David C. Aron, MD, MS, OC (optimistic cynic)

Nothing new under the sun.

What has been is what will be,
and what has been done is what will be done,
and there is nothing new under the sun.

Is there a thing of which it is said,
“See, this is new”?
It has been already
in the ages before us.

 

There is no remembrance of former things,
nor will there be any remembrance
of later things yet to be among those who come after.

Ecclesiastes  1:9-11 (Jewish Publication Society 1917)

The April 2010 issue of AHRQ Research Activities Newsletter led with the astonishing headline: “Patients admitted to the hospital on weekends wait for major procedures.” (http://archive.ahrq.gov/news/newsletters/research-activities/apr10/0410RA.pdf )  This finding was based on a report Characteristics of Weekday and Weekend Hospital Admissions that was based on data from 2007. (http://www.ncbi.nlm.nih.gov/books/NBK53602/pdf/Bookshelf_NBK53602.pdf)

 

There have been many critiques of health services research. Sometimes it has been called ‘academic,’ meaning not of practical relevance or of only theoretical interest. This particular article brings up another criticism that I have heard (and made) that health services researchers prove the obvious.  The authors of the report have used rigorous methods to support their conclusion and I suppose that should make us feel more comfortable in making the statement with scientific certainty.  However, one has the sense that this is something that could have been predicted more than 2000 years ago.

Genesis 2.1-3.  And the heaven and the earth were finished, and all the host of them. And on the seventh day God finished His work which He had made; and He rested on the seventh day from all His work which He had made. And God blessed the seventh day, and hallowed it; because that in it He rested from all His work which God in creating had made.

Exodus 20:7-10. Remember the sabbath day, to keep it holy. Six days shalt thou labour, and do all thy work; but the seventh day is a sabbath unto the LORD thy God, in it thou shalt not do any manner of work, thou, nor thy son, nor thy daughter, nor thy man-servant, nor thy maid-servant, nor thy cattle, nor thy stranger that is within thy gates; for in six days the LORD made heaven and earth, the sea, and all that in them is, and rested on the seventh day; wherefore the LORD blessed the sabbath day, and hallowed it.

Deuteronomy 5:11-14. Observe the sabbath day, to keep it holy, as the LORD thy God commanded thee. Six days shalt thou labour, and do all thy work; but the seventh day is a sabbath unto the LORD thy God, in it thou shalt not do any manner of work, thou, nor thy son, nor thy daughter, nor thy man-servant, nor thy maid-servant, nor thine ox, nor thine ass, nor any of thy cattle, nor thy stranger that is within thy gates; that thy man-servant and thy maid-servant may rest as well as thou. And thou shalt remember that thou wast a servant in the land of Egypt, and the LORD thy God brought thee out thence by a mighty hand and by an outstretched arm; therefore the LORD thy God commanded thee to keep the sabbath day.

The idea of a day of rest for the working class was an innovation and by no means the usual practice. The Jewish Sabbath was criticized by 1^st Century Roman Seneca the Younger who was quoted by Augustine in City of God:  ‘Seneca, among the other superstitions of civil theology, also found fault with the sacred things of the Jews, and especially the Sabbaths, affirming that they act uselessly in keeping those seventh days, whereby they lose through idleness about the seventh part of their life, and also many things which demand immediate attention are damaged.( De Civitate Dei. 6:11) Nevertheless the concept caught on.

Since on the seventh day even God rested and no procedures were performed, is it surprising that delays have been introduced in the system?  I am not suggesting that the fact that the Sabbath appears in the Bible is scientific proof that this is the cause of waiting for procedures.  If anything, it is only correlation rather than proof of causality. Rather, it raises the issue of how much rigorous research is required.  Should we do an RCT to be sure of the causal relationship? Further, if waiting for procedures for patients admitted on weekends was not demonstrated, would you believe it? Is there a plausible counterfactual that would explain those results?  That is also not to say that there is nothing important to be learned here. Which procedures are delayed and whether that makes a difference in outcomes are legitimate research questions that have implications for hospital staffing.  Let us just not let ourselves be carried away with our brilliance. (For the record I am not aiming this at the authors of the study which included many more findings of considerable interest; rather, the idea that this was a headline struck me as funny.) This led me to ask the question, how much of the findings of health services and related management research, particularly in my area of implementation of evidence into practice, were at least foreshadowed in the Hebrew Scriptures.

There are several articles that provide so called lessons learned or prove the importance of one factor or another and these have been published in “high impact journals” (which means that other health services researchers cite them and not that they have high impact on actual practice – I am as guilty as the next in trying to publish in such journals). For example, some of the factors associated with implementation success include:

Leadership –  One need only read the Book of Exodus; and the ever popular importance placed on the leader’s vision.  See Proverbs 29:18

Spatial sufficiency (which probably means enough space)– which facilitates co-location of primary care and mental health clinics  Putting aside the laws of physics which don’t allow two things to occupy the same space simultaneously, one might recall that the Israelites are reminded that God led them out of Egypt. The Hebrew word for Egypt (מִצְרַיִם ) literally means the narrow places. Even then, spatial sufficiency was important.

I have no doubt that there are other examples. Health services researchers would be more useful if they looked at how to implement something in the face of poor leadership or how to accomplish things when space is a constraint. It is time for a change.

Bible translations and numbering from the JPS 1917 Edition

 

http://www.mechon-mamre.org/p/pt/pt0.htm

11/30/15