Research vs. Treatment: When Will Our Mentally Ill Vets Get Healed?

imagesIn March 2014, President Obama made headlines by announcing the doubling of government funding for the Brain Initiative, a large research project deploying the latest neuro-technologies, which he said would be “transformative” and allow us to “imagine if we could reverse traumatic brain injury or PTSD for our veterans who are coming home.”   A month later, a mentally unstable veteran shot nineteen people in Fort Hood, TX. Some commentators – among them Adm. Mullen on NBC’s Meet the Press – pointed to the fact that the Brain Initiative might provide an answer to why the shooter snapped in Texas.

While this may be true in the long term, these comments reflect a consistent belief in government and business that academic, top-down research will bring the silver bullet for our most pressing problems.  As a result, we allocate too much public money to the wrong places.

Veterans need help now and cannot afford to wait the ten or twenty years required to develop this comprehensive understanding of the brain advocated by President Obama and Adm. Mullen.

In my consulting experience across a variety of science-driven fields, I have found that top-down scientific or engineering breakthroughs bring answers to major business or societal problems only in about 10-20% of cases (and that trend is decreasing).   Rather, 60-70% of solutions come from a bottom-up, practitioner-driven variety, i.e., “let’s work with the local people impacted and develop the solution with them.”  And the remaining 20-30% (also increasing) of solutions comes from “analytics”, i.e., looking at the gathered bottom-up data and identifying emerging protocols that prove effective for specific segments of people, usually involving a mix of approaches.

So why focus so much attention on what only yields 10-20% of the solutions? Political and scientific leaders love broad-based initiatives because they give them a chance to create their moon shot.  It is more exciting to announce a mapping of the brain initiative than some redesign of procedures to give veterans greater access to therapists.   But rather than try to develop a predictive model of why some vets suffering from post-traumatic stress disorder (PTSD) or mild traumatic brain injuries (TBI) will snap when others won’t, shouldn’t we make sure all of them get some basic form of care and reduce the likelihood that any of them start shooting at random? Instead of trying to be exquisitely precise in locating the gun in the haystack, shouldn’t we reduce the size of the haystack in the first place?

In fact, we already have many research-proven treatments for PTSD and TBI that would benefit vets right now.   None of them will be one-size fits all silver bullet variety.  That’s because effective treatment will always vary from patient to patient and involve a unique combination of traditional therapies and fine tuning of medication, alternative medicine and social support from friends and family.   For each person the formula may be different.  Dr. Cifu, National Director of the Department of Veterans Affairs’ physical medicine and rehabilitation program, states it this way: “The key is the right stuff for the right patient at the right time. The veteran needs to be your guide.”  In other words, it is an act of co-creation between clinician and patient. The problem with the scientific approach is that researchers in labs have not yet learned how to how to balance the variety of human need with the potential combination of solutions.  The best practitioners in the field do it every day.  We need to turn to them, because chances are that they have 60% to 70% of the solutions.  We need to invest in them to reduce human suffering.

Yes, some breakthroughs still come from brilliant scientists in the lab, but more and more of them come from an intelligent reading of what works in the field. That’s the 20-30% that comes from “analytics”. These analytics involve developing a series of ad hoc protocols that have been found to work, which were co-created between compassionate and innovative healthcare workers and the veterans seeking some relief from their pain. Not all field-developed protocols are good, but many are, at least in the local context of specific patients. This is what we should invest in: delivering these services and studying them in the process.  Unfortunately scientists have been trained to minimize the value of this field-based knowledge, arguing that little of it meets the scientific standards of medical trials.  (Even if it works.)

If we continue to search for the big breakthroughs in the sky, we may find that all our veterans will have died by the time the great breakthrough occurs. Professors in the research-dominated medical schools of yesteryear used to proudly say to their students: “no, we could not save our patients. But we could publish them!”

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