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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."

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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.
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More to come...