© Photo by Bertie
How do systems get better? According to Jeff Yass, it’s through feedback loops—iterative cycles where action leads to data, the data lead to adjustment, and the adjustment leads to progress.
In a recent article explaining why he is giving $100 million to the University of Austin, Yass argues that almost every system that works—evolution, democracy, markets, science—works because of feedback. Helpful mutations persist; ineffective leaders get voted out; prices rise or fall and producers respond; experiments confirm or reject hypotheses.
When feedback is missing or broken, systems stagnate.
Reading that piece, I couldn’t help thinking about primary care, and especially family medicine. If higher education is suffering from a lack of feedback, American healthcare suffers from a related problem: there is plenty of information, but very little continuity. And continuity—the arc of relationship over time—is what allows feedback to function.
The process of clinical diagnosis and treatment is rarely a single moment of revelation followed by a definitive cure. It is usually iterative, exactly the way Yass describes.
Primary care begins with the undifferentiated patient—not someone pre-sorted by a prior evaluation, but a real person with a chief complaint. First comes the history and physical. Then come tests and studies. Then comes the “working diagnosis.” In far too many medical settings, that’s where the story ends: the patient walks out with a label and a prescription, never to see the doctor again.
In family medicine, though, the real turning point is what happens after treatment begins. The patient’s response to therapy is feedback. If symptoms improve, the working diagnosis gains strength. If they don’t, the diagnosis weakens and must be revised. That revision may suggest a new approach, whose response becomes another data point, and so on.
With each iteration, the relationship between doctor and patient deepens and the clinical picture sharpens. Trust, familiarity, and accumulated history become a crucial and inextricable part of the clinical process itself.
One example: Attention Deficit Disorder.
For years, clinicians at Westside Family Medicine - as at most primary care practices - reflexively referred patients out for expensive neuro-psychiatric evaluations whenever ADD appeared on the differential diagnosis. Eventually we decided that ADD—like anxiety and depression—is a condition best initially diagnosed and managed in primary care. So we developed a system of in-house evaluations. It works well, but only because it relies on continuity.
Problems with focus and attention are overlap symptoms. They can come from anxiety, depression, sleep deprivation, trauma, thyroid disease, anemia, burnout, or simply a job you hate. The only way to know is to develop a hypothesis, treat, observe, refine, retest. Exactly the iterative loop Yass describes: working diagnosis → treatment → response → refined diagnosis → refined treatment.
Granted, Yass’s insight was backed by a $100 million donation, while mine is backed by… well, this blog post, for one thing. And the generally positive WFM experience, for another. But the underlying point is the same: systems work when feedback is built in, and fail when it is not.
American healthcare suffers from neither a lack of problems, nor a lack of proposals for high-priced, high-tech, high-falutin’ fixes. If it were up to me, I’d start with the basics: the feedback loop that every good system needs, provided by the continuity of care that every patient deserves.
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