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Monday, September 24, 2018

The Biden Cancer Initiative

"The Biden Cancer Initiative is a response to the lack of a cohesive, comprehensive and timely approach to cancer prevention, detection, diagnosis, research, and care."

One hopes this effort will get significant, sustained, and effective traction.

Last Friday Cheryl and I attended the local Biden Cancer Summit, which was held at John Muir Hospital in Concord (where I'd had my SAVR px heart surgery 28 days prior). Local congressman (and cancer survivor) Mark DeSaulnier hosted the event, which was comprised of a panel of clinical and medical business experts, and a panel of cancer survivors, with Q&A sessions following each panel discussion.
The CEO of the Muir Health System, Cal Knight, spoke. I subsequently introduced myself to him, and gave the hospital high praise for my treatment.
Given our long and painful history as family cancer caregivers and my own 2015 experience as a cancer patient, we found it all very interesting, if not exactly news to us. Nicely done.

Joe Biden:

I need to give some thought on how best to support this effort going forward, as I heal up fully.

All lofty, laudable principles. A number of them, however, (1, 2, 4 & 5 in particular), go to chronically contentious "multi-stakeholder" policy issue areas (e.g., "data transparency / interoperability," proprietary intellectual property vs. "open source," a more just and broadly effective health care payment system, etc). I find no detail on the website at this point addressing any of these areas in any substance (beyond, arguably, tangentially, inferentially these links). There's much drill-down work to be done (say, e.g., seven BCI "White Papers" for starters) if this undertaking is to bear fruit.

apropos, see also the NIH/NCI "Cancer Moonshot."


Again, from a BCI website link:
The Biden Cancer Initiative announced 57 new commitments from the public and private sectors in response to Vice President Joe and Dr. Jill Biden’s call to find solutions that will double the rate of progress against the [sic?] cancer. These innovative programs and partnerships focus on data sharing, patient support, education, and empowerment, research, clinical trials, access to care, disparities, and prevention and early detection...
OK. "...double the rate of progress." Do we have a current baseline aggregate operational definition of the current "rate of progress?" (Or, more plausibly, stratified rates of progress? Changes in Prevalence? Incidence? Mortality rates? Median survival times? Remission rates? etc.)


Some cautionary thoughts, via STATnews:
More research on ‘dying healthy’ will also help us live healthier

…Advances in medical treatment, including cancer treatments, are increasingly unlikely to provide further significant gains in human longevity. An analysis of 71 cancer drugs consecutively approved between 2001 and 2012, for example, suggests that their overall contribution to survival was just 2.1 months; the gains attributable to personalized cancer medicine have, so far, also been minimal.

Lacking evidence that the human life span can be radically increased by new medical technologies, we believe it’s time to shift our country’s investment priorities away from medical research that aims to extend life and instead focus on the same social, cultural, and political factors that successfully prolonged life in the last century.

That means more public investment in education, transportation, and housing. That kind of investment would directly contribute to the prevention of chronic diseases such as diabetes, heart disease, and many cancers, and would do more to improve the quality of life of the population than additional medical research aimed at treating individuals with specific diseases.

Don’t get us wrong. We aren’t suggesting that we should eliminate funding for medical research to try to prevent, or even cure, diseases. Instead, we are suggesting that public funding should emphasize research on improving and sustaining quality of life rather than focusing on increasing length of life. This means giving greater priority to diseases that affect decades of people’s lives, such as arthritis, autism, macular degeneration, and Alzheimer’s disease over end-of-life diseases like extreme dementia and many cancers…
My early 90's healthcare QI Mentor, IHC's Brent James (MD, M.Stat) cautioned us "let's don't kid ourselves that we're going to QI our way out of the larger social conundrum: every patient for whom you provide the very best care and outcome today will eventually return as a much older and sicker patient."

And, now, as I've noted recently, to the myriad largely "non-clinical" socioeconomic "upstream" factors to be taken into account, we have to add in "exposomics" to the vast "Omics" disciplines.
Tangentially, does "dying healthy" have anything to do with "A Good Death?"

Stay tuned. Forefront cancer research will surely be fraught with multiple difficulties.

Click to enlarge
"Given the billions of dollars the world invests in science each year, it's surprising how few researchers study science itself. But their number is growing rapidly, driven in part by the realization that science isn't always the rigorous, objective search for knowledge it is supposed to be. Editors of medical journals, embarrassed by the quality of the papers they were publishing, began to turn the lens of science on their own profession decades ago, creating a new field now called “journalology.” More recently, psychologists have taken the lead, plagued by existential doubts after many results proved irreproducible. Other fields are following suit, and metaresearch, or research on research, is now blossoming as a scientific field of its own.

For some, studying how the sausage is made is a fascinating intellectual pursuit in itself. But other metaresearchers are driven by a desire to clean up science's act…"
Tangentially, I cannot help but be reminded of something I wrote more than 20 years ago during my late elder daughter's cancer illness:
'Arrogant, narrow-minded, greedy, and indifferent?'
Is science the enemy? To the extremist "alternative healing" advocate, the answer is a resounding 'yes'! A disturbing refrain common to much of the radical "alternative" camp is that medical science is "just another belief system," one beholden to the economic and political powers of establishment institutions that dole out the research grants and control careers, one that actively suppresses simpler healing truths in the pursuit of profit, one committed to the belittlement and ostracism of any discerning practitioner willing to venture "outside the box" of orthodox medical and scientific paradigms.
One e-mail correspondent, a participant in the internet newsgroup, vented splenetic at length recently regarding U.S. authorities' alleged hounding, arrest, and imprisonment of alternative healers. He railed that law enforcement, at the behest of the AMA/FDA Conspiracy (a.k.a. the "corrupt AMA/FDA/NCI/ACS cartel"), had made the practice of alternative medicine illegal in the U.S. Moreover, he considered the fact that medical science can only claim "cures" for approximately 10% of the roughly 10,000 classified human diseases an a priori indictment of the mainstream profession.

I know: this is akin to the U.N. Black Helicopters/One-World-Government Conspiracy stuff of the not-too-tightly-wrapped. Still, I couldn't resist-- pointing out in (no doubt futile) reply that no one came with guns drawn and cuffs at the ready the night at Brotman Rehab when "Healing Angelite Crystals" practitioners-- devotees of India's Sai Baba-- came from Topanga Canyon to hover for hours in ceremony over Sissy (to the curious and wary befuddlement of the night shift nurses); neither did Security nor the medical staff at Brotman confiscate the goopy-looking herbal tonic we brought in, an elixir prescribed for Sissy by a Chinese herbal pharmacist doing business quite openly in Chinatown near downtown L.A.; nor would SWAT teams pounce on the backyard in the Valley where we took part in evening-long Lakota Souix "healing sweat lodge" ceremonies conducted by the venerable Wallace Black Elk; and finally, Wyndie, one of Sissy's highly skilled and effective physical therapists at Brotman did not have her certification revoked for counseling my daughter on the Hindu principles of the Chakras and efficacy of aromatherapy.

Moreover, I had to respond, the fact that we can only cure 10% of known diseases implies nothing regarding the quality of mainstream medical research and practice, unless the alternatives industry can provide hard, "case-mix adjusted," scientifically valid data showing their methods to effect consistently and significantly better outcomes-- which they cannot (a dearth of peer-reviewed studies being a central characteristic of "alternative" practice). Additionally, I asked, can anyone even cite historical curative percentages from 30, 50, or perhaps 100 years ago? Indeed, even such statistics would prove problematic-- "shooting at a moving target," as it were-- in that more subtle and clinically unresponsive maladies continue to be discovered and classified while the easier to treat are dealt with more readily. And, classificatory observation is easy compared to the work and resources required to effect cures; we should expect that identification will outpace remedy. Finally, 50 years ago death certificates listing demise from "natural causes" would today likely have identifiable diseases recorded as the cause of death.

Purveyors of medical quackery should fear the hot breath and hard heel of competent authority, but I see no evidence of suppression of alternative therapy methods that are not certifiably fraudulent. All manner of "unproven" substances are sold quite openly at retail, both in the health food stores and in the national chain outlets; all that need accompany the product is the legal boilerplate disclaimer acknowledging an absence of FDA blessing, along with the inoculating phrase 'dietary supplement.'

In fairness, as I've noted before, "I am not a scientist."

"More recently, psychologists have taken the lead, plagued by existential doubts after many results proved irreproducible."
apropos, I just finished this excellent book by esteemed psychologist James Alcock.

As reviewed at Science Based Medicine:
How We Believe
James Alcock’s new book about belief is a masterpiece that explains how our minds work, how we form beliefs, and why they are so powerful. It amounts to a course in psychology and an owner’s manual for the brain.
Harriet Hall on June 26, 2018

In James Alcock’s classic 1995 article “The Belief Engine“, he said, “Our brains and nervous systems constitute a belief-generating machine, a system that evolved to assure not truth, logic, and reason, but survival.” Now he has expanded that thesis into a book, Belief: What It Means to Believe and Why Our Convictions Are So Compelling. It’s much more than a book about belief. In the Foreword, Ray Hyman says it would be an ideal textbook for a course that provides an integrated overview of all the areas of psychology. He says every psychologist and psychology student should read it. It is an outstanding achievement of scholarship; its 640 pages include over 70 pages of references. It covers everything from the latest findings in neuroscience to a catalog of many of the questionable beliefs people hold, and why they hold them…
The neuropsychology of cognition (and our chronic risks of irrationality), basically. A must-read, IMO. Add another tome to my stash going to my abiding interest in the salient aspects of the cognitive attributes (and liabilities) of "expertise" (e.g., "how doctors think").


Got onto this via a STATnews article, "There's so much health noise..."

"I’m not a cynic. I think we need to keep an open mind and look for potential benefits wherever they may be found. But in this era of twisted facts, we all could use a nudge to keep applying critical thinking skills."
Read Alcock's compelling book "Belief." I've long and deeply studied "critical thinking," both as an undergrad and in grad school, and even thereafter got to teach it as an adjunct, but Alcock's work adds a much larger dimension. Were I teaching today, "Belief" would be a required text.

See also

Joe Schwarcz PhD - Director

I've just finished watching the Netflix "Detox" episode of Timothy Caulfield's documentary. A must-see.


Biden Summit discussions were replete with allusions to the imperative of "early detection." As reported in (firewalled) Science Magazine:
"CancerSEEK, and ye shall find?"

Most cancers are detected when they cause symptoms that lead to medical evaluation. Unfortunately, in too many cases this results in diagnosis of cancers that are locally invasive or already metastatic and hence no longer curable with surgical resection or radiation treatment. Medical therapies, which might be curative in the setting of minimal tumor burden, typically provide more limited benefit in more advanced cancers, given the emergence of drug resistance (1). On page 926 of this issue, Cohen et al. (2) describe a strategy for early cancer detection, CancerSEEK, aimed at screening for multiple different cancers within the general population. This study challenges current assumptions in the field of blood-based biomarkers and sets the stage for the next generation of cancer screening initiatives.

Given the potential curative advantage of earlier diagnosis and treatment, why have so many cancer screening approaches failed? In the past, efforts at screening healthy populations for cancer have relied on tests that were insufficiently specific. For example, most men with rising serum prostate-specific antigen (PSA) do not have prostate cancer but instead have benign prostatic enlargement. However, where accurate tests exist, there have been dramatic improvements in cancer outcomes (3). For example, advanced cervical cancer has virtually disappeared in countries where Pap screening is the standard of care; although less reliable, mammography and screening colonoscopy are recommended for early detection of breast and colon cancers in individuals above ages 40 to 45 and 50, respectively, and screening heavy smokers by use of low-dose chest computed tomography (CT) scans reduces deaths from lung cancer (4). However, these tests are imperfect, and cost-effectiveness for broad deployment remains a challenge, particularly because a multitude of false-positive test results may lead to extensive diagnostic evaluations and unnecessary medical interventions. Unfortunately, for the majority of cancers no effective early screening tests are available.

It is in this setting that emerging molecular analyses of blood specimens, so-called “liquid biopsies,” are poised to revolutionize cancer screening (5). Circulating cell-free DNA (cfDNA) in the blood consists of small fragments of DNA that are approximately 150 nucleotides in length. cfDNA is primarily derived from normal tissues, but a small fraction may be derived from tumor cells in individuals who have cancer. This circulating tumor DNA (ctDNA) may be identified by the presence of characteristic mutations in cancer genes or by variations in chromosome copy numbers (6). Recent studies have established the reliability of ctDNA genotyping for monitoring treatment response and identifying drug resistance mechanisms in patients with advanced cancer (7, 8). However, the much lower amount of ctDNA in the plasma of patients who have a localized tumor poses a challenge for early cancer screening, as does the absence of knowledge about which mutation to look for. Furthermore, some background mutations detectable in the blood may arise from nonmalignant proliferation of blood cells in older individuals, a phenomenon called clonal hematopoiesis of indeterminate potential (CHIP) (9). Importantly, cancer gene mutations alone are insufficient to identify the tissue of origin for a given cancer signal in the blood because similar mutations are present in multiple different cancers. Thus, a tissue-agnostic blood-based screening test has limited clinical utility, unless accompanied by insight into which organ should be investigated for follow-up…

There are a number of important caveats. The predictive value of any diagnostic test relies on the prevalence of the disease within the tested population. For instance, in testing apparently healthy individuals within the general population, the prevalence of all eight cancers can be conservatively estimated as 1% of people over age 64 (11). Hence, in this setting even a test that is 99% sensitive and 99% specific will yield a positive predictive value (PPV) of only 50% (half of all test positives will be a false-positive result). Similarly, a positive CancerSEEK test result would be predicted to have a PPV of 40 to 45% for a person having any of the eight different cancers (2). Although the model was not designed to screen for individual cancer types, breaking down the aggregate PPV into its individual component cancers would result in further reduction in PPV, particularly for rare cancers. Because PPVs improve with higher disease prevalence, application of any cancer screening test to subpopulations with increased genetic or environmental risk factors (for example, carriers of familial breast cancer susceptibility mutations, heavy smokers at risk for lung cancer, or patients with liver cirrhosis predisposed to hepatocellular carcinoma) would of course increase the likelihood of true-positive results.

A well-documented challenge in early cancer detection studies is that patient populations at increased risk for cancer may also have precancerous or inflammatory conditions resulting in baseline elevation of serum protein biomarkers, a confounding factor that is not well recapitulated in the healthy control population used to build the CancerSEEK test…

Undoubtedly, effective screening for early invasive cancers represents the best hope for reducing cancer mortality and morbidity. The conceptual advances and the practical feasibility of the CancerSEEK assay constitute an important milestone toward the application of early cancer detection. Most importantly, the ongoing development of cost-effective and accurate blood-based cancer screening strategies is poised to revolutionize clinical cancer care, bringing with it new emphasis on genetic and environmental risk stratification so as to tailor application of screening tests; minimally invasive imaging, biopsy, and molecular characterization of early tumors that are discovered and might be either indolent or invasive; and deployment of increasingly effective therapeutic options to stages of cancer for which they have curative potential. The vision of effective earlier cancer detection and intervention warrants validation in appropriate populations through large-scale clinical trials that are likely to radically change the way we diagnose and treat cancer.
Promising. Yet fraught with difficulty (pay particular attention to the "important caveats" paragraph).

Nonetheless, a priority research area in my view (in part, personally, because both of my late daughters presented at Stage IV).


ProPublica Patient Safety Community
Ran across this Facebook group (and joined) while searching out information about medical costs and pseudoscience / quack goods and services. Some of my prior blog riffs on patient safety issues are linked here.

Nobel Prize in medicine awarded to two cancer researchers for immune system breakthrough


On deck, "Data Science." Yet another fad?

Stay tuned. "Coding Boot Camps," anyone? More here.

More to come...

Sunday, September 23, 2018

A literal "shitstorm." What of the public health upshot?

Climate Change Comes Home To Roost In North Carolina
Breached swine lagoons. Overflowing coal waste ponds. Sewage in the streets. The hellish aftermath of climate-fueled Hurricane Florence.

FAYETTEVILLE, N.C. — Florence’s rain came down in sheets ― unrelenting, and for days on end.

The water inundated homes, many still boarded up from Hurricane Matthew two years earlier. It swallowed farm operations, killing millions of chickens and turkeys and overflowing open pits full of hog feces. It flooded coal ash ponds, sending the toxic byproduct of burning coal into area waterways. The smell of human waste tainted neighborhoods; in the small town of Benson, 300,000 gallons of raw sewage spilled into the streets.

On Friday, Charlotte-based Duke Energy reported that a dam containing a lake at one of its power plants in Wilmington had been breached by floodwaters, potentially spilling coal ash from a nearby dump into the Cape Fear River…

One immediate question of concern: what proportion of residents in the affected areas have their medical histories contained in EHRs? And, of those, what sub-proportion are housed in remote cloud-based systems largely immune from storm damage (as opposed to local in-house client-server installs in the-now flooded docs' clinics)? In the aftermath of Katrina, untold thousands of medical records were lost forever. One hopes things have materially improved since then.

I'm not finding much recent news about it. Here's one item:
With proper disaster prep, Health Information Exchanges play key role in transmitting patient data.
Natural disasters, like Hurricane Florence, present challenges to health systems and providers not only in areas directly impacted, but also to those in neighboring regions who treat patients displaced by the catastrophe. One of the greatest issues: access to patient records.

Health Information Exchanges (HIEs), play a critical role in making these records available. But there's a catch. Electronic connections must be set up in advance by HIEs in the impacted areas and in locations where patients may migrate. And, health systems and providers on both sides of the disaster must participate in an HIE and be connected to a data-sharing network for the data transfer to occur.

Because HIEs are a relatively new resource, a closer look behind the scenes of the nation's most recent widescale natural disasters demonstrates the value these organizations offer and provides lessons as health systems prepare for the future…
That's from the only news article I've thus far found on the topic.


Ugh. Raw sewage, dead livestock, fish, pets, etc, overflowing pig farms' excrement ponds, breached power plant coal ash lagoons, massive amounts of household and automotive chemicals -- note the chemical sheens evident in most post-hurricane flooding overhead photos...

Hurricane Florence Is a Public Health Emergency, Too
With its hog manure pits, coal waste ponds, and toxic Superfund sites, North Carolina is among the worst places a major cyclone could hit.


...“You don’t want hog waste flowing freely for the same reasons you wouldn’t want sewage flowing freely into the river and the house,” Gisler said. Feces is a breeding ground for bacterial pathogens like salmonella and giardia, and exposure via drinking water could cause experience a number of gastrointestinal problems. Exposure via open wounds or other mucous membranes could cause E. coli.

North Carolina has seen this before. During Hurricane Floyd in 1999, the manure lagoons from dozens of hog farms spilled “over thousands of acres of private and public lands and into the watersheds of four rivers that feed the second-largest estuary system in the nation,” according to the environmental news site Coastal Review. The storm’s extreme rainfall also killed more than 20,000 hogs, whose drowned bodies’ were scattered across the coastal landscape. The state legislature passed a moratorium on new manure lagoons after Floyd, but critics say little has been done to reduce the number of them across the state...
The continuing chronic lack of comprehensive, seamless digital health record "interoperability" (my irasible "Interoperabbable") will yet again result in significant friction hampering aggregate longitudinal public health assessments -- of this, and prior natural disasters.


I am now one full month out of my open heart SAVR px surgery. So far, so good, overall.


Largely off the press radar by now.
_____________ AnthropoceneDenial

More to come...

Wednesday, September 19, 2018

The "Silver Tsunami" and health care

I need to Photoshop myself onto that bench, first wave baby boomer that I am (born in Feb 1946).
Some good news: my cardiologist told me Friday that it was indeed a viable goal to get me all the way back to my delusional full-court hoops gym rat Jones. I start cardiac PT rehab on October 9th.
The 2018 Health 2.0 Annual Conference just wrapped up in Santa Clara. I find distressingly little mainstream press coverage, via searching Google News. Some stuff is just regurgitated press release copy.

Above, HIMSS CEO Hal Wolf:
Every hospital has to innovate for Silver Tsunami
The aging population is becoming more educated and driving transformational change, Wolf said at Health 2.0.

SANTA CLARA, CALIFORNIA — The worldwide challenge of treating aging populations is driving the healthcare industry toward innovation, according to HIMSS CEO Hal Wolf.

Speaking at the Health 2.0 conference here Monday, Wolf said that in the U.S., 49 percent of healthcare costs are covered by the government, yet as the ‘Silver Tsunami’ continues, that cost is expected to leap to 53 percent. But the problem isn’t just money, it is also the lack of manpower and skilled providers to take care of the aging population. Currently there is a gap of 7 million healthcare professionals, but that gap is only expected to grow, he said.

“That is why purely and simply … every healthcare system in the globe is trying to figure out how they are going to use innovation to take all of this [sic] disparate and disconnected components [and] bring it [sic] back together, so we can deliver care to rising populations, that are going to be sicker,” Wolf said. “That is what is siting behind the rising investment digital health. It is not something that is going to easily burst because the drivers that sit behind it are not the evaluations themselves as much as the socioeconomic drivers.”

Many are looking toward data as a way to solve problems in healthcare, as more and more of it becomes readily available. But data alone isn’t [sic] the solution, Wolf said.

“Data is [sic] fundamentally useless until you turn it into information,” Wolf said. “Until you take the data that is [sic] ones and zeros and categorize it, and put it [sic] into digestible chunks, we do not have the ability to use it [sic] the way we want to. If you think about your own apps or apps you’ve worked with, it is about taking that [sic] data and turning it into information … that information when you do comparative analysis turns itself into knowledge. This is where knowledge management is so important because it creates standards and targets and goals. There is inside knowledge and outside knowledge. Then finally when we apply little bits of data targeted against clinical utilities or capabilities or services that [sic] is what we deliver to the healthcare system.”

Healthcare is often behind on innovation. Wolf said the system is playing catchup to other industries in someways. For example, he said that his dog had a registry at its vet before his son had one at his doctor's. That doesn’t mean healthcare should catch up to old technology — rather, should be looking towards new better innovation like a segmented personalized registry. For example, a patient being treated for breast cancer shouldn’t get a breast screening reminder.

But it isn’t just the healthcare systems that are looking to change. Wolf also stressed that patients are becoming more engaged and informed about their health…
Tangentially related prior post: "Are we 'overcharged' for health care? Will it get even worse?"

Hmmm... "Innovation?"

A fine, relatively quick read. Short easily digested chapters with "accelerator" queries following each one. e.g.,

“The world makes way for the man who knows where he’s going.” - Ralph Waldo Emerson

I’ve repeatedly seen it—successful people have a future orientation. They may not know exactly how they’re going to get there, but they have a crystal-clear vision of their intended destination. Underlying this vision, storming towards the uber-successful is a three-step framework involving Clarity, Focus, and Execution.

I first learned the power of this trinity by accident. I worked my way through college as an emergency medical technician for a hospital-based ambulance service. I decided to major in respiratory therapy for one simple reason—I wanted to be a member of the flight team aboard Angel One at Arkansas Children’s Hospital. The day I began the professional portion of the respiratory therapy program, I waltzed into the department director at Arkansas Children’s Hospital and declared, “I just began respiratory-therapy school, and when I graduate, I’m going to come here and fly on your helicopter. So, if you’d like to hire me—know you can train me during the next few months, so I’ll be ready when I graduate.”

I didn’t get the job that day. A few months later, after observing me during a clinical rotation, that department director hired me. The day after I graduated, I was a member of the Angel One Flight Team. I spent the next several years living my dream. Fate had another surprise in store for me: another member of that team was my future wife, Lori.

Successful people have clarity on where they are going. They develop a relentless focus on that destination, and they understand how to impeccably execute that plan. Those three keys can make the difference between where you are and where you want to be. Make it happen!

  • What does your ideal future look like in three, five, and/or ten years? Spend the time necessary to develop crystal clarity on that desired future.
  • On what things must you intently focus to fulfill that vision or to arrive at that desired destination?
  • What things must you achieve or accomplish in the next twelve months to take you as far as possible toward that vision or destination?
  • What key actions must you take daily or weekly in order to achieve or accomplish those twelve-month milestones?
Standridge, Dr. Jeff D.. The Innovator's Field Guide: Accelerators for Entrepreneurs, Innovators and Change Agents (Kindle Locations 224-247). Fitting Words. Kindle Edition.
And so forth for 52 topical chapters.

This preface setup is noteworthy:
Innovation in any setting can be daunting. Being an entrepreneur is gut-wrenching, and filling the role of change agent takes a level of energy that most do not feel they possess. When you have the responsibility of being a change agent in your business, organization, or community, the burden of leadership weighs heavily on your shoulders…
…Innovation in any setting can be daunting. Being an entrepreneur is gut-wrenching, and filling the role of change agent takes a level of energy that most do not feel they possess. When you have the responsibility of being a change agent in your business, organization, or community, the burden of leadership weighs heavily on your shoulders… [ibid, Kindle Locations 184-186].
"The burden of leadership." Yeah. More, from the IHI Forum.

Relatedly, I'll reprise something from a December 2017 post of mine.

Below, I finished this book. Very good.

Dug it. Although, for a book claiming to have "launched the Lean Startup revolution," there is precisely nothing in it going explicitly to Lean methodology practices. Putting the "customer discovery / customer development" processes ahead of the "product development process," yeah, I get all that (and, charitably, it's foundational to a Lean philosophy, in many ways a direct descendant of Deming). But, no discussion of key topics such as "PDSA," "Value Stream," "Gemba," "Kaizen," "the 5 S's,", "A3," "Fishbone Diagram," etc.

I kept getting a recurrent feeling: "yeah, this is largely good old MBA (albeit PDSA-iterative) SWOT analysis stuff."

One thing I find consistently missing from these "innovation / startup" tomes are any substantive methodological discussions regarding old-fashioned scut-work "cost center" organizational functions -- i.e., in Lean "value stream" lingo, the "no-value-add-but-necessary" processes. Standridge at least tangentially makes mention of it in passing:
Entrepreneurs innovate while simultaneously being change agents. If wearing those hats isn’t stressful enough, payrolls and payables have to be met. Entrepreneurs must make certain their customers are served, their employees are paid, and their bills are current, while also ensuring life needs are met. No matter what blows up at work, the kids still must be housed, shuttled to school, fed, clothed, and put to bed… [ibid, Kindle Locations 198-201].
I'd just like to see more detailed and actionable "cost center process management" advice in the current startup literature. Tossing out broad allusions to "Lean," "Agile," "Innovation," (even "Effectuation") etc leaves me still a bit wanting.

I've reflected before on my own distant, haphazard tenure as a startup partner back in Tennessee:

Back in the 80's, while working at the International Technology Corporation environmental radiation lab in Oak Ridge, I was a Principal in an "exam cram" A/V business with a professor at UTK who taught private exam prep courses (e.g., SAT, ACT, GRE, LSAT) on the side. We started a company and then produced and marketed a series of 2-hour VHS videos and their accompanying print booklets in my South Knoxville hole-in-the-wall studio.

We bought "targeted" mailing lists (i.e., school guidance departments, libraries, and families with kids in school at the right grade levels) and sent out mass mailing brochures. The rule of thumb in Direct Mail back then was that a 1% return/sale rate was sufficient to be profitable were your costs fully baked in and your retail pricing still competitive.

I was the Managing Partner (Corporate VP/Sec'y-Treasurer/Registered Agent, actually). Producer, Director, Editor, Copywriter, Layout Artist, and Data Entry and UPS Shipping Clerk.

There's gotta be a DSM-V code for that...
Seat-of-the-pants multiple-hats improv management, those days.

Had I not had to miss the 2018 Health 2.0 Conference, I'd certainly been asking these types of questions of the startup atttendees.


A shot from a Twitter post (hashtag #health2con). Probably from a smartphone. There's ever-less point for my schlepping around 20 lbs of DSLR cameras and lenses, given improvements in smartphone optics.

"EMR Evolution: How the Big Players are Changing the Game"

Really would have liked to have seen that one. As noted by MobiHealthNews back in August:
Though doctors likely don’t consider their EHR a cutting-edge technology, the EHR space is actually a front line for change and innovation in healthcare. And that change is happening on a number of different axes: interoperability and open standards, personal health records, and the move into public cloud infrastructure are some of the biggest change narratives.

Microsoft, which provides technology to power many of the major EHR vendors, has a dog in each of those fights, and Microsoft Chief Medical Officer Simon Kos will be one of a handful of presenters on a Health 2.0 panel called “EMR Evolution: How the Big Players are Changing the Game,” along with representatives from Google Cloud, Cerner, and Allscripts…


Ran across this, mentioned over at Wired. The book is to be released on the 25th.

From the Amazon blurb:
Dr. Kai-Fu Lee—one of the world’s most respected experts on AI and China—reveals that China has suddenly caught up to the US at an astonishingly rapid and unexpected pace.  

In AI Superpowers, Kai-fu Lee argues powerfully that because of these unprecedented developments in AI, dramatic changes will be happening much sooner than many of us expected. Indeed, as the US-Sino AI competition begins to heat up, Lee urges the US and China to both accept and to embrace the great responsibilities that come with significant technological power. Most experts already say that AI will have a devastating impact on blue-collar jobs. But Lee predicts that Chinese and American AI will have a strong impact on white-collar jobs as well. Is universal basic income the solution? In Lee’s opinion, probably not.  But he provides  a clear description of which jobs will be affected and how soon, which jobs can be enhanced with AI, and most importantly, how we can provide solutions to some of the most profound changes in human history that are coming soon.
'Eh? See Sinovation Ventures.

Cool logo.


Screen cap from my iPhone:


More to come...

Tuesday, September 18, 2018

Hashtag #health2con

Hate to have to miss the Conference this year, but you can easily follow near- real time twitter updates here:

THE Health IT event of the year.

More to come...

Thursday, September 13, 2018


"This volume presents a comprehensive overview of the science and application of the Exposome through seventeen chapters from leaders in the field. At just over ten years since the term was coined by Christopher Wild in 2005, this is the first, field-defining volume to offer a holistic picture of the important and growing field of Exposomics. 

The term “Exposome” describes the sum of all exposures (not only chemical) that an individual can receive over a lifetime from both exogenous sources (environmental contaminants, food, lifestyle, drugs, air, etc.) and endogenous sources (metabolism, oxidative stress, lipid peroxidation, chemicals synthesized by the microbiome, etc.). The first section of this book contains chapters that discuss how the Exposome is defined and how the concept fits into the fields of public health and epidemiology. The second section provides an overview of techniques and methods to measure the human Exposome. The third section contains methods and applications for measuring the Exposome through external exposures. Section four provides an overview on statistical and computational techniques- including big data analysis - for characterizing the Exposome. Section five presents a global collection of case studies."
 A.K.A. (or closely related to) "epigenomics?" How about "HGT?" (Horizontal Gene Transfer). Where does that fit? Related to "the Upstream?" 

And, again how will all of this fit into the exam room / bedside patient encounter in the "productivity treadmill" front-line world?

 Got onto this topic via STATnews:

From the moment of conception onward, genes control our development and health. But they don’t do it alone. The exposome — all the internal and external chemical exposures we experience during the course our lives — influences, for better or worse, the genes and proteins they code for. A better understanding of the exposome, a concept still in its infancy, will help identify how nongenetic factors influence biological reactions and possibly the development of chronic diseases...

AGAIN: SEPT 16TH - 18TH, 2018

THE Health IT event of the year.
Be there. I will hate to miss this. Applied for my usual press pass. Never heard back, but, it's likely moot, given my post-op convalescence (which is proceeding apace, thought the daily conference schlep might be a bit much for me at this point).

More to come...

Tuesday, September 11, 2018

My cardiac surgeon

I had my first follow-up office visit today in the wake of my SAVR px. All signs looking good. I asked Dr. Veeragandham whether he would mind my citing him here on the blog. I didn't want to presume. He gave me the green light.

I owe my life to this man and his team at John Muir Cardiovasular Institute (inclusive of the support teams staffing the ICI and PCU).

As I was in pre-op on the 23rd, someone remarked, "oh, you got the A Team."

No exaggeration. Not one whit. Back in June when I had my hernia px, my anesthesiologist said of Dr. V., without hesitation, "if I needed to have something done, he'd be my guy."

I asked Dr. V. about "pumphead." He replied convincingly to not worry about it. I joked "how would I even know? I stay confused as it is."

He also told me I'd be OK to drive again in another week (I'm in no hurry).

You gonna need cardiac surgery? You simply can't do any better, IMO. Both in terms of technical skills and effusive beneficent humanity.
I just filled out my Press-Gainey. Gave 'em all high marks.
Some prior posts alluding to my SAVR anticipation and experience here.

SHORTLY: SEPT 16TH - 18TH, 2018
THE Health IT event of the year.
Worth every penny.

apropos of the Conference and "innovation," a book I just finished.

Nicely done. More ASAP

More to come...

Sunday, September 9, 2018

SAVR px progress

Prior to surgery I could max out the spirometer repeatedly with ease. Then, post-op, in the ICU and PCU (Progressive Care Unit), I could barely move it.

I'm now back to pinning it at 2,500 ml multiple times in a row here at home. Doin' OK. Vitals are stable (resting pulse is rather high, though), I'm out walking about 1/3rd mile at a time. Way less pain than I'd expected. Lost about 16 lbs. Fine with that. Two f/ups this week, my surgeon and cardiologist. Should be interesting.

One of my new reads:

Science Magazine book reviews are gonna bankrupt me, LOL...

THE Health IT event of the year.
Be there.



Can't say enough good about this production.

More to come...