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Wednesday, August 31, 2016

Shards writ large. Health care fragmentation disaster response implications

Above, a scene from the tsunami following the horrific 2011 Tōhoku earthquake. I wonder if that man lived.

I finished reading Sheri Fink's excellent, painful book about the aftermath of the 2005 Hurricane Katrina "Five Days at Memorial" the other day -- the central topic of my prior post.

A non-fiction masterwork, it reads at first like a totally suspenseful early Michael Crichton novel, then like a John Grisham legal drama. It will push your sense of "empathy" to the firewall. It should leave you furious at the myriad iterative and recursive failures of the breadth of authority -- some of them spanning decades, some the fruits of venality, some "merely" the progeny of incompetence. Failures that ended up leaving front-line clinicians beset by impossible moral quandaries amid the most dire of circumstances, resulting in the whole acrimonious finger-pointing "playing God" thing -- the wafts of which continue to echo to this day.

From the Amazon blurb:
In a voice at once involving and fair, masterful and intimate, Fink exposes the hidden dilemmas of end-of-life care and reveals just how ill-prepared we are in America for the impact of large-scale disasters—and how we can do better. A remarkable book, engrossing from start to finish, Five Days at Memorial radically transforms your understanding of human nature in crisis.
Again, you can get a searing sense of the disaster from her 2009 Pulitzer-winning ProPublica piece "The Deadly Choices at Memorial" (a long read). Strongly recommend you buy this book and read it closely.
Major props to Ann Neumann for turning me on to this book via one of her Facebook posts.
The epilogue of Five Days at Memorial examines the subsequent halting post-Katrina policy efforts to clarify workable normative "medical ethics" pertaining to large-scale disaster response operations, wherein exigent needs far outstrip available resources.
Emergencies are crucibles that contain and reveal the daily, slower-burning problems of medicine and beyond— our vulnerabilities; our trouble grappling with uncertainty, how we die, how we prioritize and divide what is most precious and vital and limited; even our biases and blindnesses. [Five Days at Memorial, Kindle Locations 7732-7734]
It's not like any of this is news. e.g., citing Einer Elhauge's 1994 "Allocating health care morally" (pdf) on the topic of "triage."
One might think that one could just rely on medical judgment to determine how best to allocate a fixed set of resources to maximize the health of a group. But this has not actually been a traditional focus of medical attention. Physicians have generally regarded the lack of resources to provide care for all treatable illnesses as a temporary problem requiring a budget increase, not the development of sustainable principles of allocation. Indeed, the development of such principles has sometimes been shunned as tantamount to admitting defeat. The dominant forms of nonprice rationing practiced by the medical profession have thus tended to be makeshift and poorly-conceived.

Rationing at the bedside via ad hoc, seat-of-the-pants judgments is a common phenomenon, a "method" of allocation dubbed "ad hockery." Most medical rationing does not involve even this level of conscious thought. Absent emergencies, patients are usually treated on a first-come, first-served basis that may be regarded as a means of random allocation akin to using lotteries."' But in fact, both the priority given to emergency cases and the use of waiting lists flow from the medical premise, no matter how unrealistic, that eventually all the patients will be treated.

The resulting waiting lists (interrupted only by emergencies) often produce irrational allocations that effectively deny some persons care entirely and cause needless suffering and worse health outcomes because patients deteriorate during the wait. Indeed, because first-come, first-served treatment favors patients who have waited the longest, it tends to select the sickest patients for treatment (as does emergency priority) even if they are the least able to benefit from it. But these facts either are studiously ignored to preserve the illusion that only the timing of care is being affected or are strategically highlighted in calls for greater funds. Some have even argued in favor of using random means of allocating health care in order to provoke a public outcry that might in turn produce greater funds. Rarely do the above problems provoke a conscious medical rethinking of the allocation problem.

One partial exception to this refusal to allocate is the system used in time of war or natural disasters: medical triage. But triage does not really offer a means of systemic allocation. Traditionally, medical triage sorts individuals into three categories-those who will die regardless of treatment, those who will live regardless, and those for whom treatment makes the difference between life and death-and then treats the last group first. Such triage, however, is generally used merely to time the order of treatments where it is assumed that the health problems of those who will live without immediate treatment will be treated later. Medical triage thus has little implication for how to order priorities where treatment of those whose lives can be saved (albeit for a short time and in poor condition) means nontreatment of those whose health could be significantly improved.

Hidden — and often quite dubious — allocative judgments are often imbedded in seemingly innocuous measures of medical effectiveness...
[pp. 1494-1495]
"Triage." In the case of Katrina and Memorial hospital, it was mostly about the ad hoc prioritization of the order of evacuation rather than tx per se, given insufficient evac resources -- and what to do about those among the still-barely-living who would not be evacuated at all. A terrible circumstance.

On contributory/exacerbating "fragmentation" in health care. Recall my citing of Elhauge in my post "The U.S. healthcare "system" in one word: "shards."

That stuff just goes to the adverse effects of our chronically vexing health care space fragmentation during normal times.

Fink exposes the hidden dilemmas of end-of-life care and reveals just how ill-prepared we are in America for the impact of large-scale disasters...

Yeah, OK,well think about this:

When the 2011 earthquake and tsunami struck Tohoku, Japan, Chris Goldfinger was two hundred miles away, in the city of Kashiwa, at an international meeting on seismology. As the shaking started, everyone in the room began to laugh. Earthquakes are common in Japan—that one was the third of the week—and the participants were, after all, at a seismology conference. Then everyone in the room checked the time.

Seismologists know that how long an earthquake lasts is a decent proxy for its magnitude. The 1989 earthquake in Loma Prieta, California, which killed sixty-three people and caused six billion dollars’ worth of damage, lasted about fifteen seconds and had a magnitude of 6.9. A thirty-second earthquake generally has a magnitude in the mid-sevens. A minute-long quake is in the high sevens, a two-minute quake has entered the eights, and a three-minute quake is in the high eights. By four minutes, an earthquake has hit magnitude 9.0...

Most people in the United States know just one fault line by name: the San Andreas, which runs nearly the length of California and is perpetually rumored to be on the verge of unleashing “the big one.” That rumor is misleading, no matter what the San Andreas ever does...

Just north of the San Andreas, however, lies another fault line. Known as the Cascadia subduction zone, it runs for seven hundred miles off the coast of the Pacific Northwest, beginning near Cape Mendocino, California, continuing along Oregon and Washington, and terminating around Vancouver Island, Canada. The “Cascadia” part of its name comes from the Cascade Range, a chain of volcanic mountains that follow the same course a hundred or so miles inland. The “subduction zone” part refers to a region of the planet where one tectonic plate is sliding underneath (subducting) another. Tectonic plates are those slabs of mantle and crust that, in their epochs-long drift, rearrange the earth’s continents and oceans. Most of the time, their movement is slow, harmless, and all but undetectable. Occasionally, at the borders where they meet, it is not...

Under pressure from Juan de Fuca, the stuck edge of North America is bulging upward and compressing eastward, at the rate of, respectively, three to four millimetres and thirty to forty millimetres a year. It can do so for quite some time, because, as continent stuff goes, it is young, made of rock that is still relatively elastic. (Rocks, like us, get stiffer as they age.) But it cannot do so indefinitely. There is a backstop—the craton, that ancient unbudgeable mass at the center of the continent—and, sooner or later, North America will rebound like a spring. If, on that occasion, only the southern part of the Cascadia subduction zone gives way—your first two fingers, say—the magnitude of the resulting quake will be somewhere between 8.0 and 8.6. That’s the big one. If the entire zone gives way at once, an event that seismologists call a full-margin rupture, the magnitude will be somewhere between 8.7 and 9.2. That’s the very big one...

When the next very big earthquake hits, the northwest edge of the continent, from California to Canada and the continental shelf to the Cascades, will drop by as much as six feet and rebound thirty to a hundred feet to the west—losing, within minutes, all the elevation and compression it has gained over centuries. Some of that shift will take place beneath the ocean, displacing a colossal quantity of seawater ... The water will surge upward into a huge hill, then promptly collapse. One side will rush west, toward Japan. The other side will rush east, in a seven-hundred-mile liquid wall that will reach the Northwest coast, on average, fifteen minutes after the earthquake begins. By the time the shaking has ceased and the tsunami has receded, the region will be unrecognizable. Kenneth Murphy, who directs FEMA’s Region X, the division responsible for Oregon, Washington, Idaho, and Alaska, says, “Our operating assumption is that everything west of Interstate 5 will be toast.”

In the Pacific Northwest, the area of impact will cover some hundred and forty thousand square miles, including Seattle, Tacoma, Portland, Eugene, Salem (the capital city of Oregon), Olympia (the capital of Washington), and some seven million people. When the next full-margin rupture happens, that region will suffer the worst natural disaster in the history of North America. Roughly three thousand people died in San Francisco’s 1906 earthquake. Almost two thousand died in Hurricane Katrina. Almost three hundred died in Hurricane Sandy. FEMA projects that nearly thirteen thousand people will die in the Cascadia earthquake and tsunami. Another twenty-seven thousand will be injured, and the agency expects that it will need to provide shelter for a million displaced people, and food and water for another two and a half million. “This is one time that I’m hoping all the science is wrong, and it won’t happen for another thousand years,” Murphy says.

In fact, the science is robust, and one of the chief scientists behind it is Chris Goldfinger. Thanks to work done by him and his colleagues, we now know that the odds of the big Cascadia earthquake happening in the next fifty years are roughly one in three. The odds of the very big one are roughly one in ten. Even those numbers do not fully reflect the danger—or, more to the point, how unprepared the Pacific Northwest is to face it...
Kathryn Schulz, The New Yorker, July 2015, "The Really Big One. An earthquake will destroy a sizable portion of the coastal Northwest. The question is when."

Another long read. Another Pulitzer-winner. Read the entire piece.

That scares the crap outa me. I lived in the Seattle area from 1968 to 1974. Loved it. Both of my girls were born there. Wrote my first song there, in 1969. I still have the dearest of friends there.

There will likely again be clinicians forced to "play God." In the PacNW and elsewhere.

BTW: Just finished another book.

apropos of the foregoing:
Smart Emergency Response Systems 
Keeping its citizens safe in times of emergencies or disasters is a major challenge for smart cities. Groups such as firefighters, paramedics, law enforcement and medical teams are collectively called “first responders”. The ability to coordinate and deploy such first responders after a disaster occurs can save many thousands of lives during what are called the “incident response” (during and shortly after a disaster) and “recovery” (the weeks after the disaster) time periods. 

Challenges for smart cities when it comes to disasters include: 

• lack of integrated planning 
• poor or non-existent communications during a disaster 
• inability of different agencies (federal, state, local) to act together 

The results of these challenges not being met have been amply demonstrated in the last decade during Hurricane Katrina, the Haiti earthquake, the Indonesian tsunami and hundreds of similar disasters. Fortunately, ICT solutions are available to help smart cities in this area. 

Integrated planning requires that different agencies such as fire departments, local police, paramedics, hospitals, city and state governments as well as federal agencies must plan together, using common terminology and assumptions. The norm is for such agencies to each come up with a unique set of plans in what is termed a “silo” (i.e., remote and independent) environment. This consequently leads to chaotic responses when a crisis occurs.

Integrated communications have also been a problem in the past, with each group of first responders having its own analog equipment. In past years, for instance, personnel from the Los Angeles County Sheriff’s Department, Police Department, Highway Patrol and Fire Department could not talk with each other during crises because their equipment sets were incompatible, purchased through different contracts and procurement processes. 

The inability of different agencies to act together has had dire consequences during disasters. During Hurricane Katrina, highway patrol deputies blocked access to New Orleans to technicians who had been called for and were desperately needed by the City Police Department to repair various infrastructures.

King, Brett; Lark, Andy; Lightman, Alex; Rangaswami, JP (2016-05-15). Augmented: Life in The Smart Lane (Kindle Locations 4930-4949). Marshall Cavendish International (Asia) Pte Ltd. Kindle Edition.

Interesting note on EHRs in Five Days at Memorial:
MEMORIAL’S FIFTH FLOOR was bathed only in the dim, bluish light from Toshiba Satellite laptop monitors. A night shift nurse, Michelle Pitre-Ryals, quickly typed notes into her patients’ electronic charts before the computer batteries died, despite the fact that once that happened, the electronic medical records system would be useless. Paper was high technology in a disaster. The electronic medication dispensing cart, new to Pitre-Ryals’s unit, would also shut down, its stock of medicines locked securely inside it... [Kindle Locations 2073-2077]
"Paper was high technology in a disaster." Hmmm. Notwithstanding that, much has been made of the complete, permanent loss of paper chart patient medical records throughout the Katrina impact area, in contrast to those of VA patients, who were on the VA Vista EHR system.

More on Augmented shortly. See my 2015 post "AI vs IA: At the cutting edge of IT R&D."

See also my post on Kevin Kelly's work (cited by Brett King et al) "Anything that CAN be tracked WILL be tracked." Inevitable Tech Forces That Will Shape Our Future."


Interesting: quick, inexpensive, illuminating read on "medical ethics."

"Issues in medical ethics are rarely out of the media and it is an area of ethics that has particular interest for the general public as well as the medical practitioner. This short and accessible introduction provides an invaluable tool with which to think about the ethical values that lie at the heart of medicine. Tony Hope deals with the thorny moral questions such as euthanasia and the morality of killing, and also explores political questions such as: how should health care resources be distributed fairly? Each chapter in this book considers a different issue: genetics, modern reproductive technologies, resource allocation, mental health, medical research, and discusses controversial questions..."
Stay tuned. Will update you once I've finished it. Very good thus far.

More to come...

Thursday, August 25, 2016

When does "practicing medicine" become "playing God"?

Since reading and reviewing Ann Neumann's riveting book "The Good Death," I've reached out, and we have become Facebook friends. Her thoughtful FB posts have led me to numerous related topics. I am about to download and read this book that one of Ann's posts made me aware of.

Sheri Fink is an acclaimed journalist with both a medical degree and a Ph.D. "Five Days at Memorial" recounts the horror in New Orleans at one hospital in the wake of Hurricane Katrina 11 years ago.
Five Days at Memorial is Pulitzer Prize winner Sheri Fink’s landmark investigation of patient deaths at a New Orleans hospital ravaged by Hurricane Katrina – and her suspenseful portrayal of the quest for truth and justice.

After Katrina struck and the floodwaters rose, the power failed, and the heat climbed, exhausted caregivers chose to designate certain patients last for rescue. Months later, several health professionals faced criminal allegations that they deliberately injected numerous patients with drugs to hasten their deaths.

Five Days at Memorial, the culmination of six years of reporting, unspools the mystery of what happened in those days, bringing the reader into a hospital fighting for its life and into a conversation about the most terrifying form of health care rationing.
Sheri recently did an excellent NPR RadioLab segment:
When people are dying and you can only save some, how do you choose? Maybe you save the youngest. Or the sickest. Maybe you even just put all the names in a hat and pick at random. Would your answer change if a sick person was standing right in front of you?

In this episode, we follow New York Times reporter Sheri Fink as she searches for the answer. In a warzone, a hurricane, a church basement, and an earthquake, the question remains the same. What happens, what should happen, when humans are forced to play god?

Highly recommended use of an hour.

Her Pulitzer-winning 2009 ProPublica piece "The Deadly Choices at Memorial," which looks to have laid the groundwork for her 2013 book, left me mentally exhausted. It is one searing read.

The smell of death was overpowering the moment a relief worker cracked open one of the hospital chapel’s wooden doors. Inside, more than a dozen bodies lay motionless on low cots and on the ground, shrouded in white sheets. Here, a wisp of gray hair peeked out. There, a knee was flung akimbo. A pallid hand reached across a blue gown.

Within days, the grisly tableau became the focus of an investigation into what happened when the floodwaters of Hurricane Katrina marooned Memorial Medical Center in Uptown New Orleans. The hurricane knocked out power and running water and sent the temperatures inside above 100 degrees. Still, investigators were surprised at the number of bodies in the makeshift morgue and were stunned when health care workers charged that a well-regarded doctor and two respected nurses had hastened the deaths of some patients by injecting them with lethal doses of drugs. Mortuary workers eventually carried 45 corpses from Memorial, more than from any comparable-size hospital in the drowned city.

Investigators pored over the evidence, and in July 2006, nearly a year after Katrina, Louisiana Department of Justice agents arrested the doctor and the nurses in connection with the deaths of four patients. The physician, Anna Pou, defended herself on national television, saying her role was to ‘‘help’’ patients ‘‘through their pain,’’ a position she maintains today. After a New Orleans grand jury declined to indict her on second-degree murder charges, the case faded from view.

In the four years since Katrina, Pou has helped write and pass three laws in Louisiana that offer immunity to health care professionals from most civil lawsuits — though not in cases of willful misconduct — for their work in future disasters, from hurricanes to terrorist attacks to pandemic influenza. The laws also encourage prosecutors to await the findings of a medical panel before deciding whether to prosecute medical professionals. Pou has also been advising state and national medical organizations on disaster preparedness and legal reform; she has lectured on medicine and ethics at national conferences and addressed military medical trainees. In her advocacy, she argues for changing the standards of medical care in emergencies. She has said that informed consent is impossible during disasters and that doctors need to be able to evacuate the sickest or most severely injured patients last — along with those who have Do Not Resuscitate orders — an approach that she and her colleagues used as conditions worsened after Katrina.

Pou and others cite what happened at Memorial and Pou’s subsequent arrest — which she has referred to as a "personal tragedy" — to justify changing the standards of care during crises. But the story of what happened in the frantic days when Memorial was cut off from the world has not been fully told. Over the past two and a half years, I have obtained previously unavailable records and interviewed dozens of people who were involved in the events at Memorial and the investigation that followed.

The interviews and documents cast the story of Pou and her colleagues in a new light. It is now evident that more medical professionals were involved in the decision to inject patients — and far more patients were injected — than was previously understood. When the names on toxicology reports and autopsies are matched with recollections and documentation from the days after Katrina, it appears that at least 17 patients were injected with morphine or the sedative midazolam, or both, after a long-awaited rescue effort was at last emptying the hospital. A number of these patients were extremely ill and might not have survived the evacuation. Several were almost certainly not near death when they were injected, according to medical professionals who treated them at Memorial and an internist’s review of their charts and autopsies that was commissioned by investigators but never made public.

In the course of my reporting, I went to several events involving Pou, including two fund-raisers on her behalf, a conference and several of her appearances before the Louisiana Legislature. Pou also sat down with me for a long interview last year, but she has repeatedly declined to discuss any details related to patient deaths, citing three ongoing wrongful-death suits and the need for sensitivity in the cases of those who have not sued. She has prevented journalists from attending her lectures about Katrina and filed a brief with the Louisiana Supreme Court opposing the release of a 50,000-page file assembled by investigators on deaths at Memorial.

The full details of what Pou did, and why, may never be known. But the arguments she is making about disaster preparedness — that medical workers should be virtually immune from prosecution for good-faith work during devastating events and that lifesaving interventions, including evacuation, shouldn’t necessarily go to the sickest first — deserve closer attention. This is particularly important as health officials are now weighing, with little public discussion and insufficient scientific evidence, protocols for making the kind of agonizing decisions that will, no doubt, arise again...
 A long read. A tough read. One that will bring no "closure." Worth it nonetheless.

When Katrina hit, my wife was Environmental Division Director of Quality for Baton Rouge-based Shaw Group. They were quickly awarded a number of (somewhat controversial) remediation contracts (they were the company that pumped NOLA "dry," ran the blue tarp roofing program, and administered the FEMA trailer complexes).

Cheryl subsequently spent the rest of the fall down in Baton Rouge and NOLA (we were living in Vegas at the time), where her crews worked 16-20 hours a day, 6-7 days a week. IIRC, I saw her for all of 11 days between Katrina and Christmas.

Mardis Gras 2006 was canceled in NOLA, but the party went on in Baton Rouge, and we went.


Sheri wrote in the NY Times the other day.
Whose Lives Should Be Saved?
Researchers Ask the Public

By SHERI FINK AUG. 21, 2016

BALTIMORE — In a church basement in a poor East Baltimore neighborhood, a
Johns Hopkins doctor enlisted residents to help answer one of the most fraught
questions in public health: When a surge of patients — from a disaster, disease
outbreak or terrorist attack — overwhelms hospitals, how should you ration care? Whose lives should be saved first?

For the past several years, Dr. Lee Daugherty Biddison, a critical care
physician at Johns Hopkins, and colleagues have led an unusual public debate
around Maryland, from Zion Baptist Church in East Baltimore to a wellness center in wealthy Howard County to a hospital on the rural Eastern Shore. Preparing to make recommendations for state officials that could serve as a national model, the researchers heard hundreds of citizens discuss whether a doctor could remove one patient from lifesaving equipment, like a ventilator, to make way for another who might have a better chance of recovering, or take age into consideration in setting priorities.

At that first public forum in 2012 in East Baltimore, Cierra Brown, a former
Johns Hopkins Hospital custodian, said she favored a random approach like a
lottery. “I don’t think any of us should choose whether a person should live or die,” she said...
Morally fraught, all of it. We remain pretty much unprepared to deal with the kind of post-major disaster large-scale triaging that will have to be done yet again -- with the inevitable ensuing angry non-participant 20-20 hindsight armchair accusations of "playing God."

Notwithstanding my grad degree in "Ethics and Policy Studies" and its deep study in and application of the concepts and mechanics of getting from "is" to "ought," I can't call myself an "ethicist," a title conventionally reserved for "moral philosophers" (typically at the doctoral level) who work in the field ongoing.
My EPS work was relatively pedestrian, addressing the question "should you have to take a non-cause drug test as a condition of employment, etc." About 3/4ths of my 1998 pre-thesis defense draft remains posted here.
My core takeaway from my studies is that "ethics" is not some about some authoritative "good/bad cookbook" lookup reference text. Derivation of "right/just/moral" conduct comes from deep, honest (if difficult) rational deductive and inductive deliberation that takes into account the breadth of applicable traditional and evolving foundational moral sentiment (even at the risk of some potential circularity with respect to those latter elements).
The word "philosophy" derives fundamentally from "philo" ("love of") "sophia" ("knowledge"). That it wanders off in the byzantine halls of academia into inscrutable snooty 50-dollar word-laden tedium in no way negates that.
"Ethics" as defined in the Wiki:
Ethics or moral philosophy is the branch of philosophy that involves systematizing, defending, and recommending concepts of right and wrong conduct. The term ethics derives from the Ancient Greek word ἠθικός ethikos, which is derived from the word ἦθος ethos (habit, "custom"). The branch of philosophy axiology comprises the sub-branches of ethics and aesthetics, each concerned with values.
As a branch of philosophy, ethics investigates the questions "What is the best way for people to live?" and "What actions are right or wrong in particular circumstances?" In practice, ethics seeks to resolve questions of human morality, by defining concepts such as good and evil, right and wrong, virtue and vice, justice and crime. As a field of intellectual enquiry, moral philosophy also is related to the fields of moral psychology, descriptive ethics, and value theory.
Three major areas of study within ethics recognised today are:
  1. Meta-ethics, concerning the theoretical meaning and reference of moral propositions, and how their truth values (if any) can be determined
  2. Normative ethics, concerning the practical means of determining a moral course of action
  3. Applied ethics, concerning what a person is obligated (or permitted) to do in a specific situation or a particular domain of action...
"Ethicist," specifically:
An ethicist is one whose judgment on ethics and ethical codes has come to be trusted by a specific community, and (importantly) is expressed in some way that makes it possible for others to mimic or approximate that judgment. Following the advice of ethicists is one means of acquiring knowledge (see argument, argument from authority).

The term jurist describes an ethicist whose judgment on law becomes part of a legal code, or otherwise has force of law. This may be due to formal (de jure) state sanction.

Some jurists have less formal (de facto) backing by an ethical community, e.g. a religious community. In Islamic Law, for instance, such a community following (taqlid) a specific jurisprudence (fiqh) of shariah mimics judgment of a prior jurist. Catholic Canon Law has a similar structure. Such a jurist may be a theologian or simply a prominent teacher. To those outside this tradition, the jurist is simply an ethicist who they may more freely disagree with, and whose input on any issue is advisory. However, they may find it hard to avoid a fatwa or excommunication or other such shunning by the religious community, so it may be hard advice to ignore.

Outside the legal professions and spiritual traditions, ethicists are usually considered to be either philosophers or mediators of disputes...
How about "medical ethics"?
The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. The following Principles adopted by the American Medical Association are not laws, but standards of conduct that define the essentials of honorable behavior for the physician.

Principles of Medical Ethics 

I. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights. 

II. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities. 

III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient. 

IV. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law. 

V. A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated. 

VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care. 

VII. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health. 

VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
IX. A physician shall support access to medical care for all people.
All dutifully noble and necessary. The difficulties invariably ensue in the specific applications under exigent circumstances. While deductive and inductive methods of "argument analysis" and "critical thinking" are fairly clear (i.e., premises to conclusions), once we get to the consideration of contending "moral values" (few of which can claim any scientific grounding) we are frequently stymied, stalemated.

My first grad school semester paper comprised a deconstructive argument analysis and evaluation of the 1994 JAMA "Single Paper" proposal (pdf).

A generation later we're still arguing over the same asserted (and contentious) relative merits.


We get a lot of our "moral sensibilities" via our myriad religious traditions. apropos, a favorite old book of mine is this one.

It is hard to say exactly when modern science began. Many scholars would date it at roughly 1600, when both Kepler and Galileo started using precision measurement to map the universe. But one thing is certain: starting from whatever date we choose, modern science was, in many important ways and right from the start, deeply antagonistic to established religion.

Most of the early scientists, of course, remained true believers, genuinely embracing the God of the Church; many of them sincerely believed that they were simply discovering God's archetypal laws as revealed in the book of nature. And yet, with the introduction of the scientific method, a universal acid was released that would slowly, inevitably, painfully eat into and corrode the centuries-old steel of religion, dissolving, often beyond recognition, virtually all of its central tenets and dogmas. Within the span of a mere few centuries, intelligent men and women in all walks of life could deeply and profoundly do something that would have utterly astonished previous epochs: deny the very existence of Spirit.

Despite the entreaties of the tenderhearted in both camps, the relation of science and religion in the modern world— that is, in the last three or four centuries—has changed very little since their introduction to each other in the trial of Galileo, where the scientist agreed to shut his mouth and the Church agreed not to burn him. Many wonderful exceptions aside, the plain historical fact has been that orthodox science and orthodox religion deeply distrust, and often despise, each other.

It has been a tense confrontation, a philosophical cold war of global reach. On the one hand, modern empirical science has made stunning and colossal discoveries: the cure of diseases such as typhoid, smallpox, and malaria, which racked the ancient world with untold anguish; the engineering of marvels from the airplane to the Eiffel Tower to the space shuttle; discoveries in the biological sciences that verge on the secrets of life itself; advances in computer sciences that are literally revolutionizing human existence; not to mention plopping a person on the moon. Science can accomplish such feats, its proponents maintain, because it utilizes a solid method for discovering truth, a method that is empirical and experimental and based on evidence, not one that relies on myths and dogmas and unverifiable proclamations. Thus science, its proponents believe, has made discoveries that have relieved more pain, saved more lives, and advanced knowledge incomparably more than any religion and its pie-in-the-sky God. Humanity's only real salvation is a reliance on scientific truth and its advance, not a projection of human potentials onto an illusory Great Other before whom we grovel and beg in the most childish and undignified of fashions.

There is a strange and curious thing about scientific truth. As its own proponents constantly explain, science is basically value-free. It tells us what is, not what should be or ought to be. An electron isn't good or bad, it just is; the cell's nucleus is not good or bad, it just is; a solar system isn't good or bad, it just is. Consequently science, in elucidating or describing these basic facts about the universe, has virtually nothing to tell us about good and bad, wise and unwise, desirable and undesirable. Science might offer us truth, but how to use that truth wisely: on this science is, and always has been, utterly silent. And rightly so; that is not its job, that is not what it was designed to do, and we certainly should not blame science for this silence. Truth, not wisdom or value or worth, is the province of science.

In the midst of this silence, religion speaks. Humans seem condemned to meaning, condemned to find value, depth, care, concern, worth, significance to their everyday existence. If science will not (and cannot) provide it, most men and women will look elsewhere. For literally billions of people around the world, religion provides the basic meaning of their lives, the glue of their existence, and offers them a set of guidelines about what is good (e.g., love, care, compassion) and what is not (e.g., lying, cheating, stealing, killing). On the deepest level, religion has even claimed to offer a means of contacting or communing with an ultimate Ground of Being. But by any other name, religion offers what it believes is a genuine wisdom.

Fact and meaning, truth and wisdom, science and religion. It is a strange and grotesque coexistence, with value-free science and value-laden religion, deeply distrustful of each other, aggressively attempting to colonize the same small planet. It is a clash of Titans, to be sure, yet neither seems strong enough to prevail decisively nor graceful enough to bow out altogether. The trial of Galileo is repeated countless times, moment to moment, around the world, and it is tearing humanity, more or less, in half...
A good read. Now freely available in pdf format.


Regarding New Orleans, I highly recommend David Simon's HBO series "Treme."

 'Treme' is set in post-Katrina New Orleans. It chronicles the struggles of a diverse group of residents as they rebuild their lives and their city. ‘Treme,' pronounced Truh-may, takes its title from the name of one of the city's oldest neighborhoods, an historically important source of African-American music and culture...

I loves me some NOLA. Always have. Was last there in 2013 to cover HIMSS13.

More to come...

Monday, August 22, 2016

ObamaCare in trouble? Coverage, cost, access problems...

I have no doubt you're aware that there's been a lot of fractious, angry news and blog chatter on the Internets lately focused on the broad overlapping topics pertaining to the intractably byzantine business of healthcare. And, as we head for the final approach to the 2016 Presidential election, GOP (and Libertarian) promises to "Repeal and Replace ObamaCare" have never been louder.
BTW, see my July 2015 book report on "ObamaCare is a Great Mess."
While driving home from last my last volunteer stint at, I listened to a very interesting KQED "California Report" segment, one concerning the "mental health" side of things:

Sorry, The Therapist Can't See You — Not Now, Not Anytime Soon

More than 43 million Americans have depression, anxiety, or another mental health condition. But more than half never get help. Recent laws were supposed to make it easier for Californians to access treatment, but many still face roadblocks, even with insurance...

We talk to a single mom looking for help in San Francisco, where there are lots of therapists. And we meet a young woman in Shasta County, where there aren’t.

We talk to the therapists who are trying to help. We explore the current state of enforcement. And we take a step back in history to understand how psychotherapy became a hobby of the wealthy rather than a critical service for those in need...

...[Natalie] Dunnege puts all her spare money into therapy for Strazh. She says it helps a lot. But Dunnege herself is struggling, feeling depressed and overwhelmed. She decided to look for her own therapist.

“One of the things that I’ve really had to wrap my head around is that I can’t change him. I can only change how I handle the situation,” she explains. “And not that I would want to change who he is. He’s a really good kid, but it’s a lot to handle, especially as a single parent.”

But when she logged onto her insurance website to find a therapist, she realized her copay for a mental health visit was going to be upwards of $75 – more than double her copay for other doctors’ appointments. Under a 2008 federal mental health law, those copays are supposed to be the same...

More than 43 million Americans suffer from depression, anxiety and other mental health conditions, according to the most recent federal data. But more than half the people who felt like they needed help last year, never got it. Even people who had insurance complained of barriers to care. Some said they still couldn’t afford it; some were embarrassed to ask for help. Others just couldn’t get through the red tape.

Recent health laws, the 2008 Mental Health Parity Act and the Affordable Care Act, were supposed to fix this...

But advocates say insurance companies are still finding ways to keep people who need care from getting it. Some are still not complying with the law. And some have found subtle, technically legally, ways to limit treatment...

There’s something that really bothers Stanford psychiatry professor Keith Humphreys. When he thinks of all the years he spends training the next generation of psychiatrists, the enormous investment in medical school and residency, he wants them to devote that education to taking care of people with serious mental illness.

But many of them instead set up a private practice, where they can charge $400 an hour in cash to help people who Humphreys calls “the worried well” –- people who enjoy the self-exploration of therapy but do not necessarily have a mental health problem...
Really good segment. Really disturbing. Then, there's this stuff, from THCB:
Aetna’s Obamacare Surprise

Did Aetna just pull a nasty, Trump-like move and up the ante on the Obamacare debate in advance of the election and exchange open enrollment for 2017?

The allegation is that the company withdrew from 11 state insurance exchange marketplaces for 2017 after the Justice Department failed to heed Aetna’s warning that it would do so if Justice didn’t approve its $37 billion purchase of Humana. The Justice Department announced last month that it was challenging that deal and Anthem’s proposed merger with Cigna, saying both deals threaten to sharply reduce competition in the health insurance marketplace...
Then, also at THCB, comes this creatively razor-tipped bit of anti-regulatory snark mocking the new MACRA initiative:
Value-Based Government (GACRA)

We decided that if MACRA is good for physicians, then the same thinking is probably a pretty good idea for the US government. We need Value-Based Government. It’s clear that past methods of paying for US Government services have been terribly inefficient. Costs keep going up. Quality keeps going down. We thought about doing this nationwide, with all US government personnel, but we will just do CMS leaders for now. Let’s call it a demonstration, we’re calling it  GACRA, Government Access and CMS Revaluation Act.

Eventually we want all US government employees to be value- based, no more salaries. This is an obvious improvement on how we will pay you,  The way you are paid now does not seem to work. Everyone agrees our government is too expensive to run and nothing gets done.

Here’s how value-based government works:

Every CMS leader will send in a code for every 10 or so minutes of work and exactly what they did. Yes, Andy Slavitt and Sylvia Burwell, you will not be paid as you were previously.

You will now be paid for value.

With GACRA, you will need to document every thing you do, but we will only pay for meetings and rules you make.

You will be paid for each meeting in this manner: You need to document the history of the meeting, what you discussed, how complicated the problem is, did you review any prior documentation, did you do an adequate review of the pertinent materials?  You will document a level 1,2,3,4, or 5 depending on the complexity, history etc. Don’t document a 4 if it was really a 3, that's fraud, so pay attention, its a complicated formula, but you have time to figure it out...
Read all of it. Below, this gave me the "ouch, lol" reaction:
To document all this, you must use the software that we certify, you cannot use your own. No customized software. We know better on what you need, not you. You may think you have a better way, but forget it. We don’t want innovation or new ideas, we want you to use old, one-size-fits-none software, that they will charge you a lot of money to buy and support. Sorry that its pricey and it doesn’t work well, it is what it is, don’t whine about it...
Well, you could use my Clinic Monkey ;)

In about a month, I will be joyful witness to the latest exuberant onslaught of all things cutting-edge Health IT and BioMedTech during the 10th Annual Health 2.0 Conference:

Been covering it every year since 2012. A high point of my year every year, as are the Health 2.0 WinterTech Conference that launched in 2015, and the yearly Lean Healthcare Transformation Summits.

In April I posted "Digital Health IT = "Better Care at Lower Cost." Right?" Prior to that I posted "The future of health care? "Flawlessly run by AI-enabled robots, and 'essentially' free?"

All of the whiz-bang tech and progressive process QI in the world can be stymied by the Gordian Knot comprising the hopelessly partisan socioeconomic politics of the "Payment Side." See, e.g., my prior posts on the "shards" of health care, here and here. apropos, see also my May 16th post "EHRs and the ACA: Obama's diabolical plot to enslave physicians."


Just in from STATnews:
Are insurance policies saving patients money, or keeping them from the treatment they need?

As science makes once-unthinkable treatments available, patients are increasingly facing a harsh reality: Insurance companies are forcing them to try older, less expensive therapies for months before covering pricier ones.

Insurers have long relied on a cautious approach to control costs and spare patients from expensive medications they might not need. But in more than a dozen interviews with doctors and patients, a picture has emerged of insurers growing more aggressive as they respond to financial pressures.

The result is a reliance on what is known as “step therapy,” whereby patients are forced to try cheaper treatments before they graduate to more expensive ones, even when health care providers are confident the inexpensive treatments will not work...
 Interesting. STATnews reliably rocks.

This Princeton health economist thinks Obamacare’s marketplaces are doomed

I’ve spent the past week talking to lots of health care experts and economists about the future of the Affordable Care Act. Of all the people I spoke with, Princeton University health economist Uwe Reinhardt offered the most dire and pessimistic assessment of the marketplaces' future.

Namely, he believes they’ve already entered a death spiral and are heading toward total collapse...

More to come...

Monday, August 15, 2016

Empathy: as essential to effective health care as #HealthIT?

Interesting tweet from Dr. Topol yesterday.

We all want our doctors to be kind. But does kindness actually help us get well?
Michael Stein, MD

...It’s reasonable to expect a doctor to be kind at every visit. Kindness may be less important to us when the visit is urgent, when we are in terrible pain and barely listening as we wait for relief, when the problem is diagnosed and fixed quickly. But generally, most of us assume that it matters. In ancient Greece, medical texts advised physicians to “be solicitous in your approach to the patient, not with head thrown back [in arrogance] or hesitantly with lowered glance, but with head inclined slightly as the art demands.” Today, medical schools teach and evaluate kindness at patients’ bedsides and through role-playing. As Leslie Jamison, who acted as a patient, writes in “The Empathy Exams,” “Checklist item 31 is generally acknowledged as the most important category: ‘Voiced empathy for my situation/problem.’ ”

Yet doctors and patients alike have lamented that fully booked appointment schedules, the laptop’s intrusion during history-taking, billing pressures and edicts from insurance companies are squeezing kindness out of the exam room. So what exactly do we lose when we lose kindness? It may improve doctor-patient relations and patient satisfaction, but does kindness matter for patient outcomes? Can it lower the risk of hospitalization or death? Can kindness save lives?

It seems obvious: When doctors are kind, patients do better. But when the hard-nosed and unsentimental scientist demands proof, persuasive evidence is hard to find...
Part of the difficulty may lie in conflation.

"Empathy" is not a synonym for "sympathy," strictly speaking (notwithstanding that we sloppily tend to glom the two concepts together). The former goes to the cognitive ability to understand another's point of view ("putting yourself in someone else's shoes," as the saying goes).

Whether you sympathize with that point of view is quite another matter. Finally, I guess "kindness" is an attribute we're more likely to accord someone who is sympathetic to our suffering when we're in distress.

On the other hand, I know I will get pushback here. e.g., the Wiki:
The English word empathy is derived from the Ancient Greek word ἐμπάθεια (empatheia, meaning "physical affection or passion"). This, in turn, comes from ἐν (en, "in, at") and πάθος (pathos, "passion" or "suffering"). The term was adapted by Hermann Lotze and Robert Vischer to create the German word Einfühlung ("feeling into"), which was translated by Edward B. Titchener into the English term empathy.
But, then, the Wiki entry continues:
Empathy is distinct from sympathy, pity, and emotional contagion. Sympathy or empathic concern is the feeling of compassion or concern for another, the wish to see them better off or happier. Pity is feeling that another is in trouble and in need of help as they cannot fix their problems themselves, often described as "feeling sorry" for someone. Emotional contagion is when a person (especially an infant or a member of a mob) imitatively "catches" the emotions that others are showing without necessarily recognizing this is happening.
I've also seen "empathy" referred to in three flavors: [1] "cognitive empathy" (the sense in which I use the term), [2] "affective empathy" (closer to outright "sympathy"), and [3] "somatic empathy" (the proffered ability to to accurately -- albeit vicariously -- "feel another's pain." 
UPDATE: I just did a quick search on the term "empathy" over at the rapidly growing platform, where I sometimes post stuff. A quick results scan reveals widespread use of the word as a synonym for "sympathy" (though, there are some nice exceptions. See, e.g., "Design is Mainly About Empathy").
Beyond the nominal semantic liability of "conflation," we should also note that things rarely compartmentalize into mutually exclusive boxes. Damasio pointed out in "Descartes' Error" that one must care about reasoning accurately.
Since Descartes famously proclaimed, "I think, therefore I am," science has often overlooked emotions as the source of a person’s true being. Even modern neuroscience has tended, until recently, to concentrate on the cognitive aspects of brain function, disregarding emotions. This attitude began to change with the publication of Descartes’ Error in 1995. Antonio Damasio ... challenged traditional ideas about the connection between emotions and rationality...

And, yeah, I know Damasio has his detractors. Nonetheless, his observation regarding "caring" about empathically informed, POV-aware, rational, truth-seeking reasoning remains on point. (The factually-indifferent 2016 GOP Presidential candidate apparently didn't get the Memo.)
I forget at the moment which of my many recent "omics" reads contained the observation "nurture is our nature."
Interesting book cited (by way of a NEJM review link) in the Stein WaPo article:

The treatment of medical illness today depends much more on science and technology than on the physician's ability to listen, comfort, and prescribe. Medicine is not only increasingly technical but is also increasingly involved with legal, governmental, and insurance constraints on patient care, and this state of affairs has done much to distance physicians from their patients. This important book seeks to restore empathy to medical practice, to demonstrate how important it is for doctors to listen to their patients, to experience and understand what their patients are feeling. The book-a collection of essays by physicians, philosophers, and a nurse-is divided into three parts: one deals with how empathy is weakened or lost during the course of medical education and suggests how to remedy this; another describes the historical and philosophical origins of empathy and provides arguments for and against it; and a third section offers compelling accounts of how physicians' empathy for their patients has affected their own lives and the lives of those in their care. We hear, for example, from a physician working in a hospice who relates the ways that the staff tries to listen and respond to the needs of the dying; a scientist who interviews candidates for medical school and tells how qualities of empathy are undervalued by selection committees; a health professional who considers what her profession can teach physicians about empathy; another physician who ponders whether the desire to be empathic can hinder the detachment necessary for objective care; and several contributors who show how literature and art can help physicians to develop empathy. Medicine, asserts most of these authors, is both science and narrative, reason and intuition. Empathy underlies the qualities of the humanistic physician and must frame the skills of all professionals who care for patients.
"The treatment of medical illness today depends much more on science and technology than on the physician's ability to listen, comfort, and prescribe."

That book was published 22 years ago, in 1994. The more things change, the more they remain the same? What are we waiting for?

The NEJM review (also penned in 1994) is equally interesting.
...Empathy has been so neglected and misunderstood in the field of medicine that the adequacy of a new book on the subject can be tested in large part by its success in explaining and overcoming two fallacies. The no-transference fallacy holds that faculty members can treat students like scum and they will nevertheless grow up to be compassionate physicians. The idiot-with-the-stethoscope fallacy -- taken from Robert Coles's interview with William Carlos Williams, as recounted in Coles's The Call of Stories: Teaching and the Moral Imagination (Boston: Houghton Mifflin, 1989) -- holds that empathy and compassion automatically turn physicians into blobs of emotion incapable of taking effective or thoughtful action...

Halpern's insights show why the definition of empathy in the lead essay by Spiro is basically flawed: “Empathy is the feeling that persons ... arouse in us as projections of our feelings and thoughts. It is evident when `I and you' becomes `I am you.”' Spiro here seems to be inviting the sort of uncurious self-absorption that Halpern and others warn against. Similarly, George Bascom's moving recollections of his life as a surgeon blur the distinction between empathy and sympathy and ultimately reveal Bascom much more than his patients.

Another important conceptual theme recurring in these essays concerns the extent to which empathy is emotional or cognitive. Jeanne LeVasseur and David Vance tilt toward the cognitive, whereas Halpern insists on the importance of the emotional. Joanne Lynn's important essay reminds us that true empathy may often lead to anger at injustices in our health care and social-support systems...
Recall my post from more than two years ago, dx Machina?
I spend a lot of time studying the cognitive processes of "experts," most notably those in the professions of medicine and law (the only two disciplines traditionally accorded the characterization; nowadays we've defined the appellation down to the point where your garbage truck driver is touted as an "Environmental Management Professional").

So, I read everything I can concerning "how doctors think," "how to think like a lawyer," etc...

...Smack square in this debate over whether empathy is innate or learned is the consistent and depressing observation that medical students seem to lose prodigious amounts of empathy as they progress along the medical training route. Something in our medical training system serves to stamp out whatever empathy students bring with them on day one.

The research appears to conclude that it is the third year of the traditional medical curriculum that does the most damage. This is a dispiriting finding, as the third year of medical school is the one in which medical students take their first steps into actual patient care. For most students, the third year of medical school is eagerly awaited. After two long years sitting in classrooms, you get to actually do what it is that doctors do — be in hospitals, take care of patients. One would think that these first steps into real patient care would bring forth all the idealism that drove students to medical school in the first place — idealism that is sorely tested in the first two years of memorizing reams of arcane facts.

But the reverse seems to occur. After their seminal clinical experiences involving real contact with real patients, medical students emerge with their empathy battered. Their ideals of medicine as a profession are pummeled by their initiation into the real world of clinical medicine. And it is in this demoralized state that we send them into residency to accrue what are arguably the most influential and formative experiences of becoming practicing physicians...
Highly recommended reading.

See also my post from April 2016, The future of health care? "Flawlessly run by AI-enabled robots, and 'essentially' free?"

Will there be benevolent, empathic health care robots, and soothing "apps" where you can go get some empathy?

"There is no smartphone application for empathy and offering emotional care."

The medical futurist in me cannot wait to see how the traditional model of medicine can be improved upon by innovative and disruptive technologies. People usually think that technology and the human touch are incompatible. My mission is to prove them wrong. The examples and stories in this book attempt to show that the relationship is mutual. While we can successfully keep the doctor– patient personal relationship based on trust, it is also possible to employ increasingly safe technologies in medicine, and accept that their use is crucial to provide a good care for patients. This mutual relationship and well– designed balance between the art of medicine and the use of innovations will shape the future of medicine.

Bertalan Meskó (2014-08-27). The Guide to the Future of Medicine: Technology AND The Human Touch (Kindle Locations 100-104). Dr. Bertalan Meskó (Webicina Kft.). Kindle Edition.
I first cited this Wunderkind last September.

Back to Dr. Stein at WaPo:
...At the moment, the best answer to the kindness contrarian is: Even if the evidence in favor of the therapeutic benefits of empathy is weak, there is no evidence that refutes the idea that empathy improves care. And too many patients have stories of how unkindness or the sheer obliviousness of doctors can be devastating and indelible.

Kindness carries with it a commitment to a certain way of thinking and being rather than to a particular pre-defined endpoint. By showing that they are open to patients’ experiences, doctors are helping them feel better, or at least feel at ease during office visits. Many long-standing medical recommendations (an annual physical examination, a total-body skin cancer check) are being reevaluated, and the makers of guidelines often determine that “there is not enough evidence to recommend.” Such old-fashioned medical interventions, absolutists suggest, could lead to over-diagnosis or over-treatment. But kindness at every visit is never too much to ask. Sophia was right: There is no burden added to the work of doctors if we expect them to be kind. Sometimes doctors don’t need to wait for evidence to do what is right.
Yeah, but, consider my prior posts "The Health Care Productivity Treadmill" and "Clinician Burnout."

Notwithstanding those very real and difficult structural operational concerns, more broadly as it goes to "empathy," sympathy," and "kindness," it never hurts to recall Tomasello's research on the "adaptive" utility of "prosocial" attitudes and behaviors. e.g., "A Natural History of Human Morality."

An afterthought. I recently reviewed Ann Neumann's fine book "The Good Death" (here and here). The word "empathy" appears only once therein, but her book is all about the nuances and difficulties pertaining to empathy, sympathy, and kindness -- i.e., "compassion."
Compassion is a complicated thing. It’s an emotion, both abstract and concrete, shown both in our broad support for groups or issues and in the care that we give those around us. Compassion: sympathetic consciousness of others’ distress together with a desire to alleviate it. I can write for years about equality for minority groups, the disabled, the ill, the dying, the incarcerated. I can feel that compassion sincerely, but I also know that compassion in theory is not always compassion in practice. I know what it feels like, but it’s not universal. I don’t have it for everyone who is suffering. I don’t have the capacity. Compassion in practice, when I do feel it, is fickle, too. I’ve cared about some hospice patients more than others. I’ve taken care of some loved ones more than others. And I’ve wrung my hands in guilt for the disparities. It’s easier to care for people when you trust them, but also when you know you have power over them. When you know they need you...

Neumann, Ann (2016-02-16). The Good Death: An Exploration of Dying in America (pp. 185-186). Beacon Press. Kindle Edition.
'eh? She needs to do a TED Talk.


I may have to buy this book once it's released in December.

The Amazon blurb:
A controversial call to arms, Against Empathy argues that the natural impulse to share the feelings of others can lead to immoral choices in both public policy and in our intimate relationships with friends and family

Most people, including many policy makers, activists, scientists, and philosophers, have encouraged us to be more empathetic—to feel the pain and pleasure of others. Yale researcher and author Paul Bloom argues that this is a mistake. Far from leading us to improve the lives of others, empathy is a capricious and irrational emotion that appeals to our narrow prejudices. It muddles our judgment and often leads to cruelty. We are at our best when we are smart enough not to rely on it, and draw upon a more distanced compassion.

Based on groundbreaking scientific findings, Against Empathy makes the case that some of the worst decisions that individuals and nations make—from who to give money to, when to go to war, how to respond to climate change, and who to put in prison—are too often motivated by honest, yet misplaced, emotions. With clear and witty prose, Bloom demonstrates how empathy distorts our judgment in every aspect of our lives, from philanthropy and charity to the justice system; from culture and education to foreign policy and war. Without empathy, Bloom insists, our decisions would be clearer, fairer, and ultimately more moral.

Bound to be controversial, Against Empathy shows us that, when it comes to major policy decisions and the choices we make in our everyday lives, limiting our empathetic emotions is often the most compassionate choice we can make.
I'll have to withhold judgment until after I've read it, but the foregoing gives me outset "conflation" concerns: "be more empathetic—to feel the pain and pleasure of others."

He first addresses "empathy" in clinical settings at 7:21. Wafts of Straw Man follow thereafter to about 8:00.
@7:21: We often say to one another ‘doctors and therapists should be empathic.’ And, if what you mean by empathic is 'caring, kind, and understanding,' absolutely. But, if what you mean by empathic is they should 'put themselves into our shoes, they should feel what we feel,' definitely not. This sort of empathic engagement leads to burnout. It leads to suffering and pain. It also makes them bad at what they do. @7:44
One hardly knows where to begin. First of all: "caring, kind, and understanding." Per Damasio, you have to 'care' about 'understanding,' and to the extent that you exude 'kindness' in your patient encounters, you will be more likely to elicit clinically significant and useful dx and tx information.

Again, the exasperating, wooly-headed conflation problem.

I had the great good fortune to teach "critical thinking" for a number of years at my university. I invariably admonished my students early on that "many arguments founder on imprecise definitions of key terms, which often leads people to wind up just endlessly talking past each other." (Sort of characterizes our national politics these days' 'eh?) I also studied trial lawyering and courtroom processes during my time at UTK in the '80's (Senior Seminar in Psychology of Law). Opposing Counsel typically "stipulate" to the precise agreed-upon legal meanings of core terms. And, in 1994 my first grad school paper comprised a thorough analytic deconstruction and evaluation of the JAMA Single Payer proposal (pdf). It commenced with three sinple-spaced pages of keyword definitions.

So, I'm a bit of a pedantic hardass when it comes to precision in language and communication. Sloppy language begets sloppy thinking, and vice versa. 

Q: Where (if anywhere) does "empathy" fit into "the Art of Medicine?" (An equally problematic phrase.)


A priority daily web surfing destination for me is that of Science Based Medicine. Good review of this book there.

...You might not agree that all the subjects he covers deserve to be labeled quackery, but you can’t deny that they are problems that need to be addressed. This is an incisive, thought-provoking, well-written, thoroughly referenced book that is an important contribution to science-based medicine information and reasoning.
Only $4.67 Kindle edition.


Only 7 weeks 'til the 10th Annual Health 2.0 Conference in Santa Clara.

Be there. I will. Gonna be loaded for bear this year.

Taking Lean to the screen: Removing waste from the electronic health record
Many physicians and nurses are traveling across desolate EHR wastelands replete with digital detritus, pixel dust and other non-value-add items.
By David Butler, MD

...To strive to deliver more value, many traditional healthcare systems have turned to utilizing formal process improvement methodologies such as Lean and Six Sigma, tools derived from the manufacturing industry, to deliver care efficiently and effectively. This trend and its effects have been well-documented by industry leaders like Patricia Gabow, MD, and John Toussaint. Dramatic improvements in cost reduction, quality improvement and patient safety have been seen in health systems like Toussaint's ThedaCare, Seattle Children's, Park Nicollet, and Denver Health. Centers for Medicare and Medicaid Services decreased contract modification cycle time by more than 50 percent and achieved a 95 percent reduction in post-implementation information technology change requests in national quality programs by adopting Lean.

With these success stories and over 300 books about Lean management available on Amazon, Lean is definitely hot in healthcare and not just a fad destined for hospitals' basement boxes within a few years. Many experts describe Lean as "corporate common sense" or metaphorically refer to it as "a diet and exercise routine for companies in order to stay healthy." These process improvement strategies are critical in healthcare because unlike other business models, we cannot just "have a sale" or drive more business strictly through marketing. We must streamline our processes and remove the waste and non-value add steps from the clinical care process. The most successful organizations leverage Lean transformation efforts to drive all business and clinical processes throughout their organization...
Music to my ears.

More to come...