Jonathan Bush, "More Disruption, Please"

Gotta love the guy. One Salty Dawg...

"In 20 years, digital health could actually re-tool, re-orient medicine around problems and away from geography..." [~19:25]

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"Meaningful Use"? Remember that? Anyone still care?

As we finish up Q1-2016, two of the latest available MU tabulations:

Click to enlarge if you wish.

564,621 active clinician registrations, nearly $32 billion in MU incentive payouts through January 2016. It was interesting back in January during the San Francisco  JP Morgan Conference and Health 2.0 WinterTech week that the announcement came of the 2016 demise of the Meaningful Use program -- an announcement that subsequently got awkwardly sort of walked back by ONC brass.

I launched this blog on May 10th, 2010 as an online diary of my then-new work with the Nevada-Utah Regional Extension Center (REC) after my episodic employer HealthInsight won the bi-state REC contract.

The MU initiative has been a raucously contentious one across its history. RECs were derisively referred to as "wrecks" (athenaHealth CEO Jonathan Bush once jibed that RECs should "get a quick bullet; no one will even notice." He was openly pleased to take the MU money, though). The incentive funds were seen as corporate welfare for HIT incumbents (like, well, athenaHealth). The MU compliance workflow demands were (and remain) widely hated.

I even bit the hand that fed me.

My specific core REC role was that of "workflow specialist" whose goal was to mitigate or eliminate additional labor expense associated with MU compliance in the participating ambulatory primary care clinics on my caseload. Adding just a minute or two of charting time per patient complying with MU would essentially negate any incentive money gain.

Our REC was "vendor agnostic" and served MU clients on about 40 EHRs. My personal caseload ran to about 8 of those: eClinicalWorks, e-MDs, Amazing Charts, athenaHealth, Practice Fusion, Allscripts, SOAPware, and Greenway (and a couple of one-offs whose names I now forget). The MU documentation workflow paths varied considerably from vendor to vendor. I argued -- to no avail -- that all MU documentation paths should be "one-click" via either internal Certified EHR functionality or some sort of "macro" keystroke utility.

Any noble intentions we had about "improving care" through more adept use of health IT abetted by process QI-enhanced workflows quickly fell victim to chasing REC contract payment "milestones" (1/3rd at sign-up, 1/3 at Certified EHR implementation, and 1/3rd at MU attestation). ONC needed to show nominal ARRA/HITECH "progress" on the Hill. The "body count" imperative quickly became the overarching goal.

Then, with RECs only really having hit their aggregate stride for about two years (of the 4-year initial contract term), ONC shut the whole thing down. Farzard and his successor Karen DeSalvo voiced the obligatory REC-supportive statements (see here as well), but it was clear that they had no stomach for fighting for more REC funding.

What a waste. I even offered to come to DC on my own dime and testify in support of continuing REC funding, but it was clear that nothing was going to happen.

Google "Meaningful Use" today (including the quotation marks), you'll get nearly 2 million hits (with, interestingly, athenaHeath right at the top above the fold one page one). The program has been repeatedly reported on and analyzed from every possible viewpoint. It has been under the congressional microscope. See, e.g., my "Reboot" stuff here and here.

So, total ONC/CMS outlay to date, what? MU average attestation payments to date per EP & EH?

• Medicare EPs: $27,081
• Medicaid EPs: $27,198
• Eligible Hospitals: $3,875,004

Maybe $35 billion or so total HITECH cost, inclusive of RECs and CMS admin expenses? Has it all been worth it, net? What do you think? (The critics remain legion and loud) By now we're pretty much in the provider "penalty phase," with the bulk of the MU incentive money out the door.

A broader question, one posed by Margalit Gur-Arie: "Are structured data now the enemy of health care quality?" See also its antecedent post "On Health Care Technology: EHR Call-Outs."

ERRATUM: BOOK REVIEW

I read and report on a ton of books here, -- beyond the purely tech stuff, anything related to process improvement, "leadership," organizational culture, clinical cognition, and pedagogy, etc.

I won't have to buy this book.

Great New Yorker review. Pretty funny. Fairly long read. Excerpted below. Well worth your time.

The Life Biz
How to succeed at work and at home.
BY LOUIS MENAND

“Smarter Faster Better: The Secrets of Being Productive in Life and Business” (Random House) is Charles Duhigg’s follow-up to his best-selling “The Power of Habit: Why We Do What We Do in Life and Business,” which was published in 2012. The new book, like its predecessor, has a format that’s familiar in contemporary nonfiction: exemplary tales interpolated with a little social and cognitive science. The purpose of the tales is to create entertaining human-interest narratives; the purpose of the science is to help the author pick out a replicable feature of those narratives for readers to emulate.

What enabled the pilot to land the badly damaged plane? How did the academic dropout with anxiety disorder become a champion poker player? What made “West Side Story” and Disney’s “Frozen” into mega-hits? All that was necessary, it turns out, was one key tweak to normal mental functioning or group dynamics. “Mental models” helped the pilot land the plane. “Bayesian thinking” transformed the basket case into a winner at cards. An “innovation broker” brought “West Side Story” together, and “Frozen” became the highest-grossing animation film of all time because of a principle known as “intermediate disturbance.”

Other tweaks on offer in “Smarter Faster Better” include “creating disfluency,” “a bias toward action,” “SMART goals” versus “stretch goals,” and the concept of “psychological safety.” There are a few mind-sets to avoid as well (side effects may include crashed aircraft and the Yom Kippur War): “cognitive tunneling,” “reactive thinking,” and an exaggerated disposition for “cognitive closure.” Basically, the good stuff boils down to organizational buzzwords like “lean,” “nimble,” “flexible,” “innovative,” and “disruptive.” Negative stuff has to do with mindless routines, mechanical thinking, and the need for certainty.

There is not much to disagree with here, and that is one of the intriguing things about the genre this book belongs to. Not dozens or hundreds but thousands of titles like “Smarter Faster Better” are published every year, and they account for a disproportionate percentage of total book sales. Yet they mainly reiterate common sense.

Does anybody think it’s unwise to be lean, nimble, and innovative? Who needs a book to know that rote behavior and fear of uncertainty are not going to take us very far? It’s not startling to learn that organizations that nurture a “culture of commitment” are more productive than organizations that don’t, or that setting ambitious objectives can jump-start innovation. “People who know how to self-motivate, according to studies, earn more money than their peers, report higher levels of happiness, and say they are more satisfied with their families, jobs, and lives.” I can believe that. “Determined and focused people . . . often have higher paying jobs.” I won’t argue. “An instinct for decisiveness is great—until it’s not.” An impregnable assertion.

Probably the most famous book of this type is Dale Carnegie’s “How to Win Friends and Influence People,” which was published in 1936 and has never gone out of print. It is reported to have sold more than thirty million copies. I can tell you the lesson of that book in one sentence: If you are nice to people, they will like you. You just saved yourself sixteen dollars. (Not to spoil the reading experience, but the lesson of Duhigg’s previous book, “The Power of Habit,” is: Replace bad habits with good ones.)...

These all sound like ways to help you feel better about yourself, and maybe even be a better person. But the books are not beauty products for the personality, and that is not the reason people buy them. Most functioning people are probably O.K. with the personalities and temperaments that the Good Lord or natural selection has given them. They’ve learned work-arounds for their grumpiness and fretfulness. What they’re worried about is how others see them and, specifically, how employers see them. The clue to the real purpose of these books is the section of the bookstore you find them in. They’re not in the psychology section, and they’re not in with the diet and exercise books. They’re with the business books.

This is because books like “How to Win Friends” and “Smarter Faster Better” are essentially applied management theory. They try to sum up current thinking in the business world about “human resources” and transmute it into a manual for self-improvement. People don’t read these books to find out how to be better human beings. People read them to figure out how to become the kind of human being the workplace is looking for....

The key ingredient, the replicable feature of all success stories that explains why some people do better than other people, is not arbitrarily chosen. It reflects the nature of the economic times. When Smiles published his book, in the laissez-faire era of industrial capitalism, the novel feature of contemporary life for the sort of person who bought books like “Self-Help” was economic and social fluidity. Upward mobility was newly possible for many people, but so was downward mobility. Many of the novels of Smiles’s contemporary Charles Dickens are illustrations of the latter. Smiles made the case for diligence and dedication as the ticket upward...

One striking thing about the exemplary tales in “Self-Help” is the all-consuming nature of the careers they document. There is no separation between work life and private life. Personal prosperity and professional success coincide, and this elision became a staple of the genre. The secrets of success in business are the secrets of success in life. The reason that the nature of the secrets changes is that the nature of work changes. Different modes of work call for different types of people.

Let’s say you were running a steel company a hundred years ago. You would want the workers in your factory to perform physical tasks as efficiently as possible. You’d want them to be able to move large objects around quickly and operate heavy machinery with a minimum of rest or redundant effort. You’d be looking to maximize the ratio of output to time; that would be your measure of productivity. You would therefore want your workers to become habituated, through repetition, to a specified mechanical routine. You would not want them to do a lot of thinking on the job. You would reward the most efficient workers with higher wages.

The buzzword in this manufacturing economy was “efficiency,” and its bible was Frederick Taylor’s “Principles of Scientific Management,” first published in 1911. Taylor didn’t want workers to think about what they were doing; he wanted their actions to be designed scientifically by management to maximize speed. His chief illustration had to do with pig-iron handlers, men who moved large pieces of iron all day. That example might not seem a model for the practice of daily life, but, as Jill Lepore showed in these pages a few years ago, the value of “efficiency” was duly imported into the home in the form of home economics, a scientific approach to baking pies and cleaning dishes. “Efficient” moved over from a term of business to the name for a personality type.

If you owned an advertising agency fifty years ago, on the other hand, you wouldn’t care how much pig iron your workers could carry in an hour. You would want your account executives to have winning personalities, to be able to bond easily with other people, to be likable. You would want them to have manners tailored to attract the patronage and retain the loyalty of your customers. Their task would be to persuade, not to push. You would therefore want them to be able to conceal, maybe even from themselves, the manipulative and possibly mercenary nature of their relationship with clients, and to transform a business transaction into a friendly quid pro quo. You would reward the most successful account executives with lavish expense accounts.

This is, of course, the service-economy world of “How to Win Friends and Influence People.” Among the things that the book promises to do for its readers (in the original edition; these were omitted in later printings) are: “Enable you to win new clients, new customers,” “Increase your earning power,” and “Make you a better salesman, a better executive.” It’s nice to be nice, but it also pays...

Today, if you were starting up a tech company (hey, maybe you are!), you would simply outsource your customer relations. In house, you would want your employees to be innovative and flexible, able to work in teams and adjust to new goals as they arose. You’d want to encourage your employees’ creativity by making them feel valued partners in the enterprise, active agents rather than code-writing drones. You’d be looking to maximize the ratio of brains to adaptability. You’d try to insure your employees’ commitment by making them feel that they were generating their own tasks and measures of performance, by having them “take ownership” of the workplace. You’d want reliable people who can also think “outside the box,” not people who think that successful performance means merely meeting preset goals. You would reward the most loyal employees with stock options...

LOL. Yeah, a few Dilbert Zone Moments.
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UPDATE

From STATnews:

SPECIAL REPORT
Google’s bold bid to transform medicine hits turbulence under a divisive CEO

MOUNTAIN VIEW, Calif. — Google’s brash attempt to revolutionize medicine as it did the Internet is facing turbulence, and many leaders who launched its life sciences startup have quit, STAT has found.

Former employees pointed to one overriding reason for the exodus from Verily Life Sciences: the challenge of working with CEO Andrew Conrad.

Verily, one of Google’s “moonshots,” pursues ambitious, even radical, ideas that could take years to pay off. The emerging Silicon Valley juggernaut has attracted elite scientists, engineers, and data crunchers, and inspired buzz about its futuristic projects — as well as envy among competitors nervously eyeing this upstart with a seemingly unlimited bankroll.

The three-year-old venture has operated largely out of public view and carefully manages its image; employees said talking to a reporter without permission is a firing offense.

But people who know Conrad or have worked with him said in interviews that Google has entrusted its life sciences initiative to a divisive and impulsive leader whose practices are driving off top talent and leaving openings for competitors. They said many employees in key jobs were dispirited, and described a lack of focus and clear priorities that is unusual even in the chaotic culture of startups...

Wow. "Leadership," 'eh?
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More to come...

Clinician Burnout

"Burnout." a recurrent topic in recent years, and, while it's by no means confined to the health care sector, it certainly can have particularly acutely adverse consequences there.

THCB recently posted an interesting long read, "The Antidote to Physician Burnout: A Nine Step Program" by Martin Samuels, MD.

I have some strategies for preventing “physician burnout.” I am a little over 70 years old and am not experiencing any of the symptoms of “physician burnout.” I do not state this out of any sense of pride, but I have tried to be introspective about this so as to offer some advice as to how to avoid this problem...

Job burnout is not a new idea, and it is not specific to medicine.  It has been in the psychology/psychiatry literature for quite a long time. It may be defined as a feeling of emotional exhaustion characterized by cynicism, depersonalization and perceived ineffectiveness.

In recent years, many have argued that “burnout” is extremely prevalent; not only in society as a whole but in particular in medicine. It has been said that 50% of physicians have at least one of the three cardinal features:  exhaustion, depersonalization and inefficacy...

What are the alleged causes of “burnout?” There are many, of course, but there are five major categories. The first is what is termed “overwhelming demands and work overload” often associated with sleep deprivation and a need to be “superhuman,” by which is meant the intolerance of any errors and the enormous fear that errors will cause harm to patients and /or risk of malpractice litigation. Some physicians believe this is a “zero tolerance game”.

The second alleged cause of “burnout” is what many call social conflicts, conflicting values and a breakdown of the community. In this category falls the so-called work-life balance. That is, what proportion of one’s life can one spend in work, including thinking about work, versus other endeavors, such as family, athletics, artistic pursuits, hobbies, vacation, reading and others. The third of the causes of “burnout” is the lack, or perceived lack, or loss of various resources. In the context of medicine, this might be inadequate information systems, physicians’ assistants, nurses, secretarial help and scheduling systems. The fourth cause is insufficient rewards. These can be divided into two categories:  monetary and nonmonetary rewards. In the latter category might be a sense of feeling respected and of doing something that is meaningful. The last of the five major causes of “burnout” is what many have termed “lack of fairness.” This issue of fairness affects not just medicine, but is pervasive all over the world in many different contexts. In fact, it is really a zeitgeist, or a spirit of the times. Many groups, defined by multiple criteria, feel marginalized. This could be a religious group, a racial group, a gender orientation, and so on...

In summary, the five major causes of “burnout” are: overwhelming demands, social conflicts, lack or loss of resources, insufficient rewards, and absence of fairness...

"Overwhelming demands" goes to the "productivity treadmill," no? "Social conflicts"? How about a lack of "Just Culture" organizational dynamics? "Lack or loss of resources"? Implications of poor HIT "usability" there? "Insufficient rewards, and absence of fairness"? Well, just compare the typical physician and nurse salaries to the comp packages of hospital administrators, Big Rx and AHIP execs, and a raft of Health IT 501(c)(6) "non-profit" leadership.

Then there're the eager hordes of us tiresome, meddling "process QI" and "patient satisfaction" people. From a link in one of the comments under the Samuels post:

"I don't know if any other physicians have had to suffer through a business consultant-based inservice on how to improve "customer satisfaction scores". There are discussions on how to introduce yourself to the "customer". There are the usual business based mnemonics. Physicians may actually have to demonstrate that they know how to introduce themselves to "customers"! Think about that for a second, especially if you are a psychiatrist who was trained for years in how to interact with patients rather than customers. If you are a psychiatrist who passed the oral boards, you know that failing to make the appropriate introduction led to an immediate failure on that exam. Now flash forward to the bizarre world where patients are "customers" and now there is a formula designed by business people who know relatively nothing about interacting with patients in a therapeutic manner. You are expected to demonstrate competency in this shallow business paradigm that is setup to optimize results on customer satisfaction surveys. This is a great example of how physicians are stressed on a regular basis in health care organizations and their time is wasted. It is also a great example of how public relations, rather than the latest medical knowledge is the dominant performance metric for healthcare organizations. If there is a recipe for burnout - this is it." - George Dawson, MD, DFAPA

I return to a book I cited some time back:

I love being a physician. I love it for many reasons, but the main one is because of what I am able to do for people like Antonio. And the incredible thing about being a doctor is that every one of the almost one million physicians in the United States has a similar story— not a cleft lip necessarily but a story in which the physician changed someone’s life in a magnificent way. Countless specialists and primary care physicians alike have stories in which they literally saved a life— reached in and rescued the patient from the edge of the precipice. Or they saved many lives— of children, expectant mothers, and aging grandparents. The joy and satisfaction in those moments for physicians is unlike any other experience. 

To reach the point where we can do these things requires years and years of hard work, including the rigor of a heavy science load in college followed by the unrelenting demands of medical school. Academic work combined with clinical training builds the skills that gradually transform the student into a clinician who advances to residency training and fellowship, ranging from three to eight years. Only then comes the great reward: the ability to care for people who need you. 

This is the heart of the matter. Physicians love being doctors because we have the privilege of being able to calm fears and alleviate suffering— to change and save lives. This is what motivates doctors virtually every single day of their lives. When the structure and culture in which physicians work are well aligned, it is a most rewarding job. 

But something has gone wrong in the physician world, and it is urgent that we fix it. Fundamental flaws in our system make it more difficult and less rewarding than ever to be a doctor. A 2012 Physicians Foundation survey found that nearly eight in ten doctors were “somewhat pessimistic or very pessimistic about the future of the medical profession.” A report from Harris Interactive, a leading research firm, described the practice of medicine today as “a minefield” where physicians feel burned out and “under assault on all fronts.” Mayo Clinic physicians Liselotte N. Dyrbye and Tait D. Shanafelt wrote in a commentary in the Journal of the American Medical Association (JAMA) that 30– 40 percent of physicians in the United States are “experiencing burnout.” Dyrbye and Shanafelt note that physicians suffering from burnout “are more likely to report making recent medical errors, score lower on instruments measuring empathy, and plan to retire early and have higher job dissatisfaction, which has been associated with reduced patient satisfaction with medical care and patient adherence to treatment plans.” 

Never before have physicians been under so much pressure from so many sides. Many physicians feel inundated with administrative matters that prevent them from devoting their full talents to their patients’ well-being. Ask doctors about the atmosphere in which they practice, and you often hear words such as “chaos,” “conflict,” and “dysfunction.” How can a nation transform its health care system when so many physicians feel such deep pessimism about the future of their profession? 

The reality of our situation in the United States is clear. We cannot achieve high-quality, accessible, affordable health care for all unless we solve the doctor crisis. Unless physicians are provided with the team-based support they need to focus on patient care— and are not weighed down by work that other team members can do— progress will stall. And lest anyone read into our view that we are being overly physician-centric by focusing on the doctor crisis, we strongly believe that freeing doctors to concentrate on providing excellent care is, by definition, patient-centered. In fact, when the question “what do physicians want?” is asked, the answer is clear. Physicians want the team support to be able to give their patients the time, attention, and care they need. That is what drives the great majority of doctors in our nation, and while the crisis is most acute within primary care, it applies across the specialties as well. As Dr. Jay Crosson, vice president of Professional Satisfaction, Care Delivery, and Payment at the American Medical Association, observes, “Taking physician satisfaction seriously does not mean giving physicians anything they want, but it should mean creating an environment where physicians are always able to put patients first.” 

And that is the heart of the doctor crisis. Far too often, physicians are prevented from putting their patients first— ahead of administrative hassles, finances, insurance company demands, regulations, and more. These barriers nearly all make sense when one looks at them from a point of view other than the patient, but if we put the patient’s well-being ahead of every other consideration, then it is clear that these barriers must be breached. 

Why a book focused on doctors at a time when the language of health care reform is about being patient-centered? Because my coauthor Charles Kenney and I believe that one of the most patient-centered actions we can take is to fix the doctor crisis in our country. Solving this problem is a prerequisite to creating a health care system that is patient-centered, safe, equitable, accessible, and affordable— in other words, to achieving the health care system that we so urgently need in the United States...

Cochran, Jack; Kenney, Charles C. (2014-05-06). The Doctor Crisis: How Physicians Can, and Must, Lead the Way to Better Health Care. Public Affairs. Kindle Edition. Locations 137-190.

Necessarily takes us back to Nortin Hadler MD as well:

"Figuring out a way to monetize altruism"

Chapter Nine: Medical Professionalism in the Twenty-First Century 
It is one thing to champion a trustworthy patient-physician relationship that promotes informed medical decision making and proclaim the physician to be the wise facilitator in such a relationship. But it is quite another thing to extricate such a relationship from the current dialectic, which is heavily funded to promote a systems approach to patient care. I find it impossible to remain passive in the face of this dialectic. There is an old proverb in medical circles that internists know everything but do nothing, and surgeons know nothing yet do everything. I am an internist. But I am a loose-cannon internist. 

There is a desperate need to position the patient’s narrative as raison d’être and a desperate need to provide wise ears to hear it. The only way that will happen is to create an atmosphere that demands it, an administrative structure that supports it, and a reimbursement scheme based on fees for serving. Getting there is an uphill battle, somewhat Sisyphean given the powerful push-back from stakeholders in the status quo, but it is not insurmountable. The top of the hill is the moral high ground. Medical professionalism must plant its flag there because there is no other way to serve patients well in the twenty-first century...

Again, apropos of HIT,

"If there is a role for computers in decision making, it is to facilitate dialogue between patient and physician, not to supplant the input from either or to cut health-care costs."

Indeed.

It bears repeating for the umptieth time that clinicians typically have to traverse hundreds of variables in a compressed time interval during patient encounters. Anything that gets in the way of that is inimical to health outcomes and patient safety. In this regard, the importance of (and difficulties in) effective clinical UX design are difficult to overstate.
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So, Google "physician burnout" (including quotation marks). Bring a Snickers, you're gonna be a while. ~184,000 results.

Q: To what extent does the apparently increasing "fragmentation" of the U.S. health care system contribute to clinician burnout? You might want to re-visit some Einer Elhuage, here, and here.
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I should probably also again note the excellent Danielle Ofri book "What Doctors Feel."

Beyond the paperwork, medical care itself can seem like a never-ending time commitment. Medicine has always been a full-time occupation, even for part-timers. Patients do not confine their illnesses to business hours, so night and weekend work is part of the territory, especially for primary care doctors. Doctors understand that this is built into medicine, and it is part of the commitment for which they earn respect, as well as a salary higher than that of many other professions. 

Nevertheless, as our society ages and illnesses become more chronic and complex (most people in developed countries no longer die of simple infections), the time required for medical care is expanding, and this spillover is affecting more and more doctors’ personal lives. It can be hard for physicians to voice a complaint about this, because it is part of the professional commitment. Yet at some point, this spillover can eat away at marriages, time with children, sleep, and sanity. Even when doctors are doing the clinical medicine that they enjoy and find meaningful, when it erodes the rest of their lives, they become disillusioned. Many consider quitting. 

A group of researchers followed geriatricians— primary care doctors who take care of older patients— to see how much medicine crept into their personal lives. They found that nearly eight additional hours of medical care— patient care outside of office hours— was given each week, mostly in phone calls with patients and families. A similar study of internists showed that 20 percent of their total work was spent after hours. This is equivalent to almost a full additional day of work every week. 

It’s hard to imagine a lawyer or plumber providing eight extra hours of work each week for clients just because it’s the right thing to do. And of course, it is impossible to imagine lawyers or plumbers not billing— heavily!— for it. But that is the expectation of medicine. Again, for most doctors, this is an understood part of the deal, but as these extra hours increase, they have a distinct negative impact. Eight more hours of work comes directly from the rest of the doctor’s life— family time, sleep, exercise, recreation. (Based on the standard American work schedule, that’s ten full weeks each year.) Many doctors’ lives are suffering because of this. And yet when your beeper goes off, or the hospital calls, or the answering service wakes you, there’s no other option. You must attend to it. 

Because of the rigors and length of their training, many doctors start families later than other professionals. The “junior” swath of physicians— those in their thirties and forties— enter their prime career-building years at the very same time they are starting families. A generation or two ago, there was no work-life balance issue, since most doctors were men, and they usually had wives who were home with the children. Today, of course, nearly half of all doctors are women, 12 and almost none— men or women— have spouses handy to be home with the kids full-time. Additionally, most young male doctors recoil at the experiences of their predecessors; they don’t want to miss out on their children. 

The desire to have control over one’s working hours— and especially those after-hours hours— is behind the trend of medical students drifting away from primary care specialties (internal medicine, family medicine, pediatrics, gynecology). Increasingly, students choose to stay— as the jargon has it— on the ROAD: radiology, ophthalmology, anesthesiology, and dermatology. This trend is far more alarming than the fears raised by the health-care reform bill. Doctors here are voting with their feet and moving away decisively from primary care. A survey of more than seven thousand physicians showed the highest burnout rates in front-line fields— internal medicine, family medicine, and emergency medicine. It also noted that doctors as a group demonstrate more burnout symptoms than workers in other fields. 14 Many patients— and many doctors— are asking themselves, Who will be my doctor when I need one?

Ofri, Danielle (2013-06-04). What Doctors Feel: How Emotions Affect the Practice of Medicine (pp. 156-158). Beacon Press. Kindle Edition.

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Dr. Samuels' concluding observations:

Nine Step Program to Combating Physician Burnout

Be a Professional
1. Work and learn in a truly resource limited environment but don’t be condescending
2. Empathize with your patients but don’t expect empathy for you in return
3. Spend less energy on “mindfulness” and more time on developing a theory of the mind; work is life and life is work
4. Appreciate irony and cultivate a sense of humor; don’t take yourself too seriously
5. Collect one’s own mistakes and share them but don’t expect them to stop happening
6. Study history; you aren’t that special
7. Stop feeling sorry for yourself. Realize how lucky you are to be a doctor. Others wanted to be there.
8. Find a mentor and be a mentor; you are bridge from the past to the future
9. Be realistic; no one can do everything well and stuff (sh__) will happen

Martin Samuels is the Chairman of Neurology at Brigham and Women’s Hospital in Boston and a regular contributor for THCB.

See what you think. There will be pushback. Read the entire piece. One physician commenter said "I got burnout trying to get through this long article."

LOL.

REPRISING MY "HIGH COGNITIVE BURDEN" RIFF

From my April 2015 post "Nurses and doctors in the trenches."

"... my elevator speech:

Their hard-won, sophisticated, indispensable clinical skills aside, nurses and physicians are just people like the rest of us, people more or less beset by all of the frailties, foibles, insecurities, and neuroses that typically dog us all across the breadth of our lives. The fractious, high-stakes, irreducibly high cognitive burden organizational environments within which they must function are neither of their design nor under their control, and can (and unhappily do) exacerbate interpersonal difficulties that are counterproductive to optimal patient care. I call the syndrome "psychosocial toxicity," and have blogged about it at some length in prior posts.

It's hardly confined to healthcare, to be sure, but organizational cultural dysfunction in healthcare is ultimately a patient safety issue. To the extent that we continue to view clinical co-workers through "transactional/instrumental," "superior/subordinate" lenses, our improvement efforts will be significantly hampered.

Thinking about nursing school or med school? Read both of these books ASAP. Thinking about healthcare QI, healthcare policy more broadly? Read both of these books ASAP. Thinking that you may become an acute care patient? Read both of these books ASAP.

I read everything I can relating to clinical pedagogy and process imperatives in order to better inform my views on digital health IT (the nominal topic that started this blog nearly five years ago) and healthcare process improvement. apropos, as I asserted last June:

In the face of a dysfunctional healthcare work culture, the best talent will take their skills elsewhere at the first opportunity. A psychosocially healthy workplace, then, is a significant profitability and sustainability differentiator.

A lot to think about today. Beyond citing illustrative excerpts from these books, we'll have to be going back "Down in the Weeds'," and thinking more about "The Art of Medicine." And, ruminating a bit more on the clinical process implications of Marx's "Just Culture."

'eh?

OFF-TOPIC ERRATUM

Staying with the opening matches meme above,

And, this is funny:

CODA

On twitter I asked "Clinician burnout. Is #HealthIT partially to blame?"

Dr. Carter responded forthwith:

See his post "EHR Malpractice—Coming to a Location Near You?"
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More to come...

0.946 µg/L, my latest favorite "small data" result

We'll discuss some aspects of knowledge and "Big Data," but first,

"0.946 µg/L."

Well, that was a relief to learn. My latest PSA result post-Calypso radiation tx. I finished up radiation treatment on November 10th. When I began tx, my PSA was "10.74 µg/L." (See my "Shards" posts.) A month after finishing I had my first follow-up blood draw, and the result came back "3.65 µg/L," down considerably, yet probably a bit premature for drawing any calming conclusions. The IMRT literature tells us to expect an ongoing PSA decline for two years post-tx. The RadOnco NP who called me to discuss this result affirmed that, saying she would expect that my next assay in June will likely decline further.

Relieved. But I joked with her that "I don't know that the '0.04' and '0.006' parts of that number tell me anything." She agreed.

Why not just round it to "0.9"? What we call "significant figures rounding." In the lab in Oak Ridge where I worked a quarter century ago as a programmer and QC analyst, you had to demonstrate both to regulators and your clients your bench-level empirical capability of discriminating between, say "0.005" and "0.007" or you could not report the "0.006." Similarly for the "0.04" fraction of the datum (including that of my last 2015 pre-tx result of "10.74 µg/L").

Round 'em up, pardner.

I looked around quickly for some PSA assay tech literature.

"The long-term precision (CV) for the PSA test in our laboratory, determined with commercial quality-control sera at mean values of 2.7, 0.97, and 0.81 µg/L, was 4.7% (n = 396), 8.3% (n = 259), and 8.2% (n = 487), respectively. These data suggest that the long-term precision of the PSA test in our laboratory would meet the fixed-limit criteria based on the biological variation data. A review of the data from a recent College of American Pathologists’ proficiency-testing survey indicates that most laboratories would achieve acceptable performance if the biological-variation-based fixed limits were used. In that survey, with 322 laboratories reporting, a CV of 9% at a mean value of 2.28 µg/L was achieved. A calculated fixed-limit range based on a CV of 5% is 2.04-2.48 µg/L (2 SD) and 1.92-2.60 µg/L (3 SD). This compares well with the peer 3 SD range of 1.68-2.88 µg/L. Finally, a generally accepted empirical criterion for assessing clinically significant changes of serial tumor-marker values is a change of 25%. The CV calculated from the 25% change at a mean value of 4.0, µg/L is 12.5%, which agrees with the 10.0% CV biological variation at that decision point."

OK, quickly...

"Precision" differs from "accuracy." The former goes to replicability/reproducibility whereas the latter goes to "hitting the bull's eye, dead-center of the target." Should your "shots" (e.g., lab sample runs) cluster tightly around dead-center, you can claim both "accuracy" and "precision," which are obviously what you strive for.

But, one can be quite precise, and quite precisely wrong. The shooter depicted above was biased high.

The "CV" is the "Coefficient of Variation," also conventionally known in the lab as the "RSD" -- "Relative Standard Deviation." The RSD is simply the ratio of the Standard Deviation (aka "SD" or "Sigma") to the Mean: an expression of relative variability around an average value. (Note: -- the SD is the "Root Mean Squared" variation; in plain English, the "expected average variation around an average"). If, for example, you have a mean of 100 and a SD of 10, your "CV" is 10%. Ten percent expected variability in repeated testing (1 SD, that is).

In a (mythical) perfectly "normally distributed" set of results (smooth bell curve) "99.73%" of the data will lie between ± 3 Sigma, in equal declining proportions around the mean.

A few points relating to the foregoing. [1] RSD typically increases as the concentration of the target analyte decreases. [2] "Outliers" (extreme ± values) inflate the RSD, and [3] all of it assumes distributional "normality" (the Bell Curve thing). [4] In the lab, there are no "true/known" values where patient specimens are concerned. Any single lab result is a point-estimate of an average concentration. Split my blood draw into, say, nine equal volume "aliquots" and send them in blinded triplicates to three different labs, and you will likely get nine differing reported results. Perhaps the variations will be trivial. Perhaps not. The "most accurate" result will not be directly knowable.

The best you can do is "spike" your samples with a certified NIST "standard" analyte of "known" concentration and infer that your production runs agree closely in relative terms to those of your "matrix spikes" (blood, urine, etc are "matrices"). Finally, as Theranos has learned the hard way, [5] analyte precision and accuracy are to a significant degree a function of sample size -- e.g., my results are reported in "micrograms per liter (µg/L)." They didn't draw a liter of my blood. They are extrapolating up. Extrapolating up from a single drop of blood (Theranos methodology) would be even dicier.

In our lab, the guiding phrase was "you get what you inspect, not what you expect (I had some revelatory fun at my own expense 20 years ago on that point). Lab QC remains both difficult and expensive. We patients and our clinicians, however, typically just take our reported results at face value. We assume them to be "actionable."

Notwithstanding a world wherein people now increasingly cite their academic GPAs to four decimal places, I would be perfectly fine with a reported PSA result of "0.9 µg/L." Useful to keep in mind that "0.9 µg/L" is nine-tenths of a millionth (µ="micro") of a gram in a liter of serum, a very small quantity in its own right. Gilding the lily with smaller decimal fractions simply because computers make it easy does little beyond adding to evaluative noise (what does one ten-thousandth of an ordinal scale GPA metric tell me? Nothing). In the overall context of my post-treatment prognosis given the trend of my PSA assays, my oncologist will come to the same assessment conclusion in the event he sees either "0.9," 0.95," or "0.946" in  the Labcorp report.

Another document I found (University of Washington Medical Center Department of Laboratory Medicine Immunology Division).

9. REPORTABLE RANGE OF TEST RESULTS
   Results are reported to the nearest tenth (0.1). The lowest reportable PSA result is 0.1 ng/mL. The assay does not have a maximum reportable limit since off-line dilutions can be made to bring the concentration within the working range of the assay. Estimates of imprecision can be generated from long-term quality control pool results.
   

'eh?
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FROM SMALL DATA TO "BIG DATA" AND BEYOND TO ISSUES OF "KNOWLEDGE"

A Jill Lepore New Yorker article I read yesterday caused me to jump a new book to the head of my endless reading queue.

The era of the fact is coming to an end: the place once held by “facts” is being taken over by “data.”

Neuromedia
Imagine a society where smartphones are miniaturized and hooked directly into a person’s brain. With a single mental command, those who have this technology— let’s call it neuromedia— can access information on any subject. Want to know the capital of Bulgaria or the average flight velocity of a swallow? It’s right there. Users of neuromedia can take pictures with a literal blink of the eye, do complex calculations instantly, and access, by thought alone, the contact information for anyone they’ve ever met. If you are part of this society, there is no need to remember the name of the person you were introduced to last night at the dinner party; a sub-cellular computing device does it for you. 

For the people of this society, it is as if the world is in their heads. It is a connected world, one where knowledge can be instantly shared with everyone in an extremely intimate way. From the inside, accessing the collective wisdom of the ages is as simple as accessing one’s own memory. Knowledge is not only easy; everyone knows so much more. 

Of course, as some fusspots might point out, not all the information neuromedia allows its users to mentally access is really “knowledge.” Moreover, they might claim, technological windows are two-way. A device that gives you a world of information also gives the world huge amounts of information about you, and that might seem like a threat to privacy. Others might fret about fragmentation— that neuromedia encourages people to share more information with those who already share their worldview, but less with those who don’t. They would worry that this would make us less autonomous, more dependent on our particular hive-mind— less human. 

But we can imagine that many in the society see these potential drawbacks as a price worth paying for immediate and unlimited access to so much information. New kinds of art and experiences are available, and people can communicate and share their selves in ways never before possible. The users of neuromedia are not only free from the burden of memorization, they are free from having to fumble with their smartphone, since thoughts can be uploaded to the cloud or shared at will. With neuromedia, you have the answer to almost any question immediately without effort— and even if your answers aren’t always right, they are right most of the time. Activities that require successful coordination between many people— bridge building, medicine, scientific inquiry, wars— are all made easier by such pooled shared “knowledge.” You can download your full medical history to a doctor in an emergency room by allowing her access to your own internal files. And of course, some people will become immensely wealthy providing and upgrading the neural transplants that make neuromedia possible. All in all, we can imagine, many people see neuromedia as a net gain. 

Now imagine that an environmental disaster strikes our invented society after several generations have enjoyed the fruits of neuromedia. The electronic communication grid that allows neuromedia to function is destroyed. Suddenly no one can access the shared cloud of information by thought alone. Perhaps backup systems preserved the information and knowledge that people had accumulated, and they can still access that information in other ways: personal computers, even books can be dusted off. But for the inhabitants of the society, losing neuromedia is an immensely unsettling experience; it’s like a normally sighted person going blind. They have lost a way of accessing information on which they’ve come to rely. And that, while terrible, also reveals a certain truth. Just as overreliance on one sense can weaken the others, so overdependence on neuromedia might atrophy the ability to access information in other ways, ways that are less easy and require more creative effort. 

While neuromedia is currently still in the realm of science fiction, it may not be as far off as you think. The migration of technology into our bodies— the cyborging of the human— is no longer just fantasy. And it shouldn’t surprise anyone that the possibilities are not lost on companies such as Google: “When you think about something and don’t really know much about it, you will automatically get information,” Google CEO Larry Page is quoted as saying in Steven Levy’s recent book In the Plex. “Eventually you’ll have an implant, where if you think about a fact, it will just tell you the answer.” But as Larry Page’s remark suggests, the deeper question is about information and knowledge itself. How is information technology affecting what we know and how we know it?...

My hypothesis is that information technology, while expanding our ability to know in one way, is actually impeding our ability to know in other, more complex ways; ways that require 1) taking responsibility for our own beliefs and 2) working creatively to grasp and reason how information fits together. Put differently, information technologies, for all their amazing uses, are obscuring a simple yet crucial fact: greater knowledge doesn’t always bring with it greater understanding...

The Internet of Things is made possible by— and is also producing— big data. The term “big data” has no fixed definition, but rather three connected uses. First, it names the ever-expanding volume of data that surrounds us. You’ve heard some of the statistics. As long ago as 2009, there were already 260 million page views per month on Facebook; in 2012, there were 2.7 billion likes per day. An estimated 130 million blogs exist; there are around 500 million tweets per day; and billions of video views on YouTube. By some estimates, the amount of data in the world in 2013 was already something around 1,200 exabytes; now it is in the zetabytes. That’s hard to get your mind around. As Viktor Mayer-Schönberger and Kenneth Cukier estimate in their recent book, Big Data: A Revolution That Will Transform How We Live, Work, and Think, if you placed that much information on CD-ROMs (remember them?) it would stretch to the moon five times. It would be like giving every single person on the earth 320 times as much information as was stored in the ancient library of Alexandria.

And by the time you are reading this, the numbers will be even bigger. So, one use of the term “big data” refers to the massive amount of data making up our digital form of life. In a second sense, it can be used to talk about the analytic techniques used to extract useful information from that data. Over the last several decades, our analytic methods for information extraction have increased in sophistication along with the increasing size of the data sets we have to work with. And these techniques have been put to a mind-boggling assortment of uses, from Wall Street to science of all sorts. A simple example is the data “exhaust” you are leaving as you read these very words on your Kindle or iPad. How much of this book you read, the digital notes you take on it, is commercially available information, extracted from the trail of data you leave behind as you access it in the cloud...

Lynch, Michael P. (2016-03-21). The Internet of Us: Knowing More and Understanding Less in the Age of Big Data (pp. 3-9). Liveright. Kindle Edition.

Interesting read thus far. Stay tuned. Yeah, "0.946 µg/L" is now part of my "data exhaust."

"You can download your full medical history to a doctor in an emergency room by allowing her access to your own internal files."

LOL. Talk about "Interoperability!" Merle Buskin?

I'll have to triangulate this new book with earlier stuff I've read and written of regarding "AI/IA" and other issues pertaining to "structured data." as well as Jo Marchant's new book "Cure."

QUICK UPDATE

I finished the Lynch book (all the way through the end notes). It is excellent. Will have much more to say about it, things relevant to the health care and health IT space. Among other things, will have to triangulate it with thoughts in other earlier posts of mine. See, e.g.,

• Health IT, the data, the dx, the dogs of uncertainty, and the miners' dig that is your digital life.
• The old internet of data, the new internet of things and "Big Data," and the evolving internet of YOU.

Ms. Lepore, in The New Yorker:

Then came the Internet. The era of the fact is coming to an end: the place once held by “facts” is being taken over by “data.” This is making for more epistemological mayhem, not least because the collection and weighing of facts require investigation, discernment, and judgment, while the collection and analysis of data are outsourced to machines. “Most knowing now is Google-knowing—knowledge acquired online,” Lynch writes in “The Internet of Us” (his title is a riff on the ballyhooed and bewildering “Internet of Things”). We now only rarely discover facts, Lynch observes; instead, we download them. Of course, we also upload them: with each click and keystroke, we hack off tiny bits of ourselves and glom them on to a data Leviathan...

Yeah. Pretty interesting, all of it. Again, I will have much more to say. For one thing, Dr. Lynch's chapter on "privacy" reminds me of some of my own various posts on the topic, outside of the health care space. See, e.g., my post "Clapp Trap" and its links to antecedent reflections of mine.

Also, as it goes to discussions of science and "truth," two of my long-favorite reads come to mind and are recommended.

apropos of the book on the right, see my August 2015 post "On Donald Trump®"

From "On Truth":

We are all aware that our society perennially sustains enormous infusions—some deliberate, some merely incidental—of bullshit, lies, and other forms of misrepresentation and deceit. It is apparent, however, that this burden has somehow failed—at least, so far—to cripple our civilization. Some people may perhaps take this complacently to show that truth is not so important after all, and that there is no particularly strong reason for us to care much about it. In my opinion, that would be a deplorable mistake...

...even those who profess to deny the validity or the objective reality of the true-false distinction continue to maintain without apparent embarrassment that this denial is a position that they do truly endorse. The statement that they reject the distinction between true and false is, they insist, an unqualifiedly true statement about their beliefs, not a false one. This prima facie incoherence in the articulation of their doctrine makes it uncertain precisely how to construe what it is that they propose to deny. It is also enough to make us wonder just how seriously we need to take their claim that there is no objectively meaningful or worthwhile distinction to be made between what is true and what is false [pp. 6-9].

OK, PHILOSOPHY AND EPISTEMOLOGY ARE FUN, BUT WHAT OF ANY CLINICAL IMPLICATIONS?

Jerome Carter, MD

Clinical Concepts vs. Chart Concepts – How Do They Differ?

I was goaded into mulling over this question by the same concerns that led to my writing, Is the Electronic Health Record Defunct? I am worried about being trapped in a paper-oriented thinking mode when designing clinical apps. That trap is easy to fall into because patient information is essential to patient care. All clinical work requires access to patient information, so it is easy to jump straight to thinking about what information to store and how to store it. Once snared, taking the next step of borrowing design ideas from paper charts is hard to resist. How does one separate clinical care concepts from chart concepts when creating software???

Let’s start with medication and problem lists. What concepts do these lists embody or convey? Understanding why I ask this question requires a bit of a philosophical diversion. A word, sentence, or phrase has a meaning (semantics). For example, the word aspirin has a meaning—it is a non-steroidal pain medicine and anti-inflammatory agent. It also may denote something specific (i.e., an enteric coated tablet in my hand). However, it is possible for a word or phrase to have semantic import (meaning) and yet denote nothing. Bertrand Russell illustrated this point with his storied example: “The present king of France…” Semantically speaking, anyone who understands English knows what this phrase means. The problem, of course, is that there is no king of France. Semantically, the sentence is fine; however, it denotes nothing. Now, back to clinical vs. charts concepts.

When a clinician uses a nomenclature such as RxNorm to add a drug to a patient’s current medication list, we can be sure that the semantic properties of the term are intact. However, if the patient never receives, refuses, or stops taking the drug, that RxNorm term now listed in the medication list no longer denotes a real fact about the patient. Here, we have a clinical care concept – the clinician deciding/intending to give the drug – rendered in the patient’s medication list; however, the term does not correspond to the patient’s actual situation. A drug being in a patient’s medication list has a meaning, but not necessarily any denotation. Now, here is my question to all of my philosophically-inclined readers: When building clinical care systems, should we design systems to avoid semantic/denotational mismatches? Stated another way, should we record the intention to give a medication in a different way than the way we record that a patient is definitely taking the medication?

Semantic/denotational mismatches are patient safety issues because when they occur, they convey false information about the patient. Medication reconciliation helps to address this with medication issues, but what about problems/diagnoses?

A problem/diagnosis listed in the patient record implies that the patient has that problem. By extension, the absence of a problem implies it isn’t present in the patient.  Every incorrect entry in a patient’s problem list is a semantic/denotational mismatch. What havoc might result for decision support users? How can a system’s design reconcile the clinician’s belief/intent with the actual state of the patient?...

Yeah, and it's perhaps worth citing again that which I posted on HIMSS16 Day One:

"OK. one core thing I will be looking for this week, apropos of my recent review of Dr. Nortin Hadler's book, are affirmative responses to this Hadler cite:

"If there is a role for computers in decision making, it is to facilitate dialogue between patient and physician, not to supplant the input from either or to cut health-care costs."

Now, obviously, the physician and her patient are not the only "stakeholders" in the health care space, but if all of our cherubic talk of "patient-centered care" is more than just Suit talk, then I'm looking for affirmative evidence of the foregoing. The salient question: "how does what you do/sell 'facilitate physician-patient dialogue'?"

CODA

More Lynch:

The End of Theory?
In 2008, Chris Anderson, then editor of Wired, wrote a controversial and widely cited editorial called “The End of Theory: The Data Deluge Makes the Scientific Method Obsolete.” Anderson claimed that what we are now calling big data analytics was overthrowing traditional ways of doing science:

This is a world where massive amounts of data and applied mathematics replace every other tool that might be brought to bear. Out with every theory of human behavior, from linguistics to sociology. Forget taxonomy, ontology, and psychology. Who knows why people do what they do? The point is they do it, and we can track and measure it with unprecedented fidelity. With enough data, the numbers speak for themselves ... Petabytes allow us to say: “Correlation is enough.” We can stop looking for models. We can analyze the data without hypotheses about what it might show. We can throw the numbers into the biggest computing clusters the world has ever seen and let statistical algorithms find patterns where science cannot.

Traditional scientific theorizing aims at model construction. Collecting data is just a first step; to do good science, you must explain the data by constructing a model of how and why the phenomenon in question occurred as it did. Anderson’s point was that the traditional view assumes that the data is always limited. That, he says, is the assumption big data is overthrowing... [Lynch, op cit, pp. 156-157].

"Who cares?" Seriously, dude? Anderson was simply wrong on this point, IMO. Thinking that you can do sound science absent outset nul hypotheses ("models") is naive. Give me any set of "big data" and I will come back with myriad "significant correlations" that tell us nothing efficaciously actionable (particularly in the clinical space).

Moreover, what about "data quality?" See my Nov 2013 post "(404)^n, the upshot of dirty data."
In many commercial analytic pursuits, you can be mostly wrong yet remain handsomely profitable.

The stakes in areas such as health care are quite another matter.
____________

More to come...

.alt.dx/px/tx: What about "Mind-Body Medicine"?

Well, yeah. As a life outlook generalization, if you don't believe you can achieve "x," you likely won't even try. But, what of the broad implications for health and for recovery from injury or disease? To what extent (if any) is "mind over matter" a valid and useful concept in health and health care? To what extent is anything labeled "alt." -- anything not easily reducible to an ICD-10 code for efficient conventional inclusion into an EHR -- dismissible as "quackery" or simple ignorant wishful-thinking fallacy naivete? These questions became more than epistemological abstractions for me roughly 20 years ago with my late daughter's cancer dx and

...our experience thus far with the quackery end of the alternative therapy spectrum, a distribution of propositions whose opposite terminus abuts the breadth of mainstream clinical research and practice, where methods as yet"unproven" but more logically reasonable and promising vie for acceptance by the medical establishment. In the middle lie tougher calls: does shark cartilage really shrink tumors, functioning as an angiogenesis inhibitor? (one skeptical journal article called it "the laetrile of the 90's") Hydrazine sulfate? (also reported on extensively in the mainstream clinical literature and generally-- though not uniformly-- dismissed as 'ineffective.') Nucleotide Reductase? Plant oils? Blue-green algae?

All of these unconventional therapeutic assertions-- many of which would prove to be merely unproductive, outlandish, maddening distractions-- would have to be checked out while also slogging through the vast archives of mainstream clinical literature, a quest that would take me through the most recent three years of month-by-month National Cancer Institute (NCI) hepatoma citations. Also, I began ... keyword-searching the Medline indices for anything related to Sissy's condition that might prove useful...

"alt.medicine" stuff spans the gamut from every imaginable bozo goop concoction tx to "healing and the mind." Again, from my One in Three essay:

Healing and the mind
Recall Bill Moyers' PBS series and popular book of the same name. Spanning both the alternative and mainstream spectra are the somewhat overlapping domains of "immunotherapy" and "psychoneuroimmunology." Proponents of these approaches to therapy theorize that malignancies-- in addition to the more mundane panoply of human ailments-- can take hold only in the presence of a compromised immune system. One must strengthen the immune system for long-term healing to take place. Conventional medical treatment, it is argued (and not without substantial merit) focuses far too often on combating symptoms rather than curing root causes, and chief among the root causes of disease are the dietary, psychic, and other lifestyle imbalances so widespread in our culture.

Investigations here take one through the myriad contending "healing" dietary regimens that crowd the book chain shelves. Acupuncture and medicinal herbs also employed in the effort to restore immunological balance. Dr. Andrew Weil's recent best-seller Spontaneous Healing covers these areas in quite some detail, as does Jean Carper's more recent Miracle Cures. In the Adam Smith-redux "powers of mind" camp along with Moyers' work, the likewise best-selling publications of Drs. Bernie Seigel and Deepak Chopra are surely familiar to those who frequent Barnes & Noble, Borders, or their bookstore brethren. And, renowned writer Norman Cousins recently reported on his work in psychoneuroimmunology research at UCLA in Head First: The Biology of Hope and the Healing Power of the Human Spirit. Dr. Cousins and his UCLA colleagues undertook to put the previously disparate and frequently anecdotal evidence of psychological factors in healing to the test of rigorous scientific scrutiny, concluding that physiological effects indeed do frequently arise from psychological causes, for better or worse, and that research should continue in earnest in the area of psychoneuroimmunology.

All of these works and many more, some by now dog-eared, awash with highlighter residue and freighted with sticky-notes, line my bookshelves aside the ever-accruing mounds of NCI, Medline, and countless other internet cancer information downloads I cyber-mine for nearly every day...

I enthusiastically cut my methodological teeth in the mid/late 1980's in a forensic-level radioanalytical lab in Oak Ridge, and have subsequently long been an irascible hardass for the scientific method and critical thinking. Nonetheless, I came away from Sissy's illness and death not knowing in many ways what to believe anymore.

A chronic, low-grade background epistemic ambivalence that lingers to this day.

Is western reductive science the only way of knowing? (We call that "scientism.") I am reminded of something I wrote in my 2009 post on another of my blogs, "The U.S. health care policy morass."

Several years prior to being diagnosed with fatal liver cancer, my daughter also had encounters with non-western medical diagnostic assessments, one of which might well have saved her life (and this father's now permanently broken heart) had she not blown it off. As I wrote in my "1 in 3" essay, ruminating on this aspect of "alternative medicine":

It was, after all, a Santa Monica Chinese practitioner of acupuncture and herbal medicine, one Dr. Yi Pan, who first called Sissy's attention to a problem with her liver several years prior to her HCC diagnosis. She'd been referred to him by a girlfriend for attention to a menstrual problem. Dr. Pan had a diagnostic acumen requiring no x-rays, CT scans, or blood tests. Yet, the internet medical fraud site www.quackwatch.com dismisses traditional Chinese medicine as "ineffective," as do many other critics of alternative practices.

Tragically, Sissy summarily discounted his prescient admonition. I can only speculate wistfully on the implications of our having known three years earlier.
__

Indeed. Indeed.

I bring up the foregoing only to pose some questions I ask myself all the time. 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? Would we have ICD-9 or CPT "dx" ("diagnosis") 3rd-party payor billing codes through which to encapsulate (and reimburse for) the (accurate, as they were) evaluative encounters of a Yeshi Dhonden or a Yi Pan?

The answer to the latter question is an unequivocal "no".

[Note. Re: "cognitive enfeeblement," see my review of "The Glass Cage."]

I guess a broad ".alt" concern today goes to "how much of our three trillion dollar annual NHE do we continue to waste on the 'woo'?" How much of "patient-centered care" will comprise indulging patients' OTC/DTC-buttressed magical thinking?

From "The Values and Value of Patient-Centered Care."

"[P]hilosophically, patient-centered care is an approach to care and perceived as the right thing to do. Taking this view, behaviors associated with patient-centered care, such as respecting patients’ preferences, should be justified on moral grounds alone, independent of their relationship to health outcomes."

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Among my stash of new reads:

INTRODUCTION

One weekday morning last summer, I was in the local park. It was a cheerful south London scene, with kids splashing in water fountains and playing soccer on the grass. I perched on the edge of the sandpit with two other mothers, clutching sunscreen and rice cakes as we watched our children build lopsided castles with brightly colored plastic spades.

One of the women, a bright, articulate mom I had just met, was explaining how a homeopathic medicine had cured her of longstanding, debilitating eczema. “I love homeopathy!” she said. As a scientist, I had to protest. Homeopathy is effectively water (or sugar pills) in fancy bottles— any active substance in these treatments is diluted far beyond the point at which any single molecule of the original could possibly remain. “But there’s nothing in homeopathic remedies,” I said.

My new friend looked at me scornfully. “Nothing measurable,” she replied, as if I were slightly dim for not grasping that its healing properties are due to an indefinable essence that’s beyond scientists’ reach. And in those two words, I felt that she summed up one of the major philosophical battles in medicine today.

Stacked up on one side are the proponents of conventional, Western medicine. They are rational, reductionist and rooted in the material world. According to their paradigm, the body is like a machine. For the most part, thoughts, beliefs and emotions don’t feature in treatment for a medical condition. When a machine is broken, you don’t engage it in conversation. Doctors use physical methods— scans, tests, drugs, surgery— to diagnose the problem and fix the broken part.

On the other side is, well, everyone else: followers of ancient, alternative and Eastern medicine. These holistic traditions prioritize the immaterial over the material; people over conditions; subjective experience and beliefs over objective trial results. Rather than prescribing physical drugs, therapists using acupuncture, spiritual healing and reiki claim to harness intangible energy fields. Advocates of homeopathy aren’t concerned that their remedies contain no physical trace of the active ingredient, because they believe that an undetectable “memory” of the drug somehow remains.

Conventional medicine still has the upper hand in the West, but alternative medicine is embraced by millions of people. In the U.S., the wonders of spiritual healing and reiki are regularly discussed on television news. As many as 38% of adults use some form of complementary or alternative medicine (62% if you include prayer). Each year they spend around $ 34 billion a year on it, with 354 million visits to alternative medicine practitioners (compared with around 560 million visits to primary care physicians). In London, where I live, mothers commonly put amber necklaces on their babies in the belief that this gemstone has the power to ward off teething pain. Intelligent, educated women reject crucial vaccines for their children and, like my friend, embrace treatments that make no scientific sense. Not surprisingly, scientists are fighting back. Professional skeptics on both sides of the Atlantic— debunkers like James Randi and Michael Shermer; scientist bloggers like Steven Salzberg and David Gorski; the biologist and author Richard Dawkins— aggressively denounce religion, pseudoscience and especially alternative medicine…

I’m all for defending a rational worldview. I believe passionately in the scientific method: I have a PhD in genetics and medical microbiology, and I spent three years probing the inner workings of cells at a top London hospital. I believe that everything in nature can be studied scientifically if we ask the right questions, and that the medical treatments we put our trust in should be tested in rigorous trials. The skeptics are right: if we abandon science for wishful thinking we might as well be back in the dark ages: drowning witches, bloodletting and praying that God will save us from the plague.

But I’m not sure that simply dismissing alternative medicine is the answer. In my work as a science journalist, I encounter not just those who are cured by modern medicine but those who aren’t: patients whose lives are devastated by gut problems or fatigue yet are dismissed as not having a “real” condition; people suffering from chronic pain or depression, prescribed ever-higher doses of drugs that create addiction and side effects but don’t solve the underlying problem; cancer patients who receive rounds of aggressive treatment well past the point at which there’s any reasonable hope of extending their lives.

And I regularly come across scientific findings— sometimes making headlines but often buried in specialist journals— suggesting that intangible, immaterial treatments can have real physical benefits. Patients hypnotized before surgery suffer fewer complications and recover faster. Meditation triggers molecular changes deep inside our cells. And as we’ll see in the first chapter of this book, if a treatment works no better than placebo that doesn’t mean it doesn’t work— simply believing you have received an effective remedy can have a dramatic biological effect. The mothers around me using amber bracelets and homeopathic pills aren’t ignorant, or stupid; they know from experience that these things genuinely help.

So although I believe that the alternative medicine advocates are deluded with their talk of water memory and healing energy fields, I don’t think the skeptics have got it completely right either. I started to write this book because I wondered whether they, along with conventional doctors, are missing a vital ingredient in physical health; an omission that’s contributing to the rise of chronic disease and sending millions of sane, intelligent people to alternative practitioners. I’m talking, of course, about the mind...

Marchant, Jo (2016-01-19). Cure: A Journey into the Science of Mind Over Body. Locations 65-104. Crown/Archetype. Kindle Edition. 

The Science Based Medicine people wasted no time in (relatively mildly) jumping on her case.

The publisher sent me a review copy of the book and I read it. I was expecting to hate it, but I was pleasantly surprised. I enjoyed reading it. I found it fascinating. I found myself agreeing with much of what Marchant says, and I was intrigued by some of the recent research she reports that I was not yet aware of. Preliminary studies, to be sure, but thought-provoking. The book challenged me to think more deeply about placebos, alternative medicine, and patient comfort. - Harriet Hall, MD

Jo Marchant's book brought to my mind another I've had in my stacks for more than 40 years.

MYSTERY: TIME, SPACE, INFINITY, STATISTICAL ABERRATION

Nel mezzo del cammin di nostra vita
Mi ritrovai per una selva oscura...

On the first day of Christmas, my allegedly true love gave to me a silver pillbox. Infuriating. It was true, of course, that gentleman of finance consumed pain easing pills, traveled with them, and even offered them to each other, but then, there was a lot of pain around.  fund managers chewed absently on antacids,  wondering where the last hundred million went so quickly. When you met them, they might offer you one, as if proffering a cigarette or a Life Saver. A high risk, high stress profession, wrote one psychologist in a paper. The University of San Francisco offered a course for clergymen, a laboratory in pastoral ministries, course #261, to "communicate with persons with unusual needs… Such as the sick, the aging, broken families, alcoholics, ethnic minorities, homosexuals, stockbrokers." No wonder drug companies had such nice profit margins, and sold at such high premiums.

Two gallants of my acquaintance wrote one of the best short reports I have ever read. The University portfolio they managed was down by a little over $200 million. (Do you know how long it takes to raise $200 million?) They remained fully invested, they said, because things were so bad they thought they could get no worse. "The light we saw at the end of the tunnel," they said, "was a freight train coming the other way."

Some people disappeared from the money business, and some disappeared right off the planet, ahead of schedule. If somebody had a heart attack, we said, oh sorry, when will he be back in the office? It was certainly a statistical aberration when I lost my panel, the investment strategy panel I moderated at the annual convention. My panelists were in their 30s and 40s and not fat and they liked their work, so statistically they should have not exited with one heart attack, one also attack, and one something I forget. We recruited another panel without even a moment of silence for our fallen comrades. Very cool, very macho, the show must go on.

I think what I had in mind when I began my research was that I would do some research on health. I would leave my nine foot teak desk, my phone with all its buttons lit up, and my totally filled in month at a glance calendar, go find some answers, and be welcomed back to the business community, like the first Arapaho who came back to his horseless tribe with a Pawnee Pinto. Look, fellas, now we can go twice as fast. I thought this might take a couple of months but well worth it, very important. (I could return the silver pillbox with the appropriate insult.) There was something else, Misty, unarticulated, in this program. One of my convention panelists had told me what his plans were, just as soon as he had enough time and enough money. He certainly had enough money, but he had had time back when he thought he didn't, and then he didn't.

The first physicians I consulted in this venture had all the same symptoms as my compatriots. We have to take it easier, they said wisely. Then they would answer the phone, rubbed their eyes, and say, yes, they would cover further buddy until midnight. And then they would say, what's happening, my Gawd, my stocks are down 40%, we may have to sell our ski condominium unless we raise our fees.

I would not have believed, at the outset, that I would be spending any time with exotics like Tibetan llamas and which doctors and gentlemen who had beards and wore funny close. I did not have a beard and I did not own any funny close. I would not have believed that I would ever sit in a room chanting a Sanskrit syllable, or drawing a lotus in the air with a $1.98 G. Shirmer recorder.

Minds. Trouble is mine's, not organic medicine, not some germ that comes flying through the air looking for home. This is Dr. Hans Selye, 68 years old, the distinguished Dean of stress medicine. Stress is "a physiologic response inappropriate to the situation." Misfired signals between mind and body. The physiologic response is the caveman's response when the shadow of the pterodactyl falls over him. Adrenal secretions increase and muscles tense and the coagulation chemistry gets ready to resist wounds. Fight or flight. But what Pterodactyl is this? They tell you: the market is down 20 points, or the vice president wants to see you, or, this whole operation is going to be shut down and moved to Chicago. Blam, pterodactyl time. Gives you, says Dr. Selye, headaches, insomnia, high blood pressure, sinus, ulcers, rheumatism, cardiovascular and kidney disease. And more. One from column A, one from column B. Some people have a pterodactyl every day. Why? An imbalance says Dr. Selye, an imbalance.  in what? In living. Western medicine doesn't extend its authority there, except to say take it easy, take off some weight, watch your diet.

So: lots of explorers have headed west by going east, saying, there must be a better way, and that was how this venture in — what? It's hard to define, some sort of psychology or awareness, maybe. That was how it began. Nonexistent pterodactyls flapping their great wings over fallen security analysts.

Some of my opening questions were:

Could we really learn to control her internal processes with our heads instead of with pills? (If true, I made a note, sell drug companies.)

Could we learn to pop ourselves into an alpha state? What is an alpha state? What happens if we succeed?

If someone can't hear and they have one session with a psychologist and 15 minutes worth of hypnotic induction, and suddenly they say, "I can hear!" What just happened in their brains?

What about all these claims for meditation? What do they mean by meditation? (I had just read an article in a technical journal.)

Is it true that a Sanskrit sound has a different effect on your head than one in English? (I don't know where I got that one.)

The field was not well marked. For example, in the great pharmacology textbook The Pharmacological Basis of Therapeutics, Goodman and Gilman — it has the same lock on its feels that Samuelson does in economics — three phrases begin to recur when you get to the effects of mind, or the interaction of some substance and the mind. The etiology is unknown. We don't know the cause. The site is unknown. We don't know exactly where it happens. The mechanism is unknown. Where not exactly sure how it happens.

Unknown, unknown, pictures of elephants and white space in the middle of old maps of Africa.

 at one juncture I sent a careful letter to an official in the national Institute of mental health in suburban Washington. I wanted to know, in this instance, about placebos — sugar pills — and I detailed all of my references in the work done so far, and asked: where can I go to find more? Who is doing work in this field?

"You are," the answer came. "The field is open. Please let us hear from you when you finish."

In an unmarked field, it is easy to wonder. Why on earth would I ever have read six years worth of the British medical Journal called Brain? Sheer inertia. I looked up one article on consciousness and then — look, the editor of Brain is Lord Brain. If you sent him a postcard, addressed only "Brain, Brain, London," would it get there? Was his name Brain already, or did he take "Lord Brain" as a title because he was the editor of Brain? Let's see what goes on here in Brain's Brain. (He did not have to turn to the back for the answer. The distinguished neural physiologist Lord Brain, now deceased, was born Russell Brain, and the postcard  "Brain, Brain, London" would have reached him, but faster if you added "Harley Street" and the zip code.)

It occurred to me that all the answers were not in Brain or even in medicine as we know it, fabulous as it is. There is a case in one of the journals about a Nigerian princeling in London who got sick and depressed, about two generations ago. He sent home for the witch doctor, since the Harley Street crowd couldn't do much for him. The which Dr. chanted whatever witch doctors chant, gave him a magic extract of a plant, and the Nigerian recovered. The magic extract came from a plant called Rauwolfia Serpentina, named by a French botanist.

A generation went by, and Western medicine sought to control high blood pressure and to calm people with tranquilizers. The detail salesman from the big drug companies, CIBA and Riker and Squibb, fanned out to doctors and hospitals with their great new drugs, and one of the great new drugs was reserpin, called Serpasill or Rawwiloid or Raudixin, depending on the drug company. And what did reserpine come from? Of course Rauwolfia Serpentina. The drug companies found it and wrote it up in learned journals and analyzed it; the which Dr. didn't have any journals, he got it from his daddy, who got it from his daddy, who was one hundred years ahead of CIBA and Riker and Squibb, and he was late because  Ayurvedic medicine in India knew Rauwolfia when the ancestors of the Harley Street crowd were staining themselves blue.

I had to go back to school. I brought certain abilities as student and the willingness to be an utter fool, to make up for naïve skepticism. Some of the customs had changed. I knew the dorms were coed, but when did they make the bathrooms coed? One evening in a movie theater near the University of California campus in Berkeley, the following conversation took place in the seats behind me:

She: say, I dig George.

He: Hmmmmm...

She: I mean, I really dig George's bod.

He: (a grunt)

She: why don't we have a threesome or a fivesome some time?

He: okay.

Often I felt a stranger in a strange land, or an anthropologist with a new tribe. What happened to the even numbers?

Strange schools, sometimes. Some trips, you go to Abercrombie and Fitch to get your mountaineering boots or your fishing vest. I had to buy tie-dyed jeans, because my new classmates were staring at my suit and tie.

I followed where the trail led. I met more Nobel Prize winners then I knew were there. I met biofeedback technicians who said people could train control of their heartbeats. I met meditators who said meditation was more restorative the densely.

And: an astronaut who had a mystic experience on the way back from the moon. A pro quarterback who could send signals to his wide receiver by telepathy, or something like telepathy. It blue-eyed British witch doctor, apprenticed in Lesotho or Botswana, who could attract liens by sent; Manhattan traffic gave him a tic, I had to help him across the street.

And: Masters of martial arts, aikido and kung fu, who said those arts read patterned brains. Bushels of psychiatrists and pecks of gurus. A gentleman who could push a knitting needle through his arm, command the blood to stop, and it would. Another gentleman who could smoke a cigar and send his mind to Jupiter and Mercury, simply by having it clear.

Some of it gets very far out. That was a phrase I learned from my new classmates. Far out.

There is a peculiar characteristic to this field. It is never easy to explain, and it is impossible to photograph...

LOL. A great book. The snark-daddy forbear of Michael Lewis, this "Adam Smith" guy. Another snip, apropos of Jo Marchant:

No one doubts the effect of mind on body to some extent, and the extent varies with the believer. George Bernard Shaw said he considered Lourdes a blasphemous place because they kept there all the crutches and wheelchairs of the people who walked away, but among these items was not one wooden leg, one glass eye, or one toupe.

Stuart Alsop said, "there are mysteries, how above all the mystery of the relationship of mind and body, that will never be explained, not by the most brilliant doctors, the wisest of scientists or philosophers."

There is a reason we are so sketchy on minds, and that is that we perceive the world through whatever paradigm we live in, and our present paradigm is sketchy when it comes to "mind." [Powers of Mind, pg 19]

'eh? Not much has changed since 1975 on that front.

Had to read all that stuff in with Dragon. No Kindle edition.
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apropos (?): Who wrote this?

“Physical concepts are free creations of the human mind, and are not, however it may seem, uniquely determined by the external world. In our endeavor to understand reality we are somewhat like a man trying to understand the mechanism of a closed watch He sees the face and the moving hands, even hears its ticking, but he has no way of opening the case. If he is ingenious he may form some picture of a mechanism which could be responsible for all the things he observes, but he may never be quite sure his picture is the only one which could explain his observations. He will never be able to compare his picture with the real mechanism and he cannot even imagine the possibility of the meaning of such a comparison.”

Albert Einstein, 1938.

Is it too early to start drinking?

I got that here, out of another old book from my stacks (you can now actually get this one in Kindle format):

I dropped a few lines into Photoshop.

Click to enlarge. Pretty much sums up my take on "spirituality." Is there a "supreme being"? Well, yeah, necessarily -- "that which is. Even that which is not is part of that which is."

None of which mandates an irascible anthropomorphic white-bearded old coot in the sky. Note the lower case "supreme being." That was not an accident. Just denoting the infinite noun, absent any religious ideology.

"The most preposterous notion that H. Sapiens has ever dreamed up is that the Lord God of Creation, Shaper and Ruler of all the Universes, wants the saccharine adoration of His creatures, can be swayed by their prayers, and becomes petulant if He does not receive this flattery. Yet this absurd fantasy, without a shred of evidence to bolster it, pays all the expenses of the oldest, largest, and least productive industry in all of history." - Heinlein, The Notebooks of Lazarus Long

BTW, see my "speculation on the afterlife" post.

COMING UP

I finished this book yesterday. Wow.

"The quest to discover how life works and why it matters." Highly recommended. It spans the gamut, from molecular biology / "omics" to aggregate ecosystems, replete with some riveting science history. Stay tuned.

Also on tap, in light of my renewed initiative to tie off documenting the loose ends regarding my daughter's death.

When Ann Neumann’s father was diagnosed with non-Hodgkin’s lymphoma, she left her job and moved back to her hometown of Lancaster, Pennsylvania. She became his full-time caregiver—cooking, cleaning, and administering medications. When her father died, she was undone by the experience, by grief and the visceral quality of dying. Neumann struggled to put her life back in order and found herself haunted by a question: Was her father’s death a good death?

The way we talk about dying and the way we actually die are two very different things, she discovered, and many of us are shielded from what death actually looks like...

...death in contemporary America is much more complicated than we think. Medical technologies and increased life expectancies have changed the very definition of medical death. And although death is our common fate, it is also a divisive issue that we all experience differently. What constitutes a good death is unique to each of us, depending on our age, race, economic status, culture, and beliefs. What’s more, differing concepts of choice, autonomy, and consent make death a contested landscape, governed by social, medical, legal, and religious systems...

Waiting for the Kindle price to drop from the rather high $25.99 (I have a lot of books to continue to buy). As next-of-kin caregiver I've had to attend the deaths of my daughter and both of my late parents. And, now, at the age of 70 and having just had my own turn in the cancer dx/tx barrel, issues of mortality (in addition to staying down in the Health IT tech weeds) are a bit more on my mind.
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More to come...