It will be a busy and contentious year, no doubt. I have a ton to reflect upon and write about. Per my prior post, it looks like Boehner blinked on the tax relief / unemployment extension / Medicare SGR "Doc Fix" bill. For now, that is. We're now getting government in recursive partisan election year two-month brinksmanship dramas, and we're right on the cusp of the next irritating episode.___
MY HOLIDAY READING LIST
Cheryl and I went to her Mom's in northern Alabama on the family farm for the Christmas holiday.
Seems like all I did was eat, sleep, watch football, and read for nine days. I read and finished two books, and have three more well on the way to completion (click the images below for links).
ECONNED is depressingly astute and thorough. Perversely nice to know I got a lot of things right in my earlier policy blog posts on the topic, here, here and here.
Among my long treasured hardcopy books are the Kahneman / Tversky / Slovic works "Judgment under uncertainty: Heuristics and biases" and "Choices, Values, and Frames." "Thinking, Fast and Slow" comprises a wonderful, general-reader accessible recap of an esteemed career work to date. For a nice summary by noted writer Michael Lewis ("Moneyball" of late), see "The King of Human Error" in Vanity Fair (I have all of his books).Apropos of the latest work by Dr. Kahneman is "Medicine in Denial," which I cited in an earlier REC blog post.
"Medicine in Denial" is a serious, serious throw-down to the profession (not that I buy it all uncritically; more on that as I go along). I am almost all the way through my gratis pre-pub copy. 267 pages of thoroughly, intelligently reasoned and exhaustively documented argument. My copy is now freighted with sticky notes, red pen margin notes, and yellow highlighter markups.
...We began by asserting the need for a secure foundation for care. With buildings, the value of a secure foundation is obvious, even though it gives no assurance that the rest of the building is well designed, constructed or maintained. That lack of assurance does not make the foundation any less important. On the contrary, if the foundation is not secure, then the rest of the building, no matter how well designed, constructed or maintained, is untrustworthy. And in medicine, the complex processes of patient care are untrustworthy if relevant, available information is not taken into account at the outset of care.Enter Dr. Kahneman:
E. Objections to the combinatorial approach
Physicians naturally view the judgmental approach, and the elaborate training needed for the unaided mind to apply it, as inherent in scientifically advanced medical care. By comparison, a tool-driven, combinatorial approach seems to impose both crude standardization and excessive detail—”cookbook medicine” taken to a compulsive extreme...
...Not surprisingly, then, the idea that a mechanical combination of a few variables could outperform the subtle complexity of human judgment strikes experienced clinicians as obviously wrong. The debate about the virtues of clinical and statistical prediction has always had a moral dimension. The statistical method, Meehl wrote, was criticized by experienced clinicians as “mechanical, atomistic, additive, cut and dried, artificial, unreal, arbitrary, incomplete, dead, pedantic, fractionated, trivial, forced, static, superficial, rigid, sterile, academic, pseudoscientific and blind.” The clinical method, on the other hand, was lauded by its proponents as “dynamic, global, meaningful, holistic, subtle, sympathetic, configural, patterned, organized, rich, deep, genuine, sensitive, sophisticated, real, living, concrete, natural, true to life, and understanding...This stuff is all fabulous. Bracing yet inspiring. I triangulate the foregoing with the observations found in Sperber and Mercier's "Why Do Humans Reason?" (PDF, another epistemological kick in the pants).
This quote from "Medicine in Denial" stings:
Policymakers recognize that transformation requires more than technology. Accordingly, certification and “meaningful use” of electronic health records (EHRs) are required to receive subsidies to purchase EHRs under the 2009 economic stimulus legislation. But the requirements for certification and meaningful use as currently conceived are primitive...Hard to disagree with that, my current HIT evangelist job notwithstanding.
...Failures of quality in medical records, paper and electronic, are a root cause of the health care system’s failures of economy. The HITECH Act reforms effectively acknowledge this reality, but fail to remedy it...
...Health information technology has only recently become prominent in health care reform debates. The traditional focus of health care reform has instead been economic incentives. Yet, incentives are not the central problem. No arrangement of economic incentives is perfectly aligned with patient interests, especially within an out-of-control system [pp 37-38].
But wait! There's more!
Abstracting knowledge from the problem-solving activities to which it should relate has damaging effects at many levels. One effect is that formal education becomes focused unduly on personal intellect. Cultivating a narrow range of intellectual skills and temperaments that foster academic success, the culture of education takes interpersonal skills for granted, and devalues manual skills. And it fails to instill the intellectual behaviors and perspectives that foster effective problem-solving (see part V).Love it. Let's summarize, shall we? "when information technology confers rapid access to more knowledge than anyone can learn and more processing power than anyone’s mind possesses. The goal should be mastering the behaviors involved in applying knowledge to solve problems effectively and efficiently."
In particular, traditional schooling fails to instill high standards of achievement. In most schooling, time is the constant and achievement the variable—precisely the opposite of what true education demands. Students are allotted a fixed amount of time to learn and then permitted to pass exams and courses with a B or C or worse. Inevitably, given the widely varying abilities and inclinations of individual students, not many will have the experience of passing courses at a high level of achievement. This tolerance of lesser achievement is especially harmful when learning is cumulative, that is, when success at one level requires understanding of the material from an earlier level.
Failure to enforce high standards of quality arises from the premise that schooling should instill a fixed core of knowledge, as distinguished from a core of behavior. Teaching high standards of intellectual behavior and teaching a fixed core of knowledge are mutually exclusive when a fixed time is allotted to achieving these goals. One of the three variables (time spent, amount covered and degree of mastery) has to be held constant at a high level, and that constant should be the degree of mastery. Students would differ in the amount they master and the speed with which they do so, but not in the degree of mastery they attain.
Mastery of a core of knowledge should not be the goal of education — especially in an era when knowledge is constantly becoming obsolete and when information technology confers rapid access to more knowledge than anyone can learn and more processing power than anyone’s mind possesses. The goal should be mastering the behaviors involved in applying knowledge to solve problems effectively and efficiently.
Because these principles are ignored, many students pass through 12 or more years of schooling without ever experiencing mastery, while constantly undergoing invidious comparisons to the best students. This system is harmful even for those best students, for they may acquire elitist attitudes, superficial understanding and misplaced confidence that their academic proficiency will translate into effective problem solving. For less successful students, schooling is too often experienced as a caste system rather than a vehicle for personal development. Many students emerge from their schooling with their natural abilities undeveloped and their natural optimism defeated. To fight back, some adopt an attitude of disdain towards education and intellect. These reactions to formal education are like the reaction of dying canaries in a coal mine—highly sensitive indicators of toxic conditions. In varying degrees, many students are left without the capacities and confidence that only achievement can confer and without the expanded horizons that only education can provide. [pp 229-230]
Yes.___
Other works in progress at this writing:
___JAN 2nd UPDATES
Lots of cool new stuff over on The Health Care Blog this morning. Below, from the comments, a common refrain voiced by HIT skeptics.
"Widespread iatrogentic EHR diseases?" Really? Any data, sir? When I see phrases like "directly proportional," I reflexively react "data?"
Not that I disagree with the notion regarding continual evaluation and improvement of any medical technology.
Moreover, you have to give informed naysayers their due, e.g., "IT Malpractice? Yet Another "Glitch" Affecting Thousands of Patients. Of Course, As Always, Patient Care Was 'Not Compromised'."
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I commented in this post (below). Fits with what I'm working on at the moment.
The Crash of Air France 447: Lessons for Patient Safety
By BOB WACHTER, MD
BobbyG says:There's so much to learn. One more Weed & Weed money quote for now:
January 2, 2012 at 11:34 am
”We need to ensure that our personnel have the skills to manage crises caused by the malfunction of technologies that they’ve come to rely on. We should continue to push crew resource management training and work on strategies to bolster situational awareness (I haven’t found anything better than the old House of God rule: “In a Code Blue, the first procedure is to take your own pulse.”) We need to redouble our efforts to promote realistic simulation training, and to build systems that allow us to learn from our mistakes and near misses so we don’t repeat them.”
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This is precisely a core takeaway point from Drs. Weed & Weeds’ excellent book “Medicine in Denial.” (now available on Amazon. They sent me a pre-pub proof, which is now loaded down with yellow marker, red pen margin notes and stickies; it’s excellent. Highly recommended)
to wit:
“The minds of physicians do not have command of all the medical knowledge involved. Nor do physicians have the time to carry out the intricate matching of hundreds of findings on the patient with all the medical knowledge relevant to interpreting those findings. External tools are thus essential. But the tools are trustworthy only when their design and use conform to rigorous standards of care for managing clinical information.
Without the necessary standards and tools, the matching process is fatally compromised. Physicians resort to a shortcut process of highly educated guesswork…
…We use the term “guesses” because these key initial judgments are made on the fly, during the patient encounter, based on whatever enters the physician’s mind at the time. That mind may be highly informed and intelligent, but inevitably its judgments reflect limited personal knowledge and experience, and limited time for thought. Euphemistically termed “clinical judgment,” physician thought processes cause a fatal voltage drop in transmitting complex knowledge and applying it to patient data. The outcome is that the entire health care enterprise lacks a secure foundation.
Equally insecure are the complex processes built on that foundation: decision making, execution, feedback and corrective action over time. Responsibility for all these processes falls on the mind of the physician. Here again the mind lacks external tools and accounting standards for managing clinical information.” [pp 2-3]
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I’m now triangulating all this stuff with Kahneman’s “Thinking, Fast and Slow,” Groopman’s “How Doctors Think,” Sperber & Mercier’s “Why Do Humans Reason?” etc. Fascinating.
I’ll be citing your article on my REC blog. Fits right in with my latest topics.
Unlike scientific practitioners, medical practitioners do not operate in an objective realm, where the contents of thought and knowledge exist independently of the individual mind, a realm where knowledge can be reliably transmitted and applied, where new knowledge can be rapidly translated into practice, where all knowledge can be tested against patient realities. Isolated from this objective realm, the mind becomes a negative force, a cause of confusion and disorder. Physicians are not equipped to fulfill their immense responsibility safely and effectively. Other practitioners are not equipped to share that responsibility with physicians. Patients are not equipped to work effectively with multiple practitioners, nor to assume the ultimate burden of decision making over their own bodies and minds. Third parties are not equipped to create order out of this chaos. Practitioners and patients are not accountable for their own behaviors, while third parties are left free to manipulate disorder for their own advantage."[I]nformation tools and feedback mechanisms are missing from the marketplace"? Well, "third parties are left free to manipulate disorder for their own advantage."
In short, essential standards of care, information tools and feedback mechanisms are missing from the marketplace. These missing elements are in large part already developed (see parts IV and VI below). Yet, the underlying medical culture does not even recognize their absence. This does not prevent some practitioners from becoming virtuoso performers in narrow specialties or skills. But their virtuosity is personal, not systemic, and limited, not comprehensive. Missing is a total system for enforcing high quality care by all practitioners for all patients. [pg 3]
Medical economist J.D. Kleinke would find that totally unsurprising.
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ERRATUM: This is interesting.
Judge orders UPMC deposition in Presby death lawsuit
Monday, November 14, 2011
By Sean D. Hamill, Pittsburgh Post-Gazette
An Allegheny County judge today ordered UPMC to allow an official to be deposed in a medical malpractice case about whether he altered the electronic health record of a man who died while in UPMC Presbyterian Hospital.
UPMC's attorney, John Conti, had attempted to shield Richard Simmons, UPMC Presbyterian's head of quality assurance, from being deposed during a hearing before Judge Ronald W. Folino.
Mr. Conti argued that Dr. Simmons was performing "peer review" work -- which would protect him from being deposed -- when he entered the electronic health record of Samuel Sweet three days after the 62-year-old Cheswick man died at the hospital in 2009...
That certainly bears following.
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Ahhh... The state of health care politics...
Really? Well, you learn something every day.Back to the real world.
Dr. Kahneman on "Defending the status quo"
Animals, including people, fight harder to prevent losses than to achieve gains. In the world of territorial animals, this principle explains the success of defenders. A biologist observed that “when a territory holder is challenged by a rival, the owner almost always wins the contest—usually within a matter of seconds.” In human affairs, the same simple rule explains much of what happens when institutions attempt to reform themselves, in “reorganizations” and “restructuring” of companies, and in efforts to rationalize a bureaucracy, simplify the tax code, or reduce medical costs. As initially conceived, plans for reform almost always produce many winners and some losers while achieving an overall improvement. If the affected parties have any political influence, however, potential losers will be more active and determined than potential winners; the outcome will be biased in their favor and inevitably more expensive and less effective than initially planned. Reforms commonly include grandfather clauses that protect current stake-holders—for example, when the existing workforce is reduced by attrition rather than by dismissals, or when cuts in salaries and benefits apply only to future workers. Loss aversion is a powerful conservative force that favors minimal changes from the status quo in the lives of both institutions and individuals. This conservatism helps keep us stable in our neighborhood, our marriage, and our job; it is the gravitational force that holds our life together near the reference point. [pg 305, Thinking, Fast and Slow]___
ON "PERSONALIZED MEDICINE"
I put up some linked excerpts and thoughts regarding "personalized medicine" in my November 16th post. So, I found this interesting today (click the graphic for the link).
As I contemplated what I’d like to write about for the first post of 2012, I happened to come across a post by former regular and now occasional SBM contributor Peter Lipson entitled Another crack at medical cranks. In it, Dr. Lipson discusses one characteristic that allows medical cranks and quacks to attract patients, namely the ability to make patients feel wanted, cared for, and, often, happy. As I (and several of us at SBM) have said before, it’s not necessary to invoke magic, quackery, or pseudoscience in order to show empathy to patients and provide them with the “human touch” that forges a strong therapeutic relationship between physician and patient and maximizes placebo effects without deception. In the old days, this used to be called “bedside manner,” but in these days of capitation and crappy third party payor reimbursement it’s very difficult for physicians to take the time necessary to listen to patients and thereby build the bonds of trust and mutual respect that can augment the treatments that are prescribed. Unfortunately, because of this the quacks have been all too eager to leap into the breach.Yeah. Note doubt the hucksters will always be quick out of the chute to misappropriate scientific mantle keywords and phrases.
One aspect of this tendency of medical cranks is to claim that they somehow “individualize” their treatment to the patient, as Peter points out:
There are a number of so-called holistic doctors in town who claim to practice “individualized” medicine. What this really means isn’t clear. My colleagues and I certainly individualize the treatment plans for all of our patients, using data gleaned from decades of scientific studies of large groups of patients. What “individualized” care seems to mean in this other context is “stuff I made up to make that patient feel more unique and special.”
As usual, the comments are as good as the posts at SBM.
ConspicuousCarlon 02 Jan 2012 at 2:39 pmLOL. On the other hand, I bet the folks at the "Personalized Medicine Coalition" would take exception to the conflation of alt.med stuff with
...Except for insanely expensive tailoring, nobody measures a customer’s foot and then creates a custom shoe just for them. The seller measures the customer’s foot, and then gets one of only a handful of different sizes available. Far from being so personalized as to evade scientific study, each given shoe size is actually sold to millions of different people.
And what sort of scientific study might we want to do, if the concept of a shoe had just been invented? Well, we might want to do Phase I trials to find out if shoes are safe to wear, and how big of a shoe can be worn safely. Is the wearer going to experience discomfort or injury if the shoes are too big? How big can the shoe get before the wearer risks twisted ankles and tripping? Does the shoe remain on the foot all day without falling off?
Then we might want to do Phase II trials to find out how much benefit the wearer gains from wearing a shoe within the safe range of shoe size for their foot. If shoes in any size are harmless, but still beneficial, we can sell a nice big shoe which fits everyone. If having oversized shoes produces a risk which outweighs the benefit of going barefoot (and in fact, this is the case in real life), then we would have to sell shoes in multiple sizes so that a person can get a shoe within the safe size range for their foot, just as drugs with potential side effects and overdosing are available in different amounts. The foot’s tolerance for slightly imperfect shoe size will determine how many different shoe doses we have to manufacture for a Phase III trial and mass marketing.
And then we can argue about whether or not commercial shoe production has produced enough size variety for everyone, and weigh the ups and downs of possibly having the government mandate more varied shoe sizes.
initiatives involving pharmacogenomics and epigenetics research, etc.
"My colleagues and I certainly individualize the treatment plans for all of our patients, using data gleaned from decades of scientific studies of large groups of patients."Yeah, but I think Lawrence and Lincoln Weed would give you some pushback on that.
Medical knowledge is itself an element of the health care system. Like other elements, medical knowledge is distorted by failure to migrate from the realm of subjective, personal knowledge to the realm of objective knowledge, from knowledge as it exists in the mind to its independent existence in external information tools.209 The distortion occurs in the content of medical knowledge, in its organization, and in its capacity for growth.All very interesting.
First, the content of medical knowledge is oriented towards resemblances, not differences, among individuals. Yet, the differences must be taken into account for sound decision making, especially with chronic disease. Thus, individual heterogeneity and uniqueness, no less than patterns of resemblance across populations, must become the subject matter of medical knowledge.
Second, the health care system fails to organize medical knowledge for solving the problems of unique patients, just as the system fails to organize health care providers for delivering patient-centered care. Care is thus fragmented intellectually as well as institutionally. Rather than being oriented towards patient needs, knowledge is organized for comprehension by the unaided minds of physicians. Medical specialties, for example, are defined by body system. That narrow focus reduces the burden of comprehension, but it fails to cope with the reality that patient problems normally implicate multiple body systems. Similarly, the population-based content of medical knowledge is easier for the mind to comprehend than detailed data about individual variation.
Third, the health care system fails to enforce the scientific standards and tools essential to the growth of reliable medical knowledge. Existing “knowledge” is not just incomplete but in part is simply wrong. As with other areas of science, medical knowledge is only a provisional approximation of reality. Practitioners, patients and researchers must constantly test medical knowledge against reality. In caregiving, that testing process demands taking into account all potentially relevant knowledge and patient-specific data at the outset of care, and then carefully monitoring and adjusting whatever course of action is chosen. In clinical research, that testing process demands continuously harvesting feedback on knowledge by examining meticulous records of what happens when knowledge is applied. [Medicine in Denial, VII. The Gap Between Medical Knowledge and Individual Patients, pg 178]
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CODA: A MASTER'S IN "LAW"?
I'm too old to now go to law school (I'll be 66 in five weeks). But, I recently clicked on Facebook ad (which I nearly never do). It was for the Champlain College (VT) MSL program. Interesting. Enticing.
We believe that in a world dependent on the rule of law, the law is too important to have only a few specialists understand it. As such, we've created our Master of Science in Law to help professionals who are not lawyers think and act confidently in the legal dimensions of their work, prevent needless litigation, and work productively with legal counsel when counsel is necessary.Dunno. Would that get me any traction with our HIE Counsel who keep politely blowing me off with respect to our Privacy and Security stuff? (See my prior posts. I rather doubt it.) Beyond that short-term utilitarian concern, would there be substantive net academic value? I am always up for more learning, particularly with respect to law, but, what's the likely appreciable margin here?
So, I made contact, but came away from it with disconcerting wafts of a pro forma "admissions counselor" (read call center sales rep) persistently fishing for a credit card number. Among other considerations, I was a bit red-flagged by the relatively low admission requirements.
Dubious.
They have competition, too, so it emerges. Google "Master's in Legal Studies."
Notwithstanding that it remains intriguing, I will have to search a bit longer.
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More to come...
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