Blog: DRY violations and why they matter in medicine 

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Posted on June 12, 2020
Tags:  (Information Technology) 
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DRY (Don't Repeat Yourself) design is commonplace in IT. The concept of DRY design though is paradoxically rarely followed in Medicine.

This is a cut-and-paste of a reply I made recently on a chat board with the College of Family Physicians Canada’s TimedRight portal regarding somebody's proposal to simplify the situation with FFS medicine by bringing privatization. 


".. Creating more tiers (like privatization) is a further step in the wrong direction in a series of steps in the wrong direction. Every time you try to fix a system by bootstrapping and adjunct system on to it you violate what programmers call the DRY (don't repeat yourself) principle. To the extent that DRY violations address a problem the benefits of DRY violations are linear, short term and 'parochial'.

The disadvantages of DRY violations are exponential and unpredictable. You cannot pin down the negative effects at the time you make a DRY violation as a programmer. The only thing you can predict is that they will outstrip the benefits. It is a mathematical certainty. This is not an argument that new ideas are bad. This is a reminder that if a new idea requires a DRY violation it warrants extra scrutiny.

Programmers directly inherit the consequences of these violations. As such the vetting is tighter and more long-game than what I observe in medicine.

Decision making in medicine in a communications focussed era needs to be new and flashy. This means that ideas that are not completely tethered to reality can outcompete ideas that are. Reforming a system is not as flashy as creating an alternate DRY violating add-on with lots of faith-based projections.

Reform is a harder 'sell' these days. This is too bad because it is **still** a cheaper and more effective option. ie our valuations may have changed but science and math have not.. "


DRY design does has broad application medicine.  I wish government would take a stronger interest in this and think more about the long game before they say yes to new and novel ways of connecting providers to services. It's a time-proven money saver.

When I think about violations of the DRY principle I think about how much more difficult it is now to refer somebody to see the specialist than it was 25 years ago.  Back when we just had fax machines and phone lines the only source of truth was the front desk at your clinic. Things were really straightforward. This cleared the path to think more about the patient and less about the process.

Since then it's been more progress = more problems. 

It's not that technology is bad. It's just that people don't pay attention to good design anymore and they give up too easily on repairing what they have. Why? Partly it it because technology can bad design decisions look plausibly good;  good enough to get funded that is. It's too easy to just start something new instead of evolving what you have.

Even if something proves to have been a bad idea in hindsight once it gets funded people, their reputations and a budget get attached to it. This leads to a beginning, a middle it often a very long-drawn-out end. While in force these DRY violations can do harm particularly in their later phase where they are broadly recognized to no longer helpful but still mired in sunk cost bias.

There are downsides to an over-emphasis on the DRY process in planning. I have linked to a good distillation (warning involves code) of these pitfalls below. This blog is more intended to reintroduce the notion that we may have deemphasized DRY as a design concept recently and that this may be in some use cases problematic.




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