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Monday, July 6, 2015

ObamaCare in the wake of King v Burwell at SCOTUS


From The New Yorker:
Why Obamacare’s Future is Secure
BY JAMES SUROWIECKI


...Chief Justice John Roberts’s successive opinions in defense of the Affordable Care Act—National Federation of Independent Business v. Sebelius, in 2012, and then, last week, King v. Burwell—have definitively ended the debate about the legality of Obamacare. And just as the earlier Roberts’s decision paved the way for the New Deal safety net to become permanent and widely accepted, King may well go down in history as the moment when Obamacare’s long-term survival was guaranteed.

In part, that’s because Roberts’s defense of the law was broad rather than narrow. Many observers had assumed that if the A.C.A. was upheld, it would be under the so-called Chevron doctrine, which says that when a statute’s meaning is ambiguous, courts should defer to the administrative agency’s interpretation of it, as long as that interpretation is reasonable. In the case of King, Chevron would have had the Court defer to the I.R.S., which had read a disputed sentence of the law to mean that people in states that had not established insurance exchanges, and who instead signed up on the federal one, were still eligible for subsidies. Instead, Roberts chose a different tack, ruling that when it comes to matters of deep “economic and political significance,” it is the Court’s responsibility to decide what a statute means. And that cleared the path for Roberts’s sensible judgment that, regardless of the careless way the law was drafted, when you looked as the A.C.A. as a whole, it was plain that the intent of Congress was that any citizen of the United States, assuming they met the income criteria, should be eligible for health-insurance subsidies.
"it was plain that the intent of Congress was that any citizen of the United States, assuming they met the income criteria, should be eligible for health-insurance subsidies."
 That's what I've been saying all along. I'd even predicted, albeit with some hesitancy, a 6-3 vote to Uphold.

More Surowiecki:
[The ACA] actually embodies the principles that most Americans think a health-insurance system should have. That may seem hard to believe, given how much flak the law has taken; even today, in most polls a plurality of those surveyed oppose it. But the data also show that Americans overwhelmingly think it’s important to have health insurance. They believe that insurance plans should have “guaranteed access,” meaning that insurance companies should not be able to deny coverage to people because of preëxisting conditions. In a 2013 New York Times poll, for instance, a remarkable eighty-six per cent of those surveyed opposed discrimination against preëxisting conditions. They also believe in community rating, meaning that women and men should pay the same premiums and that insurance companies should not be able to charge higher premiums just because someone has a preëxisting condition. A sizable majority of Americans also think that low- and middle-income people who don’t have health-care coverage through their employer should get subsidies to help them pay for insurance.

Americans still don’t like the individual mandate requiring them, in most circumstances, to get coverage. But if you want the aspects that are popular, you’re most likely going to need some form of a mandate, which gets younger and healthier people into the system—driving down over-all costs by helping pool risks—and prevents them from gaming it by waiting until they’re sick to buy insurance. You also need subsidies, since there’s no point in mandating that people buy insurance if they can’t afford it. The result may seem kludgy and inelegant. But if you want—and, again, most Americans do—a system that has guaranteed access, community rating, and that keeps insurance relatively affordable for the average American, you’re likely going to get something like Obamacare...
...So with every day that passes, repealing Obamacare gets tougher. Indeed, that’s why the plaintiffs in King mounted a lawsuit that was, as Jeffrey Toobin recently put it, so blatantly cynical—they knew that their best chance of scrapping the law was to have the Court do it for them. And that’s why Roberts’s refusal to do this was so momentous. It would not be surprising to learn that John Roberts thinks Obamacare is a terrible idea. But he’s done his best to insure that it’s going to be around for a long time to come.
I'd eventually started to wonder whether SCOTUS agreeing to hear King v Burwell was a Roberts Rope-a-Dope -- i.e., "be careful what you ask for." A 5-4 would have Kept (anti-ACA) Hope Alive. 6-3 is quite another matter.

"Like, enough, already! Take this back to the Hill if you want redress; quit bothering us with this weak stuff..."

In my view, the King decision was entirely consistent with the clear intent of the law. Justice Scalia was left to poignantly splutter incoherently (and rudely) in dissent. His retirement can't come soon enough for me.

OK, NOW WHAT? WE STILL HAVE MUCH WORK TO DO

All of the advances in medical science (and clinical pedagogy), health IT, and progressive delivery process QI we can muster will still be hemmed in by national policy. Will we continue to experience our health care in the "Shards" of my recent characterization? Will the ACA be complicit in that chronic fragmentation?

Below: I came to this book via the online recommendations of some of those whose work I respect. This has gotta get an award for "Ugliest Book Cover of 2015 Thus Far" (I know they're just attempting some allusive red/blue graphical metaphor stuff, but, ugh).


It's a pretty good read, and, at $2.99 Kindle edition price, an excellent value. Some summary excerpts:
Introduction 
For all the great reporting on and analysis of the Affordable Care Act done by journalists and healthcare policy wonks, the complexity of the law’s many moving parts and the high-stakes political battle surrounding it have defeated any efforts to tell a cohesive story. Yet such an accounting – one that navigates the maze of ObamaCare’s positives, negatives and alternatives with a compass unskewed by politics or ideology – is needed to make sense of the mostly unconstructive debate surrounding what may be the most far-reaching piece of legislation in nearly a half century.

While Republicans too often resort to hyperbole in criticizing the law, Democrats meet substantive complaints with a mixture of denial (ObamaCare critics are peddling myths), defensiveness (Republican ideas would cause bigger problems) and resignation (Sure, the law could be better, but the GOP will never let that happen). The American people have pretty clearly had enough of this circular conversation. Polling shows that they don’t hold ObamaCare in very high regard, but they want the law fixed, not scrapped.

This small book aims to change the conversation about ObamaCare in a meaningful way, and that begins by explaining why the American people are right: The law is sorely in need of reform. While there is no doubt that ObamaCare accomplished a world of good in its first year and a half, and there are many, many successes worth celebrating, I will show that its shortcomings are widespread, profound and very likely to grow worse over time.

This is the logical and necessary starting point for two simple reasons: 1) The first step in reaching a consensus that the Affordable Care Act must be reformed is broad recognition that it falls far short of its promise for far too many of those it was supposed to help; and 2) A clear understanding of what is wrong with the law is an essential guidepost in figuring out how it should – and shouldn’t – be fixed.

While the first half of the book is devoted to explaining what’s wrong with ObamaCare, the real purpose – and the focus of the second half – is to map out a path that can better achieve the goals of the Affordable Care Act.

Chapter 1: Swiss Cheese will explain why the Affordable Care Act is a misnomer for people in a wide variety of circumstances:

The Medicaid Gap: Millions of poor people in 21 states earn too little to qualify for exchange subsidies, yet they remain ineligible for Medicaid because their state political leaders have opted to spurn the Affordable Care Act’s expansion of the program to everyone earning up to 138% of the poverty level.

The Bronze-Plan Trap: Rather than paying an individual mandate penalty, many low-income households are opting for bronze plans that may have the appearance of being pretty cheap. Yet those high-deductible plans could have families pay as much as 40% of their annual income to cover health spending before they begin receiving any help from ObamaCare. To call these households underinsured is an understatement.

The Family Glitch:
For families in which one spouse happens to have an offer to buy health insurance through an employer, the rest of the family is ineligible for exchange subsidies, potentially putting coverage financially out of reach for well over a million spouses and children.

The Middle-Class Cliff: A couple in their early 60s with earnings just above the $ 62,920 cut-off for ACA exchange subsidies may have to pay as much as 40% of pre-tax income on premiums and medical bills if they buy the cheapest-available bronze plan.

The “Skinny” Plan Loophole: In order to limit their own liability under ObamaCare, some employers are offering so-called “skinny” plans to modest-wage workers that provide no coverage for surgery or hospitalization. This is the kind of health insurance in name only that ObamaCare was supposed to supplant.

Graham, Jed (2015-06-23). ObamaCare Is A Great Mess: A View of the Affordable Care Act Without Partisan Blinders & How to Fix It (Kindle Locations 27-63), Kindle Edition.


Chapter 1 takeaway
Judging the Affordable Care Act by how many people get coverage or based on its many, many success stories isn’t sufficient. It also needs to be evaluated based on whether it lives up to its promise of ensuring that pretty much every American household is offered the opportunity to access affordable health care. On that score, it falls far short of its goal, and only partly because the Supreme Court made the Medicaid expansion voluntary.

Millions of low-income individuals and families who are eligible for ACA subsidies are finding that the only ACA coverage they consider affordable won’t protect them from financial distress. Many other households from the working class to the middle class are cut off from much-needed help, either because an offer of employer coverage puts exchange subsidies off limits or because their income puts them just on the wrong side of the subsidy cliff. (Kindle Locations 334-343)

Chapter 2 takeaway
All of the evidence points to the conclusion that the ObamaCare employer mandate has had a measureable, though less than dramatic, effect in limiting the work hours of low-wage employees. Yet there are a host of other less-obvious ways in which the mandate also works against the goal of reducing inequality, leading employers to hold back on wage gains and possibly limit hiring, CBO has said.

The ACA, by providing bigger subsidies to those with lower incomes and making affordable health care less dependent on work, provides both the opportunity and incentive for people to choose to work less. Yet at certain points of the income spectrum, ObamaCare goes overboard in punishing work, sometimes leaving a stark choice: Earn less or forgo affordable coverage. A more careful approach is needed to balance the imperative of an effective safety net and the value of work, in part because ACA work disincentives carry a budget cost – an estimated $ 200 billion through 2024. (Kindle Locations 599-607)

Chapter 3 takeaway
While exchange enrollment will continue to ramp up over the next couple of years, design problems with ObamaCare are likely to make lower participation among the young and healthy a chronic condition, leading to premiums that are higher than necessary. Moderate-income young adults are asked to pay 75% more for a bronze plan than is charged to much older adults at the same income level. Yet ObamaCare’s individual mandate penalty is at its weakest for these young adults, amounting to less than one-third of premiums for high-deductible bronze plans, which will encourage them to gamble on staying healthy.

The negative impact on premiums of a relatively older group of enrollees is likely to be exacerbated by the way ObamaCare subsidies divide up the risk pool, sending low-income enrollees with greater health needs to the deep end, bronze purchasers to the shallow end and catastrophic buyers into a separate kiddie pool. Yet, because catastrophic coverage isn’t proving to be an affordable option in much of the country, many moderate-income young invincibles are more likely to stay out of the pool altogether. (Kindle Locations 820-829)

Chapter4 takeaway
The big test of the ACA’s ability to deliver adequate patient access to care and restrain premium increases has just begun. Some $ 8 billion a year in funding to facilitate patient access is disappearing, and temporary government programs are running low on firepower to bolster the bottom lines of insurers who price premiums too low.

The breadth of double-digit premium hikes proposed for 2016 by market-leading insurers has underscored concerns that the exchanges are attracting a population with higher average medical costs than expected. As premiums, both before subsidies and after, increase faster than income – and faster than the individual mandate penalty – the risk is that the robustness of the insured pool will deteriorate over time as the relatively young and healthy gravitate to high-deductible plans or opt to go without coverage. (Kindle Locations 1043-1051)

Chapter 5 takeaway

Although the Affordable Care Act falls short in many respects, it sets the right goal of ensuring affordable access to health insurance that provides a reasonably appropriate level of coverage. While some ideas for fixing or replacing the ACA would help some people – sometimes at the expense of others – none of the approaches target that goal of broad access to affordable coverage, whether one is young or old; healthy or sick; male or female; near-poor, working class or middle class. (Kindle Locations 1278-1282)

Chapter 6 takeaway
Improving upon the ACA’s affordability problems and making government tax subsidies for buying coverage contingent upon remaining insured can make the individual mandate obsolete. A series of reforms proposed in this chapter would cut the price of a bronze plan by up to 48% for moderate-income young adults and make not-quite-so-high-deductible coverage free, or very close to free, for everyone earning up to 200% of the poverty level. (Kindle Locations 1506-1509)

Chapter 7 takeaway
The employer mandate’s heavy burden on low-wage employers and its firewall that keeps low-wage workers from accessing exchange subsidies are inimical to the goals of the Affordable Care Act. A more rational approach to making employers responsible for contributing to workers’ health coverage could eliminate the glaring problems with the mandate, while providing a modest degree of protection for the employer-sponsored insurance market from sudden disruption. Yet, because moderate-income workers would ultimately bear much of the cost of even a reformed employer mandate, getting rid of it would be the best option. (Kindle Locations 1720-1724)
The author's argument is buttressed by a ton of data, though some of the examples bring to mind the admonition "the plural of 'anecdote' is not 'data'." Nonetheless, Mr. Graham does a pretty good job detailing the maddening complexity of the administration of the ACA and its myriad unintended consequences.

Missing from the book is any substantive discussion of the fundamental actuarial misalignment that continues to bedevil U.S. healthcare policy ("community rating" notwithstanding). As I wrote down near the end of my "Shards" post,
One of my ongoing concerns goes to the "shards" of U.S. health care that comprise the central theme of this post. IMO, it's debatable (and likely unknowable) whether the ACA has increased the prevalence of "broken glass" in the delivery system. Health care "insurance" remains only partially "insurance" in the actuarial sense. The bulk remains woefully inefficient 3rd party (parasitical?) intermediated pre-payment. The ACA is largely a huge, hypercomplex "insurance" reform law with a few QI and payment "improvement" initiatives tossed in.

One thing is clear. Without the ACA, someone like me would now be an actuarial leper --  "uninsurable." Going public with my condition absent the constraints of the ACA would have been unthinkable. (It gave me pause, I have to say, to start this post prior to today's SCOTUS announcement.)

Nonetheless, certain fundamental elements of contention remain. We know that medical actuarial utilization risk is a ~60 year proposition (speaking just of adults), highly and curvilinearly correlated with age. Yet we continue to sell health "insurance" in one-year chunks. Someone like me is now regarded by the likes of BCBS/RI as a "medical loss ratio" loser. Any clinical benefits that accrue to me are a loss to them economically during any one policy period. Those who underwrite clinically effective px's/tx's will in many cases see other parties benefit down the line (in econ-speak, "first mover disadvantage").

Again, we've known this stuff for a long time...
I remain skeptical that we're going to see any constructive, sustained bipartisan attempts at "fixing ObamaCare" with the 2016 White House race now ramping up. I would love to be wrong.

SENATE HELP COMMITTEE HEARING UPDATE, JULY 7TH


Senator Bernie Sanders calls for Single Payer. Much of the ensuing discussion (watching live right now) resonates precisely with Jed Graham's book. No prepared statements, hope there will be a published transcript. Acting Chair Senator Mike Enzi (R-WY) opened with a mostly rambling reminiscence about his having worked on health care issues with the late Senator Kennedy. He then essentially repeated the story in his closing remarks.
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TECH SIDE UPDATES

Just up at Dr. Carter's EHR Science:
Clinical Software Engineering, Part I: Moving from Generic to Specific
by JEROME CARTER on JULY 6, 2015


There is no standard method or process for creating clinical software, and this bothers me – a lot. There is no information model that everyone agrees on, no object names or properties or methods. Even though clinical care is a collection of processes, we have no standards for naming those processes, the steps that comprise them, nor any standard way of demarcating process boundaries. Despite the years and dollars that have been dedicated to creating clinical software, little has been done in the way of saying how clinical software is best designed and built. It is now time to take up that challenge.

When HITECH went into effect in 2009, EHR systems were seen as the ultimate in clinical software and the centerpiece of HIT. Six years later, we realize that care coordination and patient engagement require much more than an electronic chart, that data exchange must occur between a range of computing devices, that data can arise from any number of sources, and that influencing clinical processes requires software support. The range of processes, users, and data that clinical care systems must support is growing, resulting in new requirements that no one imagined 10 years ago...
 And, from Wired:
Medicine Is a Battlefield. Here’s How to Stay in the Know

SCIENCE, IT’S BEEN said, is a full-contact sport. Even when it doesn’t reach the Supreme Court—from whence a crucial decision upholding Obamacare rumbled forth late last week—health care is constantly tangled up with policy.

And that war in medicine is long tenured. The road to basic research is a gauntlet. Translational medicine is in a mosh pit of competing interests. Clinical trials shift end points like a juking boxer. And if you’re following these streams you won’t miss a moment of the action...
Great links in this article.
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More to come...

Sunday, July 5, 2015

Spiritual statins? Headspace.com: Health IT, meet Mindfulness IT

Add one more to the current "mobile apps" craze. In my current hardcopy New Yorker:

The Higher Life
A mindfulness guru for the tech set.

BY LIZZIE WIDDICOMBE


THRIVE, yet another TED-style ideas conference offering mental and spiritual rejuvenation to the business world. It was organized by the “Morning Joe” co-host Mika Brzezinski and the new-media mogul Arianna Huffington, and conceived, Huffington said, to correct a problem that she had perceived in herself and other harried strivers. According to the event’s Web site, “The relentless pursuit of the traditional measures of success—money and power”—had resulted in an “epidemic of burnout”: stress-related illnesses, relationship problems. In addition to frantically pursuing the traditional measures, it was time to introduce a “ ‘Third Metric’—a combination of well-being, wisdom, wonder, and giving.”

THRIVE’s speakers included women with expertise in the first two metrics: Katie Couric, Tory Burch. But a keynote address was delivered by a Third Metric expert: Andy Puddicombe, a forty-two-year-old British meditation teacher. Puddicombe trained as a Tibetan Buddhist monk before creating an iPhone app called Headspace, which teaches meditation and mindfulness techniques. Since 2012, when the app launched, Headspace has been downloaded by three million users. Among its acolytes are Richard Branson, who put the company’s meditation exercises on Virgin Airlines flights, and the Seattle Seahawks. The Times has written that Puddicombe is “doing for meditation what someone like Jamie Oliver has done for food.”

...For several years now, the overlapping worlds of business and self-help have been abuzz about mindfulness meditation. (In February, an executive coach opined in the Harvard Business Review that mindfulness “is close to taking on cult status in the business world.”) The World Economic Forum, in Davos, opens with daily meditation sessions; Fortune 500 companies like General Mills, General Motors, and Target offer their employees contemplative programs, embracing Huffington’s message that enlightenment need not be at odds with the pursuit of profit. Goldman Sachs and the Dana-Farber Cancer Institute have bought bulk subscriptions to Headspace for their employees.

As with many contemporary trends, Silicon Valley was there first. Meditation was one of the habits that seeped from San Francisco’s counterculture into its hacker culture. For years, its high priest was Steve Jobs, a Zen enthusiast. These days, it’s Chade-Meng Tan, a Google engineer who, in 2007, helped create Search Inside Yourself, a “mindfulness-based emotional intelligence” course that has since been taken by thousands of the company’s employees. Tan told David Gelles, the author of “Mindful Work,” that Google’s program represents “the fourth turning of the wheel of the dharma.” Eastern spirituality seasons much of today’s techno-utopianism. HBO’s “Silicon Valley” includes a C.E.O. who consults a guru and says things like “I don’t want to live in a world where someone makes the world a better place than we do.”


Silicon Valley’s interest in meditation is, in some respects, adaptive. “We’re at the epicenter of being stimulated with digital stuff,” Mamood Hamid, a venture investor at Social Capital, told me. “Five years ago, it was just e-mail. Now if you’re not on Twitter, if you don’t know how to use social, you’re a Luddite. And then you add the Apple Watch that’s going to be giving you notifications every five minutes—text messages, e-mails. It’s going to drive you insane.” Stewart Butterfield, the C.E.O. of Slack, noted that this is a fate that awaits us all. “I feel like we’re in the early stages of a species-level change with devices,” he told me.

All of this has led to a strange but perhaps inevitable oxymoron: digital therapy. A new class of app has emerged on iPhone screens, promising to relieve the mental afflictions—stress, distraction—that have been exacerbated by its neighbors. A venture-funded company called Big Health is developing a suite of cognitive-behavioral-therapy apps. (Its first product, Sleepio, treats insomnia.) And though Hamid considers Headspace to be the best mindfulness-meditation app, in terms of its “content and sophistication,” there are many others, including buddhify, which collects data via daily “mood check-ins”; Calm, which offers meditation exercises set to soothing nature scenes; and Insight Timer, which provides Tibetan bell sounds. Huffington has an app, too, called GPS for the Soul.


At THRIVE, Puddicombe brought up the health benefits sought by some meditators—better sleep, lower blood pressure—before getting to the heart of the matter: attention. He cited a 2010 Harvard study about mind-wandering: “Forty-seven per cent of our life is spent lost in thought. Distracted!” If we meditate a lot, “it’s almost like there’s a little more room, a bit of space in the mind.”...
Interesting article, a fairly long read. Worth your time, spike in the dubiety meter notwithstanding.
...As technologies for studying the brain have improved, a new field of inquiry has emerged, sometimes called contemplative neuroscience, which examines the effects of meditation on the brain. The preliminary findings of the studies are reported breathlessly: recent headlines in the Times include “MEDITATION FOR A GOOD NIGHT’S SLEEP” and “EXERCISING THE MIND TO TREAT ATTENTION DEFICITS.” Headspace, which employs a chief medical officer, Dr. David Cox, has a promotional pamphlet that relates an array of “Quantifiable Positive Outcomes of Mindfulness Training.” These range from “stress and anxiety reduction” to “immune function,” “compassion,” and “heart health.” When it comes to psoriasis, Headspace notes, referring to a paper co-authored by Kabat-Zinn, “the meditators’ skin cleared around four times faster than the non-meditators.” This can make meditation seem like a wonder drug: Adderall, Prozac, and Proactiv rolled into one.

While it’s true that a recent metastudy found that mindfulness meditation produces effects that are equivalent to those of antidepressants, scientists caution that the research is in its early stages. Most of the studies are pilot studies, and many lack an “active control”—a kind of meditative sugar pill, to guard against the placebo effect. (Headspace is considering developing a fake meditation app.) Bias can cloud the results, too. As one review put it, wryly, “Many researchers are enthusiastic meditators themselves.” Kerr, the neuroscientist, said that if you join “a mindfulness group or get an app like Headspace, you should not assume that your depression will magically lift or your skin will clear up.”

Many Buddhists don’t love the wonder-drug version of meditation, either. They are bothered by the way that it has come to be adaptable to any goal, from training marines to picking investments. (A Reuters article called “Meditation and the Art of Investment” quotes Ray Dalio, of the hundred-and-seventy-billion-dollar hedge fund Bridgewater Associates: “Meditation more than anything in my life was the biggest ingredient for whatever success I’ve had.”) David McMahan, the scholar, pointed out that in Buddhism mindfulness doesn’t quite work that way: “You are supposed to be mindful of something: the teachings of the Buddha!” The teachings of the Buddha are not always warm and fuzzy, nor would they play well at a corporate retreat. The most important precept, after all, is the universal truth of suffering...
Yeah. I am reminded of a small volume I read over and over again while sitting by my dying daughter's bedside in Brotman Medical Center in Culver City in 1998 during the last few months of her life.

DESPITE THE BUDDHA’S own succinct account of his awakening, it has come to be represented (even by Buddhists) as something quite different. Awakening has become a mystical experience, a moment of transcendent revelation of the Truth. Religious interpretations invariably reduce complexity to uniformity while elevating matter-of-factness to holiness. Over time, increasing emphasis has been placed on a single Absolute Truth, such as “the Deathless,” “the Unconditioned,” “the Void,” “Nirvana,” “Buddha Nature,” etc., rather than on an interwoven complex of truths. 

And the crucial distinction that each truth requires being acted upon in its own particular way (understanding anguish, letting go of its origins, realizing its cessation, and cultivating the path) has been relegated to the margins of specialist doctrinal knowledge. Few Buddhists today are probably even aware of the distinction.

Yet in failing to make this distinction, four ennobling truths to be acted upon are neatly turned into four propositions of fact to be believed. The first truth becomes: “Life Is Suffering”; the second: “The Cause of Suffering Is Craving”— and so on. At precisely this juncture, Buddhism becomes a religion. A Buddhist is someone who believes these four propositions. In leveling out these truths into propositions that claim to be true, Buddhists are distinguished from Christians, Muslims, and Hindus, who believe different sets of propositions. The four ennobling truths become principal dogmas of the belief system known as “Buddhism.” 

The Buddha was not a mystic. His awakening was not a shattering insight into a transcendent Truth that revealed to him the mysteries of God. He did not claim to have had an experience that granted him privileged, esoteric knowledge of how the universe ticks. Only as Buddhism became more and more of a religion were such grandiose claims imputed to his awakening. In describing to the five ascetics what his awakening meant, he spoke of having discovered complete freedom of heart and mind from the compulsions of craving. He called such freedom the taste of the dharma...

AN UNAWAKENED EXISTENCE, in which we drift unaware on a surge of habitual impulses, is both ignoble and undignified. Instead of a natural and noncoercive authority, we impose our will on others either through manipulation and intimidation or by appealing to the opinions of those more powerful than ourselves. Authority becomes a question of force rather than of integrity. 

Instead of presenting himself as a savior, the Buddha saw himself as a healer. He presented his truths in the form of a medical diagnosis, prognosis, and treatment. If you have a pain in your chest, you first need to acknowledge it. Then you will go to a doctor for an examination. His diagnosis will both identify the cause of pain and tell you if it is curable. If it is curable, he will advise you to follow a course of treatment. Likewise, the Buddha acknowledged the existential condition of anguish. On examination he found its origins to lie in self-centered craving. He realized that this could cease, and prescribed the cultivation of a path of life embracing all aspects of human experience as an effective treatment.

WHILE “BUDDHISM” SUGGESTS another belief system, “dharma practice” suggests a course of action. The four ennobling truths are not propositions to believe; they are challenges to act. 

There is a passage in Alice’s Adventures in Wonderland in which Alice enters a room to find a bottle marked with the label “Drink Me.” The label does not tell Alice what is inside the bottle but tells her what to do with it. When the Buddha presented his four truths, he first described what each referred to, then enjoined his listeners to act upon them. Once we grasp what he refers to by “anguish,” we are enjoined to understand it— as though it bore the label “Understand Me.” The truth of anguish becomes an injunction to act. 

The first truth challenges our habitual relationship to anguish. In the broadest sense, it challenges how we relate to our existence as such: our birth, sickness, aging, and death. To what extent do we fail to understand these realities and their implications? How much time is spent in distraction or oblivion? When we are gripped by a worry, for example, what do we do? We might struggle to shake it off. Or we try to convince ourselves that things are not the way they seem, failing which we seek to preoccupy ourselves with something else. How often do we embrace that worry, accept our situation, and try to understand it? 

Anguish maintains its power only as long as we allow it to intimidate us. By habitually regarding it as fearful and threatening, we fail to see the words etched on it by the Buddha: “Understand Me.” If we try to avoid a powerful wave looming above us on the beach, it will send us crashing into the sand and surf. But if we face it head-on and dive right into it, we discover only water. 

To understand a worry is to know it calmly and clearly for what it is: transient, contingent, and devoid of intrinsic identity. Whereas to misunderstand it is to freeze it into something fixed, separate, and independent. Worrying about whether a friend still likes us, for example, becomes an isolated thing rather than part of a process emerging from a stream of contingencies. This perception induces in turn a mood of feeling psychologically blocked, stuck, obsessed. The longer this undignified state persists, the more we become incapable of action. The challenge of the first truth is to act before habitual reactions incapacitate us...

Batchelor, Stephen (1998-03-01). Buddhism without Beliefs (pp. 4-8). Penguin Publishing Group. Kindle Edition.
I found this book quite sustaining during those most difficult of days.
WHEN ASKED WHAT he was doing, the Buddha replied that he taught “anguish and the ending of anguish.” When asked about metaphysics (the origin and end of the universe, the identity or difference of body and mind, his existence or nonexistence after death), he remained silent. He said the dharma was permeated by a single taste: freedom. He made no claims to uniqueness or divinity and did not have recourse to a term we would translate as “God.” Gautama encouraged a life that steered a middle course between indulgence and mortification. He described himself as an openhanded teacher without an esoteric doctrine reserved for an elite. Before he died he refused to appoint a successor, remarking that people should be responsible for their own freedom. Dharma practice would suffice as their guide. 

This existential, therapeutic, and liberating agnosticism was articulated in the language of Gautama’s place and time: the dynamic cultures of the Gangetic basin in the sixth century B.C.E. A radical critic of many deeply held views of his times, he was nonetheless a creature of those times. The axioms for living that he foresaw as lasting long after his death were refracted through the symbols, metaphors, and imagery of his world. 

Religious elements, such as worship of the Buddha’s person and uncritical acceptance of his teachings, were doubtless present in the first communities that formed around Gautama. Even if for five hundred years after his death his followers resisted the temptation to represent him as a quasi-divine figure, they eventually did so. As the dharma was challenged by other systems of thought in its homeland and spread abroad into foreign cultures such as China, ideas that had been part of the worldview of sixth-century-B.C.E. India became hardened into dogmas. It was not long before a self-respecting Buddhist would be expected to hold (and defend) opinions about the origin and the end of the universe, whether body and mind were identical or different, and the fate of the Buddha after death. 

HISTORICALLY, BUDDHISM HAS tended to lose its agnostic dimension through becoming institutionalized as a religion (i.e., a revealed belief system valid for all time, controlled by an elite body of priests). At times this process has been challenged and even reversed (one thinks of iconoclastic Indian tantric sages, early Zen masters in China, eccentric yogins of Tibet, forest monks of Burma and Thailand). But in traditional Asian societies this never lasted long. The power of organized religion to provide sovereign states with a bulwark of moral legitimacy while simultaneously assuaging the desperate piety of the disempowered swiftly reasserted itself— usually by subsuming the rebellious ideas into the canons of a revised orthodoxy [ibid, pp. 15-16]...
While I've been hip to the fundamentals of Buddhist thought (including the Zen) since the 60's (e.g., via the myriad writings of people like Alan Watts, Baba Ram Dass, etc), I'm not much of a routine practitioner, I must confess. Maybe I oughta buy into the Headspace app and check it out, particularly as I now traverse my own cancer journey. Is it legit? More importantly, even if the answer is "yes," will it stay that way? (Or, is the very question antithetical to Buddhist thought?)
Puddicombe is neutral on the subject of the moral status of money, saying, “It’s our relationship to it and how we choose to use it.” According to Puddicombe, one online critic called him a “very greedy monk.” But if Headspace is to bring meditation to every smartphone owner in the world—and do so better than its competitors—the company can’t afford to be unmindful of its finances. Puddicombe and Pierson say they have been approached by more than fifty investors, including most of the prominent names on Sand Hill Road, the hub of venture capital. They haven’t taken any money yet, but Puddicombe said, in a somewhat resigned tone, that “it’s almost inevitable.”

Mamoon Hamid, at Social Capital, said that, despite his admiration for Headspace, he has decided not to invest. His reason was Puddicombe. He told me, “It’s extremely compelling when a Buddhist monk walks in the door. It’s true to brand. It’s authentic.” But, he said, “at the end of the day, we want to create the biggest company around this concept without being shackled by your Buddhist-monk tendencies.” Headspace has an impressive number of users for a product that has spread almost entirely by word of mouth. But, Hamid said, “in order to get to two hundred million users, you have to break a lot of glass along the way. Your company will change over time, and are you O.K. with that?” In the end, he said, “you have to let go”—the dharma of Silicon Valley.
Puddicombe has no backup plan in the event that Headspace fails to become the Uber of mindfulness...
“at the end of the day, we want to create the biggest company around this concept without being shackled by your Buddhist-monk tendencies.”
Yeah. Precisely the problem. Venture capitalism is overpopulated with avaricious Gresham's Dynamic grifters motivated simply by the pot of honey comprising the next big IPO deal. And, as I've joked before,
"Health care needs an Uber like it needs another Gruber."
Check out the Headspace.com website. Pretty interesting.


MORE ON "WELLNESS"
World Health Organization definition of Health

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
apropos, very nice site over at U.Cal Davis:

Some excellent work there. We in the U.S. in particular have a lot of room for improvement across the breadth of these fronts, e.g., I am reminded of my May 1st post on "Upstream" issues.
The assertion is made that perhaps 90% of human health is atributable to "upstream" factors outside the clinical care delivery system: genetics (to the extent that they are still considered "outside of care delivery"), lifestyle factors, culture, poverty, pollution, and environmental factors more broadly.
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UPDATE

From The Atlantic:

...Davidson and his colleagues ran a simple experiment on eight “long-term Buddhist practitioners” whose had spent an average of 34,000 hours in mental training. They asked the subjects to alternate between a meditative state and a neutral state in order to observe how the brain changed. One subject described his meditation as generating “a state in which love and compassion permeate the whole mind, with no other consideration, reasoning, or discursive thoughts.”

“When we did this, we noticed something remarkable,” Davidson said. “What we see are these high-amplitude gamma-oscillations in the brain, which are indicative of plasticity”—meaning that those brains were more capable of change, for example, in theory, of becoming more resilient. The researchers also found in MRI scans of monks that a region of the brain known as the anterior insula was activated. “Every neuroscientist will have their favorite part of the brain,” Davidson said. The anterior insula is one of his, because it’s where a lot of brain-body coordination takes place. “The systems in the brain that support our well-being are intimately connected to different organ systems in our body, and also connected to the immune and endocrine systems in ways that matter for our health,” he said. The brain scans showed that “compassion is a kind of state that involves the body in a major way.” One example: Davidson and coauthors found in another study that meditation improved immune response to an influenza vaccine—and the subjects were not “professional” Buddhist meditators, but people who had gone through an eight-week training program in mindfulness meditation. And a short “compassion training” course, Davidson and colleagues found in a 2013 study, exhibited more altruistic behavior compared with a control group...
'eh?

CODA

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More to come...

Wednesday, July 1, 2015

Still seems like last week

On July 1st, 1998, my first-born child died in my arms in Brotman Medical Center in Culver City, California, in the wake of 26 months of cancer hell. She'd have been 47 this year, and no doubt still turning heads and raising a hilarious ruckus. Sigh...

From my forthcoming book "One in Three,"
It is the soggy and crushingly sad el Nino L.A. winter of 1998. My now- brain-met stroke-addled daughter is painfully traversing the final months of her life. While admitted to acute care facilities (she has been an acute care patient in seven across the two years of her horrific cancer struggle), she gets the best clinical attention available, no strings attached, courtesy of Medi-Cal (the California Medicaid agency for the poor and otherwise medically indigent). But, outpatient care is another matter. Sissy has ongoing need of follow-up physical and occupational therapy, regarding which Medi-Cal will not authorize reimbursement.

Her therapy team from Brotman Medical Center -- at great individual and aggregate personal and professional risk to themselves -- arrange to have her routinely come in incognito off the books (via a back door, no less) to an outpatient rehab clinic in Beverly Hills where they work on the side, to continue her therapy -- notwithstanding that we all know by that time that she will not likely survive much longer.

That is an utterly unembellished true story. There are numerous unsung heroes within our health care industry, people whose unrelenting focus is "patients first."

Sissy and Danielle, Seattle, 1974. Danielle is now Executive Director of the Bay Area Stepping Stones Project. Proud Papa of Danielle and her brother Matthew (the Brewer).


Monday, June 29, 2015

"It's not so elementary, Watson." Developments in Health IT


From The Washington Post:
IBM is now training Watson to be a cancer specialist. The idea is to use Watson’s increasingly sophisticated artificial intelligence to find personalized treatments for every cancer patient by comparing disease and treatment histories, genetic data, scans and symptoms against the vast universe of medical knowledge.

Such precision targeting is possible to a limited extent, but it can take weeks of dedicated sleuthing by a team of researchers. Watson would be able to make this type of treatment recommendation in mere minutes.

The IBM program is one of several new aggressive health-care projects that aim to sift through the huge pools of data created by people’s records and daily routines and then identify patterns and connections to predict needs. It is a revolutionary approach to medicine and health care that is likely to have significant social, economic and political consequences.

Lynda Chin, a physician-scientist and associate vice chancellor for the University of Texas system who is overseeing the Watson project at MD Anderson Cancer Center, said these types of programs are key to “democratizing” medical treatment and eliminating the disparity that exists between those with access to the best doctors and those without.

“I see technology like this as a way to really break free from our current health-care system, which is very much limited by the community providers. If you want expert care you have to go to an expert center,” she said, “but there are never enough of those to go around.”

Instead of having to find specialists in a different city, photocopy and send all the patient’s files to them, and spend countless hours researching the medical literature, a doctor could simply consult Watson, she said...

...[T]he Watson project and similar initiatives also have raised speculation — and alarm — that companies are seeking to replace the nation’s approximately 900,000 physicians with software that will have access to everyone’s sensitive personal health information.

While there’s much debate about the extent to which technology is destroying jobs, recent research has driven concern. A 2013 paper by economists at the University of Oxford calculated the probability of 702 occupations being automated or “roboticized” out of existence and found that a startling 47 percent of American jobs — from paralegals to taxi drivers — could disappear in coming years. Similar research by MIT business professors Erik Brynjolfsson and Andrew McAfee has shown that this trend may be accelerating and that we are at the dawn of a “second machine age.”

Scientists are already testing baker bots that can whip up pastries, machines that can teach math in the classroom and robot anesthesiologists.

Many physicians and academics in medicine have come to view Watson’s work with reservation, despite reassurances from IBM officials that they are trying not to replace humans but to help them do their jobs better.

“I think a lot of folks in medicine, quite frankly, tend to be afraid of technology like this,” said Iltifat Husain, an assistant professor at the Wake Forest School of Medicine.

Husain, who directs the mobile app curriculum at Wake Forest, agrees that computer systems like Watson will probably vastly improve patients’ quality of care. But he is emphatic that computers will never truly replace human doctors for the simple reason that the machines lack instinct and empathy.

“There are a lot of things you can deduce by what a patient is not telling you, how they interact with their families, their mood, their mannerisms. They don’t look at the patient as a whole,” Husain said. “This is where algorithms fail you.”...

One of the top priorities for programmers was to give Watson the power to read and understand natural language. They also gave it the ability to generate hypotheses and locate and parse evidence to support or refute them.

Much like the human brain, Watson has become smarter over time by learning from its successes and failures and from user feedback.

Watson is literally evolving.

In the beginning, Watson’s knowledge base was limited to trivia for “Jeopardy!” But since its debut on national television in February 2011, Watson has devoured many thousands of literary works, newspaper articles and scientific journal reports as well as information input  by hundreds of researchers and doctors nationwide. These experts have helped the machine brain make more reasonable inferences and conclusions by reviewing Watson’s ideas and telling it whether it is right or wrong and by highlighting which sources­ of information are considered more reliable than others.

Unlike a human brain that can be distracted, confused or inspired by huge volumes of information, Watson is not a creative thinker but a rational one. It looks at known associations among various bits of data and calculates the probability that one provides a better answer to a question than another and presents the top ideas to the user.

Rob Merkel, who leads IBM Watson’s health group, said the company estimates that a single person will generate 1 million gigabytes of health-related data across his or her lifetime. That’s as much data as in 300 million books.

“You are deep into a realm where no human being could ever make sense of this information,” Merkel said. That's where Watson comes in to create a “collective intelligence model between machine and man.”

“We’re not advocating that Watson replace physicians,” he explained. “We are advocating that Watson does a lot of reading on behalf of physicians and provides them with timely insights.”

Originally made up of a cluster of supercomputers that took up as much space at IBM as a master bedroom, Watson is now trimmer — the size of three stacked pizza boxes — and versions of it live in the server rooms of IBM’s various partners.

IBM has so much faith in Watson’s innovativeness that in January 2014 the company announced that it would invest an additional $1 billion in the technology, and it created a new division to grow the business. Since then, IBM has highlighted health care as Watson’s priority and said it will dedicate at least 2,000 medical practitioners, clinicians, developers and researchers to the effort and will partner with Apple, Johnson & Johnson and Medtronic to collect patient information that consumers had consented to share...

It is Watson’s work in cancer that is the most advanced.

Among the most ambitious projects is a partnership with 14 cancer centers to use Watson to help choose therapies based on a tumor’s genetic fingerprints. Doctors have known for years that some treatments work miraculously on some patients but not at all on others due to genetics. But the expense and complexity in identifying genetic mutations and matching them up with potential therapies has made it difficult for more than a handful of patients to benefit from this new approach...
Given the personal revelations I just posted ten days ago regarding my recent cancer dx, this is of particular interest to me.

apropos of all of this, another interesting current article, courtesy of The Daily Beast:

The Human Machine
Biologists Are From Mars, Engineers Are From Venus
As IT feverishly vies to disrupt healthcare—and to hack the human organism—engineers are running up against a mindset that’s planets apart from their own.
In less than a generation, IT has smashed, recast and obliterated entire industries. Now the wunderkinds who brought us the Internet and apps for buying Jimmy Choos are laying siege to healthcare, eager to shake-up this most bloated of industries just like they did travel, finance and pet food.

Some in IT are hammering away at healthcare’s Byzantine cost and payment systems. Others are inventing apps and gizmos to collect heaps of health data on everything from sleep patterns to a person’s complete sequence of DNA. A few even talk about disrupting the human organism itself—hacking and reengineering people’s DNA, neurons and cells as if they were processors, motherboards and lines of computer code.

Not surprisingly, this assault of the nerds has encountered considerable resistance, even as some progress is being made. Reasons include cost and payment structures that defy logic, the heavy hand of regulation in medicine, and a powerful and conservative establishment that resists change. Yet there seems to be a much more basic issue at the heart of medicine’s rebuff of the changes offered by IT: that engineers fundamentally don’t get biologists, and biologists don’t get engineers.


This starts with an attitude towards the biology of humans. Engineers like to compare people to really complicated computers. Physicians and biologists beg to differ, saying that humans are far more complex in ways that might take decades or centuries to fully untangle...
With respect to where we stand today, the money quotes:
Engineers inhabit a planet where humans create the machines and the code, and where a better, smaller, and more nimble upgrade will be unveiled at next year’s electronics show. Biologists come from a land where three billion years of evolution created the bio-machines they work with; where their software and hardware is frustratingly obtuse, messy, and obscure, despite recent advances, and filled with redundant systems and twists and turns that no human engineer would ever design.

Engineers are also in a rush. They like to start small and to scale quickly, hoping to leverage small investments into billion-dollar hits that will reach billions of people. They needn’t bother with years of training, and some superstars of IT are college dropouts. They love taking risks and failing fast, and have a powerful culture built around the idea that if you build something cool, people will come.

Biomedicine moves slowly and deliberately, and is conservative about taking risks, particularly when lives are at stake. Practitioners spend years and decades in training, learning endless protocols and standards and procedures, and many devote entire careers trying to untangle a minute facet of a single bio-mechanism. And the idea of scaling—of creating protocols, drugs, and health apps that help millions or billions of people—only works up to a certain point, since people’s underlying physiology and their diseases tend to be different. This scientific realization is at the heart of what’s called precision medicine, the tailoring of drugs and therapies to an individual’s DNA and physiology.

Like IT, biotechnology has created dazzling wonders of high technology, everything from lightning-quick gene sequencers to surgical robots and drugs that target specific gene mutations to treat cancer. Most med tech, however, requires colossal investments and most fail, just like in IT, though they seldom fail fast. This is one reason that new technologies in medicine tend to elevate costs rather then decrease them, and why IT’s efforts to do to healthcare what Priceline did to booking hotels has proven so annoyingly difficult.

Enlightened leaders on both sides are working to breach the gulf between the two worlds. Smart engineers are realizing that they need to listen to and work closely with physicians and hospitals. (Just building a cool app isn’t enough). Doctors are also becoming more entrepreneurial as they work from the inside to build systems that save money and better serve patients—though they face a long slog to make this work...
Yeah.
"Most med tech, however, requires colossal investments and most fail, just like in IT, though they seldom fail fast. This is one reason that new technologies in medicine tend to elevate costs rather then decrease them, and why IT’s efforts to do to healthcare what Priceline did to booking hotels has proven so annoyingly difficult."
Which, among other things, begets repeated congressional hearings full of "Use Case Factories,™" "interoperababble," and general Policy ADHD whining about ONC "failures."

The foregoing articles take me back "Down in the Weeds'."
A culture of denial subverts the health care system from its foundation. The foundation—the basis for deciding what care each patient individually needs—is connecting patient data to medical knowledge. That foundation, and the processes of care resting upon it, are built by the fallible minds of physicians. A new, secure foundation requires two elements external to the mind: electronic information tools and standards of care for managing clinical information.

Electronic information tools are now widely discussed, but the tools depend on standards of care that are still widely ignored. The necessary standards for managing clinical information are analogous to accounting standards for managing financial information. If businesses were permitted to operate without accounting standards, the entire economy would be crippled. That is the condition in which the $2 1⁄2 trillion U.S. health care system finds itself—crippled by lack of standards of care for managing clinical information. The system persists in a state of denial about the disorder that our own minds create, and that the missing standards of care would expose.

This pervasive disorder begins at the system’s foundation. Contrary to what the public is asked to believe, physicians are not educated to connect patient data with medical knowledge safely and effectively. Rather than building that secure foundation for decisions, physicians are educated to do the opposite—to rely on personal knowledge and judgment—in denial of the need for external standards and tools. Medical decision making thus lacks the order, transparency and power that enforcing external standards and tools would bring about...
Physicians are right to condemn forms of control that involve exclusion of information and power over decision making. But physicians are in denial about the extent to which they themselves impose these forms of control on patients. Physicians are right to reject impoverished, cookbook medicine, but they are in denial of how impoverished is their own know-how. So too are they in denial when they view themselves as “highly skillful,” because their levels of skill would be far greater within a disciplined system of care. Physicians are right that “one cannot separate the decision from its context,” and they are right to reject uninformed controls by ‘outsiders.’“ But they are in denial of how much they themselves are uninformed outsiders to patients’ lives, outsiders whose exercise of control inevitably separates medical decision making from its context. And they are in denial of the need to submit to different forms of control over their own inputs to care—both decision making inputs and execution inputs.

Available on Amazon. My most recent excerpting citation of the Weeds' seminal book comes in my April 2015 post "Nurses and doctors in the trenches."

The Incidental Economist has also cited the WaPo article: "The algorithm will see you now, ctd"

Interesting links therein:
Here’s a University of Oxford paper on how susceptible jobs are to replacement by computers. Here’s Steven Pearlstein on a book from MIT scholars on the same theme. Here’s an article on algorithms replacing anesthesiologists.
Yeah. See my May 22 post "The Robot will see you now -- assuming you can pay."

More broadly, on this topic of "the end of work," a new book is coming out.


Preview of the riff here at Jacobin.
Much of the literature on post-capitalist economies is preoccupied with the problem of managing labor in the absence of capitalist bosses. However, I will begin by assuming that problem away, in order to better illuminate other aspects of the issue. This can be done simply by extrapolating capitalism’s tendency toward ever-increasing automation, which makes production ever-more efficient while simultaneously challenging the system’s ability to create jobs, and therefore to sustain demand for what is produced. This theme has been resurgent of late in bourgeois thought: in September 2011, Slate’s Farhad Manjoo wrote a long series on “The Robot Invasion,” and shortly thereafter two MIT economists published Race Against the Machine, an e-book in which they argued that automation was rapidly overtaking many of the areas that until recently served as the capitalist economy’s biggest motors of job creation. From fully automatic car factories to computers that can diagnose medical conditions, robotization is overtaking not only manufacturing, but much of the service sector as well.
Taken to its logical extreme, this dynamic brings us to the point where the economy does not require human labor at all. This does not automatically bring about the end of work or of wage labor, as has been falsely predicted over and over in response to new technological developments. But it does mean that human societies will increasingly face the possibility of freeing people from involuntary labor. Whether we take that opportunity, and how we do so, will depend on two major factors, one material and one social. The first question is resource scarcity: the ability to find cheap sources of energy, to extract or recycle raw materials, and generally to depend on the Earth’s capacity to provide a high material standard of living to all. A society that has both labor-replacing technology and abundant resources can overcome scarcity in a thoroughgoing way that a society with only the first element cannot. The second question is political: what kind of society will we be? One in which all people are treated as free and equal beings, with an equal right to share in society’s wealth? Or a hierarchical order in which an elite dominates and controls the masses and their access to social resources?

There are therefore four logical combinations of the two oppositions, resource abundance vs. scarcity and egalitarianism vs. hierarchy. To put things in somewhat vulgar-Marxist terms, the first axis dictates the economic base of the post-capitalist future, while the second pertains to the socio-political superstructure. Two possible futures are socialisms (only one of which I will actually call by that name) while the other two are contrasting flavors of barbarism...
Interesting stuff, all of it. Including this, below (My hardcopy Atlantic):

A World Without Work
For centuries, experts have predicted that machines would make workers obsolete. That moment may finally be arriving. Could that be a good thing?
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DON'T FORGET


Register today. Hope to see you there. Joe Flower will be on hand to meet & greet and sign his newest book, scheduled for release on July 30th.


I was honored to be among the pre-publication manuscript reviewers.

OFF TOPIC ERRATUM

The day would be incomplete were I to fail to pimp my drought page.

MORE STUFF

I'm a regular at Science Based Medicine. I recently ran across this Atlantic article (I'm also an Atlantic subscriber)


I emailed SBM's Dr. Gorski to alert him. He replied:


LOL. Man! He did not disappoint.
NCCIH and the true evolution of integrative medicine

There can be no doubt that, when it comes to medicine, The Atlantic has an enormous blind spot. Under the guise of being seemingly “skeptical,” the magazine has, over the last few years, published some truly atrocious articles about medicine. I first noticed this during the H1N1 pandemic, when The Atlantic published an article lionizing flu vaccine “skeptic” Tom Jefferson, who, unfortunately, happens to be head of the Vaccines Field at the Cochrane Collaboration, entitled “Does the Vaccine Matter?” It was so bad that Mark Crislip did a paragraph-by-paragraph fisking of the article, while Revere also explained just where the article went so very, very wrong. Over at a blog known to many here, the question was asked whether The Atlantic (among other things) matters. It didn’t take The Atlantic long to cement its lack of judgment over medical stories by publishing, for example, a misguided defense of chelation therapy, a rather poor article by Megan McArdle on the relationship between health insurance status and mortality, and an article in which John Ioannidis’ work was represented as meaning we can’t believe anything in science-based medicine. Topping it all off was the most notorious article of all, the most blatant apologetics for alternative medicine in general and quackademic medicine in particular that Steve Novella or I have seen in a long time. The article was even entitled “The Triumph of New Age Medicine.”

Now The Atlantic has published an article that is, in essence, The Triumph of New Age Medicine, Part Deux. In this case, the article is by Jennie Rothenberg Gritz, a senior editor at The Atlantic, and entitled “The Evolution of Alternative Medicine.” It is, in essence, pure propaganda for the paired phenomena of “integrative” medicine and quackademic medicine, without which integrative medicine would likely not exist. The central message? It’s the same central (and false) message that advocates of quackademic medicine have been promoting for at least 25 years: “Hey, this stuff isn’t quackery any more! We’re scientific, ma-an!”...
And I get accused of writing long blog posts. Wow. Read this puppy. Where do you people find the time?

See also 'Drinking the “Integrative” Kool-Aid at the Atlantic' at The Neurologica Blog.
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EHR Science update:

The latest at Dr. Jerome Carter's excellent site.
A Care Coordination Resources Page! 
by Jerome Carter on June 29, 2015 

Most EHR systems do not excel at coordinating care across multiple sites and clinicians. At a minimum, care coordination requires support for data sharing, synchronous/asynchronous communications, role-based information access and workflow support. Creating an ideal system for managing care across people and sites presents interesting architectural and workflow challenges, and as we move closer to the next generation of clinical care systems, more research and discussion into what makes for a good care coordination system is required.

With the above in mind, a resource page dedicated to care coordination has been added to EHR Science. In the first pass at gathering resources, I have added materials that go beyond those focused on technical aspects of software design or system requirements. Because care coordination requires significant organizational changes and workflow adjustments, resources that describe and analyze impacts on patients, clinicians, and organizations have been added as well...
COMMENTARY

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More to come...