The “One” Behind the Algorithm

Abstract

Recently, I found myself a part of a team putting together what seemed like a fairly straightforward task—creating an algorithm for optimizing patient care in a specific disease process. Combining the best available evidence with expert opinion, and hopefully common sense, the goal was to create the perfect figure neatly composed and limited to (at most) 1 page (Fig. 1). With this tool, you can easily “plug your patient in” and determine what is the “best” way to manage them. After brainstorming about all the possible situations, our group was able to put forth, what I considered at the time, a fairly extensive and easy-to-follow result. Along the way, I was also sometimes astounded at situations I had not considered, which in retrospect seemed so obvious. After what seemed like hours tracking along and confirming the multiple branch points, we determined we had a comprehensive design that completed our mission.FIGURE 1: The algorithm.Following its production, it wasn’t long until several questions poured in from multiple providers. “What about the patient with this (insert subtlety here)—did you consider that?” (I hadn’t). At first they seemed like small, somewhat trivial, exceptions that couldn’t be captured in a workflow like ours, while other issues raised really improved the algorithm. Fortunately, we were able to revise the process—actually several times—and we all felt the considerations made it much more effective. After all, wasn’t that the objective anyway, to provide a helpful guide covering a wide variety of scenarios that is useful to the end user, not us? Still, upon its rerelease, we continued to be bombarded with multiple circumstances demanding changes. At first, my frustration began to grow. Perhaps I was reacting to the significant time and effort it took our group to build our algorithm together and all of the effort we had put in to provide answers for what we deemed were the vast majority of cases. Despite our well intentions, it didn’t appear to be interpreted as such. Perhaps to a lesser degree it was also my obsessive compulsive disorder, trying to figure out how I was going to make all these changes fit so nicely onto 1 page. After all, I was the “one” behind the algorithm, the author, doing my best to define answers where I could. In the end, though, an algorithm is meant for the majority and it seemed like the focus was quickly turning to all these other more nuanced situations. It seemed my email was filled with additional questions about what to do given another set of contexts. As the questions mounted, I silently remembered my initial pride in thinking our work will be pertinent to 95%+ of patients. Sure I recognized there would be “one-offs,” those that didn’t quite fit within our neatly organized series of questions, diamonds, and rectangles—those that strayed outside of the lines. Yes they would come up, but they were the exception. Yet as the revisions continued, the questions seemed to never end. After time, thought, and more collaborative work, though, we felt satisfied and fulfilled that we had created the best tool we could make. Content, I sat still, amongst the many revisions and diagrams. Within the chaos and disorder, it suddenly became clear—it wasn’t about the “one-offs,” or even the theoretical 95%—it was about the one. Through all the mechanics of research, peer-review, writing, and editing, I had lost perspective on the real reason behind the algorithm—the one patient. The one with unique circumstances and conditions that never fit into a single-page chart. The one with real emotions, hopes, and despair. The one who possesses those traits that need to be accounted for and can’t, but are critically important to understanding what makes them special and have to be taken into account in order to provide the best care. It wasn’t that the algorithm couldn’t be objectively helpful, it was about perspective—there is no 1 page for that special “one.” It also wasn’t too long ago that I was involved in a different situation with a patient that did fit rather nicely into the published algorithm. As I traced down from question to question, answering yes or no, and continuing along another set of straight lines, the patient's journey kept bringing us to the bottom right box. Only this was not the box we were looking for. Not the healthcare team, and definitely not the patient or her family. Her son kept on running his finger over and over along the various lines trying to find a different pathway, another answer that would take his mom's care to the left side of the figure. Despite multiple attempts with honest answers to the questions posed, it repeatedly brought them to that same lower right box. Two words, 11 letters, neatly arranged in a small red rectangle: “Comfort Care.” Only this time, it was not viewed as the “obvious” endpoint given the conditions listed. Glaring at that endpoint this time brought on a different sense of heaviness and emptiness, as this time I was not the surgeon, I was the patient's son. The algorithm was perfect—it did what it was supposed to do. But I hated it. I wasn’t the algorithm's author, satisfied with a job well done, a tool effectively created. I was the one searching for a way to make this scenario turn out differently for the real one who truly mattered, my mother. So the next time I look at an algorithm, I will try to keep in mind that it's not just about creating an effective tool—ensuring the correct formatting, the color coordination, or the “one-off” exceptions that may closely resemble, but don’t quite follow the chart. It's really about the mother, sister, brother, or son behind the algorithm whose incredible journey, lasting relationships, multiple touch points, dreams, and fears have led them here to this algorithm to help determine what may be the biggest challenge of their life.

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