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Wednesday, December 4, 2013

Philosophia sana in ars medica sana


I read, and read, and read. Every day. I love learning, but I am chronically prone to get too much going on concurrently, a condition now materially exacerbated by the insidious Amazon "Whispernet 1-Click." I'd been preparing to write up synergistic reviews of just some recent titles I've been reading lately.

The latter was a delightful read that I consumed mostly while riding the BART into the city last week. Been thinking a lot lately about the nexus between health care process improvement and the still-too prevalent adversarial management culture in the medical world, which results in a lot of employee churn and inhibits durable-gains process improvement. From the author's website:
Study after study confirms that career development is the single most powerful tool managers have for driving retention, engagement, productivity and results. Nevertheless, it’s frequently the thing that gets side-lined. When asked, the number one reason managers give is that they just don’t have time. Don’t have time for the meetings. The forms. The administrative hoops.

But there’s a better way. And it’s surprisingly simple: frequent short conversations with employees about their career goals and options, integrated seamlessly into the normal course of business. Kaye and Giulioni identify three broad types of conversations that have the power to motivate employees more deeply than any well-intentioned development event or process. These conversations will increase employee’s awareness of their strengths, weaknesses and interests; point out where their organization and their industry are headed; and help them pull all of that together to design their own up-to-the-minute, personalized career paths.
I'll get to this stuff in detail, but, once again, some other stuff has jumped the line to the head of the queue.

Two of my priority daily web stops are "Science Based Medicine" (SBM) and "Neurologica Blog." Yesterday, SBM posted a review of a book that was a "Hold Everything" for me.
Medicine is chock-full of philosophy and doesn’t know it.  Mario Bunge, a philosopher, physicist, and CSI (Center for Skeptical Inquiry) fellow, wants to bring philosophy and medicine together for mutual benefit. He has written a book full of insight and wisdom, Medical Philosophy: Conceptual Issues in Medicine...

Wow. I ordered the hardcopy edition immediately via my Amazon Prime, and located some front matter online. "Philosophy" -- Gr. "Philo" (love of, affection for), "Sophia" (knowledge, truth). Love of knowledge.
Several current controversies in the medical community are about key concepts or comprehensive assumptions. Hence, they are actually philosophical rather than medical, even though they are often discussed in the Lancet, New England Journal of Medicine, and British Medical Journal. Let this short list of questions suffice to prove the existence of iatrophilosophy, or the philosophy of medicine: whether a disease is just a cluster of signs or biomarkers of it; whether a bunch of clinical data suffices to describe a disease and make a correct diagnosis; whether contemporary medicine is peculiar in being evidence-based; whether physicians should abstain from framing hypotheses and theories about imperceptible things; whether randomized control trials are both necessary and sufficient to validate a therapy; whether medicine is science, technology, craft, or all three; whether complementary and alternative therapies deserve being included in medicine; whether placebos are purely imaginary or have biological effects; whether there are universal biomedical truths, or only social conventions; whether biomedical research is dominated by commercial interests and political power; and whether any of the best-known philosophers — Plato, Aristotle, Thomas Aquinas, Descartes, Spinoza, Locke, Hume, Kant, Hegel, Engels, Nietzsche, Mach, Russell, Husserl, Heidegger, Wittgenstein, Popper, and Foucault — have advanced medicine.

Moreover, an examination of medical praxis is likely to show that medics philosophize much of the time, even while claiming that philosophy bores them. Indeed, they practice logic when reasoning correctly; they tacitly embrace naïve realism when they take it for granted that patients, nurses, and pharmacies exist outside their minds; when they demand that hypotheses be checked against facts, they adopt scientific realism; they adopt a naturalistic worldview when they regard diseases as natural rather than as effects of divine curses or witchcraft; and when they treat patients even without being sure of collecting their fees, medics practice a humanistic moral philosophy. In short, medics — and paramedics and nurses and hospital administrators — philosophize just as spontaneously as they breathe.

The tacit occurrence of philosophy in medical practice does not prove that homespun philosophies suffice: let us remember Hippocrates’ warning against what he called “postulates” (untested conjectures), in particular the fantasies of the pre-Socratic physicians and philosophers. The physician must always be on guard to filter the information barrages that the medical press and the medical visitor subject her to. In particular, she must be able to evaluate the claims to miracle cures and revolutionary medical theories. She must also be able to realize, or at least not to discard a priori, the medical potential of new biological, biochemical, and pharmacological findings.

Unless philosophy itself is toxic, it may help medics separate the grain from the chaff, as well as to organize the incoming information and spy the horizon. As well, philosophy may help craft overall views of medicine, like those proposed in earlier times by such intellectual leaders of the field as Philippe Pinel, Rudolf Virchow, Claude Bernard, Robert Koch, Paul Ehrlich, William Osler, Abraham Flexner, Peter Medawar, Lewis Thomas, and Thomas McKeown.

The aim of this book is to examine some of the conceptual issues raised by biomedical research and medical practice. For example, why are the traditional medicines mostly ineffective? Are diseases things (entities) or processes? Why do many medical diagnoses turn out to be wrong? What are the differences between molecular and classical pharmacology? Why are randomized clinical trials superior to non-randomized ones? Is evidence-based medical practice as novel as advertised? Is it correct to talk about probabilities in a field where there are neither objective randomness nor probabilistic theories? Are placebo effects purely imaginary? How might the current deadlock in the development of new drugs be overcome? Why has cancer medicine failed? Should medical assistance be rationed, and if so, how? Why do “complementary and alternative medicines” flourish in modern society? And what is to be done about the philosophical schools that deny reality and truth?


At first sight, medicine is alien to philosophy, since the former attempts to heal, or at least to alleviate pain, whereas philosophers analyze and systematize very general ideas, such as those of reality, knowledge, truth, and the good. In his Ancient Medicine, Hippocrates (430–420 B.C.) warned against philosophy. However, arguably, he only rejected the fantasies of the pre-Socratics, in particular the Pythagoreans, who had strongly influenced his precursors. Half a millennium later, his great disciple Galen opined that “the best doctor is also a philosopher.”

As a matter of fact, medicine has always been saturated with philosophy, if only because medics cannot help using general ideas, such as those of reality and truth. Let us see how any contemporary physician philosophizes during a routine clinical examination. When the patient appears, the medic takes it for granted that she is a real being (ontological realism) who comes for help, something the doctor is willing to offer to the best of his ability and in accordance with the Hippocratic precept (humanism). To find out what ails her, the physician starts by asking her certain questions, whereby he tacitly admits that there is something he can get to know (epistemological realism), as well as something he can do to help her (praxiological optimism).

Thus, the contemporary physician does not believe that diseases are sent by a deity as punishment for sins, or by a sorcerer for sheer malice, and he regards medicine as an ars vivendi, not an ars moriendi. Moreover, he knows that death is the natural end of life, not God’s punishment for Adam’s original sin. In short, the modern medic adopts tacitly a secular worldview, and relies on biology rather than on theology. However, let us go back to the doctor’s office.

The patient’s replies to the doctor’s initial questions may prompt additional questions, as well as a look at the patient’s clinical history, which nowadays is just a click away — an ambivalent fact, because it results in the physician’s looking more at the screen than at the person. But, far from believing everything the patient tells him, the doctor may doubt some of it (methodological skepticism). And he will try to translate into signs or objective indicators the symptoms that the patient feels — for instance, pains into lesions. Such translation of feelings into biomarkers betrays a naturalist view of disease, that is, the thesis according to which sickness symptoms are the subjective correlates of morbid bodily processes. To carry out such translations, the physician may have to use elements of the so-called medical technology, from the humble stethoscope to the sophisticated MRI (magnetic resonance imaging) apparatus. And he won’t forget that there are neither isolated organs nor patients in a social vacuum (systemism).

As the medic absorbs the stream of data pertinent to the medical problem at hand, he keeps forming, evaluating, discarding, and replacing educated guesses (hypotheses about the nature of the disease and its possible causes). Zigzagging between data and hypotheses, he eventually hits on the conjectures that seem most plausible in the light of his knowledge and experience as well as of the data he has just collected.

These hypotheses are conditional propositions of the form “If the patient exhibits the sign or objective indicator S, then it is possible that she suffers disorder D.” Except in the case of new diseases, the conjectures of this kind are not improvised, but occur in the standard medical literature. And they are neither arbitrary nor mere empirical rules, but are based on biomedical research, in particular controlled clinical trials. And this is a peculiarity of contemporary medical practice: that it is far more indebted to experiment than to dissection, to the laboratory working on living animals than to the post-mortem pathological study.

To find out which of his hypotheses is the truest, or at least the most plausible one, the medic reflects on what they imply, and he gets ready to check them. With luck, the answers to these questions will confirm one of his guesses. If not, he will order a few tests using some advanced diagnostic tools, such as blood analysis and X-rays. In principle, the diagnostic process continues until a clear (yet still fallible) answer is reached, and a prescription can be written.

In diagnosing as well as in prescribing, the contemporary medic applies tacitly the postulate that scientific research is the best means to get to know facts. This is the scientism postulate, first stated by Nicolas, Marquis de Condorcet on the eve of the 1789 French Revolution. In other words, our doctor tacitly rejects not only the magico-religious views, but also the intuitionism, apriorism, blind empiricism, and destructive skepticism inherent in postmodern constructivism-relativism, according to which there are no truths because there is no real world out there.

In short, our physician puts into practice the maxim Learn before acting (this is the slogan of scientific action theory, the rational alternative to pragmatism and Marxism). In complex cases, such as the ones handled by oncologists, immunologists, and psychiatrists, the treatment results will be so many additional data used to revise both the initial diagnosis and the corresponding treatment. The patient doubles then as an experimental guinea pig.

Such revisions are indicated not only when the diagnosis proves wrong, but also when the patient’s immune system fails, as well as when a new drug has been used, whose efficiency has not yet been rigorously checked, or whose side effects are still poorly known. (Here is where the immoral practices of some pharmaceutical companies make themselves painfully felt.) So then, the responsible physician practices the rule that enjoins us to doubt and restart when something goes wrong.

This philosophical rule, methodological skepticism, should not be mistaken for radical or systematic skepticism, which rules out the possibility of ever attaining any certainty, even about the roundness of the Earth or the cause of pregnancies.

Finally, sometimes the physician faces moral problems. The toughest of all are the ones related to the beginning and the end of life, such a “Should one help bring to term a pregnancy with a fetus carrying a severe genetic defect?”, “To save or not to save the very immature neonate, who has no chance of living a normal life?”, “To prescribe or not a treatment that promises little and costs much?”, and “To prolong or not the life of a terminal patient who can no longer enjoy life, let alone help others live?” In cases like these, the physician and his patient and next of kin will have to opt between some traditional moral philosophy and the humanist ethics condensed into the maxim Enjoy life and help live.

In sum, the good medic, in contrast to the shaman and the practitioner of an “alternative” medicine, practices, usually unwittingly, a whole philosophical system, containing

  1. a materialist (though not physicalist) and systemic (though not holistic) ontology;
  2. a rationalist, realist, skeptical, and scientificist epistemology; and 3) a science-based action theory and a humanist ethics.
This is the philosophy that the science-oriented medic practices, not necessarily the one he claims to profess. To check this diagnosis, imagine a physician who were to discard any of the three components listed above. For example, a spiritualist medic, such as a follower of homeopathy, whose founder claimed that a remedy is the more powerful the less matter it contains; or an anti-realist, like someone who holds that diseases are not biological disorders but social constructions, or that standard medicine is an invention of Big Pharma; or an anti-humanist, like the medics who experimented on inmates in prisons or camps, or on unsuspecting peasants, or those who oppose public health care. Who could trust any of these characters? The public should protect itself not only from medical delinquents and quacks, but also from antisocial sanitary politics and from sick philosophies. Philosophia sana in ars medica sana.
Indeed. I will likely also buy the Kindle edition today. When I come across books that particularly move me, I tend to buy both the hardcopy and the Kindle versions, the latter for convenience (especially while in transit) and for easy, yellow highlighting and cut & paste quotes.

Of course, inevitably one book leads to another. So, I bought one of Mr. Bunge's other titles as well:

This one looks like a pretty deep read. Looking forward to it. One online reviewer:
"Great discussion of the concept of causality in science. While it is labeled as nontechnical (and I guess it is because it is non-mathematical), it is by no means an easy read. That said, it has influenced my thinking and has changed the way that I write about causality, experimental design and science."
Later yesterday, just when I think "OK, the Kindle tank is now full yet again," my Scientific American email update arrives. Straight back to 1-Click:

"In science fiction, artificial intelligence takes the shape of computers that can speak like people, think for themselves, and sometimes act against us. Sometimes the machines seem to know everything, and symbolize implacable and unknowable power, as in The Matrix. Such machines can also embody the limits of logic, and by extension our own powers of reason. In Arthur C. Clarke's 2001: A Space Odyssey, HAL was a computer of vast capability driven insane by the demands of his programming – to honestly and completely report information – when those instructions conflicted with orders to keep state secrets. Star Trek has given us the android, Lieutenant Commander Data, who strives to be more human. None of these visions came true in quite the way science fiction writers imagined, even though in many ways computers surpass their fictional counterparts. This eBook reviews work in the field and covers topics from chess-playing to quantum computing. The writers tackle how to make computers more powerful, how we define consciousness, what the hard problems are and even how computers might be built once the limits of silicon chips have been reached. Artificial intelligence also raises some thorny ethical questions, such as whether morality can be programmed. These are kinds of issues that make artificial intelligence and computing fascinating. Building an intelligent machine brings together the human desire to create and the question of what makes us what we are. If anyone ever builds a true thinking machine, that last question becomes much more complicated, not less. Data and HAL would probably agree."
The Power of $3.79 Amazon 1-Click Compels me...

I see relevance here pertaining to health care and "Big Data" -
Today's fastest supercomputers run too slowly to do tomorrow’s science. Despite the ongoing revolution in communications and information processing, many computational challenges critical to the future health, welfare, security and prosperity of humankind cannot be met by even the quickest computers. Crucial advances in pivotal fields such as climatology, medicine, bioscience, controlled fusion, national defense, nanotechnology, advanced engineering and commerce depend on the development of machines that will operate at speeds at least 1,000 times faster than today’s biggest supercomputers. 

Solutions to these incredibly complex problems hinge on the ability to simulate and model their behavior with a high degree of fidelity and reliability, often over long periods. This level of performance goes far beyond that of present-day supercomputers, which at best can execute several trillion floating-point operations per second (teraflops). It could take 100 years, for example, for the largest existing system to perform a complete protein-folding computation— a long-sought capability. To accomplish this kind of analysis task, researchers need hypercomputing systems that achieve at least petaflops speeds— that is, more than a quadrillion floating-point operations (arithmetical calculations) per second. Scientific American Editors (2013-01-28). A.I. and Genius Machines (Kindle Locations 216-226). Scientific American. Kindle Edition.
Recall my prior reviews of Messrs Weeds'  "Medicine in Denial"?

I come at this domain from a multifaceted perspective. While I cut my white collar teeth in a forensic-level lab environment in Oak Ridge (programmer and QC analyst), my early undergrad academic experience contained inspiring exposure to "Philosophy of Science" in addition to my statistics courses (in fact, I came to Statistics via the UTK Philosophy Department, after taking "Inductive Logic" there).

I subsequently started grad school in 1993 intending to get a Master's in Applied Mathematics, Statistics Concentration (they didn't offer a Stats MS at the time; I was by then an ASQ Certified Quality Engineer, and wanted to sharpen that saw), but, unhappy with the indifferent faculty and too-abstract curriculum, I jumped ship to UNLV's Institute for Ethics and Policy Studies (EPS), where I found a great, resonant academic home (sadly, they terminated this program, after folding it stifingly into PolySci).

EPS was an interdisciplinary program comprised at root of applied Philosophy, Econ, and PolySci, with a sprinkling of Theories and Applications of Jurisprudence. Atop this base rode students' particular policy interests. I guess you could summarize the thrust as "Not Only Doing Things Right, but Doing The Right Things."

My first EPS course was entitled "History of Ethics." Eleven required texts (and a semester paper), spanning the millenia from the ancient Greeks to the most notable contemporary ethics philosophers. I have to say, Immanuel Kant was my fav (amid some other great contenders like Aristotle).

So, while I can do IT techie stuff with the best of them, write HIPAA-compliant Policies and Procedures (and audit against them), analyze and re-design workflows, and can do QC/QA/QI and PDSA in my sleep, I always "Begin With The End In Mind." I'm no "HIT Geek." IT is just a tool, not a "Solution." How can we effectively and justly heal the sick and injured and nudge the well into staying well, all while minimizing the use of scarce resources? It remains a vexing question that confounds the brightest and most ethical minds in the business.

I've been thinking about these issues for a long time. My first grad school paper (1994) was an analytic deconstruction of the JAMA "Single Payer" proposal.

Four years later, my daughter died from cancer. I found it thereafter difficult to know what to believe anymore.

A difficulty that persists to a degree to this day. e.g., from my "One in Three" essay:
[T]he body of peer-reviewed medical literature does not constitute a clinical cookbook; even "proven" therapies-- particularly those employed against cancers-- are generally incremental in effect and sometimes maddeningly transitory in nature. The sheer numbers of often fleeting causal variables to be accounted for in bioscience make the applied Newtonian physics that safely lifts and lands the 747 and the space shuttle seem child's play by comparison. Astute clinical intuition is a necessary component of a medical art that must, after all, act and act quickly-- so often in the face of indeterminate, inapplicable, or contradictory research findings.
As I wrote in my May 2009 blog post The U.S. health care policy morass
To what extent is our potentially bankrupting dependence on crushingly expensive and ever more "sophisticated" medical technology at least in part a function of our enslaving cognitive enfeeblement wrought by reliance on such technologies?
Maybe I'll find some clarifying answers in Mario Bunge's works. In addition to some of the titles listed above there will also likely be triangulation involving some other good reads of mine:

See my May 2012 blog review of Dr. Sweet's fine book here. A year before that, May 4th, 2011, I briefly cited Dr, Groopman's book (scroll down).

Danielle Ofri is a great writer. Her book "What Doctors Feel" is a compelling piece of work.
Why Doctors Act That Way 
The experiences of medical training and the hospital world have been extensively documented in books, television, and film. Some of this has been probing and incisive, and some has been entertaining nonsense. Much has been written about what doctors do and how they frame their thoughts. But the emotional side of medicine— the parts that are less rational, less amenable to systematic intervention— has not been examined as thoroughly, yet it may be at least as important.

The public remains both fascinated and anxious about the medical world— a world with which everyone must eventually interact. Within this fascination is a frustration that the health-care system does not function as ideally as people would like. Despite societal pressures, legislative reforms, and legal wrangling, doctors don’t always live up to these ideals. I hope to delve beneath the cerebral side of medicine to see what actually makes MDs tick.

One might reasonably say, I don’t give a damn how my doctor feels as long as she gets me better. In straightforward medical cases, this line of thinking is probably valid. Doctors who are angry, nervous, jealous, burned out, terrified, or ashamed can usually still treat bronchitis or ankle sprains competently.

The problems arise when clinical situations are convoluted, unyielding, or overlaid with unexpected complications, medical errors, or psychological components. This is where factors other than clinical competency come into play.

At this juncture in our society’s history, nearly every patient— at least those in the developed world— can have access to the same fund of medical knowledge that doctors work from. Anyone can search WebMD for basic information or PubMed for the latest research. Medical textbooks and journals are available online. The relevant issue— the one that has the practical impact on the patient— is how doctors use that knowledge.

There has been a steady stream of research into how doctors think. In his insightful and practically titled book How Doctors Think, Jerome Groopman explored the various styles and strategies that doctors use to guide diagnosis and treatment, pointing out the flaws and strengths along the way. He studied the cognitive processes that doctors use and observed that emotions can strongly influence these thought patterns, sometimes in ways that gravely damage our patients. “Most [medical] errors are mistakes in thinking,” Groopman writes. “And part of what causes these cognitive errors is our inner feelings, feelings we do not readily admit to and often don’t even recognize."

Research bears this out. Positive emotions tend to be associated with a more global view of a situation (“ the forest”) and more flexibility in problem solving. Negative emotions tend to diminish the importance of the bigger picture in favor of the smaller details (“ the trees”). In cognitive psychology studies, subjects with negative emotions are more prone to anchoring bias— that is, latching on to a single detail at the expense of others. Anchoring bias is a potent source of diagnostic error, causing doctors to stick with an initial impression and avoid considering conflicting data. Subjects with positive emotions are also prone to bias; they are more likely to succumb to attribution bias. In medicine, this is the tendency to attribute a disease to who the patient is (a drug user, say) rather than what the situation is (exposure to bacteria, for example).

This is not to say that positive emotions are better or worse than negative emotions— both are part of the normal human spectrum. But if you consider the range of cognitive territory that doctors traverse with their patients— genetic testing, ordinary screenings, invasive procedures, ICU monitoring, and end-of-life decisions— you can appreciate how the final outcomes can be strongly influenced by a doctor’s emotional state...
The degree to which individual physicians are either/both scientist and philosopher is likely to vary widely-- important considerations to be aware of when proposing healthcare QI interventions. And, how many physicians are neither? How many are just extremely highly trained, experienced, and skilled "technicians" or "mechanics" for whom real "science" is something they relatively dimly recall from med school.

I have much to consider and learn as I prep to head to the IHI Forum in Orlando.


Might as well add one more to the pile. Dr. Wen was recommended to me as a Follow on Twitter. I followed the trail, to this:

Healthcare reform dominates today’s discussions. Every day, our airwaves are inundated with the latest political debates on how to increase healthcare access while reducing costs. What is rarely discussed is how patients are increasingly dissatisfied by their lack of meaningful participation in their own medical care. What is not mentioned is how medicine has morphed from thoughtful engagement between doctors and patients to cookie-cutter recipes that regard all individuals alike. And how this cookbook approach, defined by its rote and formulaic approach to practicing medicine, leads to less accurate diagnoses— and worse outcomes— for patients. But is Dr. M to blame for relying on a way of thinking, that has been taught and reinforced among doctors for a generation or more?

It used to be that people went to their doctor to find out what was wrong. That was the expectation when someone made an appointment with their local family doctor: they wanted to know what they had and how they could feel better. Ear infection: what should I take? Pulled muscle: what should I do? Broken ankle: how can you fix it?

Over the years, something happened to this common sense approach. “Algorithms” and “pathways” have proliferated in ways that have reduced each person’s unique story to simplistic recipes. More often than not, this cookbook approach ends up telling patients what they don’t have— which, while potentially reassuring, does not result in a real diagnosis.

Imagine how this approach would work in another setting. Say there is a detective who is trying to solve a murder. He becomes fixated on making sure a certain suspect is not the murderer. He spends all of his time ordering surveillance, wire-tapping, and checking the backstory of the first suspect, and it’s not until a month later that he’s ready to chase down suspects two and three— all the while the real murderer is on the loose and has had more time to wreak havoc undetected. This is not so different from the effects of cookbook medicine, which can lead doctors and patients down the path of unnecessary testing, unwanted anxiety, and, in some cases, real harm because of the delayed diagnosis. 

 Like many doctors today, Dr. M. is trained to think using algorithms, or a cookbook approach: if the patient has “chief complaint” A, then ask about risk factors 1, 2, 3. If present, then do a “work up” with tests I, II, III. If negative, then diagnoses x, y, and z can be “ruled out,” so consider additional tests IV, V, and VI. And so on and so forth goes the patient through the assembly line. At the end of the day, thousands of dollars of tests can be ordered and months of discomfort endured without ever identifying the diagnosis, the disease process, that prompted the symptoms in the first place. Patients can go from the ER to their primary care doctor’s office to any number of specialists without ever learning what’s really wrong or how they can be made to feel better.

This is cookbook medicine. We call it cookbook because it implies there is no deviation from the set recipe even as circumstances change. Actually, the term may be unfair to chefs because good chefs would never dream of strictly following their own recipes. Recipes can be helpful as a guideline— but what happens if the asparagus at the market that day is wonderful and fresh, but twice as thick as any asparagus they usually use? Surely, that means they need to adjust their cooking style. Perhaps the asparagus will have to be steamed for twice as long; perhaps this timing will now affect the tempo of the rest of the ingredients; and so on. Cooking solely by recipe produces cafeteria-style meals, a product we’d shy away from eating, much less rely on for our medical care.

Just like cookbook cooking, cookbook medicine is easy to learn and relatively simple to practice. But patients like Jerry end up receiving substandard, “cafeteria quality” care. They leave dissatisfied because they came to find out what’s wrong and they leave knowing, at best, what they don’t have. Doctors end up adopting the role of automaton, following recipes and doing as directed, but no longer empowered to listen, to think, to diagnose, and to heal. Patients end up believing that their role is to help speed the checkbox ticking as quietly and as obediently as possible. Worse still, they begin to internalize that this is the best and only way to receive medical care.

In addition to exacerbating mutual frustration from doctors and patients both, cookbook medicine has contributed to the extraordinary ballooning of medical care costs. Doctors order more tests not because there is rationale based on the patient in front of them, but because this has become the new “gold” standard in America, the “best” we have to offer. And when prescription pads fill up with tests, patients also demand them, as if tests were cures in and of themselves. It’s not difficult to see how the cost of healthcare adds up exponentially when doctors and patients both depend on tests, without questioning whether the extra tests are necessary, or worse yet, whether they may be harmful. Everyone gets trapped in an increasingly costly and increasingly dysfunctional system.

There are abundant statistics that describe the skyrocketing cost and declining quality of healthcare. The United States spends close to $ 2.5 trillion on healthcare, over 16 percent of our gross domestic product. Yet, more than 50 million people remain uninsured, and those who are insured are burdened with high costs of healthcare that leave many bankrupt. Even though we have the most advanced technologies around the world, the United States consistently ranks below other developed countries in terms of our healthcare system performance. Excessive testing is estimated to contribute $ 250 billion each year to the overall cost of healthcare. A seminal report by the Institute of Medicine found that 100,000 people die of medical error every year in the United States, more than the number that lose their lives to stroke, diabetes, and motor-vehicle accidents combined. Error in diagnosis is by far the largest component of medical error. One in twenty hospitalized patients who die will die because of misdiagnosis, and far more suffer because they never find out their diagnosis.

Attempts to improve the U.S. healthcare system have focused on cost-cutting measures that are often draconian and ineffective. Private insurance companies and public government agencies have tried to rein in costs by limiting treatment options and requiring doctors to follow algorithms around the ordering of tests, with little success to show for it. We believe that forbidding treatments just because they are expensive is not the right approach to healthcare reform. Similarly, reducing medical care to cookbook recipes is not the way to making medicine safer or more efficient.

Too often, healthcare reform targets its efforts toward the medical industry. However, medical practice centers on the relationship between the individual patient and the individual doctor. This is where reform needs to focus: we need better, leaner, and individualized care for each patient, starting with an accurate diagnosis. There is an urgent need to reform the U.S. healthcare system, but you shouldn’t have to wait until then to improve your own healthcare. To the contrary, you can start today, by transforming how you approach your doctor...
Decrying "cookbook medicine" is to music to the ears of a lot of physicians.This too will be an interesting read.


Jaco's first visit to our new veterinarian yesterday.

We've had Jaco (as in "Pastorius") for about ten and a half years now. A freeway onramp rescue puppy.

Lord, may I be half the man that my dogs think I am.


A heroic life.


Gonna have to tee up another one ASAP.

"Conflicts of interest, misrepresentation of clinical trials, hospital price-fixing, and massive expenditures for procedures of dubious efficacy--these and other critical flaws leave little doubt that the current U.S. health-care system is in need of an overhaul. In this essential guide, preeminent physician Nortin Hadler urges American health-care consumers to take time to understand the existing system and to visualize what the outcome of successful reform might look like. Central to this vision is a shared understanding of the primacy of the relationship between doctor and patient. Hadler shows us that a new approach is necessary if we hope to improve the health of the populace. Rational health care, he argues, is far less expensive than the irrationality of the status quo.

Taking a critical view of how medical treatment, health-care finance, and attitudes about health, medicine, and disease play out in broad social and political settings, Hadler applies his wealth of experience and insight to these pressing issues, answering important questions for Citizen Patients and policy makers alike."


Yet another incremental monthly trickle uptick. About a $400 million payout in October, bringing the total paid out to just shy of $17 billion. 4,246 Eligible Hospitals and about 325k Eligible Providers.



From datascience@berkeley


More to come...

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