Paradoxes of Efficiency (Part 1)

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I have been reading Edward Tenner’s The Efficiency Paradox. He got me thinking about paradoxical thinking that is rife throughout education and medicine. But before getting to either of these, I need to make clear what efficiency is–Tenner’s definition–and what the paradox of efficiency is. Here goes.

According to Tenner, efficiency is: “…producing goods, providing services or information, or processing transactions with a minimum of waste (xii).” To listen to Tenner describe his book, see here.

In education, “efficiency” came to mean teachers teaching more, faster, and better than they had before. Large class sizes in the early 20th century (e.g., 50-plus elementary school students in a class) were reduced in the name of efficiency to achieve more productive teaching, that is, faster, and better teaching.

Definitions and examples aside, what are paradoxes of efficiency?

Consider the introduction of coal as fuel to replace the more expensive oils that were used. The idea was to use coal to heat homes, power railroad engines, run generators  because coal had become technologically more available through improved mining and ship[ing to factories and home. It also burned with higher heat. It was far more efficient than previous fuels.

But as coal became increasingly available and used through industrial society, more and more coal was mined and sent to industrial plants and home causing, over decades, pollution and respiratory diseases. Coal was economically efficient in the short run but became, with increased demand for more and more coal, inefficient by damaging the environment and harming humans. This paradox was discovered in the mid-19th century and is called Jevins Paradox.

The paradox applies to other energy sources such as gasoline for cars and nuclear power increasing consumer demand for the fuels and damaging the environment over time.

Now, consider paradoxes in the practice of medicine.

Take Electronic Medical Records (EMR). Introduced to decrease administrative burdens doctors faced (e.g., writing on patient charts, what the  patient’s condition is and writing directions to nurses for what medicine and therapies patient needed) so that physicians could spend more time with patients to diagnose and treat them. EMR promised clearer communication–recall stories of doctors writing illegibly–among and between primary care doctors, specialists, nurses, and pharmacists.

In recent studies, however, EMR has neither reduced time spent on administrative tasks or freed doctors to give more time to patients. When one counts in the additional time, doctors have to spend in learning EHR and then thinking through the codes that will be reimbursed by insurers in making judgments about treatment–all of that consumes time that doctors had not considered when adopting EMR. There’s more.

According to Tenner (p.170): For every hour of direct contact [with patients], doctors spend two hours at the office filling out out EMR forms and completing other paperwork….

In emergency rooms, doctors may need to perform four thousand mouse clicks during a ten hour shift.. or on the average of one [click] every ten seconds (p.170).

Thus, as Tenner, concludes when it comes to applying new technologies as EMR to the practice of medicine to increase efficiency and effectiveness, “[E]fficiency is difficult to implement efficiently. It takes more time, money, and failures than advocates expect” (p. 168).

There are, of course, positives to EMR. Tenner points out that these electronic records often build in checklists of practice in treating patients that signal doctors what needs to be done for handling a diabetic patient, or one recovering from breast cancer surgery, or side-effects of particular drugs.

Whether these pluses outweigh the negatives, at this point the supposed efficiencies gained through introducing and using EMRs has increased inefficiencies in many doctors’ use of time. A paradox that continues to puzzle health care experts.

Another paradox is the increased efficiency in providing end-of-life cancer treatments or prolonged dementia care may create benefits for those individuals receiving treatment, but policymakers and the larger society may decide that because there is a limited pot of money available to health providers, that money efficiently spent on end-of-life-care is inefficient, on a different scale since that money may be better spent on other treatments that create more benefits for larger numbers of people needing health care.Hence, efficiency in treatment for those nearing the end of their lives may be considered inefficient when considered against the health care needs of others.

Part 2 takes up the paradoxes of efficiency in education.

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