato, who thought that knowledge came from intuitive reasoning, and Aristotle, who preferred observation. The argument has seemed especially intense lately, as one field after another has struggled to define the role of human judgment in a data-saturated society. The police officials in New York City who overhauled crime fighting were classic empiricists. The debate over education reform revolves around how well teachers can be measured and what the consequences of those measurements should be. These disagreements can sometimes be exaggerated, because everyone agrees that intuition and empiricism both have a role to play. But the fight over how to balance the two is a real one.
I asked James one day whether he had read Groopman’s criticisms, and he said yes. “Groopman’s right at one level,” James said. “You cannot write a protocol that perfectly fits any patient. Humans that come to us for care are just too variable.” James likes to say that the trained, expert mind of a physician is the most valuable resource in medicine. He adds that he is simply trying to focus that resource on the problems where it is most needed: those for which data does not have an answer.
But James then pulled out a graph that was sitting on his desk. It showed a steep fall in mortality after Intermountain put in place a heart-failure protocol. Among other things, doctors now automatically receive a beta-blocker prescription to sign, or not, as part of a patient’s discharge process. The changes appear to save about 450 lives a year. Graphs like that one, he said, are the reason he believes in evidence-based medicine. It must be done right — with hospitals monitoring outcomes at every step, quickly sharing that data with doctors and altering the guidelines as necessary — and James acknowledges it isn’t always done right. He is not defending protocols per se. He is defending measurement. “Don’t argue philosophy,” he told me. “Show me your mortality rates, and then I’ll believe you.”
Groopman declined to be interviewed for this article, but after talking with medical researchers and social scientists, I think there is a way to make sense of Groopman’s and James’s dueling narratives. The researchers say that Groopman is right to highlight examples of human judgment being just as good as data. There are many of them. Still, the overall record of decision-making approaches that are based mostly on intuition is far weaker than the record of decisions based mostly on data. To give just one example, an article in the journal Psychological Assessment, analyzing dozens of studies that compared clinical judgments with data-based diagnoses, found that clinical judgments were better in only a few instances. The two approaches were equally accurate about half of the time, but the data-based diagnoses substantially outperformed human judgment in nearly half of the studies. And with data collection becoming ever cheaper, Kahneman says that the number of occasions in which an intuitive approach beats a systemic one is getting smaller all the time.
American medicine, then, appears to have it backward. Yes, it is possible to rely too heavily on numbers and patterns when treating patients. But the bigger risk — the one we are now taking — is relying too heavily on intuition. “There is too much evidence — good evidence — that the care many patients receive isn’t up to snuff,” says Dr. Alan Garber of Stanford University.
Perhaps the clearest example is the Pronovost checklist. As many as 28,000 people in this country die each year from infections that come from intravenous lines. Several years ago, Peter Pronovost, a Johns Hopkins physician, developed a simple list of five steps that intensive-care doctors should take before inserting an IV line, in order to prevent the introduction of bacteria. The checklist reduced the infection rate to essentially zero at 108 hospitals in Michig
