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Tuesday, September 2, 2014

The healthcare workforce today. Where do we stand, and what should we do to expand and improve it?

Well, I'd planned to write about this topic yesterday, apropos of Labor Day. But, I got asked to read and review a new book on Amazon. So I did. See The Rise and Fall of Homo Economicus: The Myth of the Rational Human and the Chaotic Reality, my review.

Good book. Worth your time. He's right.
The rise of poverty and the great widening of inequalities observed in many economically advanced countries generate risks and may possibly lead to political outcomes that will not be to anyone’s benefit. In other words, we could have a regression to extremes through the ascendancy of populism, nationalism, xenophobia, and protectionism. This must not happen. We cannot avoid mistakes, but we can avoid repeating the same mistakes. Or, even better, as a famous psychologist said, to replace our mistakes with other, smaller ones.
Another one (below), central to the theme of this post.

I reviewed it as well. Excerpt:
I liked this book from the start. Initially I thought "looks like four stars for sure." I just finished it. A definite 5 Stars. Smartly written, solidly argued, drawing from a substantive breadth of credible citation sources, many of whom I was aware of, some delightfully new to me. What is particularly refreshing is the author's smooth connecting of the myriad dots. His firm grasp of a cogent argument becomes more and more obvious with each passing page.

Had I Bill Gates' money, I'd buy a copy for every teacher in the U.S. and require that each read it -- and be tested on it as a component of certification. The topic is extremely important. We risk permitting a vast expansion of a chronic (and increasingly restive) "cognitive underclass" who will be unable to compete and contribute to modern society...

...[O]ne needs to genuinely CARE about helping people learn effectively (the principal thesis in this book) -- both children and adult learners. Ian Leslie points out just how important (and how difficult) that is. Distance "Learning," MOOCs, and University of Google are not going to be our salvation. They are good ancillary tools for the "Cognitive Haves," but they will also tend to widen the educational divide, which in turn cannot but exacerbate the socioeconomic divide.

I'd implore everyone to buy it, study it closely, and pay it forward to any teachers you know. (BTW, add to the contextual reading list Schein's "Humble Inquiry."

Sorry. Couldn't resist.

OK, recall from my last post?

Where will we find sufficiently educated, trained, experienced, and competent healthcare staff, from physicians on "down"? What will it cost, and, more importantly, what about the "pedagogy"? e.g., From my Atlantic subcription.

The paradox of undergraduate education in the United States is that it is the envy of the world, but also tremendously beleaguered. In that way it resembles the U.S. health-care sector. Both carry price tags that shock the conscience of citizens of other developed countries. They’re both tied up inextricably with government, through student loans and federal research funding or through Medicare. But if you can afford the Mayo Clinic, the United States is the best place in the world to get sick. And if you get a scholarship to Stanford, you should take it, and turn down offers from even the best universities in Europe, Australia, or Japan. (Most likely, though, you won’t get that scholarship. The average U.S. college graduate in 2014 carried $33,000 of debt.)

Financial dysfunction is only the most obvious way in which higher education is troubled. In the past half millennium, the technology of learning has hardly budged. The easiest way to picture what a university looked like 500 years ago is to go to any large university today, walk into a lecture hall, and imagine the professor speaking Latin and wearing a monk’s cowl. The most common class format is still a professor standing in front of a group of students and talking. And even though we’ve subjected students to lectures for hundreds of years, we have no evidence that they are a good way to teach...
Interesting model, the Minerva thing. Methodologically very similar to my own grad school experience (with way better technology). My UNLV "Ethics and Policy Studies" Master's curriculum:
1. Argument Analysis: Reasoning and Judgment
2. History of Ethics
3. History and Theories of Jurisprudence
4. Seminar in U.S. Constitutional Law
5. Advanced Statistics for the Health Sciences
6. Aristotle's Nicomachean Ethics
7. Seminar in Corporate and Public Morality
8. Seminar in Policy Analysis
9. Environmental Policy and Scientific Objectivity
10. Integrating Reason, Ethics, and Policy
11. Thesis
36 semester hours (6 hours of Thesis). All except #5 taught in conference room small group seminar format, led/facilitated by PhD faculty. "History of Ethics" (#2), for example, had 11 required texts spanning the ancient Greeks through modern day moral philosophers. Each of us had to lead analytical discussion of a chapter or so of each book every week. Similar parsing attended each of the other courses. It was a deep, probing, bracing experience. To the extent that the Minerva pedagogy mirrors this approach, it should be a fine, effective experience for their students. This is truly "education" ("e-ducere" -- drawing out from within the student), rather than mere "instruction" -- the didactic "pouring in" of factual "structure," or its more rote and regimented cousin, "training."

We shall see.

With respect to healthcare, I have concerns about the proliferation of this kind of stuff (below).

My email inbox overflows with these kinds of pricey pitches every day. Beyond the commercial diploma mills like University of Phoenix and all manner of strip mall "colleges," a lot of mainstream universities and colleges seem to see these as profit centers. Exorbitant "Executive MBA" programs catering principally to the well-heeled have long been around, and we're increasingly seeing the concept bleed over into other domains such as healthcare. "School of Professional Studies" is always a yellow flag for me.

Worth it?

Tangentially, also in that issue of The Atlantic, see
The Law-School Scam
For-profit law schools are a capitalist dream of privatized profits and socialized losses. But for their debt-saddled, no-job-prospect graduates, they can be a nightmare.
So, cost (and brazen fraud) aside, what of "pedagogy"? From another of my recent reads:

I had spent several months at Columbia during my final year of fellowship, so I remembered well the mess of traffic and food carts that we encountered in front of the Milstein Pavilion that winter morning. Inside the marble lobby, we were met by Santo Russo, a young Italian cardiologist I had worked with. Santo was a handsome, wiry man who, despite his ill-fitting clothes and unfashionable ties, still managed to maintain a dashing air. Though he had completed his fellowship only a few years earlier, his gentle manner and good European common sense— he was pragmatic, direct, rational— made him someone I looked up to and aspired to emulate. He always had a lot to say about the hospital and American medical education. “Medical school teaches people the bad lesson that in order to succeed, you have to memorize,” he’d once told me. “People go through four years of medical school, three years of residency, three years of subspecialty fellowship, and they are never taught to think. Then all of a sudden at the end of fellowship, they are told to start doing basic or clinical research. ‘What do you mean, you don’t know the relevant research question? We don’t care that for nine years you were taught not to ask questions, to accept the prevailing wisdom. We don’t care about that. We want you to start doing research!’ A better way”— he’d gone on facetiously—“ would be to teach medical students for six days of the week and on the seventh day make them forget everything they’ve learned because it will soon be outdated anyway.”

Jauhar, Sandeep (2014-08-19). Doctored: The Disillusionment of an American Physician (pp. 79-80). Farrar, Straus and Giroux. Kindle Edition. 
"Memorization," "rote learning" is a bad idea in a world of Google instant lookup gratification? I recall one day in our HealthInsight conference room, during one of our routine HIE staff meetings. A question arose. Laptop keyboards quickly clicked all around the table. An answer was rapidly obtained and proffered. One of my colleagues, Kym Roundtree, joked "Remember back when we actually had to know stuff?"

So, well, uh, I Googled some stuff in search of an Einstein quote. Ran across this.
Educators need to be ready to foster creativity in children’s education
Many experts and futurists believe that our schools in particular need to place greater emphasis on right-brain functions such as big-picture thinking and the ability to conceptualize.
Yeah. Agree. To a point. But I couldn't suppress the immediate thought of the curmudgeonly Thomas Szasz.

A bit of Piaget, anyone? Sensorimotor stage, preoperational stage, concrete operational stage, formal operational stage...

From Curious:
The proposition that “knowing is obsolete” sounds excitingly futuristic, but its roots extend back centuries. The idea of what is sometimes called a curiosity-driven education— an education largely free of the necessity to memorize academic knowledge imparted by adults— is so attractive that we reinvent it every generation...

The trouble with adults, according to Rousseau, is that they are too eager to force their unnatural and arbitrary “knowledge” into young minds. “What is the use of inscribing on their brains a list of symbols which mean nothing to them?” he asked. Students might be able to repeat lists of facts, but they won’t understand them; the facts sit in their memories, inert and useless, destroying their ability to think for themselves.

In the late nineteenth and twentieth centuries, a series of thinkers and educators founded “progressive” schools, the core principle of which was that teachers must not get in the way of the child’s innate love of discovery. Traditional academic subjects such as history or languages or arithmetic were relegated in importance; after all, few children seem naturally interested in them. The emphasis was put on “learning by doing”— hands-on experience, rather than verbal exchange. Instructional teaching was banned or limited, exercises in play and self-expression encouraged.

Maria Montessori’s schools form the most celebrated example of the progressive philosophy in action; Larry Page and Sergey Brin both attended Montessori schools and credit the Montessori ethos as a contributor to their success. In the 1970s, Paulo Freire, an influential Brazilian education scholar, criticized teachers who “filled” students with facts alien to their “existential experience.” Rather than treating pupils like bank accounts in which we deposit information, he said, the job of education is to help children take responsibility for themselves.

The contemporary version of this progressive philosophy is associated with the phrase “learning skills” (sometimes called higherorder skills, thinking skills, or, more recently, twenty-first-century skills). Montessori and her contemporaries believed passionately in education for its own sake. The proponents of learning skills are more concerned with how schools prepare students for the world of work. They share the progressive belief that schools should spend less time on teaching specific knowledge of specific subjects. Instead, they argue, schools should focus on abstract skills such as creativity, problem solving, critical thought, and curiosity. Such skills, it is said, will equip children for whatever the future throws at them.

It’s a philosophy that has made its way deep into the educational mainstream. It can be found wherever you see an approving reference to students “taking control of their own learning” or a teacher criticized for spending too much time on instruction instead of allowing children to express themselves...
What’s less understandable is that their ideas have been proven false, repeatedly—repeatedly— shown to contradict everything modern science tells us about learning— yet are still discussed as if new, shiny, and bursting with possibility. We now know that Rousseau was wrong. The curiosity of children does not work in anything like the way he believed or his contemporary adherents propose. His ideas are seductive, but the reason they have to be constantly reinvented is that they do not work.

Leslie, Ian (2014-08-26). Curious: The Desire to Know and Why Your Future Depends On It (pp. 108-112). Basic Books. Kindle Edition.
Consider chess mastery and memorization.
On the face of it, chess is a game of pure reasoning. But the core of chess ability is knowledge; chess masters have more positions stored in their memories and are thus able to instantly recognize more positions as they come up, which frees their conscious minds to focus on evaluating the next move (or the next several moves). William Chase and Herbert Simon replicated de Groot’s experiment, adding a crucial twist. The players were shown not only real chess positions but random arrangements of pieces that would be impossible in an actual game of chess. The experts performed just as well as they had in de Groot’s experiment with the real positions, but when it came to the scrambled positions, they performed no better than the amateurs.

Chess, rather than being about an abstract thinking skill, is highly knowledge bound. Top players have tens of thousands of chess positions stored in their memories. Similar experiments have been repeated with experts from physics, algebra, and medicine, always with the same results. When the task is changed to one that lies outside the experts’ domain, they fail to transfer their skills to the new problem, because their skills are bound up with knowledge of that specific field.

Another way of putting this is that a mental skill is not the same as an algorithm— a process that can be applied to any problem, regardless of subject. Learning skills grow organically out of specific knowledge of specific domains— that is to say, facts (and I’m including here cultural knowledge, of the plot of Hamlet, for example). The wider your knowledge, the more widely your intelligence can range and the more purchase it gets on new information. This is why the argument that schools ought to prioritize learning skills over knowledge makes no sense; the very foundation for such skills is memorized knowledge.* The more we know, the better we are at thinking. (ibid, pp. 117-118).
Yeah. You gotta have a multiplicity in the pedagogy. Yes, we have to inculcate curiosity and "creativity." Yes, we have to stress "critical thinking" (my particular area of instruction some years back). Yes, we have to have a mutually respectful "Talking Stick" "Just Culture" via which to nurture and improve communication in the trenches. And, yes, we will still have to "know stuff" -- without having to resort to University of Google to bail us out all the time.

apropos, from former Kaiser Permanente CEO George Halvorson's keynote slide deck at NYeC 2013 last year, as he concluded by addressing "disparities."


This is gonna be a long post. Just getting started, there's so much to consider. Stay with me. Need.More.Coffee. I made two typos in my post title (now fixed).

Google Glass startup lands $8M
Wearable Intelligence aims to broaden its healthcare marketshare
SAN FRANCISCO | September 2, 2014

A startup that plans to take Google Glass to healthcare and other markets has landed $8.4 million in venture capital.

San Francisco-based Wearable Intelligence describes itself as a technology company dedicated to building enterprise solutions using wearable computing hardware -- such as Google Glass.

It already has a partnership with Beth Israel Deaconess Medical Center in Boston, which is using Google Glass in the ER to give them medical information hands free. With Google Glass, clinicians can call up patient information on its tiny screen.

"The deep technology knowledge and professional expertise of the folks at Wearable Intelligence, which I've personally experienced, will help us all accelerate the adoption of Google Glass in healthcare," Beth Israel Deaconess Medical Center CIO John Halamka writes in as testimonial on the Wearable Intelligence website...
Hope they'll be at Health 2.0 in Santa Clara later this month. Would love to interview them.



And back Down in The Weeds'
VIII. Medical Education and Credentialing as Barriers to Progress

A. Extending the health care reform agenda to medical education and credentialing

1. A century of stagnation
Productive use of advanced medical knowledge requires an integrated system of care with a rational division of labor in which all participants see clearly how their roles contribute to solving medical problems. All participants should be able to avail themselves of knowledge that individually they do not possess, practitioners should not be permitted to perform at a level beyond their demonstrated competence, and no group of practitioners should be able to pursue its own interests to the detriment of the larger system of care.

Progress towards a rational division of labor within an external network of knowledge tools is largely absent. Isolated advances are not evolving and coalescing into an integrated system of care. We all are trapped in a non-system, where an elite class of practitioners is permitted to rely on limited personal knowledge and intellect. Graduate medical education and credentialing protect this physician elite from competition that could otherwise reshape medical practice. The health care system has thus been remarkably slow to adapt to the new environment created by modern information technologies. And that environment is still developing. Our culture is still working out the right division of labor between human cognition and external information tools. The subculture of education, however, lags far behind the domains of science and commerce in that development...

Were Flexner to return today, he would find that current knowledge has the power to confer vastly greater advantage than it did a century ago. But he would not find that society reaps a greater fraction of that advantage. “Between the health care that we have and the care we could have lies not just a gap but a chasm,” the Institute of Medicine has found. Failings in medical education and credentialing are a central reason the chasm exists...
2. The medical school experience
According to the Institute of Medicine, “many believe that, in general, the current curriculum is overcrowded and relies too much on memorizing facts” and that “the fundamental approach to clinical education has not changed since 1910.”...
Teaching skills and behaviors is not emphasized in medical education. Rather, its “traditional emphasis is on teaching a core of knowledge, much of it focused on the basic mechanisms of disease and pathophysiological principles. But no definable core of knowledge is actually transmitted to or used by practitioners in patient care with any kind of uniformity. Whatever core of knowledge medical schools attempt to teach varies from one institution to another, students do not learn all they are taught, they retain only part of what they do learn, that residue varies with each individual, and some of that residu quickly becomes obsolete. Continuing education courses merely continue this futility. It should thus come as no surprise that continuing education has been found ineffective... [pp. 191 - 200]
"Relies too much on memorizing facts"? Well, maybe "too much," but Ian Leslie's book gives one pause here. Perhaps the issue is one of balance. "Facts" that are firmly fixed in the relevant sciences are one thing. Those that are transient are another. But, how can we know ahead of time?

Moreover, how certain can we be that salient, hard-won, critical recalled "facts" are uniformly recalled accurately at dx or px time?

Cognitive science is not reassuring in this regard.

Back down in the Weeds'. It gets worse:
In assuming that students must be indoctrinated with received knowledge as preparation for real patient care, medical schools trap student minds in what Tolstoy called “the snare of preparation.” Like a drug, such education has toxicity as well as benefit. One of its toxic effects is to reinforce a basic human need to deny uncertainty. Dr. Jay Katz has described “how readily any awareness of uncertainty succumbs to venerable authority and orthodoxy. These powerful defenses against awareness of uncertainty continue to rule professional practices.” Sociologist Robert Weaver has further described findings in the literature on this phenomenon:
A major task undertaken during medical training is learning to manage the uncertainty associated with medicine and medical education. For instance, medical students learn the disadvantages of “doubting too much” and displaying these doubts to peers, superiors, and patients. Instead, they often develop a misleading sense of certitude or come to don a “cloak of competence” to help them manage the impressions of others and, ultimately, the image they have of themselves. Confidence and belief in what one is doing is a central component of the “clinical mentality” as Friedson describes it. Doubts about the ambiguities of “unusual” cases, even when acknowledged by the practitioner, are often “silenced” or otherwise not shared with the patient.
Medical students emerge from this process with insufficient sensitivity to patient
uniqueness and the fallibility of medical knowledge.
[pg 202]
Ouch. I have seen this sort of thing in another domain in which I worked for a number ofd years -- financial risk modeling. From my 2008 post 'Tranche Warfare" --
Consider this lament by best-selling author Geneen Roth, in her recent article "I was fleeced by Madoff":

"I often asked Richard, the head of our feeder fund, how Madoff made such consistently good returns. Although Richard tried to explain it to me, it was clear he didn't know, either, because I'd leave our meetings still unable to explain to anyone else how it worked..."
Well, consider this little excerpt of recent MEGO financial jargon pertaining to the post-crash doings of the now-infamously bailed out AIG:

Pursuant to Section 13 or 15(d) of the Securities Exchange Act of 1934
Date of report (Date of earliest event reported): November 25, 2008
...Well, I'm a reasonably intelligent person with a Master's degree and more than 20 years' experience spanning a variety of business domains (including credit risk modeling), but this kind stuff leaves me bamboozled.

That's what they 'bank' on. We among The Great Unwashed (including, um, the regulators) can never hope to fathom such financial "sophistication," better to simply leave these things to the "experts."

Part of a short email note I sent to Ms. Roth in the wake of reading her lament:

You oughta read some Taleb, the "Fooled by Randomness" guy. Part of the problem I see (in agreement with Taleb) is that nobody really understood much of any of this, but once you get to a certain level of "expertise" in the financial world, you simply cannot admit to being clueless. So, it becomes a mileau of ongoing mutual bullshit...
When financiers blow smoke, people go broke. When clinicians do so, people die.

A CSC paper (pdf):

What is the Caregiver Shortage?
Evidence of a growing caregiver shortage in the United States emerged in the early 2000s when the Association of American Medical Colleges (AAMC), the American Hospital Association (AHA) and other industry groups began investigating the potential impacts of demographic changes such as baby boomer aging, population growth and chronic disease growth. Although projections vary slightly, one agreement among initial and subsequent studies has been that there will be a shortage and it will become substantial. Most studies before passage of the Affordable Care Act projected shortages of at least 124,000 physicians and 500,000 nurses by 2025 (see Table 1); and there is general agreement that the additional 32 million covered lives resulting from the Affordable Care Act requires inflating those projections — by 31,000 physicians, for example, according to the AAMC.
Physician dissatisfaction:
Physician job dissatisfaction is a growing problem. In addition to filtering back to students who are on the fence about medical school, it is impacting and threatening to impact the current physician population in other ways. One example is physicians approaching retirement age, many of whom are threatening early rather than late retirement to avoid demands such as increasing paperwork and the push for electronic health record (EHR) adoption...

Nurse dissatisfaction:

Perhaps even more disconcerting is nurse dissatisfaction. Unlike the physician shortage, which is resulting from supply not keeping up with demand, the U.S. population of nurses is projected to shrink — by 50,000 between now and 2015, and 130,000 by 2020.49 A big reason is dissatisfaction — almost one-half of nurses responding to a February 2010 survey said they plan to make career path changes within the next 1 to 3 years. A frequently-cited reason was concern for their own health.

Nurse practitioner and other mid-level provider challenges: 
Increasing roles for mid-level providers (nurse practitioners, physician assistants and nurse-midwives) is a big part of just about every caregiver shortage strategy documented during the past 10 years. The industry needs them to share some of the care load traditionally limited to physicians, and in the process free physicians to take on new roles, such as patient-centered medical home managers...
Comments on reimbursement reform and other caregiver shortage implications for health care delivery organizations are a reminder that reducing caregiver shortages and their impacts on care delivery are an integral part of health reform. That is, successful solutions to shortage challenges require not only specific efforts to address problems and implement solutions the industry has identified, but also are very much dependent upon (as well as a part of) the overall success of industry reforms. As the AAMC noted in its November 2008 Physician Supply and Demand Report, “… simply educating and training more physicians will not be enough to address these shortages. Complex changes such as improving efficiency, reconfiguring the way some services are delivered, and making better use of our physicians will also be needed.”
Interesting. "And the Health IT/Informatics/Analytics workforce shortage is not even mentioned in the paper.  So, yeah, a boxcar load of moving parts to consider, beyond just pedagogy issues.


"Remember back when we actually had to know stuff?"

OK, I got the learning solution right here.

Just joking, but, who knows? A whole new meaning to "your head is in the Cloud." What will it mean to be human, "after the (putative) Singularity"? Central to the "content acquisition / rote learning" pedagogy model is a "No Pain, No Gain" proposition, wherein synaptic connections that neurally bind increasing long-term memory knowledge require sustained and often difficult cognitive effort. Again, this is a core observation and concern in Ian Leslie's book. Significant evidence indicates that, in particular, there can be no "transfer of training effect" where there is no factual content knowledge base. Experts in field X are typically just laypeople in fields Y and Z, and their specific domain expertise is in large measure a function the knowledge bases inside their skulls, not their adroit abstract "critical thinking skills."


I cited this book some time back (April 29, 2012 post).

Approximately 15 percent of all healthcare workers and 25 percent of all physicians in the United States were born and educated elsewhere.1 This means that 1.5 million healthcare jobs are “insourced,” occupied by foreign-born, foreign-trained workers brought into the United States on special visas earmarked for healthcare jobs. This number is 50 percent greater than the total number of jobs in the US auto-manufacturing industry...

[E]ach year, we bring thousands of nurses from China to work in even better-paying jobs, rather than train young people in this country to become nurses...

On the surface, insourcing may appear to be a harmless or even win-win solution to the country’s healthcare-worker shortage. The hospital receives a much-needed worker, and the worker escapes life in a struggling country for a better life here. But we should be training more people in this country to work in those professions, especially people from rural poor and minority communities. Rather than investing in our own people and communities, however, we have decided to take the best and brightest workers from struggling countries...

Our unofficial policy of relying on the world’s poorest countries to pay for the training of workers whom we then entice and bring to this country is devastating healthcare systems around the world. The loss to a developing country when a single physician, representing what may be a significant portion of their total number of physicians, emigrates is far greater than our gain. Our failure to provide education for our own citizens and to better plan for healthcare staffing and distribution does not justify hiring nurses and physicians from the countries that can least afford to lose them.

Garrett, Laurie; Tulenko, Dr. Kate (2012-04-24). Insourced (Kindle Locations 286-398). University Press of New England. Kindle Edition.

Yes, Doctors Are Sick of Their Profession. And You’re Making Things Worse!

Dr. Sandeep Jauhar, a cardiologist, believes with good reason that many physicians have become “like everybody else: insecure, discontented and anxious about the future.” In a recent, widely-circulated column in the Wall Street Journal, “Why Doctors Are Sick of Their Profession,” he explains how medicine has become simply a job, not a calling, for many physicians; how their pay has declined, how the majority now say they wouldn’t advise their children to enter the medical profession, and how this malaise can’t be good for patients...

The truth behind “quality” metrics
There is no question that some physicians are inherently more talented, more dedicated, and more skilled than others. In every hospital, if you speak to staff members privately, they’ll tell you which surgeon to see for a slipped disk, a kidney transplant, or breast cancer. They’ll tell you which of the anesthesiologists they trust most, and which cardiologist they would recommend to someone with chest pain. But none of these recommendations are based on simplistic metrics like readmission rates or even mortality rates. They are based on observations over time of the physicians’ ability, integrity, and conscientiousness–all of which are tough to quantify.
The comments are interesting as well.

More to come...

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