Archive for May, 2009

Miller’s Magical Number Seven and Information Management

Sunday, May 31st, 2009

There was a recent post on the Medscape discussion forum which referred to an article on the use of mnemonics in psychiatry.  The title of the article is: Mnemonics in a nutshell: 32 aids to psychiatric diagnosis.  Many of these memory aids are simple acronyms such as the CAGE assessment which is used to quickly determine a person’s risk for alcohol abuse.  Of note, among the 32 aids listed is the number of discrete units used for each mnemonic.  CAGE is one of the simplest with 4 discrete units and under delirium diagnosis is “Deliriogenic Medications” which has 15.  For those fans of Miller’s Magical Number Seven this may seem excessive.  In 1956 George Miller, a cognitive psychologist from Princeton, published a paper in which he demonstrated the capacity of our working memory was about seven, plus or minus, two elements (for English speaking people).  It is interesting to note that the number 7 is frequently referenced in our language to describe a list of various elements such as: 7 days in the week, 7 numbers in a phone number7 deadly sins,  7 hills of Rome and , of course the 7 wonders of the world. As it turns out the average number of discrete units for all 32 aids is 7.5 and the most frequently occurring value (mode) is, no surprise, 7.  The range is 4-15 which appears to deviate from Miller’s claim of 7 plus or minus 2.  Since we are referring to a memory aid, the aids with a low number of elements are not critical.  Of the 32 aids only four of them appear to violate the upper part of the range.  Fortunately  a simple mnemonic trick is used to facilitate these memory aids.  Each of these is broken up into smaller discrete units much the way we break up phone numbers.  The 15 element “Deliriogenic Medications” is given the mnemonic “ACUTE-CHANGE-IN-MS”.  Even “WWHHHHIMPS”, which lists the life threatening causes of delirium can be seen as “WW-HHHH-IMPS”. With the massive growth in information in healthcare it seems like we are rapidly approaching the point where mnemonics will no longer be adequate to support human memory.  It has served as a useful bridge but the information age is becoming more and more dependent on information technology as the primary memory aid.  Miller’s Magical Number Seven will not go away though, it will become more important in how information technology presents information to us.  This is the realm of information management.  For healthcare to progress we are going to need to become much better at how we manage information.  It is going to take more than mnemonics to overcome our memory capacity limitations, not to mention the other limiting features of bounded rationality.  The information age will allow us to move beyond satisfactory solutions and endeavor toward optimal solutions.  This assumes, of course, we learn how to manage this vast amount of information in a way that compliments our natural capacity to understand and use it.

The Paradox of Blame

Saturday, May 30th, 2009

Blame, when appropriately dispensed, assigns responsibility for a past occurrence.  The event that occurred is typically one which resulted in a negative outcome.  As in, “Hey, it’s all your fault.  You screwed up.”  The paradox is, there is an interesting opportunity which becomes available when blame is not appropriately assigned.  As in, “Hey it’s your fault.  You screwed up but… (wink-wink everyone knows you really were not the one who screwed up.)”  The general rule is, none of us wants to accept blame, especially when we were not the responsible party.  There is an exception to this rule and that is when everyone knows you really were not the person responsible for the bad outcome.  This is sometimes referred to as, “taking one for the team.”  By accepting blame, you now become the responsible person (and better team player).  The opportunity granted to you for accepting blame is that you can now fix the problem caused by the person who was previously responsible.  If you fail, then it really is your responsibility.  If you succeed you have now earned the right to the new position of responsibility.  Since you were not responsible in the past, you were not in a position of authority to affect the outcome. By accepting blame, under certain circumstances, you can advance to a new position of responsibility.  This assumes, of course, you learned from your predecessor’s’s mistakes and can affect a good outcome. It’s a risky tactic but one that comes with rewards if performed effectively.  The key is to recognize and guarantee the quid pro quo.  In exchange for accepting blame, you will be given the opportunity to correct the problem.  Therein lies the paradox.  Given the choice between blaming the person truly responsible, who has proven they don’t know how to fix the problem, and “blaming” the person who is not responsible, who can fix the problem, blame sometimes tends to find the problem-solver. This is more common when responsibility is distributed to many individuals, and difficult to assign, or when saving face for the responsible person is warranted, for whatever reason.  It’s an odd thing to say but sometimes “blame” is another way of saying opportunity.