Plurality and Contrarian Opinions in Healthcare

N=1

Handing over decision making power to one person is a bad idea. Surely we know this now as a species. The limitations of individual judgment, the misalignment of incentives (principal-agent problems) and asymmetry in information/power are all major problems with one person wielding absolute power over others.

These very problems though exist in medicine and dentistry. When your GP tells you to take these high blood pressure pills for the rest of your life, or when your dentist says you need several fillings, they are providing you with a N=1 opinion. One individual with an asymmetric amount of power and knowledge persuading another to behave in a certain way. It’s salient to ask questions like is this person trustworthy?  Competent? And most importantly, is their judgment correct on this specific occasion? The odds of all three of things things not lining up, can be high. Often actions health professionals persuade you to take are irreversible, lifelong acts. Once you drill into tooth enamel, you will need that filling replaced several times in your life. So, mistakes in judgment have real human costs and long-term residual risks.

Plurality

Enter Plurality. JS Mill’s life work advocated democracy and plural voting. JSM also constantly extolled the virtues of contrarian opinions prior to decisions. In my clinic, we probably discuss only 10% of our cases prior to decision making. It still amazes me though, how often an intelligent, experienced clinician will change their treatment plan after a chat and banter with a colleague.  We’re currently doing some formal research with UoM to understand exactly how often dentists change their mind when they’re given a contrarian treatment plan to the one they prescribed. Often, it’s the difference between drilling a tooth or not. Dentistry is not a hard science which comes to decisions algorithmically. Rather, it’s a flawed science which relies on human judgment.

Our aim in the future is to have 100% of our cases benefit from plurality. Each case will have an AI + human team double checking things and providing contrarian opinions to ensure we’ve come to a measured decision.

Hawthorne Effect

I’ve written about this a little more ornately in the ring of Gyges blog here. The Hawthorne effect is a by-product of plurality. It can be summarised as, when the subject knows in advance an equally qualified peer or supervisor will check your work, it will result in that person behaving better than their usual. It’s also by default more transparent and promotes knowledge sharing. For me personally, fore-knowledge that another dentist will be looking at my treatment plan, will make my decision making a more conscious, deliberate, check listed process rather than follow quick heuristics and plan something in a time efficient way.  

In short, the very existence of a system results in better behaviour.

Plurality could and should be applied whenever irreversible, complex decisions are made. With the right technology and systems in place this goal is more realistic than ever with safer outcomes to the end consumer of medicine.