The Bias of Experience

Experience is misleading for health care policy

I work as a hematologist oncologist, and attend 3 months on service a year, and run hematology and oncology clinic year round. In this capacity, I have cared for many COVID19 patients. But I am preferentially summoned to weigh in when thrombosis is present. In other-words, my personal experience is often in the ICU, and mostly with the sickest COVID patients. I don’t see much asymptomatic covid in my practice.

Other doctors have different experiences. Some may work on COVID wards and see only moderately sick COVID19 patients. Others may work in an urgent care, and see only mild cases. An ED doctor in a hotspot with a lot of shifts may feel the stress of a swamped waiting room, and an ICU doc in a hot spot may feel like a different person after the ordeal.

However, when we think about health care policy— should we close schools or should we lockdown society—we have to transcend our personal experiences. Yes, the hospital may be swamped, but school closure means that millions of kids will stay home for the possibility a few cases are averted (actually the effect size may be even smaller). Does the harm to the million kids— in terms of their life— offset the gains by the closure? Very likely, yes. Policy has to think about everyone not just the busy doctor in the hospital.

Years ago, I worked in a clinic that focused on malignant Pheochromocytoma. Each clinic someone would ask why the primary care doctor took so long to diagnose the patient. The answer is Malignant Pheo is a 1 in a million diagnosis, and you work in a Pheo clinic! To you it seems the doctor was slow, but to the doctor, Pheo was incredibly unlikely, as it is!

When it comes to COVID19 policy, I fear we have placed too much stock in the individual impressions of front-line doctors, and this has led to distorted policy. The harms these doctors see weighs large in their mind, and it is easy for them to call for lockdowns, circuit breakers or school closures. But the harms of those restrictions are just as real and affect several times more people. They just don’t see it. Policy has to look at the big picture not merely the ED waiting room.

Often the solution is not to halt society, but increase the capacity of health systems. Don’t fire health care workers who have natural immunity, but add them to your staff roster. Pay people more. Give people more autonomy and less paperwork. Health care workers want to provide health care, not buff elaborate billing systems. Finally, stop performing unnecessary medical procedures (aka reversals - see my first book).

Hippocrates wrote about medicine, “Life is short, and art is long, the crisis fleeting; experience perilous, and decision difficult”

Experience is perilous. It can anchor you to policies that harm many people you do not see because of the harms you do see. I work hard to separate my policy brain from my clinical brain, but many others, particularly those without policy experience, struggle. It’s up to the media to ensure balanced coverage. Too bad, they failed, many times over.