HJBR Sep/Oct 2023

HEALTHCARE JOURNAL OF BATON ROUGE I  SEP / OCT 2023 15 blood sugar combined with combinations of short- and long-acting insulin formula- tions enabled sugar control throughout the day, thus reducing downstream com- plications of this disease ( process char- acterization and knowledge of how small changes in the variable will affect results). 7. Also in the 1990s, it was discovered how other risk factors such as diet, exercise, and cholesterol could also be specified and controlled, thus reducing the nega- tive impacts of secondary variables on the primary disease of diabetes ( know why and control of secondary variables). 8. The eighth and final stage of knowledge development for diabetes — complete knowledge — has not been attained yet, but we are certainly closer than ever. For Type 1 diabetes, complete knowledge might take the form of an artificial pancreas — either a closed-loop device or islet cell transplant — that controls blood sugar and obviates the need for ongoing care. For Type 2 diabetes mellitus, as I look at my own per- formance management dashboard, my current rate of diabetes control stands at 97% (mean- ing that 97% of my patients with diabetes have an A1c < 8, with the great majority of them < 7). How does all this information relate to the management of obesity? We are getting there. The key point here is that as we prog- ress through the stages of knowledge for a given chronic condition, be it diabetes or obe- sity, the ultimate path is one that will require approaches to problem solving that utilize a combination of research, scientific discovery, clinical trials, and expert opinion, but also rap- idly iterative and recursive loops of process improvement where we are holding ourselves rigidly accountable for a given outcomes mea- sure. Achieving a 97% rate of diabetes control doesn’t happen without the building blocks of scientific discovery laid out over the past century, but it also doesn’t happen without a management focus predicated upon individual patient and problem identification within a minimally viable clinical microsystem that en- gages in real-time efficient experimentation, hypothesis generation, solution testing, trial and error, serendipitous observation, discovery of new and previously unmeasured variables, and rapid cycles of solution discovery. Variables such as self-efficacy, history of adverse child- hood trauma, socioeconomic factors, maladap- tive coping mechanisms like emotional eating, conditions, such as diabetes, hypertension, and hyperlipidemia, most of the evidence created relates to new drugs or treatment interven- tions that correlate with better management of the underlying condition. What has been less prevalent in traditional healthcare, however, are variables looking at how well we are suc- ceeding at managing these conditions under circumstances where providers bear full risk for the total cost of care and accountability for the co-produced health outcomes. In prior issues of this journal, we have asserted that achieving very high levels of good blood pressure con- trol or glycemic control across a population is not only possible, but easy. The hard part is in overcoming entrenched provider mindsets, patterns of behavior, and improving the opera- tional processes that produce those outcomes. Stages of technical knowledge development were outlined in an article written by Roger E. Bohn that describes 8 stages of knowledge: ignorance, awareness, measure, control of the mean, process capability, process character- ization, know why, and complete knowledge . 1 These stages of knowledge are applied to solving technical problems through the sci- ence of operational process improvement, something that has been far too lacking in modern healthcare. Let’s look at the exam- ple of applying these stages of knowledge to diabetes care as an illustrative example: 1. In classical times all the way up to the 19th century, there was high mortal- ity from a wasting disease in which the urine was noted to be sweet ( ignorance ). 2. Then, in the early 20th century, a star- vation diet was noted to improve life expectancy in persons suffer- ing from this disease ( awareness ). 3. In 1914, a test was discovered that could measure the amount of sug- ar in a person’s urine ( measure , but cannot yet control variable). 4. Following the discovery of insulin by Banting and Best in the 1920s, blood sugar could now be somewhat con- trolled, but the treatment effects were variable ( control of the mean ). 5. Then, by the mid- to late 20th century, use of purified insulin formulations combined with daily urine testing allowed more re- liable and reproducible control of blood sugar ( process capability and control of the variable across its whole range). 6. By the early 1990s, frequent testing of In the issue before last, we reviewed some of the challenges regarding our fight against this modern epidemic of the disease known as obesity. Deriving lessons from our past, against yet another epidemic, lung cancer, we explored how battles needed to be fought not just with the tobacco industry, but within our own pro- fession as well. Ignorance about the role of cigarette smoking and its direct causative role in lung cancer (and many other diseases) was initially lacking as scientists and doctors worked valiantly to investigate and conclusively prove these causal links, finally swaying other members of the healthcare profession along with the court of public opinion. Enough ac- cumulation of knowledge and learning was eventually gleaned, leading to policy changes along with advances in our understanding of how we treat what is now known as tobacco use disorder. It wasn’t easy, and the battle still rages on, but the result is that we succeeded in reducing the incidence and prevalence of both lung cancer and cigarette smoking. In the last issue of this journal, we were joined by an esteemed colleague, Amanda Staiano, PhD, MPP, who was able to discuss a comprehensive set of guidelines put forth by the American Academy of Pediatrics for the management of childhood obesity. These guidelines were informed by scientific dis- covery and adhered to principles of mod- ern research, utilizing double-blind, placebo controlled randomized trials (RCT) whenever possible and case control, observational stud- ies, and other evidence when an RCT was not practical or feasible. Very smart scientists, like Staiano herself, participate in and influence this research, and progress inevitably ensues. People and society in general benefit from the work of these dedicated scientists and their discoveries. Having said that, we know that guidelines produced because of the devotion and hard work of these scientists should in- form, but not dictate, the practice of medicine. Concomitantly, we should also acknowledge the limitations of scientific discovery, because research and the creation of new knowledge can be messy, inefficient, and fraught with potential for bias, oversights, and mistakes. Stages of knowledge development and continuous clinical improvement When we look back at scientific discoveries for the treatment of other chronic cardiometabolic