One principle of innovation is to borrow and adapt ideas from outside one’s profession. “Addiction and the Stages of Healing” is a set of ideas I have developed, written and presented elsewhere. Portions of that work will likely be posted here from time to time. One central notion of that topic is below in the form of “Planes, Car Repair Shops, and Dentists”.
Planes: Why study survivors instead of those that drop out, no-show, or pass away?
Car Repair Shops: What if we had something similar to the kind of knowledge that allows for routine maintenance and preventative care of automobiles, and the service structures to go with it (no appointment necessary, expert technician, short appointments, known service intervals, etc.)?
Dentists: What if we had the competency and skill analogous to dentists: health across the lifespan, preventative care, problems from tiny to life-threatening, and held all available routine clinical methods?
Planes and Survivorship Bias
One long-known and well-established error in logic and method is known as “survivorship bias”. The classic example is of bombers returning to base during WWII. The challenge was deciding where to put a relatively small amount of armor on bombers, given weight limits. After studying the location of holes on returning planes, recommendations were made to place armor on the most common locations where holes were found. A statistician not related to the project questioned this logic and suggested the limited armor be placed where surviving planes had no holes (the surmised locations of holes on the planes that were not able to return).
A relatively recent revolution in addiction-related research was to begin to study recovery and have that inform treatment. That was an important change from earlier short-term studies of pre-post treatment outcomes. This newer recovery orientation in research remains an important source of information. But I wish our field also had an equally concerted and ongoing effort at studying no-shows, drop-outs, and those that did not make it.
Car Repair Shops: “Expert Care for the Lifetime of the Vehicle”.
We care about our cars, and care for them across their lifespan. This care is not by accident. It is planned. The plan is manualized for the owner and the technician by aggregation of knowledge that results in: time frames and methods for easy routine maintenance and care, known service intervals for longer/more difficult (but predicted) needs, and information for the owner about how to detect problems and what to do about it.
We have service structures to go with the vehicle: no appointment necessary, quick work based on actually knowing, predictable results of care or its lack, and other service shops for worse problems – if they arise.
I wish we had very large numbers of SUD patients enrolled in a mega-data lifelong prospective study so we could: build the data set required, to develop the sufficient knowledge required, to build the service manual — so we could be effective while nimble, with newer service structures.
One reason for this wish is that now, after my third decade of professional clinical service in our field, I know far too many that exited this life suddenly, with apparent little warning, after years or decades of abstinence, while working on recovery.
Dentists and a Whole Model
From the outside it appears as if dentists take on the whole problem and the whole solution: oral health across the lifespan, preventative care, problems from tiny to life-threatening, and hold all available clinical methods. By contrast, our field holds various structural divisions: adult/minor, wellness/pathology, and prevention/treatment, among others.
(As for our available SUD technology and their related arrangements, it is now often forgotten that our field generally grew from the inside-out as a cottage industry of non-professional willing helpers. It seems to me we would be wise to retain the resulting specialization of services by various providers for the foreseeable future). But what if we started to shift our academic and clinical training models for the next generation toward a more wholistic competency that was focused across the lifespan? After all, being well is a life-long pursuit. And we can always retain specialty services for more complex and severe presentations for whom no routinely available care could suffice.
Planes, car repair shops, and dentists – these have been a sustained meditation for me.
More on “Addiction and the Stages of Healing” will follow as time and inclination permit.