Blog#7 Foundational Concepts: Root Cause Analysis
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Root Cause Analysis - You might be familiar with the concept, or it might sound entirely foreign, but it's a type of analysis we've all likely engaged in at some point or another. Let me share a personal anecdote to illustrate its significance. Picture this: I’m strolling through the neighborhood, lost in thought, when suddenly I stub my toe on an uneven section of the sidewalk. Ouch. Sure it’s a minor inconvenience, but who's to blame? Some might shrug it off and move on, but that just isn’t me—I start playing detective. Was it the negligence of the construction crew who left the sidewalk uneven? Or perhaps the distraction caused by a passerby that altered my stride? Maybe it's the responsibility of the city for failing to maintain the sidewalk adequately? Or more likely, is it simply my own clumsiness? The possibilities can seem endless if you go down this hole. As you'll soon learn, this concept of root cause analysis is integral to our approach to preventative healthcare.
In previous articles, we've concentrated on laying the groundwork for comprehending the changing landscape of modern medicine, aiming for better health outcomes through the key health pillars. However, this week we dive deeper, confronting the stark reality of our mortality, and employing our own root cause analysis to tackle a fundamental question: What do we truly die from?
Many, including seasoned experts, tend to view mortality through the lens of its final stage, its end state. While identifying the primary causes of death may appear straightforward through a quick, cursory online search, medicine seldom operates in absolutes. Determining the precise cause of death often becomes an ongoing debate—a perpetual cycle of root cause analysis.
Consider the recent pandemic with COVID-19. While some individuals may succumb directly to the hypoxia induced by the virus, many others meet their end due to the downstream effects of the disease. A severe inflammatory response triggered by an influx of cytokines might precipitate a fatal pulmonary embolism, or an extended stay in the ICU could lead to bacterial pneumonia from prolonged intubation. Pinpointing the precise cause of death can be exceedingly challenging.
Therefore, we cannot simply fixate on the final outcome of a specific disease, ailment, or injury. I argue that the true pearly white answer actually lies in examining the cumulative burden of disease, or co-morbidities, over an individual's lifespan.
Take the case of Ms. Johnson, for instance, who spends the majority of her life leading a sedentary existence, grappling with obesity, slow but steady muscle loss (sarcopenia), chronic pain, and diabetes—a condition that wreaks havoc on her metabolic health while accelerating the deposition of fatty plaques within her arterial walls. If she ultimately succumbs to a myocardial infarction (i.e., one of those plaques dislodges, travels to her heart, and obstructs blood flow), is the myocardial infarction truly the sole culprit, or root cause? While the death certificate may attribute her demise to a myocardial infarction, the narrative may be far more nuanced.
Why does this question matter? Because it holds the key to formulating a comprehensive strategy for preventing the onset of disease in the first place.
Too often, we adopt a narrow perspective to situations like this asking, "How then can we prevent a myocardial infarction, or more generally, heart disease?" It's a valid question, indeed—an imperative one. But it isn’t the right question, as it isn’t directed at the source of the problem. Consequently, we’ve seen conventional medicine veer towards mitigating disease progression (when it has already settled in) rather than embracing the true sense of disease prevention. Whether conscious of it or not, you’ve likely been witness to this. Every pharmaceutical advertisement features characters grappling with diseases, rather than individuals who have evaded illness altogether.
Hence the utility of root cause analysis, to help us pose more poignant questions such as, “How can we prevent the underlying causes of heart disease?” It’s only a slight rephrase of the original question, but an important one to make nonetheless. In clinical practice this translates to evaluating individual risk factors and lifestyle habits that predispose to disease.
Through Medicine 2.0, we've erected colossal treatment apparatuses driven by data-centric guidelines for various medical diseases and illnesses. However, these frameworks tend to hyper-focus on either treating the final stage or stalling the progression of existing ailments. We invest a disproportionate amount of resources in addressing the consequences of disease rather than tackling their origin.
For Ms. Smith, a robust application of root cause analysis would unearth an entirely different narrative. We might redirect our resources towards preventing obesity in the first place. Alternatively, we might discover that Ms. Smith's obesity stemmed from mobility issues following a knee injury that received inadequate rehabilitation.
Of course treating any disease is important, and we shouldn’t ignore those primary disease processes that do show up on the death certificate - cardiovascular disease, metabolic disease (e.g. diabetes), neurodegenerative disease (e.g. dementia), or cancer. However, we cannot effectively prevent these afflictions if we fail to probe their origins.
In conclusion, embracing the concept of root cause analysis offers us with a powerful lens through which to understand the course of disease and mortality, all while paving the way towards proactive healthcare interventions. By acknowledging that the true causes of death often emanate from a constellation of lifestyle choices, environmental influences, and underlying health conditions, we can pivot our focus from merely treating symptoms to preventing, or at least delaying, the onset of disease.
As Nietzsche aptly remarked (or was it Kelly Clarkson?): It’s about “that which does not kill us that makes us stronger.”
