Search the KHIT Blog

Wednesday, January 6, 2016

"We need more seasoned clinicians at the front lines of digital health"

Post headline above is quoting Carolyn Bradner-Jasik, MD. From "Why I Left My Health Care Executive Role to Join a Startup."

Another cite from the post:
As Rebecca Coelius described it on The Health Care Blog, you “need to know what’s inside the box to think outside it.” Knowledge of clinical processes, including billing, compliance, and operations, is imperative for any startup that wants to intersect with health systems.

"Knowledge of clinical processes..." Yeah, and in that regard, you can't do any better than studying Dr. Jerome Carter's voluminous works at

Dr. Bradner-Jasik:
I left my role at UCSF because I was disappointed as companies with great ideas were passed over. I often sat through pitches thinking, This is terrific, but we will never buy this because …
  • The technology is great, but it doesn’t solve any pain point that we currently have.
  • The product does not integrate well with our clinical workflows, including our EHR.
  • The startup has an A+ solution to our problem, but our EHR has a C+ solution that we already paid for and can implement with little cost.
  • The technology budget has already been (over)spent on our EHR. Asking for additional resources is a heavy lift.
  • Our staff have tech fatigue from large, complex EHR rollouts. The bandwidth to train and implement another tech solution is not there.
Rock Health recently reported that digital health received $4.3 billion in funding this year.  But at the same time, 75% of this went to early-stage Series A and B rounds for innovations that may not stick. To take us to the next phase, we need more cross-pollination of perspectives, among both startups and enterprise organizations alike. The seeds of this type of collaboration have already been planted, with innovation centers popping up at healthcare institutions, and startups hiring clinicians earlier...
Good post. Read all of it. Interesting to ponder in light of next Wednesday's Health 2.0 WinterTech Conference 2016, which I will be covering.

So, what of Dr. Bradner-Jasik's startup, Mango Health?

"Mango Health helps you manage your medications and create healthy habits, so you can savor the moments that matter most."

From the L.A. Times:
“The Mango Health app reminds patients when it's time to take their medication and records each dose. It also automatically alerts users to potentially dangerous interactions between medications and supplements or with food and drink … But it’s the game component that sets the app apart.”
You might want to study the Privacy Policy. I wear a Fitbit HR my wife bought me. Their Privacy Policy is just as obtuse and vague and riddled with lawyerly weasel phrases.

The "game component" reference in the Times blurb caught my eye in particular. A little Morozov, anyone?

Yeah, I know, Evgeny's caustic riff can get a bit tiresome. Nonetheless...


Knowledge of clinical processes, including billing, compliance, and operations, is imperative for any startup that wants to intersect with health systems.
I could not agree more. But, it's easy to gloss over the fact that inside effective "operations" lies the imperative of focusing on that which minimizes the cognitive burdens and maximizes the efficacy of clinician decision-making (sometimes referred to in part as Health IT "UX"). "Operations" goes well beyond conventional notions of "Process QI." I am reminded of my posts on "Lean Healthcare."

Directly apropos as well, a couple of my prior posts:

Interesting article by my friend Scott Mace:
2016: Year of the Healthcare IT Mashup?
Scott Mace, for HealthLeaders Media , January 5, 2016

Electronic health record software manufacturers have taken early steps into application programming interface publishing, and savvy health informaticians have already created some clever mashups with them.
In late 2013, a study group of scientists released "A Robust Data Infrastructure," more commonly known as the JASON report, commissioned by ONC and AHRQ, which subsequently published the report in 2014.
(JASON is an initiative within the MITRE Corporation, a nonprofit that operates research and development centers sponsored by the federal government. JASON is spelled in all caps, but it is unclear what, if anything, it stands for.)

At any rate, the final rule for meaningful use stage 3, published in October 2015, can be found here (Google searches surprisingly don't rate this link highly, but ONC has yet to format the rules on its own website). That final rule contained language that didn't capture the headlines at the time, but was very much in the spirit of that 2013 JASON report: Electronic health record software should adopt application programming interfaces (APIs).

The use of APIs in stage 3 certified software is somewhat narrowly prescribed to potentially replace an EHR vendor's requirement to provide a patient portal, with APIs that any number of patient engagement technologies could plug into. This would bring a word to healthcare that hasn't really been heard before: mashups.

Mashups have been on the scene for a decade or more in the rest of technology. An early example combined the Chicago crime database with Google Maps. The crime database didn't have to add map functionality, and Google Maps didn't have to learn how to interpret crime data. The mashup just gave users a simple-to-understand combination of the two.

After that proof of concept, mashups took off for several years. Popular Web destinations such as Twitter and Facebook published APIs in sufficient quantity that we saw a flowering of mashups of all imaginable shapes and sizes...
Relevant to all of the foregoing, I recently interviewed Allscripts' "Chief Innovation Officer" Stanley Crane on the phone. A key takeaway:
"Most of the smartest people in Health IT don't work for Allscripts."
Stanley went on to describe to me the Allscripts "Open API Developer Toolkit" and 3rd party development affiilate program.
We’re improving healthcare collaboratively
We believe tomorrow’s game-changing healthcare tools will not be built by one company alone, but collectively by many. Healthcare innovators are everywhere, and to succeed we need to leverage the genius of all—we must be Open. Open to change. Open to collaboration. And Open to the information and insights that lead to improved outcomes. Let’s solve healthcare’s problems together. Join us, and we’ll give you the tools to build with us...
He called the Allscripts product line "an Operating system for Healthcare," one atop which independent talent can add all manner of value.

He assured me that "interoperability" is a core priority at Allscripts. We shall see. I expect that to continue to be a burning issue in 2016.

Allscripts (ticker MDRX) has been around for quite a while. Their stock peaked around $84 in early 2000, dove to less than $4 a year later, climbed back to $20 during the 2007 DOQ-IT era, went back down below $10 in 201 during the REC era, and today trades in the mid-teens.

I had MU clients on Allscripts products while at the REC. We feared for a time that they'd go under, leaving our clinics in the lurch.

Nice that they've survived.


"Empathy," "sympathy" (they're not synonyms), "cooperation," "altruism." What are the health care and health implications, for clinicians and patients alike? Are these areas accorded increasingly short shrift in the harried "productivity treadmill" world of everyday clinical operations?

We'll begin with "empathy" (the cognitive ability to perceive and understand the world from the point of view of another, irrespective of whether you sympathize with that POV). to wit, returning to Dr. Ofri,

The traditional entrance exam for medical school, the MCAT, is being overhauled to contain sections on ethics, philosophy, humanities, and social sciences. While this doesn’t guarantee students with empathy skills, it certainly widens the focus beyond organic chemistry. And programs that enrich students with humanities, long-term patient contact, and one-on-one mentoring can help minimize ethical erosion and other toxic effects of medical school.

The truth is that most students enter medical school with strong humanistic and empathic tendencies. Having worked with hundreds of medical students over the years, I know firsthand that these characteristics are not in short supply. The challenge for medical schools is to maintain and nourish these qualities during the long haul of training.

Unlike pathophysiology, however, none of this can be taught in lecture halls or with PowerPoint slides. It is the behaviors that students witness in their superiors and the behaviors that are modeled and encouraged that really count, and luckily, the new approaches of medical schools are focusing on this.

My analogy for teaching empathy is that of multiculturalism. This topic is very politically correct these days; medical schools and hospitals are scrambling to offer cultural-sensitivity seminars and culture-awareness days. These programs tend to be well meaning, extremely earnest, and only marginally useful.

What influences my own clinical practice are the lessons I received from a cadre of older, white, male physicians— my own attendings— who wore starched shirts, conservative ties (often of the bow variety), and properly buttoned white coats to every clinical encounter. They trained in an era in which their entire medical-school class looked exactly like them, with no diversity awareness, affirmative action, or cultural competence.

Yet they were among the most culturally aware people I’ve ever seen, though they probably would never use such a PC term. These physicians exemplified a very old-fashioned sort of doctoring. For them, approaching the bedside of a patient was a sacred act. They examined each patient— whether a homeless Ecuadoran alcoholic or a veiled Muslim woman or a visiting Swiss diplomat— with a thoroughness that in itself exuded respect. They asked questions to learn more and listened with an exacting ear, for the axiom that the patient’s story holds the answers was no platitude for them.

What these older physicians exhibited is termed clinical curiosity. They strove to understand their patients in order to elucidate the underlying medical conditions. This thoroughness, patience, and dogged curiosity may have been ingrained in them because they trained at a time when there were no rapid CTs or MRIs. But even now, when these diagnostic tools are at their fingertips, these physicians maintain this approach to patients, one that serves to appreciate the dignity and uniqueness of each patient and his or her illness.

I doubt if any of these physicians ever backpacked in Nepal or worked for the Peace Corps in Uganda or campaigned for human rights in Honduras or took any multicultural-awareness workshops. They simply treated every patient with respect, and strove to learn as much as possible about each one...

When these doctors treated the patients with old-school respect, exhibiting genuine curiosity about their lives, the patients responded wholeheartedly. I marveled at these older male physicians who asked such nuanced and probing questions about culture and background. In this manner, these physicians were demonstrating empathy. The very act of taking a patient and her story seriously, of being truly interested in knowing who the patient is and what her life is like and how she came to be ill and what her resources for dealing with illness were, is the basis of empathy.

Teaching empathy to medical students and interns falls not to the course directors who devise the curriculum and establish the core competencies but to the supervising doctors who oversee these trainees on the wards. Students will remember what they experience far better than what they are told in a lecture, as I learned those many years ago watching that nurse’s aide help the homeless woman in the ER.

Astute clinical teachers also explicitly point out to students what they do and say with patients to help convey empathy. Even tiny tips, like reminding students to summarize what a patient has said and offer it back for corrections, is helpful. When a doctor says, “Let me see if I have this right . . . ,” it indicates to a patient that the doctor is not only listening hard but also making an effort to understand the patient’s point of view...

Ofri, Danielle (2013-06-04). What Doctors Feel: How Emotions Affect the Practice of Medicine (pp. 52-54). Beacon Press. Kindle Edition.
Returning to a book I cited last September:

Yet another look into organizational culture issues of relevance to the health care space (e.g., see my "Talking Stick" post).
How Doctors Tried Not to Behave Like Economists

THE MOOD IN THE LECTURE theater at Harvard Business School was earnest and respectful. Sitting in the rows of seats, arranged in a horseshoe shape around a dais, were some of the most ambitious young people in the world. Attending Harvard Business School typically costs at least $ 100,000, and competition to win places is fierce. 1 The students have sky-high expectations of themselves and speakers who visit that famed lecture hall. And the man chosen to address the students on that day in early autumn 2006 was dazzling

A tall, imposing figure with a craggy face and big ears, Toby Cosgrove, sixty-five, was one of most famous heart surgeons in world. During the first few decades of his career, he had shot to glory in the medical world as a pioneering cardiothoracic surgeon who had operated on more than 22,000 patients and filed thirty patents for medical innovations. But in 2004 Cosgrove was appointed CEO of the mighty Cleveland Clinic in Ohio, one of the biggest medical centers in America, with an operating budget of $ 6 billion and staff of 40,000. The clinic was ranked among the best in America in numerous fields, including Cosgrove’s speciality of heart surgery. It offered cutting-edge treatments at prices that were better than those of most competitors. People from around the world flocked to use its services. It was, in short, a model of how a twenty-first-century hospital should operate, at least in the eyes of Harvard Business School. 

So the students listened with awe as Cosgrove explained how Cleveland Clinic worked. He was a good speaker, who exuded firm, natural authority, leavened by flashes of dry, self-deprecating wit. What most people did not know was that Cosgrove was also dyslexic. In his teens and early twenties he had struggled at school. But he had battled through this handicap to become a surgeon by virtue of ferocious willpower and a photographic memory. “Dr. Cosgrove is a brilliant man, the most ambitious person in the world since Alexander the Great,” Bruce Lytle, a fellow heart surgeon at Cleveland Clinic sometimes joked. “That is good— you need those people to change the world.” 

After Cosgrove finished his speech to the Harvard students, he took questions. The first few were admiring. But then a young, slim brunette woman named Kara Medoff Barnett, who was sitting in the second row of the auditorium, stood up. “Dr. Cosgrove, my father needed mitral valve surgery. We knew about Clevelend Clinic and the excellent results you have. But we decided not to go there because we heard you had no empathy. We went to another hospital instead, even though it wasn’t as highly ranked as yours.”

There was a startled pause. Barnett pressed on, looking Cosgrove in the eye. “Dr. Cosgrove, do you teach empathy at Cleveland Clinic?”

Empathy? Cosgrove was a loss. During his decades-long battle to become a star surgeon against fierce odds, Cosgrove had spent numerous days honing his technical skills. But he had never given much thought to empathy. It sounded hippie, if not self-indulgent. “Not really,” he mumbled vaguely, and switched the subject. 

The next day he left Boston, and tried to brush the incident off. But that odd little encounter kept buzzing through his mind. Dr. Cosgrove, do you teach empathy? Ten days later, it popped into his head again, in the unlikely setting of Saudi Arabia. The top managers of Cleveland Clinic were keen to expand in the Middle East, since it had a pool of wealthy clients. So Cosgrove decided to attend the official opening of a new hospital in Jeddah. To mark the occasion, the Saudi king and crown prince hosted a ceremony, along with many local dignitaries, and the new head of the hospital gave a passionate speech. “This hospital is dedicated to the body, spirit and soul of the patient,” he declared. As he spoke, Cosgrove glanced across to the Saudi king and noticed, to his complete surprise, that tears were rolling down his face. He felt a frisson. We’re really missing something here. He was used to thinking about medicine in dry, technical terms, or a delineated bundle of specialist skills. He did not usually think about the whole “soul.” 

But were specialist skills really enough? The question kept buzzing around in his mind. On paper, Cosgrove knew that Cleveland Clinic was an excellent medical center, or at least it was if you looked at it using the type of mental map that doctors used. There were world-class surgeons, physicians, nurses, psychologists, and physiotherapists; there were divisions of Anesthesiology, Pediatrics, Medicine, Surgery, Pathology and Laboratory Medicine, Post-Acute Care, Regional Medical Practice, Nursing, and Education. To name but a few of the specialist teams. 

But was this what sick people really wanted? Was it the best, most effective, or cheapest way to do medicine? Cosgrove was starting to have doubts. Doctors visualized medicine as a collection of technical skills. Patients did not. When people were sick they did not say “I need a cardiothoracic surgeon” or “Take me to a cardiologist.” Instead they would declare “My chest hurts,” or “I am having a seizure,” or “I can’t breathe,” or “My stomach is in pain,” or simply “I feel unwell.” 

In some sense, that differences in perception exist about medicine should come as no surprise. When anthropologists first started to study non-Western cultures in the late nineteenth century, they realized that different societies view the body and define sickness and health in subtly varying ways. Then, as anthropology expanded in the twentieth century, a sub-discipline emerged called “medical anthropology,” which examines how health is perceived, experienced, and implemented in different communities around the world. This discipline, which is one of the fastest growing areas of anthropology, argues that health is not really a matter of biology, or not just science. It is a cultural phenomenon too. Our physiology might be universal. But concepts of “sickness” can vary between different cultures, and within the same society...

Tett, Gillian (2015-09-01). The Silo Effect: The Peril of Expertise and the Promise of Breaking Down Barriers (pp. 192-195). Simon & Schuster. Kindle Edition.
Does an adroit sense of "empathy" go to the heart of that elusive "art of medicine"? I would say it goes to the "care" part of "health care." While empathic acumen may largely be a "cognitive" skill, as neuroscientist Antonio Damasio pointed out in Descarte's Error, one has to care about reasoning rationally. Rationality and emotion are not mutually exclusive domains. Moreover, while "sympathy" may be largely reflexive (and contingent), "empathy" takes work.

When I go to Jiffy Lube, the techs don't really give a flip about me and/or my car, beyond the attentive collegiality necessary for adequate "customer service." The relationship is both transient and purely transactional.

Health care, at its best, could not be more different -- intimate, and longitudinal (once you go beyond the largely mechanical processes pertaining to redress of injury, anyway).


This caught my eye over at The Atlantic:
The Physiological Power of Altruism
People who volunteer lead longer, healthier lives. Some public-health experts believe the time has come for doctors to recommend it alongside diet and exercise.

In the fight against the disease that will kill one of every four people you know, most scientists studying cardiovascular epidemiology at Harvard School of Public Health are focusing on usual suspects like cholesterol, obesity, and cardiac structure. But research fellow Eric Kim has a unique focus: purpose in life. How does it affect health, how is it gained and lost, and how can it be weaponized to keep people alive and well?

When Canadian tenth-graders in a recent study began volunteering at an after-school program for children, the high schoolers lost weight and had improved cholesterol profiles compared to their non-volunteering peers. (Even in Canada, teenagers have cholesterol problems.) In the journal JAMA Pediatrics, the researchers concluded, “Adolescents who volunteer to help others also benefit themselves, suggesting a novel way to improve health.”...
...don’t volunteer for your own health. In fact, now knowing that volunteering may be beneficial to your health, I hope I haven’t robbed you of that benefit. Try and forget everything you’ve just read.

Still, even if you go into volunteering for the wrong reasons, it’s hard to stay self-interested once you’re immersed in a cause and woven into the lives of people who need you.

“I think people who are affluent become isolated and get disconnected from the harsh realities of being disadvantaged, what that actually means,” said Kim. “Generally, if you take people who lack empathy, like Pharma Bro or the affluenza kid, and get them into volunteering, it kind of shifts that focus. ... Maybe if we want people to get health benefits from volunteering we have to someone win their hearts and minds. What would that look like? I don't know.”

It might look something like the principles of effective altruism, which is the fashionable, generally utilitarian art of applying evidence to determine the most efficient ways to improve the world. A group studying effective altruism at MIT explains that it uses data to identify projects with opportunity for scale (improving a large number of lives) and tractability (creating a measurable difference) while addressing a cause that has been previously overlooked or undervalued.

Effective altruists tend to favor large-scale public-health programs that are proven to be effective, like providing mosquito netting to prevent transmission of malaria. When you can demonstrate to people just how impactful and necessary their work can be—really making a difference, as opposed to spinning your wheels in a world beyond repair—people may be moved to take up a cause. And if Kim is right that it confers a genuine sense of purpose, the reciprocal health effects stand to be even greater...
Ayn Randians will have a cow. To the late Ayn Rand, "altruism" (via her Straw Man definition) is the penultimate evil, as it "requires the sacrifice of the Competent to the Incompetent."


How about a bit of actual science?

I. The Interdependence Hypothesis

"The commitments that bind us to the social body are obligatory only because they are mutual; and their nature is such that in fulfilling them one cannot work for others without at the same time working for oneself.”

 - Jean Jacques Rousseau, The Social Contract

Cooperation appears in nature in two basic forms: all true mystic helping, in which one individual sacrifices for the benefit of another, and mutualistic collaboration, in which all interacting parties benefit in some way. The uniquely human version of cooperation known as morality appears in nature into analogous forms. On the one hand, one individual may sacrifice to help another based on such self immolating motives as compassion, concern, and benevolence. On the other hand, interacting individuals may seek a way for all to benefit in a more balanced manner based on such  impartial motives as fairness, equity, and justice.  Many classical accounts in moral philosophy capture this difference  by contrasting a motive for beneficence (the good) with a motive for justice (the right), and many modern accounts capture the difference by contrasting immorality of sympathy with amorality of fairness.

The morality of sympathy is most basic, as concern for the well-being of others is the sign on non-owned all things moral. The evolutionary source of sympathetic concern is almost certainly parental care of offspring based in kin selection. In mammals this means everything from providing sustenance to one’s offspring through nursing — regulated by the mammalian “love hormone” oxytocin — to protecting one’s offspring from predators and other dangers. In this sense basically all mammals show sympathetic concern, at the very least for offspring,  but in some species for selected non-kin as well. In general, the expression of sympathy is relatively straightforward. There may be some cognitive complexity in determining what is good for one’s offspring or others, but once that is determined, helping is helping, with the only serious conflict being whether the sympathy that motivates the helping act is strong enough to overcome any self-serving motives involved. Acts of helping motivated by sympathetic concern are altruistic acts freely performed and are not accompanied, in their purest form, by a sense of obligation.

In contrast, the morality of fairness is neither so basic nor so straightforward — and it may very well be confined to the human species. The fundamental problem is that in situations requiring fairness there is typically a complex interaction of the cooperative and competitive motives of multiple individuals. Attempting to be fair these trying to achieve some kind of balance among all of these, and there are typically many possible ways of doing this based on many different criteria. Humans thus enter into such complex situations prepared to invoke moral judgments about the “deservingness” of the individuals involved, including the self, but they are at the same time armed with more punitive moral attitudes such as resentment or indignation against unfair others. In addition, they have still other moral attitudes that are not exactly punitive but nevertheless stern, in which they seek to hold interactive partners accountable for their actions by invoking interpersonal judgments of responsibility, obligation, commitment, trust, respect, duty, blame, and guilt. The morality of fairness is thus much more complicated than the morality of sympathy. Moreover, and perhaps not unrelated, its judgments typically carry with them some sense of responsibility or obligation: it is not just that I want to be fair to all concerned, but that one ought to be fair to all concerned. In general, we may say that whereas sympathy is pure cooperation, fairness is a kind of cooperative hesitation of competition in which individuals seek a balanced solutions to the many and conflicting demands of multiple participants' various motives.

Our goal in this book is to provide an evolutionary account of the emergence of human morality, in terms of both sympathy and fairness. We proceed from the assumption that human morality is a form of cooperation, specifically, the form that has emerged as humans have adapted to new and species unique forms of social interaction and organization. Because Homo sapiens is an ultra-cooperative primate, and presumably the only moral one, we further assume that human morality comprises the key set of species unique proximate mechanisms — psychological processes of cognition, social interaction, and self-regulation — that enable human individuals to survive and thrive in their especially cooperative social arrangements. Given these assumptions, our attempt in this book is to (1) to specify in as much detail as possible, based mainly on experimental research, how the cooperation of humans differs from that of their nearest primate relatives; and (2) to construct a plausible evolutionary scenario for how such uniquely human cooperation gave rise to human morality.
[A Natural History of Human Morality, Pages 1-3]
An excellent read. Not currently available on Kindle. I used Dragon to read the foregoing (and the following) in. After 155 pages of evidence and argument, Tomasello sums things up.

“Ethical ideas, within any even human society, a rise in the consciousness of the individual members of that society from the fact of the common social dependence of all of these individuals upon one another.”

— George Herbert Mead, Mind, Self and Society

Quite often in the social sciences the human individual is portrayed as a rational maximizer, homo economicus, driven exclusively by the possibility of concrete personal gain. This psychological model is based explicitly on the supposedly novation’s and behavior of individuals acting within a capitalist market. But it is clear, in the broader sweep of human evolution and history — beginning with the egalitarian and communal hunter gatherer societies that characterized the species for the first 95% of its existence — that  capitalistic markets are cooperative cultural institutions. They are created by a set of cooperative conventions and norms in which individuals agree to follow a set of rules that, somewhat paradoxically in this case, and power them in certain contexts to pursue personal gain to the exclusion of everything else. The rules that empower individual self-interest and capitalist markets are thus like the rules that empower a tennis players self-interest in defeating an opponent, that is, within the context of the cooperative rules that constitute the game in the first place. It is only if one neglects the cultural – institutional context of human behavior that one can hallucinate the competitive cart is leading the cooperative course.

But certainly an account of human behavior grounded in evolution, such as the current account, must take individual self-interest is primary, well before and much more fundamental than cooperative social interaction? Well, yes and no. The logic of natural selection, of course, stipulates that organisms do things that increase, or at least do not decrease their reproductive fitness one could call that self-interest. But what we normally refer to as self-interest is an individual making an active choice to favor itself over others. The vast majority of lifeforms on planet Earth are making no such choice. They are simply acting instrumentally toward their goals, and this means, for successful animals, that those goals are compatible with their continued survival and reproduction. But they have no psychological mechanisms specify that they should favor themselves over others; the question simply does not arise. To say that they are acting out of self-interest is to confuse ultimate causation with proximate mechanism.

But for some socially complex animals, including primates and perhaps other mammals, the question of the self-interest does arise. We have thus argued and presented evidence that great apes, ensemble limited occasions, will favor others over themselves. There may be an evolutionary explanation for this behavior in terms of some kind of payback, but the acting organism knows nothing of this payback; she is simply, for example, helping her friend by grooming her or joining her side in a fight, because she is her friend. But we have also argued and presented evidence that on other occasions great apes may favor themselves over others, for example, by hogging a resource even when they know that another individual wants it to. In the current focus on proximate psychological mechanisms, only something like this may be called acting out of self-interest. In general, because there is good experimental evidence that great apes often do things to benefit themselves over others (even when they know that they are thereby thwarting the others' goal pursuit), we may say that great apes are often, perhaps most often, acting out of self-interest.

Obviously, humans also have the capacity to act out of self-interest and quite often do. But we have argued and presented evidence that quite often, as well, even young children are genuinely concerned about the welfare of others without strategic calculation: they help others reach their goals, they share resources with them fairly, they make joint commitments and ask permission to break them, they act toward a “we” or group interests, they enforce social norms on third parties on the basis of presumably group – minded motives, and they have genuinely moral emotions — from sympathy to resentment to loyalty to guilt — that do not spring from any self-interested calculations at all. These empirical findings — and many others in other disciplines (see Bowles and Gintis is, 2012) — suggest that human beings have evolved biologically to value others and to invest in their well-being. We have argued here that the explanation for this fact is that human individuals recognize their interdependence with others and the implications this has for their social decision making. They have become cooperatively rational in that they factor into their decision-making (one) that helping partners and compatriots whenever possible is the right thing to do, (two) that others are equally as real and deserving as themselves (and the same recognition may be expected in return), and (three) that a open quote we” created by a social commitment makes legitimate decisions for the self and value to others, which creates legitimate obligations among persons with moral identities in moral communities.

From the individual’s point of view, this is all very genuine: the moral judgments of both self and other in the moral community or, on the whole, legitimate and deserved. We would therefore speculate that most contemporary adult human beings, if given Plato’s Ring of Gyges, which would make their actions invisible to others, would still behave morally most of the time. Invisible humans would undoubtedly break many social norms that have no connection to their second–personal morality. And they would undoubtedly behave in morally if their selfish motivations were strong enough. But in the absence of overwhelming selfish desires, invisible humans would most often help others and treat them fairly, and even feel guilty if they did not do so — assuming, of course that they viewed them as a part of their moral community. And this would hold, we hypothesize, for all individuals in all moral communities across all cultures. what we differ is simply the ways in which people from different cultures, given the different social and institutional settings within which they live their lives, understand what are the right and wrong ways to do things in particular contexts, and who is considered part of the moral community.

Our account is thus grounded in a natural second–personal morality. But in the contemporary world this natural orality is embedded in a cultural morality of social norms, and these have been crafted at different historical periods for different recurring situations, so they sometimes conflict. In facing a novel situation, then, the individual must create his own moral principles to help adjudicate among these norms and so make decisions that enable him to preserve his moral identity. The problem is that there seem to  exist  genuine moral dilemmas that appear as a kind of Necker cube: moral in one way when looked at from one angle but moral in a different way, or even immoral, when looked at from a different angle. They have no general solutions; they simply represent a collision of moral forces, and the individual must find some way to harmonize them, almost always by suppressing or overwriting something (Nagel, 1986, 1991). What alternative is there, then, to an explanation of human morality in terms of a variegated history of biological adaptations and cultural creations that each work well within their respective “proper domains” but that collide with one another in novel situations that neither nature nor culture could foresee?

It is clear that many people will think that what we have painted here is an unrealistically rosy picture of human cooperation and morality. Where we see sympathy and the sense of equality, they would propose clever strategies for fulfilling selfish interests. When I donate money to a beggar on the street, they would argue, what I am really doing is attempting to enhance my reputation in the eyes of others. But why the really? Why can I not be doing both? Nothing makes for a better behavioral decisions that something that achieves two goals at once: I help the poor person for whom I feel genuine concern, and I enhance my reputation at the same time — win–win. The fact that I have strategic motives is undoubted, but I also have generous and egalitarian motives, and whenever possible I do things to fulfill them all simultaneously. And when they conflict, many considerations determine which one wins out, but in any given situation by generous or egalitarian motives can in principle went out, as people demonstrate every day as they sacrifice themselves for others.

Some people will also think that our picture of human morality is to Rosie because human and immorality is on display for all to see every day in the world press. All day every day people lie, cheat, and steal to get their own selfish way, and there are at any given moment multiple wars going on. But people lying, cheating, and stealing are simply instances when, for whatever reason, the individuals self-interested motives have one out. The liar – cheater – dealer probably felt guilty while she was doing it and attempted to justify it by creative interpretations of the harm (or lack thereof) done. Moreover, she undoubtedly has done many moral things in other situations on other occasions and may even be close to 100% moral with family and friends. And as for wars, virtually all large – scale conflicts in the world today are between groups of people who view the situation as “us” versus “them,” for example, one country versus another. In addition, there are many other conflicts between different ethnic groups that for various reasons (quite often involving outside influences, e.g., colonialism) that have been forced to coexist under the same political umbrella. These are again instances of in – group/out – group conflicts, and again it is almost certain that those involved in them are doing many moral things with their compatriots on a daily basis. And despite all this, it is still the case that warlike conflicts, as well as many other types of violence, are historically on the wane (Pinker, 2011).

A final criticism of too much rosiness is that we have posited a sense of equivalence or equality among persons as foundational to human morality. Those who are used to thinking in terms of recorded human history will point out that it is only with the Enlightenment that social theorists in Western societies began promoting the idea of all individuals as in some sense equal, with equal rights. This is of course true in terms of explicit political thinking about the social contract after the rise of civil societies in the past 10,000 years. But the Hunter – gatherer societies that existed for the immediately preceding. — For more than 10 times that long — were by all indications highly egalitarian (Boehm, 1999). This does not mean that those individuals had no selfish motives, only that they regularly work things out with one another in a mutually satisfactory manner based on equal respect for all members of the cultural group. And recall again that our hypothesis follows the analysis of Nagel (1970) in which the recognition of others is equal beings is not a preference or motivation (as it is in enlightenment political treatises) but merely a recognition, perhaps even an unwelcome recognition, that may or may not influence the personal decisions that individuals make or the social norms that cultures create. Indeed, the main way that people justify treating others inhumanely is not motivational but, rather, conceptual: Dave viewed them as not really human at all. On the whole, it simply does not seem possible to think of anything resembling human morality without individuals who recognize and interact with others whom they cannot help but perceive as being on a par with themselves.

It is clear that morality is difficult. Human beings have natural inclinations of sympathy and fairness toward others, but still we are sometimes selfish. Others may call us to task for our selfishness, chastise us with the whips of social norms, and gossip behind our backs to ruin our reputation, and still we are sometimes selfish. Violations of our own morality make us feel guilty and chip away at our sense of who we are, and still we are sometimes selfish. Religious principles applied by an omniscient God promise eternal damnation for moral violations, and governmental laws meet out more immediate and concrete forms of damnation in this corporeal world, and still we are sometimes selfish. No, it is a miracle that we are moral, and it did not have to be this way. It just so happens that, on the whole, those of us who made mostly moral decisions most of the time had more babies. And so, again, we should simply marble and celebrate the fact that, miracle dicta ( and Nietzsche notwithstanding), morality appears to be somehow good for our species, our cultures, and ourselves — at least so far.
[ibid, pp. 158-163]
Again, pretty nice read. Well worth your time.

So, empathy, sympathy, cooperation, altruism. What do we think? Is this merely back-burner, academic stuff? People are busy just getting through the day in the clinics.

I am reminded yet again of my "Talking Stick" riff.


Seen on twitter.

Back when I was writing code during the days prior to indoor plumbing, we used to joke that "the flowchart comes last."


I'm a serial stray magnet. So, I'm signing up with Whatever they need from me.

How Images Trigger Empathy
People need to actually see what others are going through to feel compassion.

...We have all heard that one death is a tragedy, one million deaths a statistic. To perceive tragedy, we have to see a person (or, apparently, an animal) as an individual. Psychologists call this the “identifiable victim effect.” And one of the surest ways to see someone as an individual is to actually see them... 
Good article. However, again, we reflexively tend to conflate "empathy" and "sympathy" ("feel compassion"). But, maybe that's a minor pedantic beef of mine.


Peter Singer's TED Talk:


Transcript excerpts:
Each of us spends money on things that we do not really need. You can think what your own habit is, whether it's a new car, a vacation or just something like buying bottled water when the water that comes out of the tap is perfectly safe to drink. You could take the money you're spending on those unnecessary things and give it to this organization, the Against Malaria Foundation, which would take the money you had given and use it to buy nets like this one to protect children like this one, and we know reliably that if we provide nets, they're used, and they reduce the number of children dying from malaria, just one of the many preventable diseases that are responsible for some of those 19,000 children dying every day.
Fortunately, more and more people are understanding this idea, and the result is a growing movement: effective altruism. It's important because it combines both the heart and the head. The heart, of course, you felt. You felt the empathy for that child. But it's really important to use the head as well to make sure that what you do is effective and well-directed, and not only that, but also I think reason helps us to understand that other people, wherever they are, are like us, that they can suffer as we can, that parents grieve for the deaths of their children, as we do, and that just as our lives and our well-being matter to us, it matters just as much to all of these people. So I think reason is not just some neutral tool to help you get whatever you want. It does help us to put perspective on our situation. And I think that's why many of the most significant people in effective altruism have been people who have had backgrounds in philosophy or economics or math. And that might seem surprising, because a lot of people think, "Philosophy is remote from the real world; economics, we're told, just makes us more selfish, and we know that math is for nerds." But in fact it does make a difference, and in fact there's one particular nerd who has been a particularly effective altruist because he got this.
This is the website of the Bill & Melinda Gates Foundation, and if you look at the words on the top right-hand side, it says, "All lives have equal value." That's the understanding, the rational understanding of our situation in the world that has led to these people being the most effective altruists in history, Bill and Melinda Gates and Warren Buffett…
My final question is, some people will think it's a burden to give. I don't really believe it is. I've enjoyed giving all of my life since I was a graduate student. It's been something fulfilling to me. Charlie Bresler said to me that he's not an altruist. He thinks that the life he's saving is his own. And Holly Morgan told me that she used to battle depression until she got involved with effective altruism, and now is one of the happiest people she knows. I think one of the reasons for this is that being an effective altruist helps to overcome what I call the Sisyphus problem. Here's Sisyphus as portrayed by Titian, condemned by the gods to push a huge boulder up to the top of the hill. Just as he gets there, the effort becomes too much, the boulder escapes, rolls all the way down the hill, he has to trudge back down to push it up again, and the same thing happens again and again for all eternity. Does that remind you of a consumer lifestyle, where you work hard to get money, you spend that money on consumer goods which you hope you'll enjoy using? But then the money's gone, you have to work hard to get more, spend more, and to maintain the same level of happiness, it's kind of a hedonic treadmill. You never get off, and you never really feel satisfied. Becoming an effective altruist gives you that meaning and fulfillment. It enables you to have a solid basis for self-esteem on which you can feel your life was really worth living…
Interesting speaker. A "consequentialist utilitarian" philosopher of considerable acclaim (and some controversy). An "Afflict-The-Comfortable" guy. This talk goes in part to The Atlantic article I cited above, "The Physiological Power of Altruism."


I know I've ranged rather far afield here (and not sure how far the dip into "altruism" fits the topic). Started by noting that, yes, we need "seasoned clinicians" in Health IT, particularly given that a top, chronic complaint regarding HIT is the lack of -- well -- "empathy," i.e., deep digital developer awareness of the cognitive and operational (e.g., workflow) demands clinicians must continually deal with. An empathy deficit here invariably results in suboptimal UX, and by extension suboptimal patient outcomes.

I would also assert that empathy/sympathy is a two-way street. While we all love to yammer on about the imperative of "patient-centered care" in a frenzied health care world moving away from the FFS paradigm toward "P4P," a shift putting the onus on clinicians to consistently perform in a cost-effective/clinically effective manner, it behooves us equally as patients to put ourselves in the clinicians' shoes, as part of becoming "active care participants" (in addition to some of us becoming adroit HIT coders).

apropos, citing Dr. Hadler:

Clinical judgment is both an intellectual exercise and an intimate collaboration. We will have more to say about the former shortly. It is the latter that is underrecognized. If the collaboration is not successful, disquiet and dissatisfaction on the part of the patient can ensue, leading to inappropriate interventions and disappointing outcomes. There can be no intimate clinical collaboration without trust. And trust is a two-way street. The patient must feel secure that the physician is doing everything possible to place her interests above all else. 

That is never a trivial demand. The physician must subjugate all preconceptions, all emotional responses, and all that might be conflictual to the demands of the collaboration. The physician demeanor must project empathy, promote communication, and encourage confidence. The essence of professionalism is a composite of rigorous competence and trustworthiness that engenders confidence. Other trappings follow naturally: wearing acceptable attire, using appropriate body language, avoiding vernacular, maintaining proper physical distance, smiling, and being prompt. 

The last is one bane of being a patient. No one should have to wait beyond the appointed time. Sometimes this is systemic; the organizational infrastructure of the practice setting is a mess. That’s inexcusable. Sometimes an unexpected, infuriating delay is unavoidable. After all, much of clinical medicine is unpredictable. If your own clinical interview calls for actions and behaviors that consumed unexpected time, you would not appreciate someone telling you, “Time’s up.” It takes little time, though, for the physician or staff to keep you abreast of the reasons for delay and to offer you options. That’s not just courtesy; that’s part of the intimate collaboration that is the reason you sought care in the first place. 

In return for professionalism, it is necessary for the patient to participate to the fullest possible extent in the exercise of clinical judgment so that its goal can be realized. The goal is to enable the patient to assume responsibility for making clinical decisions by informed choice. There is no other goal. This is an intimate clinical collaboration, not a friendship. In fact, it is not necessary for the physician to “like” the patient to maintain professionalism. Nor is it necessary for the patient to “like” the physician. To the contrary, emotional distance promotes objectivity on both parts. “Friendship” and stronger emotional bonding between patient and physician have no role to play in the collaboration. In fact, they can be very intrusive and counterproductive; in such cases, both parties should call for a substitute physician rather than risk a distortion in clinical judgment.

Hadler M.D., Nortin M. (2013-04-01). Citizen Patient (H. Eugene and Lillian Youngs Lehman Series) (pp. 207-208). The University of North Carolina Press. Kindle Edition.

More to come...

1 comment: