On Father's Day

My first kid was born 51 years ago, her sister two years later, then their brother Matt (our last surviving child) 36 years ago.

Every day is Father's Day for me. Wishing all of you dads well.
__________

June 2019 EHR interoperababble update

From THCB:

Electronic health records (EHRs) are a polarizing issue in health reform. In their current form, they are frustrating to many physicians and have failed to support cost improvements. The current round of federal intervention is proposed rulemaking pursuant to the 21st Century Cures Act calls for penalties for “information blocking” and for technology that physicians and patients could use “without special effort.”

The proposed rules are over one thousand pages of technical jargon that aims to govern how one machine communicates with another when the content of the communication is personal and very valuable information about an individual. Healthcare is a challenging and unique industry when it comes to interoperability. Hospitals spend lavishly on EHRs and pursue information blocking as a means to manipulate the physicians and patients who might otherwise bypass the hospital on the way to health reform. The result is a broken market where physicians and patients directly control trillions of dollars in spending but have virtually zero market power over the technology that hospitals and payers operate as information brokers...

----

The draft rules for interoperability, CMS, ONC, TEFCA, USCDI are over a thousand pages. Most of the complexity stems from a design that avoids direct patient direction and transparency the way we expect banking and other automated services. This approach fragments the patient and physician experience and poses privacy and security risks that may never be solved. On the other hand, an interoperability design based on patient-designated sharing with clinicians that voluntarily post their digital contact info (personal, group, or institution) works across the full range of patient data (behavioral, HIPAA, patient-generated) and provides patients and family caregivers the transparency and accountability over health services that we need. Allowing patients to specify their authorization server further simplifies things by enabling competition for the authorization service – a digital concierge – that would give market power to individuals and deliver the pro-competitive benefits the Rule seeks.

"Banking and other automated services?" I have to voice some dubiety with respect to that apples-to-oranges analogy. "Allowing patients to specify their authorization server further simplifies things by enabling competition for the authorization service." Right, so we'll still have multiple competing architectures.

"Interoperababble?"

A hardy perenennial.

No amount of calling point-to-point interfaced data exchange "interoperability" will make it so.

Standardize the data.

Interestingly, I've spent a good bit of the day trying (with frustratedly limited success) to download my medical records in anticipation of my first patient visit next week at Kaiser. Muir (my last provider system) is on Epic. Kaiser is on Epic. You'd think that would be easy. You'd be wrong. My hernia surgery a year ago was via a surgeon at Bass Medical Group. Owned now by Muir, but on a different platform still. The urologist who dx'd my prostate cancer in 2015 was with NorCal Urology. Bought by Muir, but using NextGen (I think they've now migrated). My radiation oncology tx group was Diablo Valley Oncology and Hematology. Yet another EHR platform, one whose patient portal is useless.

I'm just going to have to write my own summary "progress note," comprised of Active Problems, Active Meds, CC, PMH, PSH, HPI, FH, SH, etc., to save the new M.A. a bit of intake time.
_____________

More to come...

Crowdfunding health care

This HuffPo piece caught my eye on my iPhone.

While health insurance or government programs like Medicaid and Medicare can shield against huge medical bills, massive debt and even bankruptcy, only the truly wealthy can feel secure that sickness won’t lead to financial ruin.

This is why thousands of Americans have turned to crowdfunding website GoFundMe in the last decade to help cover medical bills and related costs. HuffPost is profiling some of those people, and what their stories reveal about the shortcomings of the American health care system.

These are not feel-good stories.

That’s often how the news media cover these fundraisers ― focusing on the generosity of individuals giving rather than the systemic failures that created the need. While it’s hard not to be inspired by successful campaigns and the fortitude of those suffering through terrifying ordeals, such stories portray a chilling reality that Americans ― even those with good jobs and health insurance, can be one bad day away from financial ruin.

A serious disease can put financial strain on people even in countries with universal health care systems and strong safety nets. But the United States, which has neither of those things, leaves its residents uniquely vulnerable…

In my more cynical moments, I might have written the title as "Inside America's Go[Bleep]Yourself Health Care System."

Both of my late daughters died well beyond flat broke from their respective cancers. There was no "GoFundMe" in the 1990's when Sissy was ill. Her younger sister Danielle, however, got a bit of OoP and "bucket list" benefit in 2017-18 from a crowdsourcing account set up by one of her friends.

As I ponder my new Kaiser Permanente Medicare Advantage membership, my max annual OoP (out-of-pocket) caps at $6,700--plus monthly premiums of $51 ($612 for a year, even if I never use them, though I will have ongoing Rx co-pays).

I lost track of my 2018 OoP. Suffice to speculate that it was well beyond $6,700, in light of my hernia and SAVR surgeries. I know my (BS) "Chargemaster" 2018 tally on my final EoB was close to $600k.

Tangentially, as recently reported by STATnews, one family in Iowa took things to a whole 'nuther level:

When ‘right to try’ isn’t enough: Congress wants a single ALS patient to get a therapy never tested in humans

...“What about other patients who can’t afford this kind of access and don’t have this kind of political clout? Should people be contributing to a GoFundMe that is extremely unlikely to lead to benefit? What are we doing to patients when we advance this spirit of fighting disease at all costs?”

Read all of it, including the fractious comments. Tough, tough case.

UPDATE

 

How will we pay for the coming generation of potentially curative gene therapies?
Senator Bill Cassidy, MD (R-LA)

We have arrived at a special moment in health care. Innovative, life-changing gene therapies are here that will cure or ease debilitating diseases. Yet these expensive treatments are entering a market structure that was not built to price them…

...Life-changing gene therapies are coming. We must give thought now on how to determine the price of these innovative, new-age treatments and how to finance them to ensure that we realize their full, beneficial potential while also ensuring that society can pay for them...

Another good STATnews item. No amount of crowdfunding will suffice in this area. More broadly, there's a bit of "market" condundrum with respect to "precision / personalized medicine," no? A "market of one?"

UPDATE

Firewalled, but we get the point.

"The U.S. health system has been carefully structured, often through enabling legislation triggered by special interest groups, to allow the supply side of the health care sector to extract enormous sums of money from the rest of society. Nowhere is this clearer than with specialty drugs, whose prices per year of treatment now routinely exceed $100,000. Yet on Capitol Hill, this system has always had its staunch defenders, for obvious reasons."

Reinhardt, Uwe E.. Priced Out (pp. 145-146). Princeton University Press. Kindle Edition. September 2016 Princeton interieww.

TANGENTIALLY

The Worst Patients in the World
Americans are hypochondriacs, yet we skip our checkups. We demand drugs we don’t need, and fail to take the ones we do. No wonder the U.S. leads the world in health spending.

…For years, the United States’ high health-care costs and poor outcomes have provoked hand-wringing, and rightly so: Every other high-income country in the world spends less than America does as a share of GDP, and surpasses us in most key health outcomes.

Recriminations tend to focus on how Americans pay for health care, and on our hospitals and physicians. Surely if we could just import Singapore’s or Switzerland’s health-care system to our nation, the logic goes, we’d get those countries’ lower costs and better results. Surely, some might add, a program like Medicare for All would help by discouraging high-cost, ineffective treatments.

But lost in these discussions is, well, us. We ought to consider the possibility that if we exported Americans to those other countries, their systems might end up with our costs and outcomes. That although Americans (rightly, in my opinion) love the idea of Medicare for All, they would rebel at its reality. In other words, we need to ask: Could the problem with the American health-care system lie not only with the American system but with American patients?...

Yeah. Recall my prior post "Can medicine be cured? Some views from across the Pond"
_____________

More to come...

Exploiting Doctors and Nurses

Danielle Ofri, MD, in the New York Times:

…If doctors and nurses clocked out when their paid hours were finished, the effect on patients would be calamitous. Doctors and nurses know this, which is why they don’t shirk. The system knows it, too, and takes advantage.

The demands on medical professionals have escalated relentlessly in the past few decades, without a commensurate expansion of time and resources. For starters, patients are sicker these days. The medical complexity per patient — the number and severity of chronic conditions — has steadily increased, meaning that medical encounters are becoming ever more involved. They typically include more illnesses to treat, more medications to administer, more complications to handle — all in the same-length office or hospital visit.

By far the biggest culprit of the mushrooming workload is the electronic medical record, or E.M.R. It has burrowed its tentacles into every aspect of the health care system.

There are many salutary aspects of the E.M.R., and no one wants to go back to the old days of chasing down lost charts and deciphering inscrutable handwriting. But the data entry is mind-numbing and voluminous. Primary-care doctors spend nearly two hours typing into the E.M.R. for every one hour of direct patient care. Most of us are now putting in hours of additional time each day for the same number of patients.

In a factory, if 30 percent more items were suddenly dropped onto an assembly line, the process would grind to a halt…

Read the entire piece. I've cited Dr. Ofri on numerous occasions and have read her books and articles.

 

The E.M.R. is now “conveniently available” to log into from home. Many of my colleagues devote their weekends and evenings to the spillover work. They feel they can’t sign off until they’ve documented all the critical details of their patients’ complex medical histories, followed up on all the test results, sorted out all the medication inconsistencies, and responded to all the calls and messages from patients. This does not even include the hours of compliance modules, annual mandates and administrative requirements that they are expected to complete “between patients.”

According to their latest available IRS 990 (2017), the CEO of the Health Information Systems Management Society "non-profit" trade association (HIMSS) is paid about $1.25 million a year. I'm sure he's a very busy person.

As must also be the CEOs of Johnson & Johnson and Pfizer, each of whom earn close to $30 million annually.

The average primary care doc makes about $225k, according to Medscape.

AN ICONIC GRAPHIC

Yeah, it's a decade old. I'm confident that the trend has neither flattened nor reversed.

UPDATE

Monday morning rounds. Saw this cited at The Incidental Economist:

What makes us healthy?
 
We have an intuitive sense that things like what we eat, how much we exercise, the quality of our water and air, and getting appropriate health care when sick all help us stay healthy, but how much do each of these factors matter?

Studies have also shown that our incomes, education, even racial identity are associated with health — so-called “social determinants of health.”

How much do social determinants matter? How much does the health system improve our health?

Certainly worth following. 'The Drivers."

A theme I'll be hitting a few times is that to what we attribute health changes over time. It's not possible to say it's x% this and y% that *forever*. More on the @DriversofHealth blog: https://t.co/2buIV4l300 #SDoH pic.twitter.com/KQRmc1zekz

— Austin Frakt (@afrakt) June 7, 2019

_____________

More to come...

How good is Kaiser's Medicare Advantage plan?

Cheryl and I are fixin' to find out first-hand.

What are the Pros and Cons of Switching to a Medicare Advantage Plan?

Medicare Advantage, also known as Medicare Part C, makes it possible for people with Medicare Part A (hospital insurance) and Part B (medical insurance) to receive their Medicare benefits in an alternative way. Medicare Advantage plans are offered by private insurance companies contracted with Medicare and provide at least the same level of coverage that Medicare Part A and Part B provide.

You may be wondering which is the better choice: sign up for a Medicare Advantage plan or Original Medicare. There isn’t a simple answer because Medicare Advantage plans have key features that many people find attractive and other characteristics that may not match with your personal preferences and/or lifestyle…

Among the upshots of our recent move from the CA Bay Area to Baltimore was being involuntarily disenrolled from our SilverScript Medicare Part-D Rx coverage ("out of service area"), and seeing a huge premium increase in our high-deductible MediGap Part-F plans (mine was about 30% compared to last year).

During the Christmas holidays, through our future daughter in Law Eileen, we'd come to know Dr. George Brouillet, orthopedic surgeon and former President of the Maryland Medical Association. He provided us with a list of area internal med docs to check out.

None of them were taking new patients. So much for "unrestricted choice of doctors" vs "HMO."

We discussed taking a closer look at Kaiser Permanente. I'd covered a number of their HIT Conference presentations across the years, and then we got caregiver in-your-face close-up looks once Danielle was diagnosed in March 2017 (she'd signed up for KP the year before via "Covered California")

We attended a KP pitch presentation, and watched a version of this:

We ran the comparative numbers once home. No longer need Rx Part-D or our Humana Medigap monthly premiums. Net financial benefit, though, quickly becomes inscrutable.

Our KP sales rep was candid to say that we could compare their plan to that of their principal competitor--Johns Hopkins.

Kaiser is on Epic, as is Muir (where I've been a patient since 2013), so records interop transfer should be "relatively" straightforward.

BTW, KP's Maryland Advantage plan is essentially a hybrid Staff + Network "capitated/risk" HMO model. No "medical underwriting."

After a rough initial start (incompetent, indifferent Primary who should count herself lucky I didn't come after her license), Danielle's KP care was uniformly top-shelf, notwithstanding that Kaiser lost their shirts on her.

We signed up. We shall see how our experiences shake out. Stay tuned.
_____________

More to come...

Uh-oh, someone's "feeling dark lately."

Margalit is at it again. Cross-posted.

For over a decade Washington DC has been busy with fixing health care. For over a decade, the same government bureaucracy, the same advocacy (read lobbying) organizations, the same expert think tanks, the same academic centers, the same business associations, with the same people hopping around from one entity to the next, have been generating and applying the same “innovative solutions” differentiated solely by their aggrandizing names. The result? Health care is more expensive than ever. More people than ever can’t afford to seek medical care. More doctors are disheartened, to the point of committing suicide. All this while the illustrious transformers of health care are accumulating fame and riches, probably exceeding their own expectations, with no end in sight.

It is no secret that back in 2016 many of us voted for Donald Trump hoping that he will “drain the swamp” or at the very least blow it all up into a spectacular artesian fountain of filth. He didn’t and he won’t. The swamp won. Our special health care swamp is deeper and wider than most, and the Trump administration is making it deeper and wider than ever before.  The single payer lobby is simply proposing to move the existing health care swamp to a bigger and more noxious location, so it has plenty of room to expand in the future. The swampy strategy for fixing health care has always been, and by the looks of it will always be, a game of hot potato. The potatoes are us.

At the core of the guileful verbosity of health care transformation there is nothing more than an elaborate effort to shield corporations, and the governments that serve them, from financial risk. It’s really that simple. We pay our premiums and our payroll taxes, month after month, year after year, and when the time comes, if it comes, they’d much rather not pay the medical bills they are contractually or statutorily obligated to pay. Blame sick people for being sick. Blame the sick for not shopping the clearance aisle. Blame doctors for treating the sick. Blame hospitals for admitting too many sick people, too often and for too long. Punish them for the errors of their ways. Teach them a lesson or two. And most importantly, make them pay until it hurts.

Managing the Health Care Consumer
The most blatant attempt to throw people under the bus is the insanely brazen effort to remake medicine into a consumer industry. Patients, according to the narrative, are empowered when they spend their own money on health care. Increasing deductibles for health insurance, while also increasing premiums and limitting choice of service providers, is how we weaponize sick people in the war against rising health care prices. If enough diabetics choose to die rather than overpay for insulin, prices for the drug will surely go down eventually, because Southwest Airlines will come up with a disruptively innovative version of insulin that will not be as fancy, but it will be cheap enough to spur increased market participation and push Eli Lilly into bankruptcy. Any day now.

The return to pre-1965 days of consumerism in health care for the first $6,000 of medical expenditures was a good step forward, but the road to fully optimized profitability is long and full of terrors. Consumers are like goats. If left to their own devices, they will destroy your landscape in five short minutes. However, with proper guidance and supervision, they will clean and protect your property from the dangers of random wild fires. Managed Care insurance plans, coupled with high deductibles, ensure that consumers do not eat into your nice profits, while consuming enough garbage to keep your bottom line from going up in smoke.

From Volume to Value
Offloading risk to sick consumers is working relatively well by all accounts, but it is not working well enough, and it is not working for beneficiaries of public insurance where the consumer lever is rather short and limp. And so, we push the “provider” lever next. Once patients became consumers, their doctors, naturally, became providers. And just like empowered consumers, empowered providers should have some financial skin in this game. In the current system, you see, providers are just sitting there, placidly watching the register go cha-ching every ten, fifteen minutes like clockwork. If the consumer gets better, fine. If not, also fine. As long as there are no malpractice lawsuits, and the cash keeps flowing, providers are surely satisfied. How do policy makers and garden variety health care experts know this? Simple. It’s called projection.

Moving “from volume to value” does not mean moving from indiscriminate overconsumption to eclectic consumption of excellence. It means moving from lots of variably priced stuff to small amounts of cheap stuff. It means moving from assumed abundance to assumed scarcity. If you can find excellence at the Dollar Store, good for you. If you can’t, well, whatever. Saks Fifth Avenue is out of bounds. And your provider is supposed to enforce those boundaries, at his or her own risk. If you manage to sneak into Saks, your provider will be punished. If you stay where you belong, your provider will be rewarded. Simple. It’s called stewardship.

Global Budgets
This is not fair. Obviously. These very clever risk levers are based on wealth, and since we have massive wealth inequality, the levers are largely discriminatory. Wealthy providers couldn’t care less about adding or removing a dollar from each patient visit. Poorer providers can be driven out of business by a fifty cents difference in “reimbursement”.  Wealthy patients don’t have to become consumers at all. For patients who are not wealthy enough (or poor enough), even the Dollar Store is cost prohibitive. There is too much privilege at the top. The only fair solution is to shut down Saks Fifth Avenue completely. If everybody is forced into the Dollar Store, eventually the Dollar Store will get better. It will become as good as Saks, but at $1 prices, because the wealthy will demand it. Right.

Shuttering the Saks Fifth Avenue of health care is hard. You can’t just show up at Bayonne Medical Center one morning with a wrecking ball and have at it. Fortunately, the Medicare For All aficionados have a solution: Global Budgets. Once the Federal government controls all health care dollars, they give Saks Fifth Avenue a fixed amount of money to service all their customers for the year. The amount of money is calculated based on Dollar Store costs, with a little markup perhaps, so we don’t appear overly vindictive. Within a few months, you won’t be able to tell the difference between a Saks store and a Dollar Store, except maybe the crumbling façade from a bygone era. That’s how we rid ourselves of inequality and excess privilege, of course.

Remember when Paul Ryan and his evil acolytes proposed replacing the open-ended Medicaid financing model with block grants to States (i.e. fixed amount of Federal money to service all their Medicaid beneficiaries)? There is a one hundred percent overlap between the people who screamed about millions dying in the streets if Medicaid moves to block grants, and the people now climbing the Medicare For All barricades in support of global budgets. Rationing medical care for the poor, or “by ability to pay”, is immoral. Rationing medical care for everybody, regardless of ability to pay, is righteous. Simple. It’s called justice.

A Permanent Solution
It is not surprising that health insurance companies would look out for their bottom line at customers’ expense. After all, these are insurance companies, like home insurance or car insurance, which are notorious for continuously devising innovative ways to minimize current and future payouts. Perhaps it is also not too much of a shocker to see that government is at its best when working to eschew commitments made to its citizens. What should however give you pause is that both government and health insurers seem to have finally found a good way to coopt physicians into doing their bidding. Not all physicians, of course, but more than enough to make a permanent difference in the practice of medicine. Either due to misplaced fear or newfound conviction, your doctor’s prime directive now is to do no harm to the United States Treasury and the corporations for which it shills. 

Trump. Agghhh...

UPDATE ERRATUM

apropos of nothing. But, yeah, this is us. Notwithstanding our having rid ourselves of another 3/4ths of our hardcopy books prior to the Baltimore move.
_____________

More to come...

On the DiMe

Just saw this at STATnews during my morning rounds. Joined.

The Digital Medicine Society (DiMe) is the professional society for the digital medicine community. Together, we drive scientific progress and broad acceptance of digital medicine to enhance public health. Our mission is to serve professionals at the intersection of the global healthcare and technology communities, supporting them in developing digital medicine through interdisciplinary collaboration, research, teaching, and the promotion of best practices.

Put in a permanent link here in my right hand links column.

Given that I'm a fussbudget of late for "definitions," I liked this:

Defining Digital Medicine
What is digital medicine?

Digital medicine describes a field, concerned with the use of technologies as tools for measurement, and intervention in the service of human health. Digital medicine products are driven by high-quality hardware and software that support the practice of medicine broadly, including treatment, recovery, disease prevention, and health promotion for individuals and across populations.

Digital medicine products can be used independently or in concert with pharmaceuticals, biologics, devices, or other products to optimize patient care and health outcomes. Digital medicine empowers patients and healthcare providers with intelligent and accessible tools to address a wide range of conditions through high-quality, safe, and effective measurements and data-driven interventions.

As a discipline, digital medicine encapsulates both broad professional expertise and responsibilities concerning the use of these digital tools. Digital medicine focuses on evidence-generation to support the use of these technologies...

Ahhh... "evidence."

As noted at Forbes:

The Digital Medicine Society Is Developing Evidence-Based Standards For Digital Health
Professional groups and industry-wide collaborations are emerging to drive the growth of healthcare innovation. The development of high-quality, evidence-based products and services is now being supported by the Digital Medicine Society (DiMe) as well as the existing Digital Therapeutic Alliance (DTA).

The use of digital tools for better diagnosis and outcomes is rapidly progressing. The global digital health market is expected to reach $223.7 billion within five years based on increasing penetration of mobile devices, remote patient monitoring, and growing demand for advanced information systems. These products could represent a fundamental shift in healthcare services and actionable data generation according to experts…

Check 'em out. Sign up. Follow DiMe on Twitter and LinkedIn.

Wonder what the folks at HIMSS think about this. Lots of synergy potential, I would think.

BTW, apropos, I finished Susan Hockfield's book:

For the last couple of decades, as a dean and then provost at Yale, and then as president and now president emerita of the Massachusetts Institute of Technology (MIT), I’ve had the privilege of looking over the scientific horizon, and what I’ve seen is breathtaking. Ingenious and powerful biologically based tools are coming our way: viruses that can self-assemble into batteries, proteins that can clean water, nanoparticles that can detect and knock out cancer, prosthetic limbs that can read minds, computer systems that can increase crop yield. 

These new technologies may sound like science fiction, but they are not. Many of them are already well along in their development, and each of them has emerged from the same source: a revolutionary convergence of biology and engineering. This book tells the story of that convergence—of remarkable scientific discoveries that bring two largely divergent paths together and of the pathbreaking researchers who are using this convergence to invent tools and technologies that will transform how we will live in the coming century. 

We need new tools and technologies. Today’s world population of around 7.6 billion is projected to rise to well over 9.5 billion by 2050. In generating the power that fuels, heats, and cools our current population, we’ve already pumped enough carbon dioxide into the atmosphere to change the planet’s climate for centuries to come, and we’re now grappling with the consequences. Temperatures and sea levels are rising, and large portions of the globe are plagued with drought, famine, and drug-resistant disease. Simply scaling up our current tools and technologies will not solve the daunting challenges that face us globally. How can we generate more abundant yet cleaner energy, produce sufficient clean water, develop more effective medicines at lower cost, enable the disabled among us, and produce more food without disrupting the world’s ecological balance? We need new solutions to these problems. Without them, we are destined for troubled times...

Hockfield, Susan. The Age of Living Machines: How Biology Will Build the Next Technology Revolution (pp. ix-x). W. W. Norton & Company. Kindle Edition.

Nice to read something evincing net rational optimism these days during a time of aggressive science/tech denialism,,. I would hope that cutting-edge biotechnologies ("living machines") make it into the DiMe mix.

JUNE 6TH OFF-TOPIC ERRATUM: D:DAY 75

I bought "Every Man A Hero" & read almost all of it yesterday, will finish this morning. An amazing, compelling memoir, highly recommended. My late Dad also served in N. Africa & Sicily (where he lost a leg). One of my Ma's brothers was in the D-Day landing. #DDay75thAnniversary pic.twitter.com/0ce90tazdx

— Bobby Gladd (@BobbyGvegas) June 6, 2019

_____________

More to come...

KHIT Reporting from Body-More Murdaland

A.K.A. Baltimore, Maryland.

A "graffiti" screen shot from HBOs' 89 hour masterpiece "The Wire."

Back during my second tenure with the Nevada-Utah HealthInsight Medicare QIO (the 2005-2008 "DOQ-IT" initiative), I was sent to the eClinicalWorks Boston area HQ for a week of hands-on training on their eCW ambulatory EHR. One night while surfing the TV channels in my hotel room I ran across "The Wire." I'd not even been aware of it.

I was stunned, mesmerized, instantly hooked. I eventually bought the DVD box sets for all five seasons, and have watched each episode therein at least a dozen times. I can cite verbatim large swaths of the screenplay.

Yeah, I know. Get a life...

From The Wiki:

Set and produced in Baltimore, Maryland, The Wire introduces a different institution of the city and its relationship to law enforcement in each season, while retaining characters and advancing storylines from previous seasons. The five subjects are, in chronological order: the illegal drug trade, the seaport system, the city government and bureaucracy, education and schools, and the print news medium. The large cast consists mainly of actors who are little known for their other roles, as well as numerous real-life Baltimore and Maryland figures in guest and recurring roles. Simon has said that despite its framing as a crime drama, the show is "really about the American city, and about how we live together. It's about how institutions have an effect on individuals. Whether one is a cop, a longshoreman, a drug dealer, a politician, a judge or a lawyer, all are ultimately compromised and must contend with whatever institution to which they are committed."

Now Cheryl and I live here, in the venerable bucolic, Colonial "shire" that is the "Homeland District" not far from Johns Hopkins University. Mere blocks away, on the east side of the north/south York Road, police helicopters routinely circulate amid recurrent news reports of "shots fired." A recent NY Times article featured a graphic depicting a cluster of notably violent areas. Midway down was a cluster of central American countries--El Salvador, Guatemala, Honduras, Nicaragua--with the city of Baltimore right in the mix.

Whatever. I will be buying one of these t-shirts. Saw a huge mural poster on the wall of a church a couple of blocks from our house.

Repeatedly, when I tell locals that I just moved here, I get "condolences." "What? Why? Did you kill someone and have to escape California?"

Our son Matt lives here, in Pigtown with our delightful future daughter-in-law. She's a Baltimore native and an environmental engineer with the state of Maryland. They love it here. After Matt lost a second sister to cancer last year, he's our last kid standing. Moving close by was a no brainer. Our CusterFluck of a transcontinental journey is beginning to fade into a dull irritating memory. Baltimore it is. Gotta find ways to serve productively.

Baltimore is getting a lot of stuff right. Note my permanent links column hard link on the right above the fold--"Healthcare for the Homeless."

BTW, see also my April 22nd post "An #Earthday reflection from Baltimore."

I also need one of these for my yard. They're all over Homeland.

JUNE 15TH UPDATE ERRATUM

An outraged neighbor just posted about this bit of "witty" vandalism on Nextdoor.com.

I wouldn't be surprised if the perp was Biff from Delta House at Loyola University Maryland just down the street.
_____________

More to come...

"Thoughts and Prayers?"

Define "expert."

 Continuing a broad theme I recently commenced with my prior post "Define 'evidence'."

“EXPERT”
 
A person who has a comprehensive and authoritative knowledge of or skill in a particular area. - Google result
One with the special skill or knowledge representing mastery of a particular subject. - Mirriam-Webster
A person who has special skill or knowledge in some particular field; specialist; authority. - Dictionary.com
A person who is very knowledgeable about or skillful in a particular area. - Oxford Dictionary

We certainly expect that of our physicians, even as it goes to the "Art of Medicine."

Below, I cited Tom Nichols' excellent book some time back.

Recall how some people confidently claim to know more than the "experts" irrespective of the topic.

In Trump’s World, Reality Is Negotiable
The president’s resistance to learning will long outlive his administration.
Tom Nichols

“Stories that should be good, are bad. Stories that should be bad, are horrible,” President Donald Trump complained in December. But that tweet wasn’t just the latest entry in an endless series of gripes about the press—it revealed something essential about this president’s relationship to facts, and the experts who produce them. For Trump, praise is truth, criticism a lie. Reality itself, like everything else in Trump’s world, is negotiable.

Over the past two years, Trump and his enablers have accomplished something even more dangerous than trying to run a government on gut feeling and conspiracy theories. They have, by attacking sources of authoritative knowledge beyond the president himself, inoculated a huge swath of the American public against ever being informed about anything, providing millions of Americans with a resistance to learning that will long outlive his administration…

Ugh.

Now comes a new release I've been eagerly awaiting since reading "The Peculiar Blindness of Experts."

…I dove into work showing that highly credentialed experts can become so narrow-minded that they actually get worse with experience, even while becoming more confident—a dangerous combination. And I was stunned when cognitive psychologists I spoke with led me to an enormous and too often ignored body of work demonstrating that learning itself is best done slowly to accumulate lasting knowledge, even when that means performing poorly on tests of immediate progress. That is, the most effective learning looks inefficient; it looks like falling behind…

…One revelation in the aftermath of the 2008 global financial crisis was the degree of segregation within big banks. Legions of specialized groups optimizing risk for their own tiny pieces of the big picture created a catastrophic whole. To make matters worse, responses to the crisis betrayed a dizzying degree of specialization-induced perversity. A federal program launched in 2009 incentivized banks to lower monthly mortgage payments for homeowners who were struggling but still able to make partial payments. A nice idea, but here’s how it worked out in practice: a bank arm that specialized in mortgage lending started the homeowner on lower payments; an arm of the same bank that specialized in foreclosures then noticed that the homeowner was suddenly paying less, declared them in default, and seized the home. “No one imagined silos like that inside banks,” a government adviser said later. Overspecialization can lead to collective tragedy even when every individual separately takes the most reasonable course of action.

Highly specialized health care professionals have developed their own versions of the “if all you have is a hammer, everything looks like a nail” problem. Interventional cardiologists have gotten so used to treating chest pain with stents—metal tubes that pry open blood vessels—that they do so reflexively even in cases where voluminous research has proven that they are inappropriate or dangerous. A recent study found that cardiac patients were actually less likely to die if they were admitted during a national cardiology meeting, when thousands of cardiologists were away; the researchers suggested it could be because common treatments of dubious effect were less likely to be performed…

Epstein, David J. Range (pp. 11-12). Penguin Publishing Group. Kindle Edition.

Lovin' this book thus far, notwithstanding my minor quibble with his take on the 2008 financial meltdown. I used to work in subprime risk management, and had a front-row seat viewing forces that led up to the crash. See my 2008 post "Tranche Warfare." Also, Google "Gresham's Dynamic." Human affairs get regulated one way or another. Let the foxes guard the henhouses, well, you get what you get. Hyperspecialization, while certainly a major contributory factor, was by no means the whole story.

A core finding in Range is one that succinctly demolishes the specious "transfer of training" argument. Highly trained mono-hyperspecialists tend toward unwarranted overconfidence, both within their specialties, and with respect to opinions going to other knowledge/skill domains.

Title taglne, "why generalists triumph in a specialized world."

Money shot early on:

Scientists and members of the general public are about equally likely to have artistic hobbies, but scientists inducted into the highest national academies are much more likely to have avocations outside of their vocation. And those who have won the Nobel Prize are more likely still. Compared to other scientists, Nobel laureates are at least twenty-two times more likely to partake as an amateur actor, dancer, magician, or other type of performer. Nationally recognized scientists are much more likely than other scientists to be musicians, sculptors, painters, printmakers, woodworkers, mechanics, electronics tinkerers, glassblowers, poets, or writers, of both fiction and nonfiction. And, again, Nobel laureates are far more likely still. The most successful experts also belong to the wider world. “To him who observes them from afar,” said Spanish Nobel laureate Santiago Ramón y Cajal, the father of modern neuroscience, “it appears as though they are scattering and dissipating their energies, while in reality they are channeling and strengthening them.” The main conclusion of work that took years of studying scientists and engineers, all of whom were regarded by peers as true technical experts, was that those who did not make a creative contribution to their field lacked aesthetic interests outside their narrow area. As psychologist and prominent creativity researcher Dean Keith Simonton observed, “rather than obsessively focus[ing] on a narrow topic,” creative achievers tend to have broad interests. “This breadth often supports insights that cannot be attributed to domain-specific expertise alone.” [ibid, pp. 32-33]

Interesting, especially given that "I am not a scientist."

My late Dad (career Bell Labs semiconductor R&D technocrat) loved to sarcastically spout the gibe "Jack of All Trades, Master of None." He repeatedly admonished me during my childhood to find a technical niche and become "expert" in it. That was the path to success in life. The exhortation fell on deaf ears, to my parents' acute aggravation. When I finally got my Master's in 1998 at age 52, a favorite riff of mine was the late Eric Sevareid's "Jack of All Trades, Master of None, Save For That of Jack of All."

apropos of where this all points to, "Is there a science of deliberation?" Would it necessarily entail "Range?" How does all of that cohere with "Open Mindedness?" We're gonna have to get good at all of this stuff if we're to be effective "Champions of Science" at all levels.

Particularly in the medical field. e.g., here, and here, to cite just a couple of relevant prior posts.

Need I put up a subsequent post "Define 'Science'?" to wit,

Trump Administration Hardens Its Attack on Climate Science
WASHINGTON — President Trump has rolled back environmental regulations, pulled the United States out of the Paris climate accord, brushed aside dire predictions about the effects of climate change, and turned the term “global warming” into a punch line rather than a prognosis.

Now, after two years spent unraveling the policies of his predecessors, Mr. Trump and his political appointees are launching a new assault.

In the next few months, the White House will complete the rollback of the most significant federal effort to curb greenhouse-gas emissions, initiated during the Obama administration. It will expand its efforts to impose Mr. Trump’s hard-line views on other nations, building on his retreat from the Paris accord and his recent refusal to sign a communiqué to protect the rapidly melting Arctic region unless it was stripped of any references to climate change.

And, in what could be Mr. Trump’s most consequential action yet, his administration will seek to undermine the very science on which climate change policy rests…

If we don't get climate science right, little else will matter.

Mr. Best Words.

Need we also have a post entitled "Define 'definition'?" Should we go all the way to annoying sophomore undergrad Phil101"Define 'truth'?"

UPDATE

New issue of Science Magazine showed up today. This new book is reviewed. I downloaded it. Stay tuned.

As noted at Vox.com:

The decline of trust in science “terrifies” former MIT president Susan Hockfield
If we don’t trust scientists to be experts in their fields, Hockfield says on the latest episode of Recode Decode, “we have no way of making it into the future.”

Dr. Susan Hockfield
…[O]ne of the things I really do worry about is this current lack of confidence in experts and expertise. It’s what science is about. We test ideas, we contest ideas, and if we don’t believe that there are things that are more right than others, which is where we place our bets now, we have no way of making it into the future.

KS: I agree. The truth is now political, you get that? So you have to be political.
I get that and it terrifies me. So we have to continue to insist on an apolitical realm. Politics are never out of it entirely. We have to insist on an understanding that there are people who understand areas better than we do. I don’t pretend to be an engineer. I don’t pretend to be a physicist. If the physicists at MIT tell me that they’ve figured out gravitational waves, I’m going to trust them more than I’m going to trust myself to imagine whether or not there are gravitational waves.

KS: Right.
But this idea that there are people with expertise that we should value and value their opinions greater than others. I understand that people might debate the fine points of climate change, but the fact is that the best science indicates that we’re in trouble.

KS: Right.
If an asteroid were coming toward Earth, don’t you think we’d mount every possible defense to send it off its course, rather than say, “Asteroids don’t exist?” Of course we would. So it’s simply folly to my mind not to step up and invent the technologies that are going to prevent us from the ravages of climate change that we’re inflicting on the planet, or frankly whether it’s us or anyone or some other natural operation.

KS: Right.
It’s our job to protect ourselves so that we have a better future.

KS: Absolutely. Or maybe we’ll just learn our lesson. It’s probably the way it’s going to go, unfortunately the way it’s going to go.
Well, I hope not…
_____________

More to come...

AI-assisted NLU data analytics: Fat Tales, the 45th Moment of distributions, a.k.a. Trumptosis

From the WaPo Department of Blinding Glimpses of the Empirically Obvious.

From The Washington Post. Seriously?

Trump is twice as extreme as his predecessors in the past century. That’s dangerous.

It is the best of times. It is the worst of times.

In our current age of foolishness, things are “incredible,” “thriving,” “booming,” “prospering,” “tremendous,” “beautiful,” “very much happy” — the “greatest,” “best” and “most.”

It is also a “disaster,” a “mess,” “disintegrating,” “really bad,” “even worse” than the “worst,” “ridiculous,” “nasty” and “fake” — with “abuses,” a “lot of problems” and in a “spiral down.”

All of the above thoughts were proclaimed by President Trump within the span of a few minutes this week. So extreme is his rhetoric that even an attempt to portray himself as calm devolved into hysterical hyperbole…

Click the graphic below to enlarge.

The "Fourth Moment" of statistical distributions is known as "Kurtosis," a.k.a. the relative measure of "Fat Tails"

Get it? LOL.

Still working on updates for my prior post, but this was too good to pass up. We need "AI" to figure this stuff out? "Trumptosis," a new "best word."

And, no, it's not really funny.
_____________

More to come...

Define "evidence"

Ahhh... "Just the facts." 

My (non-dictionary) definition:

EVIDENCE: Information which renders a true conclusion more likely, or (much more rarely), constitutes proof of a true conclusion (a.k.a. "dispositive evidence").

Anyone see anything at least episodically problematic there? Say tuned. Lots to unpack in this upcoming post. Let's just say for openers I'm a bit of a pedantic stickler for precise definitions as a starting point for rational and productive discourse (e.g., "Deliberation Science," anyone?).

It behooves us to all be singing from the same sheet of music.

“EVIDENCE,” OXFORD DICTIONARY

1. The available body of facts or information indicating whether a belief or proposition is true or valid. ‘the study finds little evidence of overt discrimination’

1.1 (Law) Information drawn from personal testimony, a document, or a material object, used to establish facts in a legal investigation or admissible as testimony in a law court. ‘without evidence, they can't bring a charge’


1.2 Signs or indications of something. ‘there was no obvious evidence of a break-in’

BTW, apropos of 1.1, my trusty Black's Law Dictionary (10th ed.) devotes five pages [pp 576-581] to the word "evidence" and its related phrases and usages (most of them obviously pertaining to the legal domain).

"Information which renders a true conclusion more likely..." The briefest reflection extends that definition to sensory organ initiated perceptions. Is that rustling in the bushes outside your tent that of a bear? Does that acute smell of gas portend an incipient explosion? Is that "sound of 100 approaching freight trains" evidence of a tornado headed your way? Is that mole cancerous? etc.

In terms of human "arguments," any assertive premise statement ("truth claim") that fails to improve the likelihood of a true conclusion is at best simply rhetorical noise, and at worst a rhetorical fallacy. We have too much of it in our discourse.

SPEAKING OF "THE LAW"

A recent article in my AAAS Science Magazine made me aware of this:

H. R. 4174, ‘‘Foundations for Evidence-Based Policymaking Act of 2018’’—01/14/2019, Public Law No: 115-435.

"There is no natural constituency for evidence-based policy. It should, by rights, be the public who wants the most from their government (and their public funds). But the public, like most politicians, is often not aware of the ins and outs of evaluation methods and evidence. Think tanks and academics have long filled this gap and will likely continue to play key roles. But legislation signed into law in early 2019 could transform the way U.S. government officials design programs by introducing more scientific evidence into the process…"

Really? Under a Donald Trump administration? How did that happen? He signed the final bill. We can rest assured he carefully read every word of its 29 pages.

‘‘SUBCHAPTER II—FEDERAL EVIDENCE-BUILDING ACTIVITIES
 
‘‘§ 311. Definitions
‘‘In this subchapter:

‘‘(3) EVALUATION.—The term ‘evaluation’ means an assessment using systematic data collection and analysis of one or more programs, policies, and organizations intended to assess their effectiveness and efficiency.

‘‘(4) EVIDENCE.—The term ‘evidence’ has the meaning given that term in section 3561 of title 44.

44.USC.3561

(6)Evidence.—
The term “evidence” means information produced as a result of statistical activities conducted for a statistical purpose.

(10)Statistical activities.—The term “statistical activities”—
(A) means the collection, compilation, processing, or analysis of data for the purpose of describing or making estimates concerning the whole, or relevant groups or components within, the economy, society, or the natural environment; and
(B) includes the development of methods or resources that support those activities, such as measurement methods, models, statistical classifications, or sampling frames.

(12)Statistical purpose.—The term “statistical purpose”—
(A) means the description, estimation, or analysis of the characteristics of groups, without identifying the individuals or organizations that comprise such groups; and
(B) includes the development, implementation, or maintenance of methods, technical or administrative procedures, or information resources that support the purposes described in subparagraph (A)...

Well, isn't that interesting? Enter "Data Science," anyone?

A couple of passing thoughts on evaluative classification of empirical "evidence." In conventional usage, we often resort to qualitative ordinal ranking, with evidence strength thought of as ranging from "dispositive" to "nll," with (descendingly) "extremely strong," "strong," "moderate," "weak," "extremely weak" designations in between. Sometimes we gussy things up by stating nominally "quantitative" evidentiary "probabilities" when, properly, to cite just one caveat, we should be proffering what are really "probability estimates." The potential problems with inferential statistics bloom exponentially from there. See, e.g., my 1998 thesis rant on drug testing lab stats naivete.

UPDATE: just in, of relevance,

EPA Changes Math to Allow Burning of More Coal

___

"EBM," ANYONE?

"Evidence-Based Medicine." Not universally loved, historically. Still often dissed as anti-innovation "cookbook medicine" by apologists for "Eminence-Based Medicine."

"[S]ince antiquity, the mark of distinction of a learned man had been the certainty of his knowledge. A doctor knew—he did not need to test his kind of knowledge empirically because this would imply acknowledgement of uncertainty."—Ulrich Tröhler

DONALD TRUMP CLAIMS "EXPERTS ARE ALWAYS WRONG ABOUT EVERYTHING. CONSEQUENTLY..."

Are they?

The Neurologica Blog asks "How do we know?"

"...Science itself is not a set of “facts” but a method of exploration. It starts from specific premises, and it doesn’t even hold that these premises are Truth, just that they are necessary for science to function. We call these premises methodological naturalism – every material effect has a material cause, and there is no magic or miracles (arbitrary suspensions of the laws of nature). At least you cannot invoke such miracles when making an argument. Based on this premise, science uses logic and observation not to prove things correct, but to prove things wrong. (That is a key point – you can never prove something wrong if you can invoke miracles as needed.) By conducting experiments and making observations science can exclude hypotheses that are incompatible with the evidence. Whatever is left, the explanations that have survived dedicated attempts at proving them wrong, are then considered tentatively to be possible or even probable explanations. The longer a scientific notion survives, and the more independent lines of evidence that lead us to the same conclusion, the higher our confidence in that idea..."

SCIENCE MAGAZINE UPDATE

"At a time rife with a disregard for facts and the methods used to produce them (even when they portend a catastrophic future), perhaps [C.P.] Snow, were he alive today, would encourage scientists and humanists, engineers and artists, to focus on the one culture to which we all  belong."

In May 1959, Charles Percy Snow took the stage at the Senate House in Cambridge to give the annual Rede lecture. The British chemist-turned-novelist’s appearance—a rotund jowly face atop a bulky, shambling figure—led wags to comment that the speaker was well rounded in more than just his intellect.

Snow’s talk, titled “The Two Cultures and the Scientific Revolution,” broadly diagnosed a problem he believed challenged the future of all western democracies. For years, he had noted that British humanists and scientists shared “little but different kinds of incomprehension and dislike” (1, 2). The inability of literary scholars and scientists to understand and communicate with one another was not just an intellectual loss, Snow claimed, but something that threatened the ability of modern states to address the world’s problems...

Great, extensive, timely review I ordered the book. Only six bucks in paperback.

YET ANOTHER BOOK TO CONSIDER

This was cited in the notes of the Science Magazine article:

Downloaded it, read it in short order. Excellent.

The Cold War was a time when psychology came into its own as a tool of social analysis. With marked rapidity the structural, institutional, and economic ways of understanding American society that had dominated academic and public discourse in preceding decades gave way to explanations framed in terms of the psyche…

If psychology could explain everything, there was one aspect of the self that held special importance to the intellectual and policy worlds: open-mindedness. Open-mindedness was a kind of mind characterized by autonomy, creativity, and the use of reason. To the scientific experts, intellectuals, and policy makers who developed and utilized the concept of the open mind, this type of self served simultaneously as model and ideal of national and intellectual character. They projected upon the open mind their aspirations for the American character and liberal pluralist democracy, for scientific thinking and true intellectual inquiry. Indeed, for some of these individuals the open mind transcended the academic and political, as its traits were even conscripted to serve as criteria for human nature itself.

Cold War intellectuals and policy makers saw in open-mindedness solutions to the most pressing problems faced by the nation. Those who defined American foreign policy believed that open-minded autonomy, a hallmark of American virtue, posed a threat to the communist system. Traditional or authoritarian societies could not be sustained in the presence of a citizen body that thought autonomously, but for a modern democracy like America, open-mindedness would have the opposite effect, offering social cohesion. The open mind meant a respect for individuality, tolerance of difference, appreciation of pluralism, and appreciation of freedom of thought. If citizens were sufficiently equipped with these virtues, thought policy makers and social critics, the nation would flourish…

Cohen-Cole, Jamie. The Open Mind (pp. 1-2). University of Chicago Press. Kindle Edition.

I wrote an Amazon review.

I emailed the author: "You are one damn fine scholar." A compelling tour through my 73 years (and my many years working in science / engineering / tech domains) and the decades that preceded them. "Open-mindedness" has hit a serious rough patch in recent years--in particular in the turbulent wake of the last Presidential election. We are coming upon a time when it may well soon be ruled at the highest level that behaviors grounded in "open-mindedness" violate some peoples' Constitutionally-protected "religious freedom," and that, reciprocally, behaviors stemming from irrational, close-minded prejudice will be ruled as "Constitutionally-protected" on grounds of "religious freedom." (Not just "opinions," actions.)

You want a good historical understanding of how we got here, read this book. Beyond its erudition and cogent observations, i found it a FUN read.

_____________

More to come...