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Tuesday, January 15, 2019

The entire POINT of Health IT

Science-Based Medicine has a great new book review up.

"Cognitive Errors and Diagnostic Mistakes is a superb new guide to critical thinking in medicine written by Jonathan Howard. It explains how our psychological foibles regularly bias and betray us, leading to diagnostic mistakes. Learning critical thinking skills is essential but difficult. Every known cognitive error is illustrated with memorable patient stories..."
Stay tuned. I range far afield on this blog, episodically and recurrently addressing all manner of tangentially-related topics, but it always comes back to this: that which aids accurate dx reasoning is the entire point of "health information" and the technology that makes it available to clinicians. Anything that hampers that priority is to be identified and eliminated -- e.g., poor workflows (including those emanating from lousy HIT UX), useless administrative / compliance data burdens, myriad other distractions, etc.

But, tech is just a tool. Consistently scientific clinical reasoning is the goal. Again, SBM:
He includes a thorough discussion of the pros and cons of limiting doctors’ work hours, with factors most people have never considered, and a thorough discussion of financial motivations.

The book is profusely illustrated with pictures, diagrams, posters, and images from the Internet like “The Red Flags of Quackery” from sci-ence.org. Many famous quotations are presented with pictures of the person quoted, like Christopher Hitchens and his “What can be asserted without evidence can be dismissed without evidence”.

He never goes beyond the evidence. Rather than just giving study results, he tells the reader when other researchers have failed to replicate the findings.

We rely on scientific evidence, but researchers are not immune from bias. He describes the many ways research can go astray: 235 biases have been identified that can lead to erroneous results. As Ioannidis said, most published research findings are wrong. But all is not lost: people who understand statistics and the methodologies of science can usually distinguish a good study from a bad one…
Contents

1 Introduction 1
Summary 1
Errors in Medicine 2
Cognitive Biases 4
Cognitive Biases in Medicine 7
This Book 8
2 Ambiguity Effect 15
3 Bandwagon Effect and Authority Bias 21
Social Loafing and Diffusion of Responsibility 41
Reactance Bias 46
4 Confirmation Bias, Motivated Cognition, the Backfire Effect 57
Belief Bias 75
5 Curse of Knowledge 89
6 Decision Fatigue 93
7 Feedback Sanction 103
8 Financial Bias 109
Mere Exposure Effect and Norm of Reciprocity 122
9 Forer Effect 139
10 Framing Effect and Loss Aversion 145
Sunk Costs, Endowment Effect, Choice-Supportive Bias 150
Anchoring Effect 155
Contrast Effect 163
11 Affective Error 169
Attribution Biases:​ The Fundamental Attribution Error and Self-Serving Bias 183
12 Gambler’s Fallacy and Hot Hand Fallacy 203
13 Hasty Generalization, Survival Bias, Special Pleading, and Burden of Proof 211
Survival Bias, Special Pleading, and Burden of Proof 225
14 Hindsight Bias and Outcome Bias 247
False Memories 254
15 Illusionary Correlation, False Causation, and Clustering Illusion 265
16 In-Group Favoritism 285
17 Information Bias 303
18 Nosology Trap 307
19 Omission Bias 321
Commission Bias 327
20 Overchoice and Decision Avoidance 345
21 Overconfidence Bias 351
22 Patient Satisfaction Error 369
23 Premature Closure:​ Anchoring Bias, Occam’s Error, Availability Bias, Search Satisficing, Yin-Yang Error, Diagnosis Momentum, Triage Cueing, and Unpacking Failure 379
Introduction 379
Anchoring Bias 379
Occam’s Error 386
Availability Heuristic 389
Search Satisficing 396
Yin-Yang Error 404
Diagnosis Momentum 406
Triage Cueing 408
Unpacking Failure 414
Failure-To-Close Error 417
24 Representativene​ss Bias 425
Base Rate Neglect 429
Zebra Retreat 438
25 Screening Errors 445
26 Selection Bias and Endowment Effect 457
Introduction 457
Application Steps 457
27 Semmelweis Reflex 467
 Galileo Fallacy 473
28 Systems Errors 501
Alarm Fatigue 501
Defensive Medicine 506
Graded Clinician Error 511
The Electronic Medical Record Error 514
29 Blind Spot Bias 525
30 Research Errors 537
Introduction 537
Expectation Bias 538
P-Hacking and HARKing 541
File Drawer Effect/​Publication Bias 546
Poor Surrogate Outcomes 547
Non-Representative Study Populations:​ 548
Citation Plagiarism 549
Lack of Replication 549
Predatory Publishers 551
Conflicts of Interest 553
Legal Threats 554
Ghostwriting 555
Fraud 556
Solutions 559
Conclusion 565
Index 577

BTW: A cautionary prior post of mine: "Treat the numbers instead of the patient?"

See also my prior post "Clinical cognition in the digital age."

Having had the great fortune to teach "critical thinking" at the university level for a number of years, this stuff goes to my wheelhouse and prime interests.

BTW, highly recommend this SBM book as well.


UPDATE

From THCB, the "aSOAP note?" Comment by Leo Holm, MD
The patient chart has needed revolution for a long time now. Too many obstructionists like the AMA, CMS, MGMA and other groups who think a complete review of systems means anything other than trolling the patient. I guess they need a legacy bridge to guard to keep themselves relevant. We need a patient centered form of documentation with the concision that will serve doctors and patients alike. Unfortunately, there do not seem to be any “disruptive innovators” in this realm. This has been exacerbated by the data mongers who want every morsel of information as structured data…even though they don’t have the slightest idea of what to do with it that would be meaningful for patients. The obfuscation and disorganization of critical patient data is dangerous, and the ones who are causing it need to be held accountable. That was a good first shot for putting together a far more meaningful note.
Interesting. See my prior post "EBM and the SOAP process."
"...data mongers who want every morsel of information as structured data… even though they don’t have the slightest idea of what to do with it that would be meaningful for patients."
Hmmm... See "Are structured data the enemy of health care quality?"

"SOAP?" "SOAPe?" "aSOAP?" "POMR?"

Let's recap, shall we?
"That which aids accurate dx reasoning is the entire point of "health information" and the technology that makes it available to clinicians. Anything that hampers that priority is to be identified and eliminated."
Back to where we began. It's worth mentioning that that extends beyond tech to clinical pedagogy. "How doctors (are trained to) think."


Beyond those categories of concerns, how about our hardy little enervating perennial, the problematic "productivity treadmill?"

EMAIL INBOX UPDATE

…While burnout has long been a worry in the profession, the report reflects a newer phenomenon — the draining documentation and data entry now required of doctors. Today’s electronic record systems are so complex that a simple task, such as ordering a prescription, can take many clicks.

Doctors typically spend two hours on computer work for every hour they spend with patients, the report said. Much of this happens after they leave the office; they call it “pajama time.”

Medicine has become more regulated and complex over the past several years, generating what doctors often consider to be meaningless busywork detached from direct patient care. That’s when they start to feel disheartened, authors of the report said.

“A lot of physicians feel they are on a treadmill, on a conveyor belt,” said Dr. Alain A. Chaoui, president of the Massachusetts Medical Society and a family doctor in Peabody…
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More to come...

Sunday, January 13, 2019

Speaking of a "National Emergency"

We have a fake "emergency" and a real one.
TrumpFakeEmergency
The signals are blaring: Dramatic changes to our climate are well upon us. These changes — we know thanks to a steady drumbeat of alarming official reports over the past 12 months — could cripple the U.S. economy, threaten to make vast stretches of our coastlines uninhabitable, make basic food supplies scarce and push millions of the planet’s poorest people into cities and across borders as they flee environmental perils.
All is not yet lost, we are told, but the demands of the moment are great. The resounding consensus of scientists, economists and analysts tells us that the solution lies in an unprecedented global effort to immediately and drastically drop carbon emissions levels.,,

See my prior posts on Climate Change. See also my post setting forth Trump's incoherent denials.

UPDATE

From The Atlantic:
"Are We Living Through Climate Change's Worst Case Scenario?"
STATnews update:
"Climate change is affecting health now. Our leaders must take action"
BTW, I guess we could cite a 2nd real national emergency -- #RussianAssetInTheWhiteHouse.


HEALTH CARE UPDATE: JUST FER GRINS

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More to come...

Thursday, January 10, 2019

The 2019 Trump federal shutdown. Any emergent health impacts?


We are mired in an absurd and increasingly dangerous time.
TrumpFakeEmergency
“I have the absolute right to do a national emergency if I want.” — 45th rate "Acting" Celebrity Apprentice @POTUS @realDonaldTrump
"DO" a "national emergency?" SMH. One either exists or it does not.

Are we seeing any significant public and individual health impacts yet? The stresses on furloughed federal workers have gotta be severe and damaging.

Stay tuned. Think "FDA. USDA, EPA, HHS, CMS, NIH, CDC," etc.at the agency level for openers.

Paul Krugman: "Does contaminated food smell like Freedom?"

UPDATE

The Guardian's Jessica Glenza:
How the government shutdown could affect your health
Key government services like food inspections, health exposure assessments and cash assistance for groceries have been frayed


Food inspections, assessing health effects of toxic chemicals and cash assistance for groceries – all are services performed by the federal government, and all are now frayed by the partial government shutdown.

The US Food and Drug Administration, responsible for inspecting more than 80,000 food facilities, has curtailed inspections. The Agency for Toxic Substances and Disease Registry has suspended health exposure assessments. Cash assistance to buy groceries, commonly called food stamps, are funded through February – but beyond that is a question mark.

As the partial US government shutdown appears to be heading into its fourth week over a row of border wall funding, funds for programs like these increasingly look like reservoirs in a drought, with bureaucrats shuffling money to keep taps flowing but little more than uncertainty on the horizon…
Government Shutdown Spares Medicare, Medicaid, But Has Other Impacts
The partial government shutdown is not affecting Medicare and Medicaid, but other health-related services are feeling the pinch.
ERRATUM

I just finished this book.


Compelling. 1,650 curated citations, sort of a comprehensive "meta-analysis" comprising the "theory-of-the-case" evidence on Donald Trump. Recommend also House of Trump, House of Putin and The Apprentice, just to cite two more I've studied.


This is indeed a dangerous time.
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More to come...

Saturday, January 5, 2019

Digital Health Tech growth notwithstanding, we're "not any healthier?"

Intrepid CNBC journalist @chrissyfarr poses a core question.


Lots to address there, much of it perhaps above my pay grade (but, then, I no longer have a "pay grade"). First, can we accurately (scientifically) quantify (relatively) "healthier, as a society?" Might we find multiple dueling definitions, and/or differing trends within various socioeconomic strata (the latter likely the case, IMO)? apropos, see Beth Macy's riveting book "Dopesick" (review here, scroll down).

Second, all the noble, high-minded health digitech startup making-the-world-a-better-place rhetoric aside, Venture Capitalists' priorities necessarily remain profitable "exits" launching from the shortest feasible "runways."  Should that entail delivering "improved health" in the process, so much the better.
Also, as my medical economist friend JD Kleinke pointed out in a Facebook response, there's the "affluent worried-well early-adopter" self-selection bias. A lot of novel health digitech skews toward the already fit.
Third, see my recent post "Population health and an aging world."

Fourth, ironically, the more clinical (and consumer-facing) data to which we gain access, the more we realize how much more we really need to improve both dx accuracy and px/tx efficacy. Availability of "data" grows exponentially (much of it "noise," unfortunately). Available time for its effective clinical analysis and utilization remains fixed -- at best.

Finally for now, see my prior posts on "climate change and health impacts." Evidence accrues that the impacts are no longer hypothetical, far-off abstractions and theories.

Stay tuned. This post will likely accrue episodically across the next few days.

First, this STATnews piece is timely and interesting:

The pull of JPM may be irresistible, but will San Francisco’s problems push people away?
By ADAM FEUERSTEIN @adamfeuerstein, REBECCA ROBBINS @rebeccadrobbins, and DAMIAN GARDE @damiangarde JANUARY 4, 2019

SAN FRANCISCO — If you were to ask health-care and biotech executives where they want to be next week — where they truly want to be — they will not say San Francisco. Anywhere, they will say, but San Francisco.

There’s the garbage and the human excrement on the sidewalks. There’s the mad dash to try find available accommodations. There’s the panhandling, evidence of the city’s handling of its worsening homelessness crisis. Oh, and there’s the $14,000 meeting cubicles and the coffee, available (this is true) for $170 per gallon.

And yet everyone who’s anyone will be here during the four days of “JPM Week” — the biotech industry’s largest and most important business and networking meeting, headlined by the J.P Morgan Healthcare Conference…
Hmmm... It has not escaped my notice that there's no Health 2.0 WinterTech Conference this January (it ran concurrent with JPM Week). Neither did they put on a Technology for Precision Health Summit in December 2018 (both of them hosted in SF). Also, the AARP Innovation@50+ Pitch Conference has disappeared.

Interesting.

"WHAT THE HEALTH?"

A dear long-time friend of ours (she's a a nuclear engineer who worked for my wife) turned us on to this documentary:

 

Just watched all of it. I find it at once very interesting and rather troubling. In any event, it coheres nicely with this book I'm now deep into:


Jan 6 update: I finished this book. He concludes,
Fighting the obesity epidemic will require a radical change in our attitude toward food and eating. We will need to view many types of food as potentially dangerous, requiring caution and regulation. We will need to think much more strategically about such life choices as our employment, housing, family structure, habits of daily living, locomotion, commuting, and recreational activities. There may come a time when we respond with horror to stories of friends spending the day on a couch watching television, just as we today look back in shock at nineteenth-century tales of multi-day binges in a local opium den. We will need to reconsider our education systems, our embracing of choice, and the limits of parental authority over children’s eating habits. We will need to redesign our built environments and reconsider our perceptions of appropriate automobile use. We will need to rethink the costs of tolerating overly long work shifts, over-scheduled children, and disrupted family mealtimes. That is, we will need to do all of this if we wish to lose weight and prevent our children from dying prematurely. 

If we continue on our current trajectory, we have every reason to believe that our present problem will grow worse. Given our natural inclination to sloth, our rapacious appetite for sugar and simple starches, our hyper-mechanized and unwalkable environments, our sedentary work styles, and our inadequate control over our own eating, there is little to stop us from growing ever fatter. Diabetes, heart disease, joint pain, physical discomfort, professional and social failure, and early death await us if we continue as we have been.

Engel, Jonathan. Fat Nation (Kindle Locations 2788-2800). Rowman & Littlefield Publishers. Kindle Edition.
Excellent scholarship and analysis, right down to the biochemical molecular level. Excellent writing. Jonathan is all over it.

BTW, Science-Based Medicine is not a big of fan of "What The Health." They have not (yet) reviewed "Fat Nation." There's a Slate review here.

Another relevant book I ran across over at Science Magazine:

"Is it shocking that many food companies do whatever they can in the name of fatter profits? Maybe, but it’s old hat for Nestle, who has spent five decades honing her expertise and is a leading scholar in the field of nutrition science. In this book, she details nearly every questionable food company tactic in the playbook, from companies that fund their own food science research centers and funnel media attention to nondietary explanations for obesity, to those that cherry-pick data or fund professional conferences as a plea for tacit approval..."

ERRATA

Meanwhile, the health of Ranger the 91 lb Rescue Puppy remains a mixed bag a year on (our son found him running loose late one night last January in the Delta just west of Sacramento, no tags, no chip, dirty piece of rope for a "collar").


Real piece of work, this dog. Estimate he's now about 4 yrs old. We've now had to resort to "compounding pharmacy" custom Rx ($$$) for those intractably infected ears. I joke that he's gonna need a veterinary GoFundMe page.

He is a joy, though. Mr Amiable. Nice family room leather sofa ya got there, Ranger.

MY WAY FORWARD

Time to hang 'em up?



I've had a really good, fun run, just for the pro bono fun of it. What began as pretty much an ongoing photography-augmented online diary of my REC Meaningful Use job and health digitech conference coverage has simply continued on. 800,000+ hits later, people keep reading, so I keep posting. But, nearly six years out of the EHR trenches, my tech observations are increasingly viewed-at-a-distance speculative and theoretical. And, my chops are not all that robust as a "Futurist."

I've got some ideas on what priorities to segue to in the year ahead. Still pondering them. Still recovering from our searing 2018. Just grateful to be alive.

Speaking of conferences,


In 2012, on a lark, I applied for a press pass, given that they were in Las Vegas that year, where I was living and working in the Meaningful Use program.

To my complete surprise, they granted it.

This is the Biggie, the "Comdex / CES" of Health IT (though, the annual IHI Forum is no slouch). Estimating ~45,000 attendees this year at HIMSS19.
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More to come...

Tuesday, January 1, 2019

The "Science of Success?"

"S = Q(r)"


So, the other day while reading through my December 14th hardcopy issue of Science Magazine,


I ran across a review of the book depicted above. I have to confess, my first-blush reflexive reaction comprised a bit of dubiety -- "like, what is this doing here in the AAAS flagship periodical? Universal Laws of Success? Another TED Talk self-help hustle?"

Nope. Now I know. Science, man. The author's concluding words:
I opened this book with the statement that scientific laws are immutable—we can’t rewrite them to serve our goals. Rather, we can use our awareness of them to inform our future choices and to benefit our world. The same is true for the Laws of Success. We can’t alter them, but we can use them to evaluate when performance is sufficient for success and when it isn’t. The lessons we can extract from these laws will help us find a balance, deciding how much effort we should devote to honing our skills vs. networking, assessing how credit will be allocated on projects we’re involved in, and strategically choosing collaborators to boost creativity. When we break down and demystify success using the tools of science, we learn to see what we can control and what we can’t. Most important, we can apply various laws in tandem to best enhance outcomes. And we can use this knowledge to dissect the success narratives around us, unraveling the mechanisms at work in the lives of the people we revere—an exercise that humanizes our heroes.

Like Einstein’s, many success stories appear to hinge on one or a series of accidents. Hollywood celebrities are known to call up the tale of their big break—when a fortunate encounter or a powerful acquaintance placed them in the public eye. There is a luck element to this, for sure—and it usually has to do with that first nudge that kick-starts preferential attachment. But, as the Q-factor reminds us, luck is useless unless we repeatedly take advantage of opportunities when they do present themselves.

We now know that the Laws of Success underlie every success narrative, ordering what seems random in barely visible ways. That means, knowing what we now know, that we have the unique opportunity to situate ourselves for success. We can move beyond self-help tropes, which place far too much emphasis on enhancing performance, and instead approach our futures with strategies adapted to our goals and needs. We can use the Laws of Success to better our outcomes, just as we can exploit the laws of motion to engineer better airplanes.

We can also see how the inequalities around us are shaped by these laws and use our awareness of the mechanisms behind success to create a more equitable society. How? By kick-starting the success of the many deserving people around us. By helping the less visible nodes in our networks create vital links. By noticing children hindered by their circumstances and giving them a nudge. By recognizing that there’s more to success than simple performance, we can assist hopeful up-and-comers with an arsenal of practical strategies.

Instead of praying for a lucky windfall, we now have a foundational science to work with in achieving both personal and societal goals. The science may be new, but the Laws of Success are not. Like all scientific laws, they’re universal and eternal. They underpin millions of individual stories of failure and success, each of which can be examined and understood through this new lens. Everyone from Martin Luther King Jr. to the Beatles to Einstein were, for all their genius, ignorant of the laws that skyrocketed the exceptional accolades they received. We, now, are not. And that just might be the crucial advantage we can use in our quest to join their lofty heights.


Barabási, Albert-László. The Formula (p. 242). Little, Brown and Company. Kindle Edition.
He made the case, in spades. If ever there were a cogent, comprehensive volume of data-driven analytics, this is it. A complete joy to read. I could hardly put it down.

apropos of our health tech space, the author riffs on
...the way the FDA approves new medical devices. At approval meetings, a chairperson seats people around a conference table according to her discretion. After initial presentations by the device manufacturer and two formal reviewers, the chairperson asks the committee member seated nearest to the reviewers to comment. The chairperson then guides the discussion, going clockwise or counterclockwise in the room, allowing each member to raise issues. In theory, this gives everyone a fair shot at voicing potential concerns.

But it doesn’t. The device’s approval is typically determined by those who are asked to speak first. They’re the ones who get to frame the key questions. The later speakers are unable to raise new issues effectively; the concerns of the first speakers have been posed and set the tone. In other words, where people sit in a meeting, and the order in which they speak, can impact whether a medical device is approved for public use.

Think about that the next time you’re in the OR. A doctor might have been able to offer you an innovative new therapy had the key argument for it been voiced early…
[ibid, pp. 93-94]
The book is loaded with such findings, across a wide breadth of domains. He also does a good job with issues of 'leadership" and how it impacts success.

"This is not just an important but an imperative project: to approach the problem of randomness and success using the state of the art scientific arsenal we have. Barabasi is the person." 

--Nassim Nicholas Taleb, author of the New York Times bestselling The Black Swan
and Distinguished Professor of Risk Engineering at NYU

I quickly ordered two hardbound editions, one for my wife and one for my son Matt and his Eileen.
"We can also see how the inequalities around us are shaped by these laws and use our awareness of the mechanisms behind success to create a more equitable society."

Yemen, 2018. Yeah, that's difficult to look at. As it should be. To my "Futurist" friends, how can we rationally and effectively advocate for what just future should look like (given that we have a large say in the matter)?

JAN 2 UPDATE 

From my New Yorker email update today:

… [Anderson’s] bank experience showed how you could be oppressed by hierarchy, working in an environment where you were neither free nor equal. But this implied that freedom and equality were bound together in some way beyond the basic state of being unenslaved, which was an unorthodox notion. Much social thought is rooted in the idea of a conflict between the two. If individuals exercise freedoms, conservatives like to say, some inequalities will naturally result. Those on the left basically agree—and thus allow constraints on personal freedom in order to reduce inequality. The philosopher Isaiah Berlin called the opposition between equality and freedom an “intrinsic, irremovable element in human life.” It is our fate as a society, he believed, to haggle toward a balance between them.

In this respect, it might seem odd that, through history, equality and freedom have arrived together as ideals. What if they weren’t opposed, Anderson wondered, but, like the sugar-phosphate chains in DNA, interlaced in a structure that we might not yet understand? What if the way most of us think about the relation between equality and freedom—the very basis for the polarized, intractable political division of this moment—is wrong?…

…If one person’s supposed freedom results in someone else’s subjugation, that is not actually a free society in action. It’s hierarchy in disguise.

To be truly free, in Anderson’s assessment, members of a society had to be able to function as human beings (requiring food, shelter, medical care), to participate in production (education, fair-value pay, entrepreneurial opportunity), to execute their role as citizens (freedom to speak and to vote), and to move through civil society (parks, restaurants, workplaces, markets, and all the rest). Egalitarians should focus policy attention on areas where that order had broken down. Being homeless was an unfree condition by all counts; thus, it was incumbent on a free society to remedy that problem. A quadriplegic adult was blocked from civil society if buildings weren’t required to have ramps. Anderson’s democratic model shifted the remit of egalitarianism from the idea of equalizing wealth to the idea that people should be equally free, regardless of their differences. A society in which everyone had the same material benefits could still be unequal, in this crucial sense; democratic equality, being predicated on equal respect, wasn’t something you could simply tax into existence. “People, not nature, are responsible for turning the natural diversity of human beings into oppressive hierarchies,” Anderson wrote…
A long-read well worth your time. Relevant to the topic of this post. Has embedded audio transcript.
“People, not nature, are responsible for turning the natural diversity of human beings into oppressive hierarchies.”
'eh? 

As Tomasello has demonstrated to my satisfaction "oppression" is evolutionarily maladaptive. See my cite of "A natural history of human morality."

Dr. Anderson's latest book:

"One in four American workers says their workplace is a "dictatorship." Yet that number probably would be even higher if we recognized most employers for what they are—private governments with sweeping authoritarian power over our lives, on duty and off. We normally think of government as something only the state does, yet many of us are governed far more—and far more obtrusively—by the private government of the workplace."
__

In sum, I could not recommend "The Formula" more highly. Read the Science Magazine review. Get a copy. Study it closely. See what you think. Happy New Year.

NEW YEAR'S DAY OFF-TOPIC ERRATUM

Saw this at the NY Times. Screen-scraped it off my iPhone.


2018 S&P lost 6.2%. Tracks proportionally with the DJI and NASDAQ -- very high correlative R-squares. Swell. I'm reluctant to login to my IRA account.
_____________

More to come...

Monday, December 31, 2018

My 2018 in 3 words: grief, gratitude, and anger


It's obviously more complex than that (and there is some overlap among these categories), but those three words come most readily, succinctly to mind.

Grief
Still trying to wrap my head around having now lost both of my daughters to cancer. I lived for my kids. See "A tale of two sisters."

There will be much more of their stories to tell. One task for 2019.

April 27th, 2018, about 5 hours before Danielle peacefully departed this life.
Since 2017 I've also lost a number of long-time dear friends -- Kurt Kolstad, Mike Kinder, Rick Stevens, and Joey Turner. Those losses continue to sting. But, we all have to deal with such pain. Look out over any crowd, there's a lot more quiet mourning happening all the time than we might unreflectively assume.

Gratitude
First, everyone in our family and huge circle of friends stepped up for us repeatedly without fail across the wrenching course of Danielle's illness and death. I can never thank you all enough.
Second, my wife and best friend of nearly 45 years -- she, the Former Evil Stepmother Now Beatified -- did most of the heavy lifting, especially toward the end. I got sole custody of the girls in 1974. Cheryl has been with me every step of the way. I am not worthy (BTW, today's her birthday. Happy Birthday, sweetie!).

Finally, my cardiologist (who prefers to not be named), my heart surgeon Dr. Ramesh Veeragandham, and the entire Muir team who saved my life. I was headed for either a stroke or fatal heart failure. Ironically, the entire experience was the least stressful episode of the year. I discharged early from cardiac rehab PT on December 18th. My cardiologist told me on the 14th "I don't need to see you for a year." He also told me my getting back into my absurd full-court pickup Jones is a realistic goal. Check Ball...
Anger


Build a wall, indeed. The less said about this absurd human wrecking ball, the better. One "Angry Democrat" here, that's for sure.
__


Wishing you all a healthy, happy, and prosperous 2019. I hope to be Busking in Baltimore by summer, and hanging with our son Matt and his fabulous Eileen.
__

CODA

I would be remiss to not shout out special thanks to Eileen's delightful aunt Maggie Sam Sheehan and her equally delightful partner Dr. George Brouillet for their gracious hospitality and friendliness over the Christmas holiday. Just wow.

P.S.

Oh, and Roll TIDE!


I'm Ranger, and I approved this blog post.
_____________

Thursday, December 27, 2018

2019 in the health care space?

"I never make predictions, especially about the future." - Yogi Berra
"The great thing about being a health care futurist is that you never have to update your slides." - Health Care "Futurist" Ian Morrison
LOL. Ian also once quipped during a Health 2.0 Conference Keynote "I've got slide decks older than some of my clients."

Below: this is an actual thing.


"APF." Not kidding. Hmmm... Wonder if Ian is a member? (As well as my equally cool Futurist friend Joe Flower? And, how about Jacob Ward?)
From the APF website: "What is a Futurist? A professional futurist is a person who studies the future in order to help people understand, anticipate, prepare for and gain advantage from coming changes." Okeee-dokee, then. "studies the future"? (Wiki page on "Futurist.")
Michael Burry MD, now there was "Futurist" ("The Big Short" guy).

Stay tuned. Just got home from a Christmas trip back to the Baltimore area to see our son Matt. Met the most gracious, spectacular people in his circle. Stayed silent about being gone on social media, for what should be obvious reasons.

First, some random stuff in the waning 2018 days.

Finished this book while gone:


Highly recommended. A comprehensive, scholarly, accessible (and non-partisan) history of the evolution of the space. From the Amazon blurb:
Written for nonexperts, this is a brisk, engaging history of American healthcare from the advent of Medicare and Medicaid in the 1960s to the impact of the Affordable Care Act in the 2010s. Step by step, Jonathan Engel shows how we arrived at our present convoluted situation, where generic drugs prices can jump 1,000 percent in a day and primary care physicians can lose 20 percent of their income at the stroke of a Congressional pen.

Unaffordable covers, in a conversational style punctuated by apt examples, topics ranging from health insurance, pharmaceutical pricing, and physician training to health maintenance organizations and hospital networks. Along the way, Engel introduces approaches that other nations have taken in organizing and paying for healthcare and offers insights on ethical quandaries around end-of-life decisions, neonatal care, life-sustaining treatments, and the limits of our ability to define death. While describing the political origins of many of the federal and state laws that govern our healthcare system today, he never loses sight of the impact that healthcare delivery has on our wallets and on the balance sheets of hospitals, doctors' offices, government agencies, and private companies.
I'm already rather well-read up on this type of material, but Jonathan's was thoroughly enjoyable and instructive nonetheless. I would encourage everyone to read it, health care professionals and lay people alike.

Gonna be starting his latest release shortly.


Again, the Amazon blurb:
The diet and weight-loss industry is worth $66 billion – billion!! The estimated annual health care costs of obesity-related illness are 190 billion or nearly 21% of annual medical spending in the United States. But how did we get here? Is this a battle we can’t win? What changes need to be made in order to scale back the incidence of obesity in the US, and, indeed, around the world? Here, Jonathan Engel reviews the sources of the problem and offers the science behind our modern propensity toward obesity. He offers a plan for helping address the problem, but admits that it is, indeed, an uphill battle. Nevertheless, given the magnitude of the costs in years of life and vigor lost, it is a battle worth fighting.

Fat Nation is a social history of obesity in the United States since the second World War. In confronting this familiar topic from a historical perspective, Jonathan Engel attempts to show that obesity is a symptom of complex changes that have transpired over the past half century to our food, our living habits, our life patterns, our built environments, and our social interactions. He offers readers solid grounding in the known science underlying obesity (genetic set points, complex endocrine feedback loops, neurochemical messengering) but then makes the novel argument that obesity is a result of the interaction of our genes with our environment. That is, our bodies have always been programmed to become obese, but until recently never had the opportunity to do so. Now, with cheap calories ubiquitous (particularly in the form of sucrose), unwalkable physical spaces, deteriorating rituals and norms surrounding eating, and the withering of cooking skills, nearly every American daily confronts the challenge of not putting on weight. Given the outcomes, though, for those who are obese, Engel encourages us to address the problems and offers suggestions to help remedy the problem.
Hmmm... this quote comes to mind:
“Medicine is supposed to be about helping you through the accidents — the misfortune of a genetic disease, the misfortune of a trauma, the misfortune of some pathogen. Nobody went to medical school to babysit someone through a life of self-inflicted misery because of two deadly habits: sedentarism and excessive consumption of refined carbohydrates.”Greg Glassman, CEO, CrossFit Health
Glassman has a point, but I think things are a good bit more complex than that.

Like I said, stay tuned. lots to ponder and write about (still dragging my butt finishing up several other books in chronic, halting progress). We got home about 1 a.m. Gotta go fetch the dogs from vet/boarding. Can't wait to see that bill. Ranger is still having persistent ear infection problems.

UPDATE ERRATUM

From my latest hardcopy snailmail edition of Science Magazine:


apropos of my prior riffs on climate change,
…[T]he deeper cause of the ecological crisis: a pervasive worldview that imbues the trends of more with a cachet of inevitability and legitimacy. This worldview esteems the human as a distinguished entity that is superior to all other life forms and is entitled to use them and the places they live. The belief system of superiority and entitlement—or human supremacy—manifests in a range of anthropocentric commonplace assumptions, linguistic constructs, institutional regimes, and everyday actions of individual, group, nation-state, and corporate actors. For example, the human is invested with powers of life and death over all other beings and with the prerogative to control and manage all geographical space. The all-encompassing manifestation of the belief system of human supremacy is precisely what constitutes it as a worldview…
From "Reimagining the human."
Beyond Human Dominance
The dominant framework of tech
nofixes, technological schemes, and fine-tuning efficiencies is by itself no match for the tidal wave of human expansionism expected in this century. Looming before us is the imminent escalation of food, energy, materials, and commodities production, and resulting increases in wildlands destruction, species extinctions, wildlife extirpations, freshwater appropriation, ocean degradation, extractionist operations, and the production of industrial, pesticide, nitrogen, manure, plastic, and other waste—all unfolding amid climate-change ordeals.

In the face of this juggernaut, a singular focus on a techno-managerial portfolio seems fueled by a source other than pragmatism alone. That portfolio—which would include such initiatives as climate geoengineering, desalination, de-extinction, and off-planet colonization—is in keeping with the social rubric of human distinction. The prevalent corpus resonates with a Promethean impulse to sustain human hegemony while avoiding the most expeditious approach to the ecological predicament—contracting humanity's scale and scope by means that will simultaneously strengthen human rights, facilitate the abolition of poverty, elevate our quality of life, counter the dangers of climate change, and preserve Earth's magnificent biodiversity.

To pursue scaling down and pulling back the human factor requires us to reimagine the human in a register that no longer identifies human greatness with dominance within the ecosphere and domination over nonhumans…
 Good luck scaling back our speciocentric hubris.

See all the articles under Tomorrow's Earth.


BELOW, NEWS HEADLINE TODAY

UPDATE

Interesting, in light of the foregoing on "reimagining the human." From The Atlantic:
An Elephant’s Personhood on Trial
A legal case involving a famous solitary elephant poses a fundamental question about animals’ rights.
"Personhood?" Yeah. Some of us want to bestow it on human zygotes.

BTW, see EO Wilson's "Half Earth."

MORE FROM SCIENCE MAGAZINE DEC 14TH ISSUE

This issue is jammed with great stuff. to wit,

Revealing the brain's molecular architecture
The PsychENCODE Consortium


The brain, our most complex organ, is at the root of both the cognitive and behavioral repertoires that make us unique as a species and underlies susceptibility to neuropsychiatric disorders. Healthy brain development and neurological function rely on precise spatiotemporal regulation of the transcriptome, which varies substantially by brain region and cell type. Recent advances in the genetics of neuropsychiatric disorders reveal a highly polygenic risk architecture involving contributions of multiple common variants with small effects and rare variants with a range of effects. Because most of this genetic variation resides in noncoding regions of the genome, establishment of mechanistic links between variants and disease phenotypes is impeded by a lack of a comprehensive understanding of the regulatory and epigenomic landscape of the human brain…
Man, I've been reading all day. My brain is tired...

Developments in the neuroscience area will likely enhance progress in AI/ML, I would think. Expect significant advances in the coming year.

BUT, WAIT! THERE'S MORE!

This book was reviewed in this foregoing cited issue of Science Magazine:


"Off topic?" Nah.
...Maybe it’s a tinkerer’s curiosity that turned me into a scientist. Early on, physics allowed me to explore the sprockets and gears of the universe and the very forces that control our lives. Looking for more challenges, I turned later to the complexities of networks and data. For a vigilant asker-of-questions, I’ve chosen the right corner of the scientific world to call home. As long as a line of inquiry is based on numbers—the more the merrier—I can pursue it doggedly, following its scent through the maze of data now available to researchers in our hyper-connected, technological world. Hunting down an answer inevitably leads to more questions, new possibilities that hover like gnats on the periphery of any research I conduct. I try to swat them away and stay focused on the task at hand, but I’m not that different from the kid I once was, stubbornly asking “Why?” in response to… well, pretty much anything. It is the quest for answers that gets me up in the morning and keeps me up at night.

These days I run the Center for Complex Network Research, in Boston, where my job is exploring the “why” behind topics as varied as how people or molecules interact, where and how links form, and what our interconnectedness can tell us about society or our biological origins. We’ve examined the topology of the World Wide Web. We’re looking at how tiny hiccups in our genetic networks lead to disease. We’re exploring how our brains control their billions of neurons and how molecules in food attach to our proteins, ensuring our long-term health.

I love this kind of stuff—the math behind our social fabric, the way numbers provide a framework for understanding the essence of our connectedness. When I use models and tools to delve into unlikely topics for scientific analyses, these frameworks inevitably deepen our knowledge…


Barabási, Albert-László. The Formula (pp. 4-5). Little, Brown and Company. Kindle Edition.
So much to learn, so little time.

OK, TAKE IT BACK TO THE TOP...


Stay tuned. For openers, Forbes' "Top 8 Healthcare Predictions for 2019." Not sure that I'm buyin' a lot of that at first blush.

Erratum: BobbyG on "The Future of Science" in 2016.

JOE FLOWER'S YEAR-END THOUGHTS
It’s December 30, 2018.

Healthcare is complex. Simple solutions are useless. Any simple picture of the future is a lie. Simple techno-optimism or innovationist neophilia get us nowhere…

Simple futurism is entertainment. It points at each shiny thing—AI, contractual blockchain, virtual worlds, augmented reality, cell transformation, haptic rebuilds—and says, “Wow! Look at this.” It’s a Jetsons way of looking at the future, as real as using the Flintstones as a guide to the past.

Thinking about the future is a complex business. It requires clarity, penetration, a broad view, and the insights of complexity science. Futurism based on the insights of complexity is a tool for thinking, planning, strategizing…

These skills can be learned…

A futurism based on complexity looks at every element, shiny, dull, or invisible, and asks:

  • “What is it for?”
  • “How does it get its energy?”
  • “How does it affect other elements?”
Complex futurism can connect the dots and the 3-D networks of dots building out over time to paint the pictures of future scenarios, of ways the future could really turn out, what will take us there, and what strategies we might employ to meet them…

Healthcare is changing — consolidation, new tech, political chaos, a vast and growing IT overburden, shifting rules, ever-rising costs, new solutions, business model experiments. And it will continue to do this for some time...
'eh?

NEWS YEAR'S EVE ADDENDUM

Via STATnew:
What will 2019 bring for science and medicine? We asked the experts
PERSONAL HEALTH CARE ERRATUM

Just got what will likely be my last 2018 Humana EoB statement in the mail. Year-to-date (thru 12/24) "total billed charges," just a tad more than $544,000 (those BS "chargemaster" prices). Mostly evrything having to do with a minor surgery (large inguinal hernia) and a major one (open heart aortic valve replacement).

I have no way to know which providers actually got how much (the Medicare, Humana, and Silverscripts EoBs across the year each run to many pages of obtuse FFS detail). And, I've not really tallied up my own 2018 OoP (out-of-pocket). It was plenty.

Suspect that in the aggregate, reimbursements have been on average perhaps ~25% of "list." Fair?
_____________

More to come...