Managing chronic conditions such as diabetes through adaptive expertise.

Posted May 26, 2014

We live in an era of Big Data with reams of scientific findings to guide our choices. We should feel grateful for all this information, but too often we feel overwhelmed — how are we supposed to sort everything and know what to do?

The field of Evidence-Based Medicine (EBM) is a good example of how to cope with this information explosion. Medical researchers are publishing their results at a dizzying pace and there are far too many articles and reports for any general practitioner or even any specialist to track. EBM tries to cut through this tangle with the notion of “best practices” — the treatment strategies that the medical community believes are most justified and effective for any given condition. EBM seeks to synthesize the existing studies into rule-like best practices.

We can call this Transformation1: Converting data into rules. Our lives become much easier if we can rely on checklists and standard operating procedures. These forms of best practices are a definite advantage over the undigested welter of statistical results. Panels of objective subject matter experts work hard to generate Transformation1.

Rules, procedures, checklists, and best practices are most effective in well-ordered situations that are highly repetitive and unaffected by context. There is a right way to do the job and it doesn’t change much — it doesn’t vary depending on the nature of the patient or the medical condition. Atul Gawande’s wonderful book The Checklist Manifesto describes Peter Pronovost’s checklist for inserting a central line during surgery in a way that dramatically reduces the risk of infection. When the surgical team follows a few simple and straightforward steps, and doesn’t omit any of them, post-operative infection rates plummeted. A huge success.

However, when we leave the highly repetitive world, best practices become less useful. For the past 20 years my colleague Helen Altman Klein has been investigating the cognitive demands on patients who are trying to manage Type 2 diabetes. [See: Everyday Expertise: Cognitive demands in diabetes self-management &Type 2 Diabetes Self-Management: Controlling a dynamic system]. There is no shortage of rules and best practices for patients to follow. Just the reverse. The medical community has generated hundreds of rules and now diabetes patients have to sort out all the rules and their implications. Transformation1 hasn’t solved the problem of proliferating information; it has just moved it to another level.

Diabetics may be able to follow these rules if they lead sedentary, restricted lives, eat the same meals at the same times, get regular exercise, and are shielded from psychological stressors. But most people aren’t so fortunate (or unfortunate). Throw in travel, unexpected crises, deadlines, unannounced visitors, meals on the run at unfamiliar restaurants, and the rules don’t work so well anymore. We just can’t apply context-free rules to a complex life. It is no surprise that so many diabetics struggle to sustain healthy levels of blood glucose.

Fortunately, investigations into expertise have shown people who are skilled have moved beyond rules. They have learned to make sense of situations without depending on rules and procedures and best practices. Instead, they grasp how to make things happen and how to avoid problems. We might describe them as having richer mental models of how things work. They appreciate the different forces at play. They can anticipate what is likely to happen next in order to achieve certain outcomes.

And this is where Transformation2 comes in. Transformation2 is the shift from rules and best practices to adaptive expertise, usually in the form of richer mental models. Thus, some people with diabetes learn that there are a few leverage points for increasing and decreasing blood glucose: exercise (which burns off the excess blood glucose), diet (avoiding foods that rapidly pump up blood glucose, such as “white” carbohydrates like flour, rice, potatoes, along with sugar), stress (which mobilizes blood glucose as part of a fight-or-flight reaction) and a few others. With this general model, they can make choices even in hectic times. One determined man enjoyed eating buffalo wings with his friends. By testing his blood glucose levels, he found that three buffalo wings were OK, but five led to an unacceptable BG spike. Notice how this adaptive expertise is different than “Banish any thoughts of buffalo wings because they’re unhealthy for you.” Another success story was a woman who noticed that her BG levels spiked when her daughter-in-law visited. So she got into the habit of taking long walks prior to the visits. Those who reach Transformation2 are not just following the doctor’s orders; they become adaptive experts and act as detectives, gaining insights into how to work around challenges in their own lives.

Transformation2 is about adaptive expertise. There can’t be a standard set of rules for these sorts of skilled adjustments.

Practitioners often run into patients with several different disorders and problems. These patients are outside the scope of best practices. For example, physicians who care for patients afflicted with both diabetes and asthma have to trade off different treatments. Rule-based best practices aren’t of much use when the rules conflict with each other. Physicians need to move to Transformation2 so they can cultivate adaptive expertise about how to adapt the rules, rather than clinging to them.