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Aug. 8th, 2014 02:06 pm
Lumpers and splitters
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nightengaleskndAbout halfway through my second year of fellowship, in the middle of a series of disagreeing e-mails between me and one of my attendings, I realized the crux of the problem.
I was a lumper, in a department (really, in a field) full of splitters.
I learned the terms when I studied taxonomy in high school. The lumpers try to fit organisms into somewhat broader categories, deciding that slight differences might distinguish varieties or breeds or strains but keeping both under the same species. The splitters take these same differences as a sign that two organisms are in fact distinct species. (I know there are further definitions of species based on the ability to interbreed.) The two kingdoms split off into five, and later 6, based on further information showing fundamental differences.
In medicine, there are some clear cut diagnoses. Except there aren’t. An ear infection is an ear infection. But do you code separately if the child also has a fever or do you decide that a fever is part and parcel of the ear infection? I’d probably just code for the ear infection and save the fever code for a time when the kid has a fever without a clear cause. But then, I’m a lumper.
In my field, where diagnoses are less clear cut, it gets even trickier. Sometimes we end up labeling and listing symptoms, especially in younger children and those with more complex presentations. We might list ADHD, a speech and language disorder, an anxiety disorder and aggressive behaviors, all out separately and address each one Sometimes we don’t even have a diagnosis, so “developmental delay” and “temper tantrum” become diagnostic codes.
Sometimes we can find an Occum’s Razor that explains everything. The child has delays in language and adaptive skills, and flaps his hands and hyperactive behavior compared to other children his age, and we’re calling it autism. At least, I am calling it autism. Someone else might code for autism, and then code for a speech-language disorder or a communication disorder or developmental delays. Most developmental pediatricians wouldn’t code for hand-flapping separately, but a neurologist might comment on “motor stereotypies.” They’re the ones that also diagnose a child with both “epilepsy,” “partial complex seizures,” and an “abnormal EEG.”
When do we diagnose hyperactivity separately? Whenever the child is more active than others his age? Just if the child is so much more active that it is causing impairment (above and beyond impairment from the core traits of autism)? Only if we are prescribing medication? The DSM IV-TR did not permit the diagnosis of ADHD if symptoms could be explained by autism, but people diagnosed them together anyway. The DSM 5 has no such restrictions. So the kid could walk out of the office with a single diagnosis of autism, or three or four additional diagnoses that may or may not add additional information.
Some of it is personal style but some is due to the self-preservation instinct of many physicians who wish to earn a living. Insurance reimburses physicians based on a number of factors, including procedures performed, time spent with the patient and the degree of complexity presented by the patient. Complexity is partly calculated by the number of diagnostic codes. Insurance also requires a corresponding diagnosis before approving specific medications. So “hyperactive” may not lead to medication coverage but “ADHD” might. If I prescribe Zoloft using autism, rather than anxiety as my diagnosis, the medication may be denied. Some schools will only provide support for children labeled as having “dyslexia” rather than “learning disabilities” or “reading disorder.” Sometimes we just stack up diagnoses and forget to get rid of old ones. If the child has a “motor delay” at 9 months and then is later diagnosed with cerebral palsy at 2, we should go back through the problem list and take out the “motor delay” diagnosis. But we don’t always get around to doing that.
I’m finding my peace. If I have to split so that the child can get the medication or our department can get paid or the child can get services in school, I’ll split. (I’m not talking about making incorrect diagnoses for financial gain here, but more saying “developmental coordination disorder” for a child to get OT, instead of keeping it subsumed under the larger umbrella of “developmental delay.”) And I generally will split off a diagnosis for which I am making specific treatment recommendations. For example, if I am just giving general strategies to deal with anxiety I may not split it off, but if I recommend medication or counseling I will.
Just labeling it as a difference between lumping and splitting helped a lot, actually, and made me a lot more willing to split at times.
Now I am trying to sort through 20 years worth of accumulated papers. I’m a pack rat. I’m actually managing to get rid of some papers entirely, which is a BIG DEAL for me. I mean, I know I no longer need driving directions to a camp I worked at for one summer in 1998, but it’s hard to actually go through the folder of papers from camp and toss the directions into a box for recycling. And I’m also trying to reorganize the ones I’m keeping, and trying to develop a sustainable storage system for papers going into the next 20 or more years.
Currently I have a folder for each of my medical school rotations, which contains both didactic and clinical stuff. And then I have folders from residency that contain both didactic and clinical stuff. I’ve reached the realization that it would be more helpful for me to have papers clustered together by content than kept in separate spaces based on when I obtained them. For example, I have handouts on ADHD from med school, residency, fellowship and random conferences I’ve attended. I am likely to continue to acquire further papers on ADHD, being who I am and doing what I do and all. It would probably be more helpful for my future to have a single ADHD file than to have some of these handouts in a box marked “med school” and others in a folder labeled “community resources – WV” because I picked them up at a parent training I attended in WV. So I’m going to lump.
But I’m running up against subtle distinctions. Where do I put personal medical documentation that was generated solely to provide me with test accommodations? Do I put such letters in with my other medical paperwork? In with the test scores themselves? In some separate folder marked “accommodation paperwork”? My vaccination records are mainly used now when I apply for a job, not for my actual health needs, so should I keep them with my other medical records or employment information? Do I keep medical financial paperwork in with other financial information or in with other medical information? What about disability stuff that I obtained in medical education setting but use to help myself get accommodations. Would that fall under “rehab medicine” or “accessibility”? What about material from my college Disability Law class?
I can’t just lump everything in together in a box, because then I’ll never be able to find anything. And I can’t just split everything into little separate folders because I’ll forever trying to remember which folder I want and I’ll never be able to find anything. And right now, that I’m not working, may be the last time I have in years to really organize everything, so I don’t just want to shove things into folders to be done with it. Nor do I want to sit here with 7 file boxes of papers in my living rooms and piles of papers on every surface in a perpetual state of indecision paralysis.
There’s a place for lumping and a place for splitting and a time to know the difference. And there’s a living room full of papers I’m going to try to go back to lumping. . . or splitting. . . into some sense of order.
I was a lumper, in a department (really, in a field) full of splitters.
I learned the terms when I studied taxonomy in high school. The lumpers try to fit organisms into somewhat broader categories, deciding that slight differences might distinguish varieties or breeds or strains but keeping both under the same species. The splitters take these same differences as a sign that two organisms are in fact distinct species. (I know there are further definitions of species based on the ability to interbreed.) The two kingdoms split off into five, and later 6, based on further information showing fundamental differences.
In medicine, there are some clear cut diagnoses. Except there aren’t. An ear infection is an ear infection. But do you code separately if the child also has a fever or do you decide that a fever is part and parcel of the ear infection? I’d probably just code for the ear infection and save the fever code for a time when the kid has a fever without a clear cause. But then, I’m a lumper.
In my field, where diagnoses are less clear cut, it gets even trickier. Sometimes we end up labeling and listing symptoms, especially in younger children and those with more complex presentations. We might list ADHD, a speech and language disorder, an anxiety disorder and aggressive behaviors, all out separately and address each one Sometimes we don’t even have a diagnosis, so “developmental delay” and “temper tantrum” become diagnostic codes.
Sometimes we can find an Occum’s Razor that explains everything. The child has delays in language and adaptive skills, and flaps his hands and hyperactive behavior compared to other children his age, and we’re calling it autism. At least, I am calling it autism. Someone else might code for autism, and then code for a speech-language disorder or a communication disorder or developmental delays. Most developmental pediatricians wouldn’t code for hand-flapping separately, but a neurologist might comment on “motor stereotypies.” They’re the ones that also diagnose a child with both “epilepsy,” “partial complex seizures,” and an “abnormal EEG.”
When do we diagnose hyperactivity separately? Whenever the child is more active than others his age? Just if the child is so much more active that it is causing impairment (above and beyond impairment from the core traits of autism)? Only if we are prescribing medication? The DSM IV-TR did not permit the diagnosis of ADHD if symptoms could be explained by autism, but people diagnosed them together anyway. The DSM 5 has no such restrictions. So the kid could walk out of the office with a single diagnosis of autism, or three or four additional diagnoses that may or may not add additional information.
Some of it is personal style but some is due to the self-preservation instinct of many physicians who wish to earn a living. Insurance reimburses physicians based on a number of factors, including procedures performed, time spent with the patient and the degree of complexity presented by the patient. Complexity is partly calculated by the number of diagnostic codes. Insurance also requires a corresponding diagnosis before approving specific medications. So “hyperactive” may not lead to medication coverage but “ADHD” might. If I prescribe Zoloft using autism, rather than anxiety as my diagnosis, the medication may be denied. Some schools will only provide support for children labeled as having “dyslexia” rather than “learning disabilities” or “reading disorder.” Sometimes we just stack up diagnoses and forget to get rid of old ones. If the child has a “motor delay” at 9 months and then is later diagnosed with cerebral palsy at 2, we should go back through the problem list and take out the “motor delay” diagnosis. But we don’t always get around to doing that.
I’m finding my peace. If I have to split so that the child can get the medication or our department can get paid or the child can get services in school, I’ll split. (I’m not talking about making incorrect diagnoses for financial gain here, but more saying “developmental coordination disorder” for a child to get OT, instead of keeping it subsumed under the larger umbrella of “developmental delay.”) And I generally will split off a diagnosis for which I am making specific treatment recommendations. For example, if I am just giving general strategies to deal with anxiety I may not split it off, but if I recommend medication or counseling I will.
Just labeling it as a difference between lumping and splitting helped a lot, actually, and made me a lot more willing to split at times.
Now I am trying to sort through 20 years worth of accumulated papers. I’m a pack rat. I’m actually managing to get rid of some papers entirely, which is a BIG DEAL for me. I mean, I know I no longer need driving directions to a camp I worked at for one summer in 1998, but it’s hard to actually go through the folder of papers from camp and toss the directions into a box for recycling. And I’m also trying to reorganize the ones I’m keeping, and trying to develop a sustainable storage system for papers going into the next 20 or more years.
Currently I have a folder for each of my medical school rotations, which contains both didactic and clinical stuff. And then I have folders from residency that contain both didactic and clinical stuff. I’ve reached the realization that it would be more helpful for me to have papers clustered together by content than kept in separate spaces based on when I obtained them. For example, I have handouts on ADHD from med school, residency, fellowship and random conferences I’ve attended. I am likely to continue to acquire further papers on ADHD, being who I am and doing what I do and all. It would probably be more helpful for my future to have a single ADHD file than to have some of these handouts in a box marked “med school” and others in a folder labeled “community resources – WV” because I picked them up at a parent training I attended in WV. So I’m going to lump.
But I’m running up against subtle distinctions. Where do I put personal medical documentation that was generated solely to provide me with test accommodations? Do I put such letters in with my other medical paperwork? In with the test scores themselves? In some separate folder marked “accommodation paperwork”? My vaccination records are mainly used now when I apply for a job, not for my actual health needs, so should I keep them with my other medical records or employment information? Do I keep medical financial paperwork in with other financial information or in with other medical information? What about disability stuff that I obtained in medical education setting but use to help myself get accommodations. Would that fall under “rehab medicine” or “accessibility”? What about material from my college Disability Law class?
I can’t just lump everything in together in a box, because then I’ll never be able to find anything. And I can’t just split everything into little separate folders because I’ll forever trying to remember which folder I want and I’ll never be able to find anything. And right now, that I’m not working, may be the last time I have in years to really organize everything, so I don’t just want to shove things into folders to be done with it. Nor do I want to sit here with 7 file boxes of papers in my living rooms and piles of papers on every surface in a perpetual state of indecision paralysis.
There’s a place for lumping and a place for splitting and a time to know the difference. And there’s a living room full of papers I’m going to try to go back to lumping. . . or splitting. . . into some sense of order.
no subject
The lumping vs splitting is interesting...I think working in medical research made me more of a splitter than I normally would have been...
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I like electronic format for some things, but I'm still attached to at least some of these pieces of paper. Like graded college papers and pamphlets from different organizations. I've used electronics medical records systems that are supposedly "paperless" by scanning in papers and. . . it works for some things but really not for others.
I wonder how much of lump/split tendencies are innate to people and how much are reinforced by training and environment. I'm actually very autistically detail oriented in a lot of ways, but then I like to categorize the details. Or put them into file boxes. . .
no subject
Grad stuff is collecting dust sorted by class, except for the few things I reference all the time which are out among the relevant classroom materials (voc, Deafblind...) I doubt I'll ever touch any of the rest of it again.
And now I do keep everything electronically in Pocket or Evernote. Papers just get lost or forgotten about. If it is electronic I can find it again.
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But yeah. So OK. Do articles on newborns with lung disease go into a respiratory/cardiovascular folder, an ICU/ER folder or do I create a separate section on preemies? How about metabolic syndromes - endocrine, genetics or development? I've never been good at these edges - it's why I always preferred to write up my patient notes based on problems rather than body systems. Pneumonia is a problem, and I don't have to decide if it's pulm or ID. Right now I'm making piles with temporary headings and then comparing the sizes and moving stuff back and forth.
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Your mental organization is by problem so that's the organization your file system should use. I know, if only it was that easy.
I'm on "vacation" - we should chat if your computer will play nice.
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Amusingly, my excavation has also unearthed the paper I wrote on prematurity for med anthro in 1998. I quoted a hot-off-the-press longitudinal study that had come out in 1997, following 150 kids. Unsurprisingly, I made reference to the high quality of life scores of these teens. I noted that 30% had one or more disability, including 19 with cerebral palsy, 5 with autism and 9 who were blind. I further noted that "the cause of autism is unknown." Can you imagine ever dismissing autism away in a sentence or two today?
I then commented that "the medical profession tends to avoid the issue of disability whenever possible. Many suburban pediatricians send children with disabilities to specialists in large cities even for primary care. It is easy to see how the blind, physically and mentally handicapped child may get lost in the medical details of ophthalmology, neurology or psychology, without enough focus on the whole life of a child and his or her family."
This was a good year or two before I first learned of the field of DB pediatrics, mind you. Some things, such as the language, have changed since 1998. Other things, not so much.
The main barrier to chat right now isn't the computer but the tendons. I think I've hit my typing limit for the day but we can aim for the weekend.
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For stuff that I've accumulated throughout university and conferences I've brought myself to recycle a lot of the quizzes and assignments, unless they are particularly special to me for some reason. I'm in the process of scanning things like handouts and articles and other things that I might have a use for in the future. Organizing these inside my computer is a whole other dilemma, though!
I personally am not comfortable using something like Evernote to organize personal files (financial and health records, for example), but this might be a solution for the masses of teaching and education resources I've accumulated over the years. I've only been in this field for seven years and have another 30+ years to go (assuming I stay in the same field and retire when I'm 65), so I feel like there's a LOT more stuff I'll be accumulating in future years!
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Two things. First, they're your things, so your use cases are important. Second, intellectual arrangement is more important than physical arrangement. As long as you know what box it's in--or should be in--it doesn't matter what box that is.
My suggestion:
Series I: Works by others (e.g. ADHD, the papers arranged by diagnosis, which you expect to reference and add to)
Series II: Med school rotations (minus separated materials in Series I)
Series III: Courses (e.g. Disability Law)
Series IV: Medical paperwork (subseries or -folders for test accommodation, vaccination, etc.)
Series V: Financial (can do subs if needed)
Series VI: Employment
Series VII: Conferences/Organizations
If all else fails, tack on Miscellaneous; Correspondence could be useful, too.
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So I need a specific piece of paper and I go through piles and piles of things looking for it. Like my vaccine records. I'm looking for them now because I need them to apply for my job. I've got some in with other medical stuff, and some in with my med school application paperwork, and some I thought were with my fellowship orientation paperwork, if I could only FIND my fellowship orientation paperwork. . . and so I mentally categorize vaccinations as a medical thing, but in reality I only need them for school and employment things. Which cognitive dissonances.
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I read about this in a book about computers, but I think it could work for physical files as well, as long as you're not doing it with everything ... that could get too complicated.