Less is More

Craig Joseph, MD
By: Craig Joseph, MD
Date: October 24, 2019

I’ve always been fascinated by minimalism. Be it philosophy, architecture, or design. The ethos of “less is more” seems contradictory at first, but it proves accurate and predictive in many aspects of life, or at least in my life. Much as the Fibonacci sequence shows up in random places all throughout nature, I find the concept of minimalism popping up in my clinical world and professional world.

As longtime readers will know, I’m a pediatrician. I no longer practice, but I did so for long enough that I learned a thing or two. I spent most of my career in small groups with just a handful of doctors, so I knew many of my patients (and their parents – ok, their moms) very well. I knew which moms were nervous and high-strung and which moms just wanted the know if their child needed a prescription for an antibiotic or not (One of my favorite moms once told me, “If I had one of those fancy flashlights of yours to look into my kid’s ear, I’d never come back to this office again.” I gave her a hug because I thought that was a good idea; little did she know that I didn’t want to see her kid if I couldn’t do anything helpful for her or him!).

Minimalism in HITI learned that without being paternalistic, I should never give a parent a list of everything that could be wrong with their child. Can you imagine bringing your child to the pediatrician for a sore throat and being told, “Well, I think it’s just a viral upper respiratory infection, but of course, I can’t rule out something terrible like cancer or meningitis.” That seems like crazy talk, but it’s true. Fatal diseases can start out looking like common, self-limited infections. But . . . if it’s a very unlikely diagnosis, there’s no need to blurt out that information. Some parents would ask me to promise them this won’t turn into X or Y. I’d have to reply that I couldn’t promise them anything; heck, I couldn’t promise them that the sun won’t explode tomorrow. Is it possible? Yeah. Is it likely? Heck no!

What does this have to do with minimalism? It’s just part of keeping it simple. I tried to give the parent and/or the patient the information that they needed, but not more than they should have. If meningitis or cancer was high enough in my differential diagnosis, then unfortunately, I shared that information. But if it were not on my top five or 10 diagnoses, then why over complicate the situation? Is this paternalistic? Maybe a bit, but I think it’s necessary. When I ask my lawyer or accountant a straightforward question, I don’t want a 15-minute lecture on case law or reference to some unreadable financial regulation. If I need to hear that information, fine. But generally, I’m paying the professional to synthesize lots of information down to just what I need, when I need it. That’s minimalism.

During my second month of practice after finishing residency, the senior partner came up to me and said that Mrs. Smith was none too happy with me. He asked me if I remember her from yesterday. I said that sure I did. She brought Johnny into the office because she feared he had an ear infection. “And what did you tell her?” my boss queried. I informed her that Johnny certainly had a cold, and he had some clear fluid behind his left tympanic membrane, but when I insufflated, the drum moved pretty well, so I didn’t think it was infected at that point. Plus, he didn’t seem to be in much pain when I was examining him, so that sealed the lack of an ear infection diagnosis in my book (Are you experienced clinicians wincing reading this?). “Yeah,” the senior partner said, “That was the wrong answer. The right answer was I don’t see any evidence of an ear infection at this point, but if Johnny gets worse, you should bring him back.” I protested that is what I said! It wasn’t what I said. I said too much. I should have been keeping it appropriately simple.

Keeping it as simple as possible in information technology (IT) and electronic health record (EHR) configuration has another name: usability. The concepts around user-centered design and usability guide us to keep everything as simple and obvious as possible. Throwing all kinds of useless information at doctors and nurses is easy; picking out the likely helpful and key data points is difficult. Mark Twain wrote that “I didn’t have time to write a short letter, so I wrote a long one instead.” Yeah, I get that.

In the IT shop, we try to practice the “less is more” principle. If it’s unlikely that a doctor, scheduler, or biller will need information, let’s not put it out there with flashing red lights. Essentially, we’re following the 80/20 rule, or at least trying to do so. Sometimes we get it right, and despite that, our users say, “But what about the 20%? You mean I have to take an extra step or two to find those data points?” Yeah, that’s what we mean. Our goal is to give you the information that you need when you need it. It’s difficult for sure, but it’s a goal worth striving toward.

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