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Wednesday, May 29, 2019

Define "expert."

 Continuing a broad theme I recently commenced with my prior post "Define 'evidence'."

“EXPERT”
 

A person who has a comprehensive and authoritative knowledge of or skill in a particular area. - Google result
One with the special skill or knowledge representing mastery of a particular subject. - Mirriam-Webster
A person who has special skill or knowledge in some particular field; specialist; authority. - Dictionary.com
A person who is very knowledgeable about or skillful in a particular area. - Oxford Dictionary
We certainly expect that of our physicians, even as it goes to the "Art of Medicine."

Below, I cited Tom Nichols' excellent book some time back.


Recall how some people confidently claim to know more than the "experts" irrespective of the topic.

In Trump’s World, Reality Is Negotiable
The president’s resistance to learning will long outlive his administration.
Tom Nichols


“Stories that should be good, are bad. Stories that should be bad, are horrible,” President Donald Trump complained in December. But that tweet wasn’t just the latest entry in an endless series of gripes about the press—it revealed something essential about this president’s relationship to facts, and the experts who produce them. For Trump, praise is truth, criticism a lie. Reality itself, like everything else in Trump’s world, is negotiable.

Over the past two years, Trump and his enablers have accomplished something even more dangerous than trying to run a government on gut feeling and conspiracy theories. They have, by attacking sources of authoritative knowledge beyond the president himself, inoculated a huge swath of the American public against ever being informed about anything, providing millions of Americans with a resistance to learning that will long outlive his administration…
Ugh.

Now comes a new release I've been eagerly awaiting since reading "The Peculiar Blindness of Experts."

…I dove into work showing that highly credentialed experts can become so narrow-minded that they actually get worse with experience, even while becoming more confident—a dangerous combination. And I was stunned when cognitive psychologists I spoke with led me to an enormous and too often ignored body of work demonstrating that learning itself is best done slowly to accumulate lasting knowledge, even when that means performing poorly on tests of immediate progress. That is, the most effective learning looks inefficient; it looks like falling behind…

…One revelation in the aftermath of the 2008 global financial crisis was the degree of segregation within big banks. Legions of specialized groups optimizing risk for their own tiny pieces of the big picture created a catastrophic whole. To make matters worse, responses to the crisis betrayed a dizzying degree of specialization-induced perversity. A federal program launched in 2009 incentivized banks to lower monthly mortgage payments for homeowners who were struggling but still able to make partial payments. A nice idea, but here’s how it worked out in practice: a bank arm that specialized in mortgage lending started the homeowner on lower payments; an arm of the same bank that specialized in foreclosures then noticed that the homeowner was suddenly paying less, declared them in default, and seized the home. “No one imagined silos like that inside banks,” a government adviser said later. Overspecialization can lead to collective tragedy even when every individual separately takes the most reasonable course of action.

Highly specialized health care professionals have developed their own versions of the “if all you have is a hammer, everything looks like a nail” problem. Interventional cardiologists have gotten so used to treating chest pain with stents—metal tubes that pry open blood vessels—that they do so reflexively even in cases where voluminous research has proven that they are inappropriate or dangerous. A recent study found that cardiac patients were actually less likely to die if they were admitted during a national cardiology meeting, when thousands of cardiologists were away; the researchers suggested it could be because common treatments of dubious effect were less likely to be performed…


Epstein, David J. Range (pp. 11-12). Penguin Publishing Group. Kindle Edition.
Lovin' this book thus far, notwithstanding my minor quibble with his take on the 2008 financial meltdown. I used to work in subprime risk management, and had a front-row seat viewing forces that led up to the crash. See my 2008 post "Tranche Warfare." Also, Google "Gresham's Dynamic." Human affairs get regulated one way or another. Let the foxes guard the henhouses, well, you get what you get. Hyperspecialization, while certainly a major contributory factor, was by no means the whole story.

A core finding in Range is one that succinctly demolishes the specious "transfer of training" argument. Highly trained mono-hyperspecialists tend toward unwarranted overconfidence, both within their specialties, and with respect to opinions going to other knowledge/skill domains.

Title taglne, "why generalists triumph in a specialized world."

Money shot early on:
Scientists and members of the general public are about equally likely to have artistic hobbies, but scientists inducted into the highest national academies are much more likely to have avocations outside of their vocation. And those who have won the Nobel Prize are more likely still. Compared to other scientists, Nobel laureates are at least twenty-two times more likely to partake as an amateur actor, dancer, magician, or other type of performer. Nationally recognized scientists are much more likely than other scientists to be musicians, sculptors, painters, printmakers, woodworkers, mechanics, electronics tinkerers, glassblowers, poets, or writers, of both fiction and nonfiction. And, again, Nobel laureates are far more likely still. The most successful experts also belong to the wider world. “To him who observes them from afar,” said Spanish Nobel laureate Santiago Ramón y Cajal, the father of modern neuroscience, “it appears as though they are scattering and dissipating their energies, while in reality they are channeling and strengthening them.” The main conclusion of work that took years of studying scientists and engineers, all of whom were regarded by peers as true technical experts, was that those who did not make a creative contribution to their field lacked aesthetic interests outside their narrow area. As psychologist and prominent creativity researcher Dean Keith Simonton observed, “rather than obsessively focus[ing] on a narrow topic,” creative achievers tend to have broad interests. “This breadth often supports insights that cannot be attributed to domain-specific expertise alone.” [ibid, pp. 32-33]
Interesting, especially given that "I am not a scientist."
My late Dad (career Bell Labs semiconductor R&D technocrat) loved to sarcastically spout the gibe "Jack of All Trades, Master of None." He repeatedly admonished me during my childhood to find a technical niche and become "expert" in it. That was the path to success in life. The exhortation fell on deaf ears, to my parents' acute aggravation. When I finally got my Master's in 1998 at age 52, a favorite riff of mine was the late Eric Sevareid's "Jack of All Trades, Master of None, Save For That of Jack of All."
apropos of where this all points to, "Is there a science of deliberation?" Would it necessarily entail "Range?" How does all of that cohere with "Open Mindedness?" We're gonna have to get good at all of this stuff if we're to be effective "Champions of Science" at all levels.

Particularly in the medical field. e.g., here, and here, to cite just a couple of relevant prior posts.

Need I put up a subsequent post "Define 'Science'?" to wit,
Trump Administration Hardens Its Attack on Climate Science
WASHINGTON — President Trump has rolled back environmental regulations, pulled the United States out of the Paris climate accord, brushed aside dire predictions about the effects of climate change, and turned the term “global warming” into a punch line rather than a prognosis.


Now, after two years spent unraveling the policies of his predecessors, Mr. Trump and his political appointees are launching a new assault.

In the next few months, the White House will complete the rollback of the most significant federal effort to curb greenhouse-gas emissions, initiated during the Obama administration. It will expand its efforts to impose Mr. Trump’s hard-line views on other nations, building on his retreat from the Paris accord and his recent refusal to sign a communiqué to protect the rapidly melting Arctic region unless it was stripped of any references to climate change.

And, in what could be Mr. Trump’s most consequential action yet, his administration will seek to undermine the very science on which climate change policy rests…
If we don't get climate science right, little else will matter.


Mr. Best Words.


Need we also have a post entitled "Define 'definition'?" Should we go all the way to annoying sophomore undergrad Phil101"Define 'truth'?"

UPDATE

New issue of Science Magazine showed up today. This new book is reviewed. I downloaded it. Stay tuned.

As noted at Vox.com:
The decline of trust in science “terrifies” former MIT president Susan Hockfield
If we don’t trust scientists to be experts in their fields, Hockfield says on the latest episode of Recode Decode, “we have no way of making it into the future.”
Dr. Susan Hockfield
…[O]ne of the things I really do worry about is this current lack of confidence in experts and expertise. It’s what science is about. We test ideas, we contest ideas, and if we don’t believe that there are things that are more right than others, which is where we place our bets now, we have no way of making it into the future.

KS: I agree. The truth is now political, you get that? So you have to be political.
I get that and it terrifies me. So we have to continue to insist on an apolitical realm. Politics are never out of it entirely. We have to insist on an understanding that there are people who understand areas better than we do. I don’t pretend to be an engineer. I don’t pretend to be a physicist. If the physicists at MIT tell me that they’ve figured out gravitational waves, I’m going to trust them more than I’m going to trust myself to imagine whether or not there are gravitational waves.

KS: Right.
But this idea that there are people with expertise that we should value and value their opinions greater than others. I understand that people might debate the fine points of climate change, but the fact is that the best science indicates that we’re in trouble.

KS: Right.
If an asteroid were coming toward Earth, don’t you think we’d mount every possible defense to send it off its course, rather than say, “Asteroids don’t exist?” Of course we would. So it’s simply folly to my mind not to step up and invent the technologies that are going to prevent us from the ravages of climate change that we’re inflicting on the planet, or frankly whether it’s us or anyone or some other natural operation.

KS: Right.
It’s our job to protect ourselves so that we have a better future.

KS: Absolutely. Or maybe we’ll just learn our lesson. It’s probably the way it’s going to go, unfortunately the way it’s going to go.
Well, I hope not…

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More to come...

Saturday, May 25, 2019

AI-assisted NLU data analytics: Fat Tales, the 45th Moment of distributions, a.k.a. Trumptosis

From the WaPo Department of Blinding Glimpses of the Empirically Obvious.

From The Washington Post. Seriously?
Trump is twice as extreme as his predecessors in the past century. That’s dangerous.

It is the best of times. It is the worst of times.

In our current age of foolishness, things are “incredible,” “thriving,” “booming,” “prospering,” “tremendous,” “beautiful,” “very much happy” — the “greatest,” “best” and “most.”

It is also a “disaster,” a “mess,” “disintegrating,” “really bad,” “even worse” than the “worst,” “ridiculous,” “nasty” and “fake” — with “abuses,” a “lot of problems” and in a “spiral down.”

All of the above thoughts were proclaimed by President Trump within the span of a few minutes this week. So extreme is his rhetoric that even an attempt to portray himself as calm devolved into hysterical hyperbole…
Click the graphic below to enlarge.


The "Fourth Moment" of statistical distributions is known as "Kurtosis," a.k.a. the relative measure of "Fat Tails"

Get it? LOL.

Still working on updates for my prior post, but this was too good to pass up. We need "AI" to figure this stuff out? "Trumptosis," a new "best word."

And, no, it's not really funny.
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More to come...

Monday, May 20, 2019

Define "evidence"

Ahhh... "Just the facts." 

My (non-dictionary) definition:
EVIDENCE: Information which renders a true conclusion more likely, or (much more rarely), constitutes proof of a true conclusion (a.k.a. "dispositive evidence").
Anyone see anything at least episodically problematic there? Say tuned. Lots to unpack in this upcoming post. Let's just say for openers I'm a bit of a pedantic stickler for precise definitions as a starting point for rational and productive discourse (e.g., "Deliberation Science," anyone?).

It behooves us to all be singing from the same sheet of music.
“EVIDENCE,” OXFORD DICTIONARY

1. The available body of facts or information indicating whether a belief or proposition is true or valid. ‘the study finds little evidence of overt discrimination’

1.1 (Law) Information drawn from personal testimony, a document, or a material object, used to establish facts in a legal investigation or admissible as testimony in a law court. ‘without evidence, they can't bring a charge’



1.2 Signs or indications of something. ‘there was no obvious evidence of a break-in’
BTW, apropos of 1.1, my trusty Black's Law Dictionary (10th ed.) devotes five pages [pp 576-581] to the word "evidence" and its related phrases and usages (most of them obviously pertaining to the legal domain).
"Information which renders a true conclusion more likely..." The briefest reflection extends that definition to sensory organ initiated perceptions. Is that rustling in the bushes outside your tent that of a bear? Does that acute smell of gas portend an incipient explosion? Is that "sound of 100 approaching freight trains" evidence of a tornado headed your way? Is that mole cancerous? etc.
In terms of human "arguments," any assertive premise statement ("truth claim") that fails to improve the likelihood of a true conclusion is at best simply rhetorical noise, and at worst a rhetorical fallacy. We have too much of it in our discourse.
SPEAKING OF "THE LAW"

A recent article in my AAAS Science Magazine made me aware of this:
H. R. 4174, ‘‘Foundations for Evidence-Based Policymaking Act of 2018’’—01/14/2019, Public Law No: 115-435.
"There is no natural constituency for evidence-based policy. It should, by rights, be the public who wants the most from their government (and their public funds). But the public, like most politicians, is often not aware of the ins and outs of evaluation methods and evidence. Think tanks and academics have long filled this gap and will likely continue to play key roles. But legislation signed into law in early 2019 could transform the way U.S. government officials design programs by introducing more scientific evidence into the process…"
Really? Under a Donald Trump administration? How did that happen? He signed the final bill. We can rest assured he carefully read every word of its 29 pages.
‘SUBCHAPTER II—FEDERAL EVIDENCE-BUILDING ACTIVITIES
 

‘‘§ 311. Definitions
‘‘In this subchapter:

‘‘(3) EVALUATION.—The term ‘evaluation’ means an assessment using systematic data collection and analysis of one or more programs, policies, and organizations intended to assess their effectiveness and efficiency.
‘‘(4) EVIDENCE.—The term ‘evidence’ has the meaning given that term in section 3561 of title 44.
44.USC.3561

(6)Evidence.—
The term “evidence” means information produced as a result of statistical activities conducted for a statistical purpose.

(10)Statistical activities.—The term “statistical activities”—
(A) means the collection, compilation, processing, or analysis of data for the purpose of describing or making estimates concerning the whole, or relevant groups or components within, the economy, society, or the natural environment; and
(B) includes the development of methods or resources that support those activities, such as measurement methods, models, statistical classifications, or sampling frames.

(12)Statistical purpose.—The term “statistical purpose”—
(A) means the description, estimation, or analysis of the characteristics of groups, without identifying the individuals or organizations that comprise such groups; and
(B) includes the development, implementation, or maintenance of methods, technical or administrative procedures, or information resources that support the purposes described in subparagraph (A)...
Well, isn't that interesting? Enter "Data Science," anyone?
A couple of passing thoughts on evaluative classification of empirical "evidence." In conventional usage, we often resort to qualitative ordinal ranking, with evidence strength thought of as ranging from "dispositive" to "nll," with (descendingly) "extremely strong," "strong," "moderate," "weak," "extremely weak" designations in between. Sometimes we gussy things up by stating nominally "quantitative" evidentiary "probabilities" when, properly, to cite just one caveat, we should be proffering what are really "probability estimates." The potential problems with inferential statistics bloom exponentially from there. See, e.g., my 1998 thesis rant on drug testing lab stats naivete.
UPDATE: just in, of relevance,
EPA Changes Math to Allow Burning of More Coal
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"EBM," ANYONE?

"Evidence-Based Medicine." Not universally loved, historically. Still often dissed as anti-innovation "cookbook medicine" by apologists for "Eminence-Based Medicine."
"[S]ince antiquity, the mark of distinction of a learned man had been the certainty of his knowledge. A doctor knew—he did not need to test his kind of knowledge empirically because this would imply acknowledgement of uncertainty."—Ulrich Tröhler
DONALD TRUMP CLAIMS "EXPERTS ARE ALWAYS WRONG ABOUT EVERYTHING. CONSEQUENTLY..."

Are they?

The Neurologica Blog asks "How do we know?"
"...Science itself is not a set of “facts” but a method of exploration. It starts from specific premises, and it doesn’t even hold that these premises are Truth, just that they are necessary for science to function. We call these premises methodological naturalism – every material effect has a material cause, and there is no magic or miracles (arbitrary suspensions of the laws of nature). At least you cannot invoke such miracles when making an argument. Based on this premise, science uses logic and observation not to prove things correct, but to prove things wrong. (That is a key point – you can never prove something wrong if you can invoke miracles as needed.) By conducting experiments and making observations science can exclude hypotheses that are incompatible with the evidence. Whatever is left, the explanations that have survived dedicated attempts at proving them wrong, are then considered tentatively to be possible or even probable explanations. The longer a scientific notion survives, and the more independent lines of evidence that lead us to the same conclusion, the higher our confidence in that idea..."
SCIENCE MAGAZINE UPDATE
"At a time rife with a disregard for facts and the methods used to produce them (even when they portend a catastrophic future), perhaps [C.P.] Snow, were he alive today, would encourage scientists and humanists, engineers and artists, to focus on the one culture to which we all  belong."
In May 1959, Charles Percy Snow took the stage at the Senate House in Cambridge to give the annual Rede lecture. The British chemist-turned-novelist’s appearance—a rotund jowly face atop a bulky, shambling figure—led wags to comment that the speaker was well rounded in more than just his intellect.

Snow’s talk, titled “The Two Cultures and the Scientific Revolution,” broadly diagnosed a problem he believed challenged the future of all western democracies. For years, he had noted that British humanists and scientists shared “little but different kinds of incomprehension and dislike” (1, 2). The inability of literary scholars and scientists to understand and communicate with one another was not just an intellectual loss, Snow claimed, but something that threatened the ability of modern states to address the world’s problems...
Great, extensive, timely review I ordered the book. Only six bucks in paperback.

YET ANOTHER BOOK TO CONSIDER

This was cited in the notes of the Science Magazine article:


Downloaded it, read it in short order. Excellent.
The Cold War was a time when psychology came into its own as a tool of social analysis. With marked rapidity the structural, institutional, and economic ways of understanding American society that had dominated academic and public discourse in preceding decades gave way to explanations framed in terms of the psyche…

If psychology could explain everything, there was one aspect of the self that held special importance to the intellectual and policy worlds: open-mindedness. Open-mindedness was a kind of mind characterized by autonomy, creativity, and the use of reason. To the scientific experts, intellectuals, and policy makers who developed and utilized the concept of the open mind, this type of self served simultaneously as model and ideal of national and intellectual character. They projected upon the open mind their aspirations for the American character and liberal pluralist democracy, for scientific thinking and true intellectual inquiry. Indeed, for some of these individuals the open mind transcended the academic and political, as its traits were even conscripted to serve as criteria for human nature itself.

Cold War intellectuals and policy makers saw in open-mindedness solutions to the most pressing problems faced by the nation. Those who defined American foreign policy believed that open-minded autonomy, a hallmark of American virtue, posed a threat to the communist system. Traditional or authoritarian societies could not be sustained in the presence of a citizen body that thought autonomously, but for a modern democracy like America, open-mindedness would have the opposite effect, offering social cohesion. The open mind meant a respect for individuality, tolerance of difference, appreciation of pluralism, and appreciation of freedom of thought. If citizens were sufficiently equipped with these virtues, thought policy makers and social critics, the nation would flourish…


Cohen-Cole, Jamie. The Open Mind (pp. 1-2). University of Chicago Press. Kindle Edition.
I wrote an Amazon review.
I emailed the author: "You are one damn fine scholar." A compelling tour through my 73 years (and my many years working in science / engineering / tech domains) and the decades that preceded them. "Open-mindedness" has hit a serious rough patch in recent years--in particular in the turbulent wake of the last Presidential election. We are coming upon a time when it may well soon be ruled at the highest level that behaviors grounded in "open-mindedness" violate some peoples' Constitutionally-protected "religious freedom," and that, reciprocally, behaviors stemming from irrational, close-minded prejudice will be ruled as "Constitutionally-protected" on grounds of "religious freedom." (Not just "opinions," actions.)

You want a good historical understanding of how we got here, read this book. Beyond its erudition and cogent observations, i found it a FUN read.
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More to come...

Thursday, May 16, 2019

On Sorcery

...Thank goodness we have you to turn to, Representative Stickland, for homespun wisdom that isn’t tainted by either higher education or the sulfurous fumes of Beelzebub. As a licensed pest control technician, you are well-positioned to critique the instruments of the occult.

I mean, of course, vaccines. Vaccines are powerful dark magic that have eliminated child-killing diseases such as polio, smallpox and — until recently, in this country — measles. If left unchecked, necromancers such as Dr. Hotez and myself would gladly vaccinate every child in Texas who doesn’t have a medical condition affecting their immune system. Our sorcery already prevents 2 to 3 million unnecessary deaths every year, and we would gladly prevent even more.

We would cackle over our big steaming cauldrons as we prevent children from contracting tetanus and experiencing such intense muscle spasms that they break the bones in their spines!

We would interpret diabolical messages from the blood of salamanders as we vaccinate kids against whooping cough, which can kill babies by driving their oxygen levels so low that their hearts slow and they experience cardiac arrest!

The demons lurking among us would howl in ecstasy as we prevent mumps, which can sterilize boys, and measles, which can cause a slow, incurable inflammation of the brain. Nothing would spark more joy in the evil heart of Satan than seeing Texas kids fully protected against vaccine-preventable disease!...


Rachel, I still want to read your doctoral dissertation.
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More to come...

Wednesday, May 15, 2019

On data dashboards

Click either above to enlarge.

Interesting, iconoclastic post at THCB:
We Are Not A Dashboard: Contesting The Tyranny Of Metrics, Measurement, And Managerialism
By DAVID SHAYWITZ

The dashboard is the potent symbol of our age. It offers the elegant visualization of data, and is intended to capture and represent the performance of a system, revealing at a glance current status, and pointing out potential emerging concerns. Dashboards are a prominent feature of most every “big data” project I can think of, offered by every vendor, and constructed to provide a powerful sense of control to the viewer. It seemed fitting that Novartis CEO Dr. Vas Narasimhan, a former McKinsey consultant, would build (then tweet enthusiastically about) “our new ‘control tower’” – essentially a multi-screen super dashboard – “to track, analyse and predict the status of all our clinical studies. 500+ active trials, 70+ countries, 80 000+ patients – transformative for how we develop medicines.” Dashboards are the physical manifestation of the ideology of big data, the idea that if you can measure it you can manage it.

I am increasingly concerned, however, that the ideology of big data has taken on a life of it’s own, assuming a sense of both inevitability and self-justification. From measurement in service of people, we increasingly seem to be measuring in service of data, setting up systems and organizations where constant measurement often appears to be an end in itself…
Good post. Read all of it. What do you think?
...Data sciences and technology could, and must, play a vital role. But they haven’t earned the right to be considered an end in themselves. They represent potentially valuable tools, ideally in the hands of experienced and inquisitive practitioners, who uniquely appreciate the subtleties of their domain – McClintock’s phrase “feeling for the organism” comes to mind; who have the humility to recognize the limits of knowledge; and who will actively seek to leverage the benefits potentially offered by data, analytics, and measurement, thoughtfully applied.
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More to come...

Sunday, May 12, 2019

"This doctor posted online in favor of immunization."


An infuriating article in The Boston Globe.
This doctor posted online in favor of immunization. Then vaccine opponents targeted her
By Liz Kowalczyk


Dr. Monique Tello was attending a medical conference last fall when a speaker on social media suggested the physicians search themselves on Google. Why not, thought Tello, an internist at Massachusetts General Hospital.

She was stunned by what she found.

More than 100 negative one-star reviews and derogatory comments had been posted about her on popular physician rating websites.

“Ignorant, and could care less about her patients,’’ she recalled one poster writing.

“Danger,’’ another warned.

Tello soon discovered these comments were not from people who had been her patients, she said, but instead from anti-vaccine activists. The reviews on the websites Vitals and Healthgrades began pouring in last August, soon after Tello wrote pro-vaccine commentary on another doctor’s Instagram account…
Read all of it. Simply infuriating. See @ScienceBasedMed's voluminous postings on the vaccination issues.


Dr. Tello is fighting back. e.g., on Facebook:

Bullying and cyberbullying of physicians is becoming an enormous issue, especially now that so many of us are trying to have more of an online presence. Many of us have experienced being bullied online through comments on out pages, fake bad reviews, and more. Sometimes if can be massive groups that decide to attck like the antivaxxers or fans of a particular person or group. We need better education and support when this happens. I hope this can be that place. Please share your stories so we can learn from you. Please ask your questions so you can learn from others. Please post anything you think might be valuable to fellow physicians this may be happening to.
I'm not an MD, so I can't join (it's a closed group). If you're a doc, join up and fight back. What's next with these lunatic people? Actual assaults? Death threats? Attempted (or successful) murders of vaccination proponents (like have happened over the abortion issue)?

Enough of this Idiocracy stuff.

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ON DECK

Saw a book review on STATnews. Bought the book immediately.

From the Amazon blurb:
From a giant of health care policy, an engaging and enlightening account of why American health care is so expensive—and why it doesn't have to be
Uwe Reinhardt was a towering figure and moral conscience of health care policy in the United States and beyond. Famously bipartisan, he advised presidents and Congress on health reform and originated central features of the Affordable Care Act. In Priced Out, Reinhardt offers an engaging and enlightening account of today's U.S. health care system, explaining why it costs so much more and delivers so much less than the systems of every other advanced country, why this situation is morally indefensible, and how we might improve it.
The problem, Reinhardt says, is not one of economics but of social ethics. There is no American political consensus on a fundamental question other countries settled long ago: to what extent should we be our brothers' and sisters' keepers when it comes to health care? Drawing on the best evidence, he guides readers through the chaotic, secretive, and inefficient way America finances health care, and he offers a penetrating ethical analysis of recent reform proposals. At this point, he argues, the United States appears to have three stark choices: the government can make the rich help pay for the health care of the poor, ration care by income, or control costs. Reinhardt proposes an alternative path: that by age 26 all Americans must choose either to join an insurance arrangement with community-rated premiums, or take a chance on being uninsured or relying on a health insurance market that charges premiums based on health status.
An incisive look at the American health care system, Priced Out dispels the confusion, ignorance, myths, and misinformation that hinder effective reform.
Stay tuned. Relatedly, see my posts going to "An American Sickness" and "Are we overcharged for health care?"


ALSO OF NOTE

My latest Science Magazine hardcopy arrived today. Loaded with cool stuff, including this (firewalled, alas):
Building upon foundations for evidence-based policy
There is no natural constituency for evidence-based policy. It should, by rights, be the public who wants the most from their government (and their public funds). But the public, like most politicians, is often not aware of the ins and outs of evaluation methods and evidence. Think tanks and academics have long filled this gap and will likely continue to play key roles. But legislation signed into law in early 2019 could transform the way U.S. government officials design programs by introducing more scientific evidence into the process…
Very interesting. I will be all over this stuff. I'm already dissecting the legislation it cites.

ERRATUM


We need "evidence-based" deliberation more than ever.
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More to come...

Friday, May 10, 2019

KHIT.org, Day One of Year Eleven


OK, where do I go from here?


Monday, May 10th, 2010 I launched this solo pro bono effort as our QIO/REC work commenced on the (now widely mocked) ONC Meaningful Use initiative. While it began as sort of an online "diary" of my work, I've taken it topically wherever I thought broadly useful and relevant. I will likely continue with that M.O. going forward. I have some specific ideas I'm not yet ready to reveal as we continue to try to fully settle in from our crazy move to Baltimore. Stay tuned.

Ten years. Eligible to be tried as an adult.

SOME NEWS

Researchers Now Have Even More Proof That Air Pollution Can Cause Dementia

A few years ago I stood in a cramped trailer beside the busy 110 freeway in Los Angeles as researchers at the University of Southern California gathered soot thrown off by vehicles pounding by just a few yards from their instruments, which rattled whenever a heavy truck passed. I was there to learn about how scientists were beginning to link air pollution—from power plants, motor vehicles, forest fires, you name it—to one of the least understood and most frightening of illnesses: dementia.

At that time, as I reported in Mother Jones, the research implicating air pollution as one factor that can contribute to dementia was alarming, consistent, and, ultimately, “suggestive.” Since then scientists have published a wave of studies that reveal that air pollution is much worse for us than we had previously imagined.  The evidence is so compelling, in fact, that many leading researchers now believe it’s conclusive. “I have no hesitation whatsoever to say that air pollution causes dementia,” says Caleb Finch, gerontologist and the leader of USC’s Air Pollution and Brain Disease research network, which has completed many of these new studies. In terms of its effects on our health and welfare, Finch says, “air pollution is just as bad as cigarette smoke.” This evidence arrives alongside the alarming news that air quality is actually worsening for many cities in the United States, while the Trump Administration continues its effort to delay or roll-back environmental safeguards…
But, hey,


My late Dad spent the last seven years of his 92 in dementia-addled befuddlement in VA long-term care. It was not fun.

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More to come...

Thursday, May 9, 2019

Health Information Technology news items

THE OTHER BIG LESSON WE SHOULD LEARN FROM THERANOS

LAST MONTH, IN a Safeway supermarket in Casa Grande, Arizona, Akos Med Clinics opened the “medical clinic of the future,” which uses augmented reality, artificial intelligence, and telemedicine to treat patients who walk in. It was the 11th Akos clinic in the state, each one tucked inside of a Safeway.

The pairing of clinic chain and supermarket chain has been fortuitous, Akos executives say. To start, there is the natural parallel between the speed and efficiency of self-checkout at the supermarket and the speed and efficiency of the Akos clinics. Just as there is no cashier at self-checkout at Safeway, there is no doctor or nurse at an Akos clinic. Instead patients are guided by AR-enabled computers to record basic measurements of themselves—weight, temperature, blood pressure, and blood oxygen content—as well as images of their ear, nose, and throat, and sounds made by their chest, lung, and abdomen.

The results are relayed to the company’s headquarters, where a medical professional speaks to the patient via video linkup, so-called telemedicine, and is aided in diagnosis by artificial intelligence. There is an assistant at the clinic who can perform blood tests as a follow-up or call 911, if needed; prescriptions can be emailed to a pharmacy.

Akos has found Safeway super­markets a good fit in another way too—the markets had plenty of clinic space available, recently built. A different company had abruptly abandoned its dream of using supermarkets and pharmacies to host its new medical technology. You may have heard of the outfit. It’s called Theranos…
Ahhh... Theranos.

Good article. Read all of it.
...These innovations assume that the problems with the medical system—the unaffordability, the lack of doctors in some areas—cannot be fixed through collective action (Medicare for all comes to mind), but must be cleverly managed.
In other words, medical hacks, masquerading as medical solutions.
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"CHIPHIT?"
Consolidated Healthcare institutions, Insurance companies, Pharmaceutical companies and Health Information Technology companies (CHIPHIT complex)
From The Health Care Blog.
"...If we hope to have the healthcare system we need, society must redirect resources away from the CHIPHIT complex and into the hands of those who unambiguously prioritize a holistic, high quality, low cost and egalitarian healthcare system."
Assumes facts not in evidence, Your Honor (not that I disagree with the sentiment).
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ERRATUM


I launched this blog 10 years ago tomorrow (that's 332.045 Scaramuccis). Thanks for reading it. I've tried to effectively address the gamut of issues. And I will continue, on a broader scale. Stay tuned.

The latest on our stressful transcontinental move, btw.
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More to come...

Monday, May 6, 2019

“We are eroding the very foundations of our economies, livelihoods, food security, health and quality of life worldwide”

- atmospheric chemist and IPBES chair Robert Watson


Read the report. We are running out of time. Prior related topical posts here.

UPDATE

New book coming out soon.


Read The Atlantic article adapted from it, "The Peculiar Blindness of Experts." Very important stuff.
...[T]he track record of expert forecasters—in science, in economics, in politics—is as dismal as ever. In business, esteemed (and lavishly compensated) forecasters routinely are wildly wrong in their predictions of everything from the next stock-market correction to the next housing boom. Reliable insight into the future is possible, however. It just requires a style of thinking that’s uncommon among experts who are certain that their deep knowledge has granted them a special grasp of what is to come...
Among others, I am reminded of those who call themselves "futurists." They even have their own Professional Association.
People like "Nobody knows more about ________ than me" Donald Trump never pass up an opportunity to assert that experts are always wrong about everything. Consequently, we must do our best to get substantive things right, notwithstanding that the possibility of error is always with all of us.
I ask again; is there a "science of deliberation?" We certainly need it.
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More to come...

Margalit Gur-Arie is at it again

Yikes...

The Medicare For All Heptagon

I am going to make a prediction here. No matter who we elect in 2020, Bernie or Trump or anything in between, Medicare For All is not going to happen in America. One can run an electrifying campaign on the promise of Medicare For All, or indignantly against it, but this is pure theater on both sides. I don’t know if God can make a rock so big and heavy that even He can’t lift it, but I do know that government can make corporations so big and powerful that even government itself can’t break them.

For decades our government encouraged the health care industry to consolidate vertically, horizontally and obliquely so it can achieve “economies of scale” and therefore lower consumer prices. In the last couple of decades, the government also compelled the industry to computerize its operations, because technology makes everything better and cheaper. Once the resulting monopolistic behemoths were summoned into existence, it was time to nationalize the whole lot, into one super monopoly, with super technology and super economies of scale. The only other example of such government monopoly in America is the Military.

Obviously, our standing armies must be, by definition, a national monopoly, but note that the Navy is not building its own ships and the Air Force is not building its own planes and the Army is not manufacturing tanks. The government is contracting with private suppliers for pretty much everything, from butter to bullets. The Military Industrial Complex is a network of very large and utterly corrupt contractors for the government, yielding more power over foreign and fiscal policy than Congress, the President, and all citizens put together, while delivering practically nothing either on budget or on time. A powerful Military is essential to America’s safety and global success, so we grind our teeth and keep paying. And medical care for hundreds of millions of people is at least as important.

I am not entirely sure how people think Medicare For All is going to work. Are you folks envisioning an angry President Bernie dragging Samuel Hazen into the Oval, wagging his finger at him and making an offer Mr. Hazen cannot refuse? Something like, “I will pay $50 per head and not a penny more, because health care is a human right, and if you want to be a disgusting millionaire or billionaire, go write a bestselling book, like I did…”, at which point Mr. Hazen will be hanging his head down in shame and gratefully take the $50 deal. Upon his return to Nashville, Mr. Hazen will immediately schedule book writing workshops for all HCA department chiefs to compensate for cutting all salaries in half. Yeah… no, that’s not how this works.

Go ask Northrup Grumman or Lockheed Martin or General Dynamics or even Boeing or Booz Allen or any other “beltway bandit” how getting money from the Feds really works. There are well-greased revolving doors between the Pentagon and its contractors. There are stock options and executive positions for high ranking Federal employees. There are 535 people in Congress responsible for allocating budgets, and all 535 are for sale. Most of this infrastructure is already in place for health care too and building the HHS Heptagon shouldn’t take very long. The American President has little to no power over Federal spending, and even less so when it comes to large procurement contracts, as the current occupant of the White House discovered the hard way, during the Lockheed F-35 kerfuffle.

Clearly large health systems will survive and thrive under a Medicare For All law, but how about private health insurance? Future President Bernie says they will all be banned. Is that so? Currently a full third of Medicare beneficiaries are insured and “managed” by a handful of large private health insurers. Medicare is paying those private contractors fixed amounts of money per head for their services. Medicaid is doing the same for most of its beneficiaries, and all military health insurance (TRICARE) is contracted out to the usual suspects. Basically, the vast majority of people covered by public insurance, are really insured by gigantic insurance corporations. Fact: under the hood, taxpayer funded health care is the bread and butter of private health insurance companies.

When future President Bernie and the hordes of uninformed supporting characters in the 2020 elections festival say that private health insurance will be banned, they are lying to you. What will be banned under a Medicare For All law, is your ability or your employer’s ability, to purchase health insurance directly from a private company. Instead, the government will procure contracts in bulk as it sees fit, assign people to them as it sees fit, and pay for these contracts with tax revenue as it sees fit. Just like they pay for battleships, fighter planes, bombs, tanks and such.  The United States Military is known for lots of great things. Value-based purchasing, and cost-effectiveness in general, are not among those things.

Depending on who you ask and what is included in the definition of health care, Medicare For All is projected to cost between three and four trillion dollars per year, which is five times the amount we spend on the Military. This number is calculated based on costs under current law, minus the waste generated by the cacophony of hundreds and thousands of different insurance plans, different health care facilities and their too many to count service and product vendors. The projections do not include the effects of the inevitable massive consolidation of everything health care into a dozen or so Federal contractors, able and willing to demand multi-billion dollars contracts for services worth a few million dollars at most on the open market. Remember the Obamacare marketplace website? Multiply that by orders of magnitude and you have Medicare For All.

Medicare For All is as egregious a misnomer for this plan as the Affordable Care Act was. When they say Medicare For All, they mean Federal government procured health insurance for all. When they say everything soup to nuts will be covered, they mean everything the heavily indebted Federal government thinks should be covered, and can afford to cover, will be covered. When they say health care will be better, more plentiful and much more affordable, they mean please vote for me in 2020. Medicare For All will be built on the largely immovable foundation our government chartered and nurtured for half a century. If you want a glimpse into a Medicare For All future, go look at any Medicaid Managed Care plan in any impoverished southern State, and look at the balance sheets of the associated contractors and sub-contractors.

It doesn’t have to be this way. We don’t need to bulldozer everything we have, and we certainly don’t need to pretend that we can, or that we must. And we need to remember that the proper role of government in a free country is not to manage the health or the care of all its citizens. Free people are not the wards of a State responsible for keeping them healthy, productive and happy. The role of a democratic government is to keep predators, foreign and domestic, including corporate ones, at bay, while providing a sturdy safety net for the few who cannot care for themselves. Let’s do that instead. It will be better, faster and cheaper than the fictional construct called Medicare For All.
I don't agree with Margalit on everything, but I have to seriously respect her views.

This stuff will be a dominant concern in the 2020 campaign, as it was in the recent mid-term.
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More to come...

Saturday, May 4, 2019

Another "Omics" in the health care space

My wife just passed along this Washington Post article to me.
"Doctors who are kind have healthier patients who heal faster, according to new book"
I bought and downloaded the book. Thanks, Cheryl. Add another branch to the "Omics," 'eh?

Stay tuned.


From the Amazon blurb:
A 34-year-old man fighting for his life in the Intensive Care Unit is on an artificial respirator for over a month. Could it be that his chance of getting off the respirator is not how much his nurses know, but rather how much they care?

A 75-year-old woman is heroically saved by a major trauma center only to be discharged and fatally struck by a car while walking home from the hospital. Could a lack of compassion from the hospital staff have been a factor in her death?

Compelling new research shows that health care is in the midst of a compassion crisis.
But the pivotal question is this: Does compassion really matter?

In Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference, physician scientists Stephen Trzeciak and Anthony Mazzarelli uncover the eye-opening data that compassion could be a wonder drug for the 21st century.

Now, for the first time ever, a rigorous review of the science - coupled with captivating stories from the front lines of medicine - demonstrates that human connection in health care matters in astonishing ways. Never before has all the evidence been synthesized together in one place.

You will see compelling evidence that:

  • Compassion has vast benefits for patients across a wide variety of conditions
  • Missed opportunities for compassion can have devastating health effects
  • Compassion can help reverse the cost crisis in health care
  • Compassion can be an antidote for burnout among health care providers
  • 40 seconds of compassion can save a life
After seeing all the evidence, the answer is crystal clear: Compassion matters...in not only meaningful but measurable ways.
We shall see. From the Foreword by Senator Cory Booker:
We are often led to believe that sentiments like compassion, love and kindness are expressions of weakness rather than signs of strength. And we are often all too ready to give in to the false belief that meanness somehow equates to toughness and that empathy is empty of power... [Kindle location 168]
"...meanness somehow equates to toughness..." Remind you of anyone of late? Hmmm...

I look forward to studying this book. I have to think that one reason I sailed through my SAVR px last August was the empathic, compassionate care of my cardiac surgeon and his team.

I left a comment under the WaPo article.
There is good scientific evidence that prosocial behaviors--up to and including the altruistic (sorry, Ayn Rand)--have evolutionary "adaptive utility." See, e.g., Tomasello's "A Natural History of Human Morality." Which simply makes sense when you fully reflect on it. "Nature may be red in tooth and claw, but it is not merely so." - Sam Harris. 

I just bought the book and will report on it at KHIT.org ASAP.
ONE FURTHER NOTE

The author of the WaPo article has a heavy duty Sheet and a new book out.


"The science of happiness?" There's that word "science" again. More stuff to study and evaluate.

ERRATUM

"Physicists, philosophers debate whether research can ever solve certain mysteries of the universe—and the human mind"
Well, duhhh.. Seriously? Scientific American, no less. My favorite Hastie & Dawes quote: "Two Cheers for Uncertainty."

C'mon, think about it.
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More to come...