The Short & Long Game
JASON HERE. AT THE BOTTOM OF THIS REPRODUCTION YOU WILL FIND THE ORIGINAL COMMENTS SECTION OF THIS POST. I DECIDED TO INCLUDE THEM BECAUSE OF HOW MUCH THEY ADDED TO THE CONVERSATION.
The following is reproduced with permission from Cinema, a former Twitter personality & blogger who left the social media world about 3 years ago. The reproduction is intended to preserve & share insightful posts from Cinema's blog. This post was originally published in April 2014.
Cut & Dry Version: It’s not Process > Outcomes, it’s Process & Outcomes. There is a feedback loop between Process and Outcomes which allows Outcomes to drive the Process and vice versa. One major filter that might encourage you to focus on the outcome more than the process is the element of time. Outcomes are important for short term success, while focus on Process is requisite for long term success. You cannot arrive at the long term without surviving the short term.
The Long Sunday Afternoon Version:
By now I’m sure you’ve read about the importance of working on your Process > Product. Just a simple google search will yield multiple hits on this very topic. A couple fantastic reads on this can be found here & here [pdf].
To the best of my understanding, in order to achieve long term success one needs more than a shiny product; they also need an iterative process that efficiently and effectively produces the desired product or outcome. This direct progression from process to product has been repeated ad nauseum, and with good reason!
So, why another article on the same beaten down topic? One reason: attempts to focus on the process while hoping to effect your desired outcome don’t always work. I will attempt to provide an understanding of two very important elements of this process that are usually left out of the equation. First, let’s quickly introduce the Principle of Reflexivity.
According to George Soros the principle of reflexivity is in effect when “distorted views can influence the situation to which they relate because false views lead to inappropriate actions”. He goes on:
For instance, treating drug addicts as criminals creates criminal behavior. It misconstrues the problem and interferes with the proper treatment of addicts. As another example, declaring that government is bad tends to make for bad government.
makes reflexivity a very broad phenomenon that typically takes the form of feedback loops. The participants’ views influence the course of events, and the course of events influences the participants’ views. The influence is continuous and circular; that is what turns it into a feedback loop.
This same reflexive quality exists between Process & Outcomes. Not only does your process yield an outcome, but the nature of your outcomes feed back into your process by encouraging Process modification. It seems so obvious that nobody will likely deny this effect; but it gets interesting… more interesting.
Outcomes aren’t always entirely predictable in terms of their 1st order effects, let alone secondary consequences. They are usually multivariant and require a reiterative process to distill the actions needed to effect a certain outcome. Now, consider this: the outcomes may have a positive or negative effect on the reiterative process. So, which is the driver here? The Process? Or The Outcomes?
Clinicians (Outcomes) and Researchers (Process) – including the armchair variety – need to recognize the recursive nature of Process & Outcomes and place their communications within this context. This will also reduce an often-cited error within the medical profession; as N. N. Taleb says, “Doctors most commonly get mixed up between absence of evidence and evidence of absence.” (Emphasis mine)
Let’s contextualize this. You’re a skilled & very capable physical therapist who recognizes a pattern in the treatment of a certain classification of symptoms. Your treatment (let’s call it treatment X) yields positive results repeatedly within bounds of these classification of symptoms. While an explanation is lacking, the outcome is obvious & repeatable. What is it that informs the process in this situation? It is purely outcomes based analysis that feeds back into the treatment process.
The concept of “Phenomenology” quietly slipped into play, so let’s define it according to Taleb from Antifragile:
Phenomenology is the observation of an empirical regularity without a visible theory for it.
Phenomenology, being blatantly practical, applies to and is found in basic daily activities of life. For example, you may not be able to explain (or describe) why or how a certain spice flavors your food, but you recognize the flavor and it makes your meals so much more delightful. You know how it should taste in the end; all you do (without thinking too deeply about it) is modify & iterate your process of incorporating the spice until you know when and how much to recreate into your delicious concoction.
This feedback loop from Outcomes to Process is essential in streamlining future (and short-term) decision-making. While explanations (Process) may be lacking, the repeated positive outcomes provide validity on its own. This feedback is either dismissed via circular reasoning that exempts the potential for honest exploration, or is outright ignored on grounds of lack of evidence when the evidence of validity is present in the repeatable outcome itself.
Recognizing and applying the feedback loop from Outcomes to Process has no standard game plan to follow, no studies can capture the essence of what the outcomes could be and how they might be applied to your process. I believe this is where the “Art” resides – incorporating Outcomes to modify and drive your Process. So, the next time you hear a debate on whether “it” is an “art” or a “science”, you have a framework to see both sides of the coin and realize that they are part of the same cycle. Science is the Process, while the Art lies in incorporating Outcomes back into your Process.
A major factor in the feedback loop between Process & Outcomes is the effect of time. Focusing on the process more than outcome requires the luxury of time to allow for an iterative process that gradually chips away inefficiencies. When running a business, start-up, or any venture with your reputation at stake, time is usually of the essence. Many minimize the Process to produce an Outcome to be molded by the trials of business & consumer response. A start-up without a product will likely get stranded before the running even started. A business without customers will likely fail in-spite of a fluid process. You can have an efficient process, and even correctly predict the outcome, and still be lured to shipwreck by the sirens of time. The best of the best still have to face the tyranny of Father Time.
Time is just one factor; there are likely one or two other factors (physical resources, etc) that might be equally significant in a particular situation.
Over the long run focusing on the Process is a prudent choice, however, you need to give yourself the opportunity to experience the long run by surviving the many short runs. The long run doesn’t matter if you don’t make it past the short run.
Recognizing the importance of the reciprocal (& reflexive) nature of Process & Outcomes can alleviate friction in seeing the big picture while simultaneously inviting novel approaches (& possible solutions) to old problems. Such vision and understanding requires clear and honest communication within the context of this feedback cycle filtered through the lens of time.
Outcomes are important for short term success, while focus on Process is requisite for long term success. You cannot arrive at the long term without surviving the short term.
THE ORIGINAL "COMMENTS" SECTION OF THIS POST. ENJOY!
Kenny Venere (@kvenere) says:
I enjoyed your post quite a bit, very thought provoking. I appreciate you sharing it.
A few thoughts I had when reading through —
“You’re a skilled & very capable physical therapist who recognizes a pattern in the treatment of a certain classification of symptoms. Your treatment (let’s call it treatment X) yields positive results repeatedly within bounds of these classification of symptoms. While an explanation is lacking, the outcome is obvious & repeatable. What is it that informs the process in this situation? It is purely outcomes based analysis that feeds back into the treatment process.”
I recognize that this is a hypothetical situation, but is it one that is truly possible in clinical practice? Are we able to reliably identify patterns that consistently yield obvious and repeatable outcomes from our intervention? I’d argue not. The clinical environment that we live in is simply too chaotic for us to have an outcome that is obvious and repeatable specifically due to some intervention on our part. We as clinicians are often prone to bias and errors in reasoning (confirmation bias, post hoc ergo proper hoc to name a few), our patients recoveries are incredibly difficult to predict and are the result of innumerable variables (many of which are simply beyond our control). With this in mind, how much can our ad hoc analysis of outcomes reasonably inform our decision making or process? If we obtain a good outcome in the short term using interventions and methods that lack a scientifically defensible premise, how does this inform our process? We need to be acutely aware of the limitations and pitfalls of our observation and interpretation of outcomes before allowing them to significantly inform our practice.
A scientifically grounded process should be the foundation of our reasoning, decision making, and interventions throughout the continuum of care. Such a focus does not preclude short term successes, innovation or positive outcomes, but is likely less susceptible to the potential errors in interpretation of a clinical outcome. This approach allows us to be confident that we are making the best decisions and providing the best care to our patients, in both the short and long games.
Looking forward to hearing what you think.
The hypothetical situation described is probably how many of the various treatments & treatment philosophies developed. How many founders of the many models of PT based their approach 100% on RCTs or other contemporary research? Most actually applied themselves in the clinic and developed a paradigm of treatment that was fleshed out in later years.
Biases will never be completely eliminated; we should use them to the benefit of patient outcomes instead of trying to practice in a hypothetical climate liberated from biases. I would say pretending you can work in an environment uncoloured by biases is strongly biased by the very biases (and/or others that you/I/we may not be aware of) one is struggling to avoid.
In regards to the importance of Process – it is undoubtedly a requisite for success. It also requires a tolerance for failure in order to reap the rewards of an iterative process; this is where time & resources come into play. Any venture that speaks of the importance of focusing on Process inherently has survivorship bias. They survived long enough to give you their advice to focus on the Process; this doesn’t account for all the others who also focused on their Process while sinking under the lack or shortcomings of Outcomes. We rarely hear about failures and the stories behind them because history has a strong survivorship bias – the winner tells her version of the story.
I’m not discounting the value of Process; I’m highlighting the significance of recognizing the importance of feedback loop from Outcomes to Process in order to make it thru the short term before even qualifying for the long term.
Lastly, your clinical Process will be informed by your Outcomes. It’s inescapable for the thoughtful clinician.
Hope this helps.
Kenny Venere (@kvenere) says:
Thanks for your reply.
I was not suggesting we base our approaches 100% on RCTs and contemporary research, but instead suggesting we utilize a science based foundation to direct our processes. That is, an approach that is congruent with what we know of basic physiology, pathology, psychology, neuroscience, etc. Again, this does not preclude innovation but affords us a framework in which to develop plausible interventions and paradigms (which can later be supported or refuted by RCTs and contemporary research).
We are in agreement that biases can never be eliminated, but we should strive to identify them and recognize how they affect our interpretation of the outcomes we observe in the clinic. Certainly it is foolish to suggest anyone can work in an environment that is unbiased; as I stated previously, the clinical environment we exist in is simply too chaotic.
There is no doubt an interplay between outcomes and process, but we should be aware how limited we are in our ability to interpret our observed clinical outcomes given the large amount of confounders present in a clinical encounter. With that in mind, I feel it is more prudent to focus on the process of scientifically sound physical therapy in both the short and long term.
There’s also the issue of how we define/measure a successful clinical outcome, but that’s another comment
Kenny, I think both of us give import to the scientific process and human biases.
The differing perspectives might be 1) interpretation and value of Outcomes and 2) willingness to reach outside mainstream & currently popular paradigms.
On 1) I think this is one of those things where if you think you can or think you can’t, you’re right! You cannot have Process w/o incorporation & interpretation of Outcomes; Process is blind w/o Outcomes feedback. Also, you can’t see “it” if you aren’t looking for “it”. This is where correlation of your findings are paramount in guiding you down relevant avenues of treatments/approaches. If you say you can’t possibly learn a skill, then you never will; it is self limiting. One cannot succeed if s/he cannot interpret & apply their Outcomes.
On 2) What is known is worth less than what is unknown in the sense that the unknown can decimate current findings, beliefs & practices. Of course you should optimize what you already know, but realize that paradigm shifts rarely sprout from the mainstream/accepted framework; look to the “fringes” for that. Nearly everything practiced in PT today was once considered “fringe”.
Kenny Venere (@kvenere) says:
No argument there, Cinema I’ve enjoyed the discussion, as always.
We as a profession continue to refine our ability to (hopefully) humbly interpret and apply information gleaned from outcomes, this is a good thing.
As long as what comes from the fringes is later subjected to an explicit protocol of development/understanding and does not remain purely in the realm of outcomes (or “it just works”), I have no doubt the future of the profession is bright.
Enjoy the weekend!