In thinking about the problem of why it is easy to grab onto one bit of information and keep responding in the same way I realized it is similar to why I get stuck in repetitive patterns of behavior that I am sometimes jarred into realizing are not as productive or satisfactory or healthy as they should be.  Whether we process information intuitively or analytically (or more typically probably a mixture of both), humans do crave some degree of organization and routine.  It is in the balance between total rigidity and total chaos that we must tread in order to enhance our ability to think creatively to learn and grow while having enough routine and organization to build on what we have already learned and do well.  


When we are faced with decisions, it is much easier to deal with a yes/no solution.  Algorithms are one means of sorting through chaos and enabling us to feel we have some control over the flood of information that we all must process on a daily basis.  They are comforting.  They provide structure.

At the same time, poorly constructed algorithms can lead us to ignore important information.  And here is where I feel we run into problems with indicators and decision making, particularly numerical indicators.  Numerical indicators can put us in our left brain analytic mode -- whereas qualitative indicators can put us in our right brain intuitive mode.  And sometimes we really need our right brain to help process the implications of the numerical indicators.  

Cutoff values can often be very useful on a population basis - and for public health programs.  They can lead to broad strategies to reach far more people than a one on one clinical approach can achieve.  A gardening program that increases the beta-carotene intake of millions of families in Bangladesh on the basis of surveys showing a high percent of the population with a low serum retinol level (with a cutoff value) can be a very useful.  And tracking whether the percent of the population above or below that cutoff level can tell you that the program is working.  

Here's the rub however.  A cutoff level for serum retinol will enable you to determine the percent of the population at risk -- and enable a policy maker to make the decision to intervene or not.  Yet, if the percent of the population at risk doesn't decrease (or even increases) the manager of that program may need more information than the policy maker.  The manager of that information will need to find out WHY the program didn't work as intended.  That manager may need to know whether or not the population was actually eating the food from the gardens.  If the population just sold the foods, they may still be benefitting from the increased income in other ways. So, the gardening program is still beneficial -- just not for its intended purpose.  The manager would not know this unless the manager actually had the foresight to collect information about income generation.  The manager needs to think differently than the policy maker.

So, perhaps that gardening program might need an educational program to assist families to come up with tasty recipes for those vegetables they are growing or encourage them to retain some of those vegetables -- or a whole host of conceivable interventions.  That manager will then need to gather a lot of qualitative information to understand how to add components to the program to improve the consumption of beta-carotene rich garden produce.  He might need to conduct focus groups with the women growing the gardens, women who purchase produce from the gardens, men who might be controlling the money generated from the gardens, grandmothers who might be doing some of the cooking or influencing recipes  etc..

On an individual level, the family certainly isn't going to be able to afford to monitor their own serum retinol levels on a continual basis.  Moreover, if they happened to have gone through a season when they were eating lots of mangos -- and then entered a season when mangos were unavailable and they were not eating those vegetables -- their serum retinol levels might not change for an entire six months.  It would make no sense for them to follow their serum retinol levels.  It would make more sense for them to have some general guideline --- such as eat 2-3 servings of green leaves or orange vegetables and fruits a day.  Not the most accurate of indicators of their own diet -- but clearly a very visible and doable goal.  A mom cooking for the family would need to know all sorts of information, like the kids won't eat the vegetables unless they are finely chopped and have a particular sauce -- or they are included in a dish with potatoes --- or that her husband detests peas and will storm away from the table if anyone's plate has peas on it.  And as with any biochemical indicator, retinol values can be influenced by other factors and some people who are below the cutoff are fine and others who are above the cutoff are not.

Now, in term of our use of indicators it very much depends on whether or not we are working in on a public health scale making decisions about a population or on a clinical level where we are making decisions about an individual. Now at the public health scale it does make sense to have some sort of protocol to ensure that the vast majority of the population is getting a certain standard of care.  Unfortunately,  what I often find problematic is that this lead to algorithms whereby the trigger when a cutoff value has been crossed results in an action or intervention -- when in fact the trigger when that cutoff value has been crossed SHOULD BE to collect additional information to assist that individual to make a more fully informed decision. 

Some of my pet peeves are that "colic" and  "failure to thrive" are considered diagnoses.  Others have said this on Lactnet as well.  These are NOT diagnoses, these are symptoms.  So, anytime someone posts about these "symptoms" we all have our standard knee jerk ideas about the "intervention" that we think works best for the type of clients we see (myself included).  Instead, we should see these as symptoms and be asking "What additional information do we need to collect to help this mother make reasonable decisions about the next steps?"  And I think this is the underlying fundamental problem anytime we trot out our personal favorite indicators for intake, milk production, and growth.  As well as the problem that we sometimes really don't understand what that tool is telling us.  When we make assumptions extrapolating beyond the indicator -- for instance that a stool is really measuring intake -- when really it just tells you that the baby's plumbing is working and the baby must have eaten something (although this might actually only be the amniotic fluid) rather than the baby ate plenty -- or when we see a baby who is at the 3rd percentile and assume that the milk supply is inadequate and start supplementing with formula -- or when we hear that a baby is crying more than 3 hours 3 times a day for 3 days in a row and we eliminate cow's milk from a mothers diet -- then we can sometimes apply the wrong intervention.  

I think, in general, indicators really deserve far more thought and attention than they currently do.  We too readily accept assumptions about them.

Sincerely, Susan Burger

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