The fog of war in healthcare

A Fog of war is a military term for the uncertainty of war. First used in 1832 by a Prussian military analyst Carl von Clausewitz.

"War is the realm of uncertainty; three quarters of the factors on which action in war is based are wrapped in a fog of greater or lesser uncertainty. A sensitive and discriminating judgment is called for; a skilled intelligence to scent out the truth." — Carl von Clausewitz, 1832

What relevance does that "war term" have to patient healthcare? Well, actually a lot. The human body is a complex system, which is still only roughly understood. 

Just to underpin the point. https://www.sciencemag.org/news/2020/10/you-may-have-new-organ-lurking-middle-your-head

So, uncertainty is bound to exist no matter what - even with the best of tools and healthcare professionals. We should assume everyone’s health persists in a realm of uncertainty. 

Why is health uncertainty bad? Well uncertainty in itself is not bad - but its results are. There is a saying called "Ignorance is bliss", which refers to a person that is satisfied or perhaps even happy without the knowledge, that the person doesn't have. Knowledge that might sadden or harm the person. 

Personally - I have a hard time seeing how a state of naivety ever is a good thing and especially with regards to health. Not knowing is hardly ever a good thing, since preemptive treatment is the most efficient way of treating the greatest generalised causes of death - like cardiovascular disease. 

´80% of premature heart disease, stroke and diabetes can be prevented`WHO 

For doctors trying to keep their patients healthy and well, lifting the veil of uncertainty, with regards to their patient's health condition is of paramount importance - as it is necessary to diagnose and treat their patients correctly and efficiently. 

Some studies indicate that "...diagnostic errors affect at least 1 in 20 US adults.". - we could probably safely assume that most of those errors originated from some sort of uncertainty. 

Fair enough! but what are the primary causes of health uncertainty?

From my danish perspective, there are several serious problems with how primary care is done - that all stem from uncertainty in a reality pressed for time.  

1. Doctors in primary care are pressed for time. So much so, that they rarely have more than a superficial insight into most of their patient's health. They often have to rely on patient self-reporting. Which means that the patients themselves have to identify if they have a health issue that needs doctors attention, guidance and or treatment. 

This approach moves the responsibility of action over into the hands of the individual and away from the health professional. For the most part - a person with no health expertise whatsoever or the ability to discern what is serious or what is nothing to worry about. This is a serious problem in itself - but there is more. 

2. Diagnosing with too little data. When a patient actually reports a problem that seems insignificant or simple - they are often prescribed a quick solution. A solution based on the following data points:

+ The given symptom or symptoms. 

+ ID, name, age, sex and height

+ a visual observation on how well the patient looks and behaves. 

+ perhaps medical history (Often limited and without context)

+ perhaps a check for a specific problem, with questions and tests.

If the issue disappears or solved by the given solution, the doctor and the system would deem the patient to be healthy and well. Yet at that very same moment, the patient might have several underlying issues, unknown to both doctor and patient. Why? well, this approach relies not on actual data, but on patient self-reporting based on how they are feeling at that moment - and a stressed-out doctor's ability to guess based his/hers knowledge as context for a superficial and short health evaluation. 

What is often left unknown and superficially explored, is actual health data on the organ-systems, such as the cardiovascular-, respiratory- and muscular system. 

Seeing as the WHO has reported that "...Cardiovascular diseases (CVDs) are the number 1 cause of death globally, taking an estimated 17.9 million lives each year." 31% of all global deaths. This seems like something that would be wise to catch preemptively and have insight into. As cardiovascular disease are something that happens over time, from lifestyle/diet or from birth.   

In software development, no developer with experience would ever diagnose a bug without knowing the code or having a strong insight into the issue in the given context. 

If you get a mechanic to fix a car, you would expect him to at least inspect it for issues. 

The human body is way more complex than simple software or a car, so we should at least spend as much time investigating and understanding the underlying system when it is about something as serious as our health. 

Fair enough - but why can't we just rely on patient self-reporting?

3. Self-reporting is unreliable. Being well vs feeling well. Well, it is a problem. Because for most people their health is very likely unknown, at least to the degree where they either feel well or bad, sick or well. No room for in-betweens... unless you have been bad for so long, that you don't recall what well means anymore. 

Most of us are well enough for everyday life, but for some - perhaps even most doing physical work - would be hard or even dangerous. Some might feel well in the moment but at the same time be extremely stressed. Some might walk around with a genetic disease or a tumour growing. In short, feeling well has nothing to do with being well. 

Relying on patient self-reporting, without real data to put into their issues into proper context, is dangerous in my eyes - and the data available on the number of known misdiagnoses seem to hint at a serious diagnose problem.  

Those reasons should underpin why we need to lift the fog of war, even in healthcare. 

Great! So how can we counter this uncertainty within healthcare? 

In my eyes, it is clear that much of the problem with uncertainty stems from a lack of time, money and of course good technical tools - for there are many bad ones out there. So let's identify how we could counter the time and uncertainty issues.

Health transparency - give the individuals/users true control: Let's start with those for whom it is most important - The individual in question. Every individual should have the ability to track their own general health condition and symptoms in an intelligent personal health profile. So the individual knows exactly what works, what should be fixed - and what their doctors believe they should do to stay healthy, become healthy or get well. 

This health profile should be controlled and owned by the individual. As it is rarely the case that one doctor will be able to help you with every health issue. Secondly, you should always have the freedom to get second opinions. Thirdly it would give you the ability to add data on your own independent of potential gatekeepers.  

Doctors should in partnership with their patients have an instant overview of the physical state of the patient down to every organ system. So when the patient suffers from a symptom, the symptoms are put in the right data context. If there are no data on fx. the cardiovascular system, then the doctor should retrieve the information, with the most efficient method. If the health data is critically outdated, then the doctor should get it updated. 

This should counter some of the uncertainty for the person in question, that otherwise might lose oversight and vital context, that would be needed to diagnose more efficiently. 

In my eyes, this could alleviate some of the fog of war with patient healthcare.🤔

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If you think, I am on to something please leave a comment, share and let us connect.

And if you want access to a solution, that tries to fix some of the issues with "the fog of war" in healthcare - then sign up for Atmos.

Atmos is an early stage startup project that attempts at making it easier to track and follow up on multiple health issues independently or in collaboration with your doctor.

https://useatmos.com/

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