Patterns in Medicine


We came across a booklet that could be a good example for the kind of studies by the envisioned Thinkibility University. At its West Wing, scientists dissect the basic thinking patterns in a scientific discipline.

Siddhartha Mukherjee was asking himself: If there is a science of medicine, then science has laws. Physics has laws. Chemistry has laws. Biology has laws.

The simple question was: If that’s the case, then what are the laws of medicine? These were not meant to be universal commandments. These were meant to be explorations about principles that might hold true about medicine today and about medicine in the future. That was the framework for this book.

Law One : A strong intuition is much more powerful than a weak test.

Law Two: “Normals” teach us rules; “outliers” teach us laws

Law Three: For every perfect medical experiment, there is a perfect human bias

Watch or read here an interview with him about the book. You could also read the Ted book: The Laws of Medicine Field – Notes from an Uncertain Science

For us, Gijs and Asa, it is not the description of the laws of a scientific discipline that interests us – how interesting they are by itself but the possibility they give to escape from it. Once spelled out, laws are just vehicles to set up new approaches.

In short, at the West Wing of the Thinkibility University, they are thinking laterally about science.


We have earlier written about patterns in science and possible escapes from them in the following blogposts:

Our next post about the topic “Patterns in Science” will be about Patterns in Law. Could it be that in Western law assumptions are hidden that hinders us in modern times?

Not to miss?  Follow Thinkibility. The blog about Thinking, Creativity, Innovation and Design.


Sub-boxing Everywhere

In all highly developed civilizations, we see a trend to more:

  • segmentation: division into segments
  • specialization: made or used for one particular purpose, job, place, etc.
  • differentiation: development from the one to the many, the simple to the complex, or the homogeneous to the heterogeneous
  • classification: a category into which something is put

You could say that products, jobs, scientific disciplines, processes, phenomena, etc are continually divided up into smaller parts or “conceptual boxes”. The consequence is that such societies become more complex: finding the right “box” and making choices are becoming increasingly laborous and burdensome.

Segmentation is one of the eight trends in TRIZ that predicts the future development of a system that could happen. Below some examples:

Sub-specialties of cardiology are developed along electrical properties of the heart, the use of ultrasound, catheters, and nuclear medicine.

In economics and marketing, product differentiation (or simply differentiation) is the process of distinguishing a product or service from others, to make it more attractive to a particular target market.

Some hundred years ago sport shoes were invented as an alternative of the rather rigid all-day-shoe of leather. Nowadays for nearly any sport there is a specialized shoe available, specifically designed for that sport.

Sometimes the further segmentation reaches to the point of absurdity:


Market segmentation is a marketing strategy which involves dividing a broad target market into subsets.


Segmentation has been one of the strongest strategies in marketing as it is traditionally practiced. If you enter a new category, you attempt to create a product that is distinct from those already there, by carving out a niche. However, segmentation is a more-of-the-same strategy and could be easily counterproductive because it is based on the existing products and markets. Instead of fighting over an ever decreasing fragment of a market, by transforming a product enough to make it suitable to satisfy new or different needs, it is possible to create a new market. It is called lateral marketing.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) offers a common language and standard criteria for the classification of mental disorders.The DSM-I, from 1952, listed 106; the DSM-III, from 1980, listed 265, and the current DSM-IV has 297 mental disorders. It means that over 5o% of all Americans will have a diagnosable mental illness in their lifetimes. It seems that “b0xing”and “sub-boxing” provoke their own dynamics, as explained in this interesting article: Abnormal is the New Normal by Robin S. Rosenberg


Poor Social Design – Thinkibility Nibble

According to a Dutch report, the number of people with intellectual disabilities getting paid care,  increased between 1998 and 2011 fivefold (the figures for other Western countries will not be much different)

The large increase is not because more people have a disability, but because the diagnosis is now  made more often by changing demands in society. This would be partly because more and more digital services, such as Internet banking and the smartcard, have becomm widely available. That someone has a mild intellectual disability is by that more likely to be noticed.

Zahlstation im real,-  Future Store

Read again.

The number of people with intellectual disabilities getting paid care are increasing because more and more services become digital available.

It is normally assumed that (digital) technology will make our existence  easier, yet large population groups are excluded from participation in society by using the same (digital) technology.

Instead they get paid off for their inconvenience, caused by a poor design of digital services.

Technology should be used to make things more simple. Techology that make thinks more complex is simple of a very poor design quality, even for not intelectual disabled.

Key Performance (mis) Indicators


Key Performance Indicators are meant to keep an organisation on track. By measuring the performance over time, you are able to look at deviations and to take measures. As Wikipedia defines it: A  key performance indicator (KPI) is a type of performance measurement. An organization may use KPIs to evaluate its success, or to evaluate the success of a particular activity in which it is engaged. Sometimes success is defined in terms of making progress toward strategic goals, but often success is simply the repeated, periodic achievement of some level of operational goal (e.g. zero defects, 10/10 customer satisfaction, etc.).

The concept behind Key Performance Indicators is to build a feedback loop between input and output. Its working principle does not differ from a thermostat, which senses the temperature of a system so that the system’s temperature is maintained near a desired set-point.


In order to get not market driven organisations more efficient the adage “The numbers tell the tale”has become fashion among governments, institutions and not-for-profit companies. There are several metrics or key performance indicators.

However, Key Performance Indicators can also lead to perverse incentives and unintended consequences as a result of employees working to the specific measurements at the expense of the actual quality or value of their work. In the social sciencesunintended consequences (sometimes unanticipated consequences or unforeseen consequences) are outcomes that are not the ones intended by a purposeful action. Perverse incentives are a type of unintended consequence. A perverse incentive is an incentive that has an unintended and undesirable result which is contrary to the interests of the incentive makers.

There are a lot of examples of bad designed Key Performance Indicators. We came across, but not exhaustive:

  • Police officers get a predetermined quota of fines to give out. The unintended effect of this KPI that the police organisation will be focused on easy to obtain files, f.i. traffic fines instead of fighting serious crime;
  • An organisation involved in handling objections has a KPI for the amount of rejected complaints. Imagine how employees will approach complaints. . .
  • It is generally accepted that the progress of students is evaluated by tests. However, student tests assess only a small part of needed knowledge, skills and attitude of students. Also, often the purpose of the test, timely warning of learning difficulties and study delays, dilutes to “a (missed) ticket to the next hurdle”;
  • An agency of child protection is responsible for placing abused or emotional neglected children in foster parents and child care institutions. It is very logic to design a KPI: like the number of placed children. If this performance is coupled to the financing of the agency, it can easily lead  to placing children out of their home, against sound indications that there is no need for or against parents objections;
  • It is complete reasonable to expect higher efficiency and experience of surgeons as a hospital performs at least 30 knee surgery or angioplasty a year. However, such a KPI can lead to more instead of less knee surgery and angioplasty, an example of a perverse effect contrary to what was originally intended (an intended solution makes a problem worse);
  •  The selling of mortgages as an end in itself, even to people who could no pay the interest, led to the bank crisis in 2008. Another example of a negative, unexpected detriment occurring in addition to the desired effect of the policy to motivate sellers to do better their best.
  • To increase the efficiency of university studies universities are judged on the number of successful students per year. It is now tempting to reduce the requirements for passing exams.
  • In order to increase the efficiency of General Practitioners many assurance companies allow for not more than ten minutes consults by patients. This KPI leads to far more referrals to medical specialists because GP’s have not much time to carefully investigate the medical complaints. This is an example of a counterproductive KPI: it is more of an “obstacle” than a help in the achieving of a productive project or an objective;
  • Crews of warships run annual series of nautical and operational exercises. Through a complex multi-factor analysis, a KPI is derived: Operational Employ-ability. Members of Parliaments asked questions when the KPI decreased to 10%, as a warship was actually deployed in a crisis;
  • Notorious are budgets: the setting of expenditure levels for each of an organization’s functions. It expresses strategic plans of business units, organizations, activities or events in measurable terms. However, such budget tends to be exhausted at the end of the year, because organizational units realise that they will be shortened in budget for next year, because last year they needed not the full budget. So, as an example, in many towns you can observe that every five to ten years the same streets and squares are completely overhauled without any need but in order to use the full budget.

Many Key Performance Indicators have unintended effects. They function as rules for behavior. Key performance Indicators are designed to notice need for adjustments of the course of an organisation. However, more often than not, they are invitations to cheat, by employees but equally by companies and institutions,  especially when financial consequences are attached to the KPI.

Whenever designing or encountering a Key Performance Indication, be warned!


unintended consequences

For more examples of perverse incentives, see here. For examples of unintended consequences see here.

To built up your Thinkibility skills, imagine your are the director of a hospice. You have set a thinking task: how to improve the occupancy (KPI) of the hospice. Then check your answers with How Dying Became A Multibillion-Dollar Industry.