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Sunday, March 17, 2019

A Margalit must-read. She is always worth the wait.



How will we pay for health care?
"One glaring commonality between all Medicare for All proposals is that they are neither Medicare nor for all. Nobody is proposing to make Medicare available to all Americans, which is rather strange if you think about it. The battle cries of Medicare for All, the ubiquitous #Medicare4All hashtags, are pure propaganda."
Margalit Gur-Arie
Disquisition on Medicare for all

Medicare for all Americans is on the table now. Think about it. The not-in-our-lifetime utopian vision of every progressive liberal, complete with dancing rainbows and unicorns, is now within reach. Alternatively, the socialized medicine Trojan Horse that will turn these United States into a toilet-paper free Venezuela is now before Congress. There are over half a dozen bills in Congress, introduced by serious people with serious intentions, proposing some version of government administered universal health insurance in America.

Whichever ideological camp you’re in, it is a profound disgrace that in America today many people cannot afford basic medical care, as profound a disgrace as having veterans sleeping on sidewalks, as profound a disgrace as having one in five children living in poverty, as profound a disgrace as having Americans going to bed hungry. This was not supposed to happen in our “shining city upon a hill whose beacon light guides freedom-loving people everywhere”. It just wasn’t supposed to be this way in a country founded on the inalienable right to pursue happiness. Regardless of why it happened, whose fault it is, or how to “fix” it, America was not supposed to be this way. It just wasn’t.
"We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America."
Our union is as far removed from perfection as it was in the years leading to the events of April 12, 1861. Whether you obsess over political affairs or social issues, our justice system seems to be established on very shaky and uneven ground. Domestic tranquility must have been some sort of eighteenth century inside joke. Our welfare is anything but general, the much-admired blessings of liberty seem to accrue to the few who do very little to secure them, and things don’t look any better for our children and grandchildren. We can debate the fine legal points, the Articles and the Amendments, but there is no question in my mind that we are failing miserably in at least five out of the six stated goals of our Constitution.

What do all these polemics have to do with “fixing” health care, you may ask. Health care is not a standalone issue. It cannot be debated, let alone “fixed”, in a political, historical and moral vacuum. Our health care woes are one manifestation of a much larger systemic failure of American society. The “concentration of power” in fewer and fewer hands is a calamity that was foreseen by a bitter, desperate man as he lay dying, and promptly ignored by many generations since, including our own. John C. Calhoun stared into his self-inflicted perdition and we stared back at him from the flames.

“At this stage, principles and policy would lose all influence in the elections; and cunning, falsehood, deception, slander, fraud, and gross appeals to the appetites of the lowest and most worthless portions of the community, would take the place of sound reason and wise debate. After these have thoroughly debased and corrupted the community, and all the arts and devices of party have been exhausted, the government would vibrate between the two factions (for such will parties have become) at each successive election … These vibrations would continue until confusion, corruption, disorder, and anarchy, would lead to an appeal to force”.
The tragedy at this point is that we, as an “E Pluribus Unum”, cannot rationally analyze, let alone agree on, either the nature or the cause for our failure to thrive, and as long as that remains the case, we will not be able to “fix” health care, or anything else for that matter. But perhaps there is still some room for discussion at the edges of Armageddon…

----------------------------------------

One glaring commonality between all Medicare for All proposals is that they are neither Medicare nor for all. Nobody is proposing to make Medicare available to all Americans, which is rather strange if you think about it. The battle cries of Medicare for All, the ubiquitous #Medicare4All hashtags, are pure propaganda. The proposed plans range from letting a few more poor people buy into Medicaid (not Medicare) to the Cadillac plans of Bernie Sanders, John Conyers and the brand new bill introduced by Pramila Jayapal, including prescription drugs, dental, vision and long-term care, with no premiums, no deductibles and no copays, given free to all citizens, regardless of financial status. In addition to the official bills introduced in Congress, there are lengthy proposals from policy groups touting their superiority and/or soundness compared to all other Medicare for All arrangements. The opposing faction is peculiarly devoid of grand ideas.

The problem with grand ideas though is that, by definition, they must rest on a multitude of assumptions and some assumptions are better than others. You can assume for example, that breaking an egg on a hot surface will get you breakfast. It’s been done trillions of times and therefore one can say that this is a pretty safe assumption, maybe even a fact. You can then be tempted to assume that putting a hot rod through an egg will yield the same results, since the egg is broken and in contact with a hot surface. Now obviously, the hot rod is just a first step, and after extensive tinkering you have a brand-new type of frying pan with an electronic egg breaker embedded in the middle. It costs ten times as much as the frying pan you trashed and it’s only good for eggs, but it does break the eggs, something you never knew was a problem. Oh, and it only makes scrambled eggs, so you save time on complex cognitive tasks.

Obamacare sounded pretty good before it morphed into a pugilistic contest between bureaucracies. Berniecare, sounds pretty good too. I mean what’s there not to like? All health care is free, and we don’t have to pay more than we are paying now for health care. We may even need to pay less, in aggregate. And the payments will be more justly distributed across the population. And every single person, no matter how privileged, will have the same exact glorious health care. Heck I’ve been arguing for a system like that myself. For those interested, I am also arguing for peace on Earth, prosperity, health and happiness to you and your loved ones.

----------------------------------------

Despite what hot-headed reformers are trying to tell you, American health care is not worse or scarcer than it is in other developed nations. It is better and more plentiful. The sole problem with health care in this country is that it is not affordable for most Americans. What does “not affordable” mean though? Does it mean that health care prices are too high? Does it mean that we don’t choose our care wisely? Or does it mean that people are too poor? The answer is of course yes and no on all counts. Furthermore, “fixing” any one of the above problems will likely exacerbate the others. Nobody knew health care could be so complicated, obviously, but it is.

Real GDP per household (2.2 persons) stands around $120,000. Median income per household is half as much. We currently spend on average $24,000 per household per year on health care. If every household got a fairer share of GDP, perhaps health care would be less “not affordable”, but even in the most egalitarian scenario, health care would still be a huge financial burden. Medicare for All seeks to shift the health care burden from individual households to the nation. When the nation is faced with burdens of this type, it either goes into debt or cuts budgets. Debt of this magnitude spells bankruptcy down the road, and budget cutting translates into Rationing. Pick your poison.

But maybe we can ration wisely. Maybe we can replace volume with value. Maybe. Either way, when volumes for one service line go down, another service line seems to miraculously become more popular. If we force all service lines to cut down on volume, prices per unit will inexplicably start soaring to keep the topline steady. Then how about combining nationalized health care financing with price controls, as all Medicare for All bills are suggesting? After all, this is working well for Medicare, no? Yes, it is working for Medicare, because hospitals and doctors can charge the difference to private insurers. If there are no private insurers, hospitals and doctors will need to cut their costs. How do most firms cut costs? By letting employees go and/or reducing their salaries.

---------------------------------------- 

Over 16 million Americans are currently working in the health care industry. If you want to cut that mythical 30% that is presumably waste, I can guarantee in writing that before one wasted piece of paper is eliminated, 6 million people will be out of work. In all fairness, a couple of the more radical Medicare for All proposals include income replacement and “retraining” for a few hundred thousand health insurance industry workers envisioned to be displaced, which amounts to a few drops in the disaster bucket. Such massive unemployment will wipe out entire communities, not to mention the stock market, pensions, retirement savings, tax revenues, and safety net budgets. It may also deal the long overdue coup de grâce to the struggling American middle class.

In a service economy, which is what all progressive minds are glorifying now, if you cut spending on services, you shrink the economy, with all attendant consequences. And no, having more money in your pocket to buy more crap from China does not improve the situation one bit. The supreme irony is that when we add the resultant financial aid for those who will lose their health care jobs, and the many more affected by the ripples of our trimmer health care expenses, we will end up precisely where we started, if we’re lucky, which is not very likely. The point here is not to bash Medicare for All plans. The point is to highlight the magnitude of what is discussed. By comparison to Medicare for All bills, Obamacare was just minor tinkering, and look where it got us.

There are only four countries in the world, including our own, that have a GDP greater than our annual health care expenditure. Restructuring health care in America is like restructuring the entire economy of, say, France or the United Kingdom, and then some. The United States is the third most populous country after China and India and has the greatest influx of new immigrants each year. Pointing to how great the Singapore model is working, or how quickly Taiwan transformed its health care system is, forgive me, laughable. If we learn one thing from the Obamacare escapade, it should be that in health care, nothing, absolutely nothing, scales as predicted on paper.

Finally, as hard as it may be for you these days, please remember that smart people, with yards of skin in this game, may disagree with your preferred solution, not because they are greedy, not because they hate poor people, not because they can’t do the math, not because they are evil, and not because they are deplorable or crazed Marxists. So, please, get off your soapbox (I certainly did), look reality in the face without fear or prejudice, start listening to ideas that make you uncomfortable, and understand that pontificating about Medicare for All is as useful as bloviating about free-markets.
Wow.
"The not-in-our-lifetime utopian vision of every progressive liberal, complete with dancing rainbows and unicorns, is now within reach. Alternatively, the socialized medicine Trojan Horse that will turn these United States into a toilet-paper free Venezuela is now before Congress. There are over half a dozen bills in Congress, introduced by serious people with serious intentions, proposing some version of government administered universal health insurance in America."
She didn't post for about a year. After a while I quit checking her blog. My Bad. See "The Bonfires of Health Care." Bookmark her blog.
"By comparison to Medicare for All bills, Obamacare was just minor tinkering, and look where it got us."
Yeah.

Cross-posted with permission.

Citing Margalit in 2015: "Are structured data the enemy of health care quality?"
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More to come...

Friday, March 15, 2019

Science in my iPhone inbox


"That's Debatable"? Recall my post on "Selling Science"? See also "Selling pseudoscience to the gullible." Additionally, there are my "Anthropocene Denial" posts.

SPEAKING OF SCIENCE

My latest hardcopy arrived.


"Prediabetes?"

The war on ‘prediabetes’ could be a boon for pharma—but is it good medicine?
KEY TAKEAWAYS
A questionable condition


Sweeping diagnosis In 2004 and 2010, the American Diabetes Association (ADA) expanded the blood sugar range it considers a sign of prediabetes, creating tens of millions of potential patients in the United States. The U.S. Centers for Disease Control and Prevention joined ADA in raising the alarm, portraying the condition as a first step toward frank diabetes.

Little risk Prediabetes does little or no harm on its own, and fewer than 2% of prediabetics in the ADA range progress to diabetes each year. Many studies suggest that for most people the usual treatments for prediabetes, diet and exercise, do little to further reduce the risk of diabetes.

Strong medicine Industry is developing at least 10 classes of drugs targeted to prediabetes. ADA also lists existing diabetes and weight loss drugs as options for people with prediabetes, and doctors are prescribing them “off label.” Many of those drugs can have serious side effects.

Money trails ADA and some of its physician advisers who have discussed drug treatments for prediabetes receive extensive financial support from pharmaceutical companies. The organization and its advisers say the payments have not affected their recommendations.

Again, you have to read Seamus O'Mahony's "Can Medicine Be Cured?" (specifically chapter 6, "How to invent a disease.") Pay particular attention to his trenchant observations on the depressingly widespread misapprehension of clinical "risk" (some of it willful). How much money are we wasting inventing and "treating" specious "diseases?" It's not a trivial question.
Q: "What's the definition of a 'well person'?"
A: "a patient who has not been adequately worked up."
Iconoclastic psychiatrist Thomas Szasz once jibed irascibly about the ultimate medical px, the "humanectomy."
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More to come...

Tuesday, March 12, 2019

Happy 30th Birthday, World Wide Web

[Per TechCrunch] The inventor of the World Wide Web, Sir Tim Berners-Lee, has published an open letter to mark the 30th anniversary of the day — March 12, 1989 — when he submitted his original proposal for an information management system that went on to underpin the birth of online services…
"Today, 30 years on from my original proposal for an information management system, half the world is online. It’s a moment to celebrate how far we’ve come, but also an opportunity to reflect on how far we have yet to go.

The web has become a public square, a library, a doctor’s office, a shop, a school, a design studio, an office, a cinema, a bank, and so much more. Of course with every new feature, every new website, the divide between those who are online and those who are not increases, making it all the more imperative to make the web available for everyone…"
Worth your time, all of it. BTW, the "internet" predates the "world wide web" by about another 30 years.
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More to come...

Friday, March 8, 2019

Health care for the homeless


More on that logo art in a moment. Love it.

First, as part of my customary early morning online news review workflow, I ran across this at The Atlantic:
Medieval Diseases Are Infecting California’s Homeless
Typhus, tuberculosis, and other illnesses are spreading quickly through camps and shelters.


…“Our homeless crisis is increasingly becoming a public-health crisis,” California Governor Gavin Newsom said in his State of the State speech in February, citing outbreaks of hepatitis A in San Diego County, syphilis in Sonoma County, and typhus in Los Angeles County.
“Typhus,” he said. “A medieval disease. In California. In 2019.”

The diseases have flared as the nation’s homeless population has grown in the past two years: About 553,000 people were homeless at the end of 2018, and nearly one-quarter of homeless people live in California.

The diseases spread quickly and widely among people living outside or in shelters, helped along by sidewalks contaminated with human feces, crowded living conditions, weakened immune systems, and limited access to health care.

“The hygiene situation is just horrendous” for people living on the streets, says Glenn Lopez, a physician with St. John’s Well Child & Family Center, who treats homeless patients in Los Angeles County. “It becomes just like a Third World environment, where their human feces contaminate the areas where they are eating and sleeping.”

Those infectious diseases are not limited to homeless populations, Lopez warns: “Even someone who believes they are protected from these infections [is] not.”…
Shit. Literally and metaphorically.

I have never been homeless (came close once, in 1967, in the wake of an extended period of illness). I can't imagine.

More recently, before my younger (now late) daughter was dx'd with Stage IV pancreatic cancer, I was a weekly volunteer with the San Francisco "Muttville.org" senior dog rescue center. The nation's most highly overeducated dog rescue shelter laundromat attendant. My parents never let us have pets. I've been a stray magnet ever since. "Senior dog rescue?" I'm there.


The seven or so blocks between the 16th and Mission BART station and Muttville burst at the sidewalk / curbside seams with the shopping carts, blue tarps, tents, and raggedy deitrus of the homeless.

Nasty. Sad. Pungent odors in the air. Watch where you step.

I try to imagine. And I am so grateful for our relative good fortune. As I write, Cheryl and I are doing the final paperwork to close on our 3rd (and likely final) home purchase, in Baltimore, to be close to our son, who happily lives there with his (Baltimore native and state environmental engineer) Eileen in Pigtown.

He has now lost both of his elder sisters to cancer and is the last kid standing. We have to be nearby.


In light of our lovely over-the-ingoing-budget-cap price tag on this place we settled upon, I feel a coming-out-of-retirement stint looming in my future (Cheryl has certainly earned her slack). With my new aortic valve firmly pounding away, I'm loaded for Bear. (There's always Busking, LOL.)

So, just out of curiosity I started putzing around on SimplyHired.com. Talk about a target-rich environment in Baltimore-DC area: "writer," "analyst," "policy analyst," "ethicist," "ASQ," "quality engineer,"... tons.

"Lean health care?" Yes!

Which led me to "Health Care for the Homeless" of Baltimore (and Maryland more broadly). They're soliciting for a (Lean) "Performance Improvement Specialist."

We need to talk. These folks are doing important work.

to wit, apropos of the above Atlantic article, see their page "Homelessness makes you sick."

Indeed.

Their national affiliation:

nhchc.org
UPDATE


Wow. Just wow.

Below, is this cool, or what?


Again, The Atlantic:
"People living on the streets or in homeless shelters are vulnerable to such ['medieval' disease] outbreaks because their weakened immune systems are worsened by stress, malnutrition, and sleep deprivation. Many also have mental illness and substance-abuse disorders, which can make it harder for them to stay healthy or get health care."
ERRATUM

In 2012 while covering one of my many conferences I met and immediately befriended techie internal med physician Jan "Doc" Gurley, a well-known authority on the medical plights of the homeless. She'd long been with the San Francisco Department of Public Health.

A couple of years ago, she just seemed to fall off the planet. No one among my Health 2.0 crowd knows what has become of her. The last time we spoke she told me of her new effort to address the medical plights of parolees (who overwhelmingly become homeless--if not reincarcerated--in short order). I told her I'd love to help with that. She told me she was taking CCTV classes at Berkeley to learn how to do video documentary episodes.

Then, "poof." Vanished.

Disconcerting. Anybody?

ON DECK

Amazon's "AI" has certainly "got my number."


I expect this book will cohere nicely with my prior post "Can medicine be cured?"

"Polypharmacy?" "Overdo$ed America?"
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More to come...

Tuesday, March 5, 2019

Can medicine be cured? Some views from across the Pond

If you're concerned about where things are headed, this is a compelling read.


At once witty and sobering. Has me re-thinking a few of my own opinions, even as it reinforces a number of others.
Contents

Welcome Page
About Can Medicine Be Cured?
Dedication
Chapter 1. ‘People Live So Long Now’
Chapter 2. The Greatest Breakthrough since Lunchtime
Chapter 3. Fifty Golden Years
Chapter 4. Big Bad Science
Chapter 5. The Medical Misinformation Mess
Chapter 6. How to Invent a Disease
Chapter 7. ‘Stop the Awareness Now’
Chapter 8. The Never-Ending War on Cancer
Chapter 9. Consumerism, the NHS and the ‘Mature Civilization’
Chapter 10. Quantified, Digitized and for Sale
Chapter 11. The Anti-Harlots
Chapter 12. The McNamara Fallacy
Chapter 13. The Mendacity of Empathy
Chapter 14. The Mirage of Progress
Epilogue
From the Amazon blub:
A fierce, honest, elegant and often hilarious debunking of the great fallacies that drive modern medicine.

'A deeply fascinating and rousing book' Mail on Sunday.


'What makes this book a delightful, if unsettling read, is not just O'Mahony's scholarly and witty prose, but also his brutal honesty' The Times.

Seamus O'Mahony writes about the illusion of progress, the notion that more and more diseases can be 'conquered' ad infinitum. He punctures the idiocy of consumerism, the idea that healthcare can be endlessly adapted to the wishes of individuals.

He excoriates the claims of Big Science, the spending of vast sums on research follies like the Human Genome Project. And he highlights one of the most dangerous errors of industrialized medicine: an over-reliance on metrics, and a neglect of things that can't easily be measured, like compassion.
Indeed. to wit,
14: The Mirage of Progress

Progress – rather than compassion – is the core belief of the medical–industrial complex. The philosopher John Gray wrote that ‘questioning the idea of progress at the start of the twenty-first century is a bit like casting doubt on the existence of the Deity in Victorian times’. The belief in progress reflects the power of science to change our lives. Over the last one hundred years, longevity has increased dramatically, and immunization has reduced or eradicated diseases that used to kill millions of people. The benefits of science seem so self-evident that only a fool or a madman would question it, or the idea of progress. But science, which gave us all these unalloyed benefits, also gave us nuclear bombs and napalm; it is entirely possible that technology may render the world uninhabitable for humans. Then, progress will end. John Gray has never denied the reality of scientific progress, or its benefits, but has consistently argued that although scientific knowledge increases from generation to generation, gains in ethics and politics are more easily lost: ‘They have to be learned afresh with each new generation.’…
[Kindle edition location 2696]
One nice attribute of this book is that you need not read it in chapter order. My path thus far has been that of introductory material, Chapter 1, Epilogue, 14, 13, 12, 10, 5, 2, and 3 (some of it driven by my frequent cut-to-the-chase keyword/phrase searching).

Seamus is not a big fan of Eric Topol, nor Bertalan Mesko, btw.
Eric Topol views doctors like me as the chief professional obstacle to digital health: ‘Half of American physicians are over age fifty-five, far removed from digital native status (under age 30).’ Topol (sixty-four), with his 2.8 million Instagram followers, is the disco-dancing dad of digital health. The self-styled ‘medical futurist’, the Hungarian Bertalan Meskó, is Topol’s ideal digital native doctor: ‘Since the age of fourteen, I have been logging details of my life every single day. It means not one day is missing from my digital diary which now consists of over 6,600 days with data.’ Like Topol, he argues that ‘the ivory tower of medicine is no more’, and that ‘patients, now called e-patients or empowered patients, who are ready to hack and disrupt healthcare need guidance.’... [Kindle location 1962]
Yikes. Ahhh... "Futurists."



Update: Below, I am reminded of this book, from a 2012 post:

"Slow Medicine"
See also my recent post "Overcharged?"

SPEAKING OF BOOKS, OFF-TOPIC ERRATUM

On my way to OAK airport recently to pick Cheryl up, I heard a KQED Forum segment whose guest was Benjamin Dreyer, Copy Chief at Random House. They discussed his new book:



I bought it. I'm a pretty fair writer, but this book will help me improve significantly. Very witty and informative. It's giving me some recurrent SMH "Edwin Newman Moments."

They discussed the nexus between "critical thinking" (which I've taught) and clear oral and written prose. Yep. Would that I take my own advice more often.

SOME CLOSING SEAMUS RIFFS
"Most of the diseases that kill us now are caused by, and associated with, ageing. We just wear out. Dementia, heart disease, stroke and cancer kill us now, not smallpox and Spanish flu. Medicine can still pull off spectacular rescues of mortally sick young people, but these triumphs are notable for their relative rarity. The other flaw in the Big Science theory is that a great deal of what is laid at medicine’s door to fix has nothing to do with malfunction of the machine; much of the work of GPs is helping people cope not with disease but with living problems, or ‘shit life syndrome’, as some call it…

…Research, unfortunately, will never help most of what ails mankind: growing old and dying. These are eternal human verities, but we expect medicine to somehow solve this riddle. Epidemiologists and public health doctors would argue that medicine now contributes little to health in developed countries, and that poverty, lack of education and deprivation are now the main drivers of poor health. This is almost certainly true. Although vaccination and antibiotics contributed significantly to the increase in human longevity in the mid-twentieth century, medical care now has little direct influence on the health of a population, accounting for only about 10 per cent of variation. Furthermore, some have argued persuasively that if we were to simply apply evenly and logically what research has already proven, health care would be transformed..."
[Kindle locations 532 & 561]
I'd better leave it that, in terms of "Fair Use." You should buy this book. Seamus' book is a veritable abattoir of clinical Sacred Cow Herd demise.

BTW, Dr. O'Mahony wrote an earlier book that is not available electronically.


ADDENDUM

Jus' sayin'.
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More to come...

Thursday, February 28, 2019

The scourge of medical billing

I know this stuff all too well. As I'm sure do many of you.

From NPR:
MARY LOUISE KELLY, HOST:
This is what having cancer in the U.S. these days entails - grueling treatment, yes, but also surprising medical expenses, insurance denials, depleted savings accounts, even bankruptcy. Anna Gorman reports from Texas on one family coping with the financial fallout of cancer.


ANNA GORMAN, BYLINE:

Carol Marley is 50 years old. She has pancreatic cancer. Every day counts. And every day brings a frustrating phone call with an insurer or medical provider.

CAROL MARLEY:

This is Carol Marley calling. I'm getting ready to be going out of town for a treatment for my cancer, so I really - I need some help. If you could please call me today, I would appreciate it.

GORMAN:

Even though pancreatic cancer is one of the deadliest cancers, Carol's doctors caught it earlier than most.

C MARLEY:

I have faith in God that my cancer is not going to kill me. I have a harder time believing that this is going to get straightened out and isn't going to harm us financially.

GORMAN:

Carol is a nurse near Austin, Texas. She was diagnosed in July, and the cancer hasn't spread beyond her pancreas. Her health and the finances weigh on her.

C MARLEY:

It's incredibly stressful. I mean, I don't sleep at night. I take anxiety medication, you know, more often than I want to...

Just what you need when you're fighting serious, life-threatening illness.

This is a particularly pernicious area exacerbated by chronic data opacity / siloing, and what I irascibly call health IT "interoperabble."

My own 2015 experience with prostate cancer consumed most of that year. My head-scratching hassles with the medical billing industry were mostly a recurrently eye-rolling annoyance. See my prior post "The U.S. healthcare 'system' in one word: 'shards'."

Ten months after losing my younger daughter to pancreatic cancer on April 27th 2017, I continue on her late behalf to foist off aggressive attempts to collect absurd amounts of money (though by now it is abating). Twenty years prior to her death, we lost her elder sister to (unrelated) cancer. Similar postmortem bureaucratic hassles ensued.

Both of my girls died beyond flat broke as a result of their illnesses. Not that any of that mattered to medical bill collectors. But, the money gumshoes all eventually came to learn that they were messin' with the Wrong Irishman.
Danielle is survived only by her son, my grandson Keenan. Notwithstanding that I am not legally on the hook from any of her residual debts, I try to shield him from most of this crap so he doesn't get gamed into assuming liabilities for which he is not responsible. The Wrong Irishman knows the ropes. I used to work in subprime risk management. I know all about delinquency, collections, and charge-offs.
Listen to the entire NPR episode. Read the transcript. I so wish this woman well.
"Every misspent dollar in our health care system is part of someone's paycheck" -- Brent James, MD, M.Stat
Yeah. An observation in passing:
“I don’t think in ideological terms. I never have,” Obama said, continuing on the health care theme. “Everybody who supports single-payer health care says, ‘Look at all this money we would be saving from insurance and paperwork.’ That represents one million, two million, three million jobs [filled by] people who are working at Blue Cross Blue Shield or Kaiser or other places. What are we doing with them? Where are we employing them?”

Graeber, David. Bullshit Jobs: A Theory (p. 157). Simon & Schuster. Kindle Edition.
Stay tuned. Once again, political talk of "Medicare for All" and "Single Payer" (my 1994 Argument Analysis pdf) are in the air as the 2020 presidential race heats up. It will no doubt be as contentious as the "Obamacare" reform, if not more so.

apropos, see my post on the CATO Institute book "Overcharged" (a post which cites other relevant reads as well).

UPDATE: SPEAKING OF BOOKS

Reviewed at Science Magazine:

A science writer probes the one risk factor shared by a bevy of devastating diseases

Chronic disease states—including diabetes, most cancers, and cardiovascular and neurodegenerative syndromes—have become the leading drivers of morbidity and mortality. Medicine has set out to develop therapies for each condition separately, and yet they share a common denominator: aging. This has led to the revolutionary idea that interventions that slow aging will have the biggest impact on our collective health: not just extending life span but also delaying or preventing the onset of many diseases and improving functional parameters later in life.

But what causes aging, and how do we intervene? In Borrowed Time, Sue Armstrong describes proposed hallmarks of aging—which include accumulation of cellular damage, loss of stem cell function, cellular senescence, and others—and makes a cogent case for the role of each in driving age-associated dysfunction. Along the way, she describes the origins and development of the aging research field…
 Looks interesting. Only $9.99 Kindle price. In the wake of the stresses of the past couple of years here, I'm certainly feeling and seeing the effects of aging, at 73 now. 
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More to come...

Monday, February 25, 2019

Selling pseudoscience to the gullible

Trump Wants To Set Up ‘Ad Hoc’ Panel To Fight Conclusions About Climate Change: Report
The group of scientists would be tasked with countering a sweeping federal report released last November that warned of a dire future.
Using the Best Words, President Trump dismisses the 2018 U.S. and IPCC climate change reports
Evidence for man-made global warming hits 'gold standard': scientists
OSLO (Reuters) - Evidence for man-made global warming has reached a “gold standard” level of certainty, adding pressure for cuts in greenhouse gases to limit rising temperatures, scientists said on Monday...
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More to come...

Monday, February 18, 2019

Selling science: effective communication with decision makers

Finished this excellent, important book across the weekend, and spoke by phone with co-author Amy Aines today.


Highly recommended. Five stars. Not about communicating science to the public, but to decision makers, e.g., philanthropists, grant-making institutions, corporate entities, politicians and government agencies, venture capitalists, etc.
"Selling" is the grubbier, lesser synonym of "championing," yeah, I know. The latter connotes educated, credible sincerity.
Let's cut right to the chase, shall we?

ELEVEN TENETS OF CHAMPIONING SCIENCE

…Executed well, these eleven actions can help every scientist communicate ideas to change the world. Throughout the book, we develop these concepts in detail, but if you get no further than absorbing this list, you will be on your way to becoming a more effective communicator and science champion.

  1. Be passionate. Palpable enthusiasm is contagious. It will carry people along for the great ride of science. Sharing what inspires you about your work will help others see its potential.
  2. Build the big picture first. Resist the temptation to dive into the details. Frame what you say by succinctly explaining what exists today, the future possibilities, and how your work will fill the gap.
  3. Know who’s listening. Think carefully about what your audience knows and their prevailing sentiment. Determine what you want them to think, do, and feel after they hear from you. Find out how they like to receive information and adapt accordingly.
  4. Spend more time on why it matters and less time on how you do it. Never promote science for the mere sake of science. Always demonstrate the value to people and the planet we inhabit.
  5. Extract the essence. Formulate your overarching messages and support points. Tell that story. Never dumb it down.
  6. Be understandable. Use plain, common language. Avoid or translate acronyms. Start from where your audience is, not from where you are. Use iconic references to anchor scientific concepts to everyday, familiar experiences.
  7. Balance precision with impact. Choose language carefully to be clear and directionally accurate. Long phrases bog down the listener. Think and speak in short sentences. There is no need for hype. Learn to deliver a compelling narrative.
  8. Be human and credible. The integrity of your word must be unquestionable. Verify your facts. Evaluate your sources. Be yourself. Make an emotional connection by showing up as a person first and a scientist second.
  9. Influence patiently. Convincing decision makers is a process, not a single act of persuasion. Use information as a gift. Engage often to build understanding and show the value of supporting your science. Learn what matters to your audience.
  10. Collaborate thoughtfully. Advancing your ideas doesn’t mean you have to go it alone. Seek out advisors, influencers, and partners who can help carry your science further.
  11. Enable your listeners to act. Know the purpose of your communication. Make the ask every time. Leverage each conversation and presentation to build support for advancing your work. Remember that you are ultimately building relationships for the long run.
Aines, Amy L., Roger D., Championing Science, University of California Press. Kindle Edition locations 280- 295.
My advice? Commit these 11 tenets to memory. Repeat them to yourself aloud multiple times.

I read the book with intense interest and enjoyment, and can attest that they made the case thoroughly. I would make this required reading in scientific curricula.
Scientists are great communicators—with other scientists. We are schooled in the exacting art of talking to our professors and colleagues, people deeply steeped in both the importance and the nuance of our topic. We can talk about the incredible details of modern science in an efficient way, condensing complex arguments into short discourses. But once we go out beyond the academic world to make an impact, scientists from every discipline face a brand new challenge—communicating science to decision makers.

Decisions about which scientific endeavors are advanced and how they are pursued usually get made by people who are not experts in the field. Corporate chief technology officers, elected officials, government program managers, venture capitalists, heads of nongovernmental agencies, and, often, senior management have the power to award funding and support new discoveries. These decision makers are well educated, hardworking, sincere, and extremely busy. Over the course of a day, they may be expected to make important decisions on topics spanning a myriad of unrelated fields. It is incumbent on us as scientists to quickly and effectively make our case. We must learn to talk about our work in succinct and compelling ways that convince the people who are pivotal to our success to take action…
[ibid, Kindle location 106]
Indeed, indeed. I am pretty well up to speed on the persuasion psych and "critical thinking" literature (with a particular focus on clinical reasoning), but after reading Amy and Roger's book I feel significantly better informed.

Below, from Amy's website:


Yes.

A lot to reflect on here. I jotted down an entire page of notes for my call with Amy. She had spot-on answers for all of my questions.

FROM AAAS, "DEMOCRACY'S PLIGHT"

Of direct relevance to Championing Science, recent OpEd in Science Magazine:
Scientists work with a deep sense that their quest for reliable knowledge leads somewhere—that following the evidence and excluding bias help to make sense of the world. It may be a slow process, and interactions in the scientific community are not without friction and false steps, yet scientists are devoted to the quest because they observe that it works. One can make sense of the world. Einstein famously said, “the eternal mystery of the world is its comprehensibility,” and scientists understand that evidence-based scientific thinking leads to this comprehension. Scientists could do a better job of sharing this powerful insight.

As I fret over recent challenges to democracy, it seems that a cure for what ails democracy may lie, in part, in science. Citizens are increasingly asserting their values, hopes, and opinions without apparent interest in finding a shared understanding of the actual state of things. Without such a shared understanding, those values and hopes cannot rationally be expressed and realized. Observers speak of “truth decay,” dismissal of expertise, and neglect of evidence. Collectively, these are problems of enormous importance because they threaten democracy itself. Democracy is at risk when it becomes simply a contest of fervently held opinions or values not grounded in evidence…
'eh?
Amy and I had a cool discussion concerning the word "evidence" (I asked what it meant to her). We use it all the time, but do we all mean the same thing? "Evidence," in my view, is simply that which makes a true conclusion more likely -- or, in rare cases proves it outright. Everything else is just noise -- language and data clutter. As such, evidence ranges from "nil" to "dispositive." Envision a bell curve distribution (or a skewed or flat distribution) of "evidence." In popular language we typically refer to evidence in qualitative terms, i.e., nil-to-weak-to-moderate-to-strong-to-incontrovertible. In science, they love their "p-values" (going to probability estimates). 
Another tangential point: evidence must not only have "truth value" but also "materiality," topical relevance. Ask any trial lawyer.
For now, speaking of "Science," recall my prior post "The Science of Success?"


I was dubious when I first saw that title, but, again, case made. Also highly recommended. As is this one below:


If you hope to initiate or change beliefs, it behooves you to understand the salient aspects of them.

UPDATE

Amy sent me this YouTube link:
An Evidence-Based Approach to Science Communication — Webinar

Alan Alda Center for Communicating Science


For all our careful work, scientists can still succumb to biases and assumptions that sabotage our efforts to engage with the public. Valuable new insights into public attitudes towards science are replacing conventional opinion with solid data. Learn how to avoid falling into the traps that still plague many in the scientific community...
BTW, You may have noticed that I'd accorded the Alan Alda Center a permanent right-hand column link on this blog.
Everything is "branding" these days.
Interesting, from the above webinar:
Christopher Volpe, PhD, @4:13 “...For the last 20 years, I’ve really been more of a professional marketer then I’ve been a scientist, and that makes some science folks cringe, but, believe it or not, the scientific method and the marketing method are remarkably similar, they just use different languages...”
Hmmm... how about "The Presentation Secrets of Steve Jobs?"

Recommend you visit also the "Science Counts" website:

"ScienceCounts is deciphering Americans’ complex views about science to develop more effective ways to foster grassroot support for scientific research and exploration."
Cool.

CIALDINI and GARDNER
Championing Science cites Robert Cialdini's "Six Principles of Influence": reciprocity, commitment/consistency, social proof, authority, liking and scarcity.
I am also reminded of Howard Gardner's book Changing Minds and his "7 Re's": seven levers for persuading others to embrace new ideas:
  1. Reason: You present all relevant considerations of an idea, including its pros and cons.
  2. Research: You provide numerical and other information about your idea’s ramifications, or data relevant to your idea.
  3. Resonance: You and your ideas are convincing to your listener because of your track record, effective presentation, and sense of your audience.
  4. Representational redescriptions: You deliver your message in a variety of formats, including stories, statistics, and graphics.
  5. Resources and rewards: You draw on resources to demonstrate the value of your idea and provide incentives to adopt your idea.
  6. Real-world events: You monitor events in the world on a daily basis and, whenever possible, draw on them to support your idea.
  7. Resistances: You devote considerable energy to identifying the principal resistances to your ideas (both conscious and unconscious resistances) and try to defuse them directly and implicitly.
As I reflect on all of the foregoing, I should again note that I am not a scientist. Just an aware, concerned citizen. We have serious pressing issues that will be in ongoing need of science and public support for it. I would put climate control science at the top of the list. Failure there will exacerbate of host of other serious global social, public health, political, and economic problems, perhaps irremediably so.

I have no illusions regarding the difficulties involved in "selling science" where it butts up against powerful economic interests with huge stakes in an unsustainable status quo. We gotta Bring Our A-Game.

A REFLECTION

I've been pondering science issues for a long time, particularly in the medical space. From my "One in Three" essay in the late 1980s concerning my late elder daughter's cancer illness:
Is science the enemy? To the extremist "alternative healing" advocate, the answer is a resounding 'yes'! A disturbing refrain common to much of the radical "alternative" camp is that medical science is "just another belief system," one beholden to the economic and political powers of establishment institutions that dole out the research grants and control careers, one that actively suppresses simpler healing truths in the pursuit of profit, one committed to the belittlement and ostracism of any discerning practitioner willing to venture "outside the box" of orthodox medical and scientific paradigms.

One e-mail correspondent, a participant in the internet newsgroup alt.support.cancer, vented splenetic at length recently regarding U.S. authorities' alleged hounding, arrest, and imprisonment of alternative healers. He railed that law enforcement, at the behest of the AMA/FDA Conspiracy (a.k.a. the "corrupt AMA/FDA/NCI/ACS cartel"), had made the practice of alternative medicine illegal in the U.S. Moreover, he considered the fact that medical science can only claim "cures" for approximately 10% of the roughly 10,000 classified human diseases an a priori indictment of the mainstream profession.

I know: this is akin to the U.N. Black Helicopters/One-World-Government Conspiracy stuff of the not-too-tightly-wrapped…
Those anti-science attitudes have hardly gone away.

UPDATE: OF ACUTE RELEVANCE

Just came across this book via a MSNBC interview segment. Downloaded it and started my study.

…Perversely, decades of climate denial and disinformation have made global warming not merely an ecological crisis but an incredibly high-stakes wager on the legitimacy and validity of science and the scientific method itself. It is a bet that science can win only by losing. And in this test of the climate we have a sample size of just one.

No one wants to see disaster coming, but those who look, do… all told, the question of how bad things will get is not actually a test of the science; it is a bet on human activity. How much will we do to stall disaster, and how quickly?

Those are the only questions that matter…


Wallace-Wells, David. The Uninhabitable Earth (p. 219). Crown/Archetype. Kindle Edition.
Again, I refer you to my "Anthropocene Denial" series of posts.

From the foregoing page 219 near the conclusion of David's book, let us return to his onset, page 3.
It is worse, much worse, than you think. The slowness of climate change is a fairy tale, perhaps as pernicious as the one that says it isn’t happening at all, and comes to us bundled with several others in an anthology of comforting delusions: that global warming is an Arctic saga, unfolding remotely; that it is strictly a matter of sea level and coastlines, not an enveloping crisis sparing no place and leaving no life undeformed; that it is a crisis of the “natural” world, not the human one; that those two are distinct, and that we live today somehow outside or beyond or at the very least defended against nature, not inescapably within and literally overwhelmed by it; that wealth can be a shield against the ravages of warming; that the burning of fossil fuels is the price of continued economic growth; that growth, and the technology it produces, will allow us to engineer our way out of environmental disaster; that there is any analogue to the scale or scope of this threat, in the long span of human history, that might give us confidence in staring it down.

None of this is true...
[ibid, pg 3]
David expresses a bit of qualified caution at the beginning of his end notes section (which comprises roughly 30% of the book's volume).
NOTES

All science is speculative to some degree, subject to some future reconsideration or revision. But just how speculative varies from science to science, from specialty to specialty, indeed from study to s
study.

Within climate change research, both the fact of global warming (about 1.1 degrees Celsius since humans first began burning fossil fuels) and its mechanism (the greenhouse gases produced by that burning trap heat radiating upward into the planet’s atmosphere) are, at this point, established beyond any shadow of a doubt. Exactly how that warming will play out, over the next decades and then the next centuries, is less certain, both because we don’t know how quickly humans will drop their addiction to fossil fuels, and because we don’t know precisely how the climate system will recalibrate in response to human perturbation. But the notes that follow are, I hope, a road map to the state of that science, in addition to being a bibliography for this book.
  [ibid, pg 233]
Since I posted the foregoing, I've run into some pushback from noted climate scientist Michael E. Mann (whom I've cited before).
"The evidence that climate change is a serious problem that we must contend with now, is overwhelming on its own. There is no need to overstate the evidence, particularly when it feeds a paralyzing narrative of doom and hopelessness."
More on all that in a bit. Are we to be continually stymied by "analysis paralysis" / credibility contention going to complex issues of science having significant economic and ethical policy implications?

UPDATE: I finished The Uninhabitable Earth. Riveting. Sobering. It will have to have its own review post. Highly recommended. 

ERRATUM

Trump’s pick to lead climate security panel calls climate science ‘a cult’
Rear admiral slams "extreme, fringe" pick to head White House climate and security panel.


In his ongoing war with U.S. intelligence agencies, President Donald Trump is now challenging the military’s longstanding conclusion that climate change poses a serious national security threat to America, appointing a fringe climate science denier to lead the effort…
UPDATE

apropos of the climate issue, ran into what looks to be another interesting book (available on Feb 26th).


The Amazon preview looks very intriguing.
For the entire globe, the era of plentiful water appears to be over.
Forget energy price shocks, mass unemployment, fiscal crises and financial failures. Even biodiversity loss, ecosystem collapse, human-made environmental catastrophes or the spread of infectious diseases pale in comparison…

Water problems are also strongly linked to two other prominent global risks—climate change and food insecurity. By 2050 more than 40 percent of the world’s population will be living in water-stressed regions, which is around 1 billion more people than live in such areas today. Around 2.7 billion people are also affected by water shortages each year. Meanwhile, 663 million people—one in ten of the world’s population—lack access to safe water and 2.4 billion—one in three—do not have use of a toilet. These water stresses and shortages will only worsen with the rising temperatures, more frequent droughts and variable rainfall that will accompany global warming. Growing water scarcity will, in turn, magnify the economic and environmental impacts of climate change.


Barbier, Ed (2019-02-25T22:58:59). The Water Paradox. Yale University Press. Kindle Edition.
You might like my 2015 rumination on "The Western US Drought."
_____________

More to come...