Search the KHIT Blog

Saturday, June 29, 2019

In Memoriam

Former NYPD detective and heroic 9/11 First Responder Luis Alvaraz has succumbed to the cancer caused by his months of daily combing through the World Trade Center wreckage and its lethal hell of toxins.


Tuesday, June 25, 2019

Define "science"

OK, continuing my riffs begun by "define 'evidence'" and "define 'expert'"--do we all mean the same thing by the word "science?"

Physicians are usually quick to point out that the word "cancer" actually denotes a host of diseases that share not only core etiologic similarities but also significant clinical differences. Similarly, when we say "science" are we really alluding to many "sciences" that differ materially (and range from heuristically "soft" to algorithmically "hard")?

Dr. Rudolph's book has thus far got me off down a number of interesting rabbit holes.

...[W]hen I began studying to be a science teacher in college, I was surprised to learn that there was no such thing as the scientific method. That was certainly the message my science-teaching methods professor instilled in us. He taught that the focus of our teaching instead should be on something called “scientific inquiry,” the details and complexities of which we learned about from an early 1960s essay by a University of Chicago professor by the name of Joseph Schwab.

Rudolph, John L. (2019-05-31T23:58:59). How We Teach Science. Harvard University Press. Kindle Edition.
Schwab, 'eh?
...Joseph Schwab (1909–1988), a contributor to the innovative Biological Sciences Curriculum Study (BSCS) high school biology course materials, who advanced our understanding of inquiry-based instruc- tion. He enrolled in the university at age 15, earning undergraduate degrees in English and physics and later a doctorate in genetics (Westbury and Wilkof 1978). Schwab worked at the University of Chicago for over 50 years, where John Dewey had set up the Lab School and where educator Ralph Tyler (1902–1994) became well-known for his work in curriculum development. 

The phrase “teaching science as enquiry” is conspicuous in a 1962 lecture by Schwab at Harvard University titled “The Teaching of Science as Enquiry.” Schwab preferred the use of enquiry to inquiry, because he disagreed with the ideas surrounding inquiry then being promoted, especially by psycholo- gists. His idea of enquiry instruction was to teach students about the major paradigms of science, that is, the manner in which a certain community of scientists view a major idea and the way they investigate it. In his lecture, Schwab urged science educators to stress the conceptions of science and how they change over time. He placed a premium on how scientists view the ideas (content) they are developing and how these ideas shape what scientists do and say about the data they collect. Science should not be viewed as dogma, he said, but as revisionary and fluid. Teachers misrepresent science when they present it as a rhetoric of conclusion or as a finished product..
. "Historical development of teaching science as inquiry."
"Inquiry" vs "enquiry?" Any substantive connotative difference there, or just "you say 'tomato' I say 'tomahto?'
BTW, regarding "educate," my grad school program director and mentor, the late Dr. Craig Walton, was fond of asserting that the etymology of the term is "e-ducere,"--to elicit, draw out, which requires of the learner both persistent, wide-ranging curiosity and a "critical thinking" mindset. Differs fundamentally from "instruction" and training.
 Back to John Rudolph (apropos of my KHIT-related interests):
Discussions of scientific methodology typically erupt publicly when the authority or the legitimate scope of science is in conflict with other social or cultural norms, knowledge systems, or local claims. The sociologist Thomas Gieryn has referred to these moments as boundary disputes. In debates over what does and does not count as science, what gets ruled in (as science) is allowed the authority to decide what counts as true. While a boundary dispute centers on the question of where the line between science and non-science is drawn, the decision about where to make that demarcation almost always hinges on an interpretation of process or methodology...
"Climate change," anyone? We know what Donald Trump "thinks."


Dr. Rudolph also makes considerable note of this:

You can buy the Kindle version for $9.99 or read for free it online.


Over the course of human history, people have developed many interconnected and validated ideas about the physical, biological, psychological, and social worlds. Those ideas have enabled successive generations to achieve an increasingly comprehensive and reliable understanding of the human species and its environment. The means used to develop these ideas are particular ways of observing, thinking, experimenting, and validating. These ways represent a fundamental aspect of the nature of science and reflect how science tends to differ from other modes of knowing.

It is the union of science, mathematics, and technology that forms the scientific endeavor and that makes it so successful. Although each of these human enterprises has a character and history of its own, each is dependent on and reinforces the others. Accordingly, the first three chapters of recommendations draw portraits of science, mathematics, and technology that emphasize their roles in the scientific endeavor and reveal some of the similarities and connections among them...
OK, that publication is necessary and good, but 25 years old. What have we accomplished? Where are we of late in terms of "science cred?" From "Research!America"-
From natural disasters to an opioid epidemic that prompted a public health emergency declaration, science was at the forefront of events that shaped our nation in 2017. National public opinion surveys commissioned by Research!America throughout the year revealed that a majority of Americans agree that public and private sector research is critical to better health, economic growth, global competitiveness and more. While the perception of science and scientists is positive, based on survey findings, scientists and our nation’s scientific enterprise remain largely invisible to the public.
The public overwhelmingly (82%) considers scientists trustworthy spokespersons for science, far above elected officials and the media. This level of trust includes an expectation that scientists will be the primary messengers for scientific issues, even those with policy implications. More than half of Americans agree that scientists should play a major role in shaping public policy in many areas, not only in medical and health research, but also in education (58%), infrastructure (55%) and national defense (51%). Americans recognize that science plays a role in their well-being, where they live, work and play. Yet many are unaware of the science community and those responsible for scientific advances. A strong majority of Americans (81%) cannot name a living scientist, more than two-thirds (67%) cannot name an institution, company or organization where medical or health research is conducted, and less than a quarter (21%) know that medical research is conducted in all 50 states. The findings have been consistent over the past decade, indicating the need for stronger engagement between scientists and the public.
A strong majority of Americans (71%) say they have confidence in scientific institutions compared to only 31% for Congress and 46% for the Presidency. When asked if great strides in science and innovation will continue while Donald Trump is President, opinions were divided (46% agree, 33% disagree and 22% not sure), with more Republicans (74%) than Independents (44%) and Democrats (22%) agreeing. Furthermore, a significant number of Americans (79%), including strong majorities across the political spectrum, agree that it is important for President Trump to assign a high priority to putting health research and innovation to work to assure continued medical progress (85% of Democrats, 79% of Republicans and 72% of Independents). As we pivot towards midterm elections in 2018, it is important for scientists and science advocates to ask candidates about their level of commitment to research and innovation to ensure a healthier and more prosperous future for our nation.
OK, back to the top. Define "science." See "Our Definition of Science" by the UK Science Council.
Science is the pursuit and application of knowledge and understanding of the natural and social world following a systematic methodology based on evidence.
 Ahhh... "evidence." That which makes a true conclusion more likely (or "proves" it, best case).
I searched "Science for all Americans" from beginning to end. The word "evidence" appears 57 times. Not once is there any definition of what the word means. It is simply assumed that we all have the same understanding. Is that OK? No biggie? BTW, the word "evident" shows up eight times, again with the assumption that we all know what is meant.
Chapter 9: Project 2061 and the Nature of Science

If the period from the mid-1950s through the 1960s was the golden age of science education, with its unprecedented levels of federal funding and involvement of bill laureates and other top scientists, the decade of the 1970s into the first half of the 1980s represented an era of comparative neglect. Attention to academic subjects in schools declined with the new political emphasis on urban poverty and concerns about the regressive nature of formal education that arose in the late 1960s with the more liberal views of the rule of schooling in American society. At the same time, the image of science in public favor in these years as a result of his association with environmental degradation, on one hand, and with militarization and the Vietnam War, on the other. This shift in educational priorities along with the new critical views of science led to conditions of general decline in science education that raised alarms among the scientific elite.

Those worries were felt acutely by the leadership of the American Association for the advancement of science, prompting its executive director, William Carey, to recruit Jim Rutherford in 1981 to lead a new effort to rebuild science education across the nation. Rutherford came to the AAAS from his stint as assistant director for education at the National Science Foundation the position as assistant secretary for research and improvement at the newly established Department of Education. He was someone earlier with the levers of change, such as they were, in the American educational system Rutherford's immediate task was to move education to the top of the AAAS agenda, and specifically to enact elements of a January 1981 resolution passed by the Association's Board of Directors quote to reverse the damaging decline of science and engineering education in the United States."

The challenge Rutherford-based was profitable. Since the mid-1970s, science education had been pushed to the margins of public consciousness, and the crushing recession along with the education version of the newly installed Reagan administration made prospects for any federal initiatives bleak. "It is easy enough to say that business and industry, the scientific and engineering societies, and the foundations are to pick up the slack," Rutherford wrote to a friend. But it wasn't clear to him at the time what those institutions could do to really make a difference. What was obvious to Rutherford was that a long-term plan was needed rather than some fixed. As he saw it, his job was to develop something that quote the Association can stick with the decade or longer that it takes for anything to have a lasting impact on our complex educational system."

Rutherford told the possibilities in the summer of 1982. The scientists of the 1950s had had the shock of Sputnik and the military threat from the Soviet Union to help usher reforms into the schools. The biggest threat of the 1980s, however, was economic — from Japanese automobile imports, for example. Grasping for something bold and symbolic, Rutherford latched onto Halley's comet — a satellite of a different sort. It seemed to fit the bill. The famous comet, he noted, was due to appear that October, the same month as the 25th anniversary of the Sputnik launch, and it would be 75 years before it would return again. What sort of changes might take place in our civilization between those visits? Used Rutherford. Looking at the dramatic changes that had occurred between prior flybys, he concluded that "we cannot accurately describe the world as it will be when Halley's comet next returns." However, he asserted, we do know that "the changes that will be brought about in our culture, in our way of life, will have more to do with the utilization of science and technology than with anything else."
What was needed, and Rutherford's view, was an entirely new approach to science education, one that would prepare children born in 1986 — the year of the comet would make its closest pass by Earth — to live in the scientific and technological 2, when those students would grow up to work, have children, eventually retire, and live to see the comment return in the year 2061. The length of time between sightings gave Rutherford the Longview he and AAAS were looking for to avoid yet another crisis driven crash program that was unlikely to produce meaningful and enduring change. Project 2061, as he named it, was bold and imaginative, clearly something outside the typical educational reform box. Its central goal was to articulate "what understanding of science and technology will be important for everyone in tomorrow's world" and then to work towards realizing that goal in a systematic way... [How we teach science, pp 180-182]
I encourage everyone to read the entirety of Project 2061 material. And buy and read John Rudolph's book. And join AAAS.


I've previously cited this fine book:


Another important historical read. Lots of overlap with "How We Teach Science."

What's my point here? Go back to my "Is there a 'science of deliberation'?" What do we mean by "deliberation?"
When you encounter the word "deliberation," what typically comes right to mind? Jury service, yes? I'm looking into the psychology of that as well. (Excellent book.) Also, in my grad school program, deep and thorough "moral deliberation" was our constant focus ("Ethics & Policy Studies").
Finally for now, is there really such a thing as "Data Science?" Or that mostly another Bright Shiny Thing marketing hook for expensive, institutionally lucrative graduate school programs?

Stay tuned, Not done by any stretch. Juggling a lot of bowling pins this week.


Science Based Medicine rocks.
Media Literacy Is Key
Media literacy is an important component to teaching science and critical thinking. We’ll add that to our to-do list.

Educating the public about medical myths and misconceptions has various challenges. The psychological deck seems to be stacked against us. It’s easier to scare people with possible risks than to reassure them with facts. People tend to be more compelled by emotional anecdotes than dry data. There is something inherently compelling about conspiracy theories that attract many people. People are good at remembering dramatic details, but poor at remembering whether or not they are true and what the source of the information is.
But perhaps the most profound factor making our job difficult is that once an idea has taken root in someone’s mind, it is remarkably difficult to change. Humans are instinctively good at motivated reasoning and confirmation bias. We see what we want to see, remember the bits that support our narrative, and can rationalize away pesky things like logic and evidence. The result can be a powerful, even overwhelming, illusion of confident knowledge, even in notions that are patently absurd. We can then erect elaborate defenses around these beliefs to protect them from reality…

There are basically three types of preventive education that are likely to reduce susceptibility to pseudoscience. The first is scientific literacy. There is some controversy over how effective this is, however. A few decades ago the “knowledge deficit model” was dominant, and the prescription for belief in pseudoscience was to teach people science. However, recent research has not been kind to the knowledge deficit model. You cannot usually change someone’s mind about an emotionally held belief with just information…

…You can move the needle a bit with public education about certain topics. Sometimes beliefs are based more on misinformation than emotion or identity, and if you correct that misinformation you can change beliefs. This is very topic specific, and also is affected by the kind of information you give and how it is presented. For example, global warming denial is strongly predicted by political ideology, and not at all by scientific literacy. However, vaccine denial does correlate with low scientific literacy, which implies that science education can be a mitigating factor…

The second type of education is critical thinking. This relates more directly to the point about narratives. Critical thinking is about metacognition, knowing how to think with a valid process that is self-reflective and therefore potentially self-corrective. If someone understands exactly how conspiracy thinking is a cognitive trap, they are less likely to fall into that trap. Critical thinking and scientific literacy is a powerful combination – this is essentially what we mean by scientific skepticism, which is exactly what we are doing here (in the realm of medicine)…
'eh? Read all of it. This is why SBM is a requisite daily stop for me. As is The NeuroLogica Blog.

apropos, see my prior post "Selling science: effective communication with decision makers."


I continue to plumb "How we teach science" (while finishing up two Game Theory books).

My path here thus far has been cut-to-the-chase circuitous (an expedient MO I employ when I trust an author and the book lends itself to a non-linear read): Introduction, Chapter 1, Chapter 10, Conclusion, Chapter 4, Chapter 6, Chapter 7.

Final words:
The continued focus on students mastering scientific practice—doing science—in the hopes that some of these larger, contextual understandings will come along for free seems misguided. Perhaps the last word on this is best left to Schwab. During the Golden age of science curriculum reform, he warned that many science classrooms were "being converted into research microcosms in which every high school student, regardless of interest and competence, is supposed to act, on a small scale, like a scientist." This, unfortunately, seems to be where the current emphasis lies as well (when it isn't on the technical content of science itself). And Schwab noted to that such an approach was poorly suited to accomplishing if a understanding of the nature of scientific work. Given the choice between teaching about scientific inquiry and having students engage in the actual process of inquiry, "it is the former which should be given first priority," as Schwab said. Understanding what science is and how it works in the social context of our time is the necessary end for which we need to strive if, in Schwab's words, "we are to develop the informed public which our national need urgently demands." [How we teach science, pp. 230-231]


I forgot to cite my earlier post "Is there a science of success?"


All of the foregoing brings me back to my initial core KHIT concern--science-based, optimally effective health care, aided by technology where appropriate. Today I reflected on a book I bought in hardcopy back some time ago. It's now available in Apple iBook format, which I rarely use.

Well, lookeee who shows up right off.

Foreword by Harlan M. Krumholz, MD, MS 
Medicine is an information science. In an earlier era, medicine moved from religion to science via laboratory work on the mechanism of disease. Doctors improved their results by reflecting on the likely cause of disease and the likely response of an individual to a treatment based on that understanding of disease. Although many benefitted from that approach, others were harmed because assumptions were not sufficiently tested empirically. There was a recognition that advances in the lab needed to be supplemented with more rigorous studies in patients, especially when the benefit was modest and not easily demonstrated. Moreover, as these studies grew, the need for doctors to be able to manage the information, understand it, and apply it wisely also grew. 

Today, the expert clinician must have a command of information and know how to apply it. There is more attention than ever on the quality of treatment decisions and the assumptions that underlie them. The key to knowing how best to synthesize the available information and produce the best recommendations and decisions requires an appreciation of cognitive science...


Medical education tends to focus on medical content. We teach the facts and emphasize what is known. We often assume that if we apply the facts and rules, as an engineer applies principles and equations, we can solve most medical problems. But clinical medicine is not engineering—there are simply too many missing pieces, too much uncertainty. When faced with uncertainty, we inevitably use reasoning. But medical education gives the process of medical reasoning short shrift and rarely teaches it explicitly. We diligently teach the “what” but students often learn the “how” on their own...

This book does not present any great discoveries but, instead, synthesizes ideas that have been hiding in plain sight for years. During the past three decades, the field of cognitive psychology has developed a substantial literature on decision making but somehow hasn’t had much influence on doctors, who make tough, nuanced decisions every day. I am not a cognitive psychologist, but I have learned a great deal from Herbert Simon, Gerd Gigerenzer, Daniel Kahneman, Gary Klein, and others whose work on intuition and heuristics is directly relevant to medical decision making. Influenced by the work of Ian Hacking, I have included some introductory ideas about probability, logic, and statistical inference. I am also steeped in the literature on clinical reasoning by authors such as Alvin Feinstein, Larry Weed, Jerry Kassirer, Harold Sox, David Sackett, Pat Croskerry, Donald Redelmeier, Jerome Groopman, and Kathryn Montgomery. I continue to learn about medical reasoning from many colleagues, too numerous to list, and I hope that this book accurately reflects their teaching…
Pretty cool, I have to say. BTW: See my 2014 riff on "The Art of Medicine."

More to come...

Tuesday, June 18, 2019

Well, Jeez, I guess we can all just pack it up and go home now

Courtesy of Science Based Medicine.

A timely development, given that
U.S. Health Care Ranked Worst in the Developed World

The U.S. health care system has been subject to heated debate over the past decade, but one thing that has remained consistent is the level of performance, which has been ranked as the worst among industrialized nations for the fifth time, according to the 2014 Commonwealth Fund survey 2014. The U.K. ranked best with Switzerland following a close second…

Although the U.S. has the most expensive health care system in the world, the nation ranks lowest in terms of “efficiency, equity and outcomes,” according to the report. One of the most piercing revelations is that the high rate of expenditure for insurance is not commensurate to the satisfaction of patients or quality of service. High out-of-pocket costs and gaps in coverage “undermine efforts in the U.S. to improve care coordination,” the report summarized…
Donald Trump, Oct 2016 rally in Florida
Yeah, right. Of course.

Speaking of "science," a new book review is up in AAAS Science Magazine.

Compared with reading, writing, and arithmetic, science is a relative newcomer to the primary and secondary school curriculum, emerging only in the late 19th century. Nevertheless, proponents of the subject have established it as central to what an educated person needs to know, not least because of the promise of good jobs in scientific fields.

Even if nearly every school district in the United States now treats it as a required subject, there has been almost no consensus on what science classes should entail. Some have claimed that the subject should be taught as a single methodology, presenting the scientific method as a fixed number of discrete steps. Others emphasize it as a disparate collection of techniques—some inductive, others deductive, and divided up into specific disciplinary approaches. Teachers have disagreed on whether it is best taught through textbooks or laboratory experiments, as a set of conclusions and facts, or as a mode of inquiry. Most contemporary scientists would agree that there is no single method for doing science, but beyond that, there has not been much to agree on…
I've not gotten to this one yet. Totally burrowed into two books on "Game Theory" at the moment.


I now have a hardbound copy of Dr. Rudolph's new book (cited above), courtesy of the the author. I've been skulking around his website, finding therein a motherload of cool stuff (albeit paywalled) going to my KHIT interests. e.g.,
What Do We Mean by Science Education for Civic Engagement?
John L. Rudolph and Shusaku Horibe

Accepted 16 November 2015

Abstract: One of the most frequently cited goals for science education over the years has been to provide students with the understanding and skills necessary to engage in science-related civic issues.
Despite the repeated insistence on the importance of this kind of democratic participation, there has been little effort in the research community either to define just what science-related civic engagement entails or to ask whether the research or practices in the field are suited to accomplishing this goal. In this paper we take a step toward this end by offering a precise definition of science-related civic engagement drawing on work from the fields of philosophy and political theory. We argue that such engagement can be found in instances requiring both the use and production of scientific knowledge and examine the various avenues of that engagement. We then explore some implications such a definition might have for thinking about science education research and practice.

© 2015 Wiley Periodicals, Inc. J Res Sci Teach 53: 805–820, 2016
Keywords: civic engagement; democratic participation; science-related social issues

Most educators, policy makers, and researchers with even a passing interest in science education would agree that a central goal of teaching science is to prepare young people to deal with science-related issues they are likely to encounter in their lives as citizens. Explicit references to this civic goal are found nearly everywhere. In their landmark statement of scientific literacy, Science for All Americans (1989), Rutherford and Ahlgren, for instance, insist that science education should equip people to “participate thoughtfully with fellow citizens in building and protecting a society that is open, decent, and vital” (p. xiii). Nearly two decades later, we find policy documents making the same connection between science education and its value in civic settings. In the National Academy report Taking Science to School (2007), the ability to “know, use, and interpret scientific explanations” and “generate and evaluate scientific evidence and explanations” are among the key “strands of proficiency” necessary for individuals to “participate in society as educated citizens”…

An Inconvenient Truth About Science Education
by John L. Rudolph - February 09, 2007

The teaching of global warming is emerging as a hot-button issue in U.S. schools. One district has begun to treat the subject as something akin to evolutionary biology—a subject some feel is more conjecture than scientific fact. This raises important questions about how well science education in this country has prepared the public to deal with the science behind the leading socioscientific issues of our time. More content isn’t the answer. What’s needed is greater attention to how science is actually done in all its variety.
The first speaks to "Deliberation Science." The latter goes to "Anthropocene Global Warming Denial."

Stay tuned.
BTW, I continue to work my way through two books on "game theory," as I noted above--one of them highly mathematical, the other more prose logic-oriented. I'm reminded of one of our old musician jokes: "Q: Do you read music? A: Not well enough to hurt my playing."  Equivalently, "Q: Do you know game theory? A: Not well enough to get in the way of my reasoning skills."
"All models are wrong. Some models are useful." - George Box


Back when I was working for the HealthInsight REC ("Meaningful Use" program) I routinely bit the hand that fed me when I felt it was warranted. Among other irreverent things, I posted a spoof "Certified EHR" site I called "Clinic Monkey" (tangentially riffing on Survey Monkey, which we used all the time).
When I put it up I embedded "under the hood" an mp3 autoplay endless loop file of ambulance sirens and jungle critters screeching and yacking, for comic effect. No longer works in Safari. I think it's an html thing, no longer supporting the old legacy "embed code." Whatever. It was funny.
One morning I got to the office and found a toy set of simian "office workers" on my chair. One of my colleagues had bought it for me. A Clinic Monkey admirer, no doubt.

Off to the garage I go forthwith after work.

BobbyG's on-the-fly Dollar Store photoshoot cyc.

Yeah, I have an Attitude. One frowned upon by the Really Serious (and snark-challenged) People. It's OK to lighten up.

More to come...

Sunday, June 16, 2019

On Father's Day

My first kid was born 51 years ago, her sister two years later, then their brother Matt (our last surviving child) 36 years ago.

Every day is Father's Day for me. Wishing all of you dads well.

Friday, June 14, 2019

June 2019 EHR interoperababble update

From THCB:
Electronic health records (EHRs) are a polarizing issue in health reform. In their current form, they are frustrating to many physicians and have failed to support cost improvements. The current round of federal intervention is proposed rulemaking pursuant to the 21st Century Cures Act calls for penalties for “information blocking” and for technology that physicians and patients could use “without special effort.”

The proposed rules are over one thousand pages of technical jargon that aims to govern how one machine communicates with another when the content of the communication is personal and very valuable information about an individual. Healthcare is a challenging and unique industry when it comes to interoperability. Hospitals spend lavishly on EHRs and pursue information blocking as a means to manipulate the physicians and patients who might otherwise bypass the hospital on the way to health reform. The result is a broken market where physicians and patients directly control trillions of dollars in spending but have virtually zero market power over the technology that hospitals and payers operate as information brokers...
The draft rules for interoperability, CMS, ONC, TEFCA, USCDI are over a thousand pages. Most of the complexity stems from a design that avoids direct patient direction and transparency the way we expect banking and other automated services. This approach fragments the patient and physician experience and poses privacy and security risks that may never be solved. On the other hand, an interoperability design based on patient-designated sharing with clinicians that voluntarily post their digital contact info (personal, group, or institution) works across the full range of patient data (behavioral, HIPAA, patient-generated) and provides patients and family caregivers the transparency and accountability over health services that we need. Allowing patients to specify their authorization server further simplifies things by enabling competition for the authorization service – a digital concierge – that would give market power to individuals and deliver the pro-competitive benefits the Rule seeks.
"Banking and other automated services?" I have to voice some dubiety with respect to that apples-to-oranges analogy. "Allowing patients to specify their authorization server further simplifies things by enabling competition for the authorization service." Right, so we'll still have multiple competing architectures.


A hardy perenennial.
No amount of calling point-to-point interfaced data exchange "interoperability" will make it so.

Interestingly, I've spent a good bit of the day trying (with frustratedly limited success) to download my medical records in anticipation of my first patient visit next week at Kaiser. Muir (my last provider system) is on Epic. Kaiser is on Epic. You'd think that would be easy. You'd be wrong. My hernia surgery a year ago was via a surgeon at Bass Medical Group. Owned now by Muir, but on a different platform still. The urologist who dx'd my prostate cancer in 2015 was with NorCal Urology. Bought by Muir, but using NextGen (I think they've now migrated). My radiation oncology tx group was Diablo Valley Oncology and Hematology. Yet another EHR platform, one whose patient portal is useless.

I'm just going to have to write my own summary "progress note," comprised of Active Problems, Active Meds, CC, PMH, PSH, HPI, FH, SH, etc., to save the new M.A. a bit of intake time.

More to come...

Tuesday, June 11, 2019

Crowdfunding health care

This HuffPo piece caught my eye on my iPhone.

While health insurance or government programs like Medicaid and Medicare can shield against huge medical bills, massive debt and even bankruptcy, only the truly wealthy can feel secure that sickness won’t lead to financial ruin.

This is why thousands of Americans have turned to crowdfunding website GoFundMe in the last decade to help cover medical bills and related costs. HuffPost is profiling some of those people, and what their stories reveal about the shortcomings of the American health care system.

These are not feel-good stories.

That’s often how the news media cover these fundraisers ― focusing on the generosity of individuals giving rather than the systemic failures that created the need. While it’s hard not to be inspired by successful campaigns and the fortitude of those suffering through terrifying ordeals, such stories portray a chilling reality that Americans ― even those with good jobs and health insurance, can be one bad day away from financial ruin.

A serious disease can put financial strain on people even in countries with universal health care systems and strong safety nets. But the United States, which has neither of those things, leaves its residents uniquely vulnerable…
In my more cynical moments, I might have written the title as "Inside America's Go[Bleep]Yourself Health Care System."

Both of my late daughters died well beyond flat broke from their respective cancers. There was no "GoFundMe" in the 1990's when Sissy was ill. Her younger sister Danielle, however, got a bit of OoP and "bucket list" benefit in 2017-18 from a crowdsourcing account set up by one of her friends.

As I ponder my new Kaiser Permanente Medicare Advantage membership, my max annual OoP (out-of-pocket) caps at $6,700--plus monthly premiums of $51 ($612 for a year, even if I never use them, though I will have ongoing Rx co-pays).

I lost track of my 2018 OoP. Suffice to speculate that it was well beyond $6,700, in light of my hernia and SAVR surgeries. I know my (BS) "Chargemaster" 2018 tally on my final EoB was close to $600k.

Tangentially, as recently reported by STATnews, one family in Iowa took things to a whole 'nuther level:
When ‘right to try’ isn’t enough: Congress wants a single ALS patient to get a therapy never tested in humans
...“What about other patients who can’t afford this kind of access and don’t have this kind of political clout? Should people be contributing to a GoFundMe that is extremely unlikely to lead to benefit? What are we doing to patients when we advance this spirit of fighting disease at all costs?”
Read all of it, including the fractious comments. Tough, tough case.


How will we pay for the coming generation of potentially curative gene therapies?
Senator Bill Cassidy, MD (R-LA)

We have arrived at a special moment in health care. Innovative, life-changing gene therapies are here that will cure or ease debilitating diseases. Yet these expensive treatments are entering a market structure that was not built to price them…
...Life-changing gene therapies are coming. We must give thought now on how to determine the price of these innovative, new-age treatments and how to finance them to ensure that we realize their full, beneficial potential while also ensuring that society can pay for them...
Another good STATnews item. No amount of crowdfunding will suffice in this area. More broadly, there's a bit of "market" condundrum with respect to "precision / personalized medicine," no? A "market of one?"


Firewalled, but we get the point.

"The U.S. health system has been carefully structured, often through enabling legislation triggered by special interest groups, to allow the supply side of the health care sector to extract enormous sums of money from the rest of society. Nowhere is this clearer than with specialty drugs, whose prices per year of treatment now routinely exceed $100,000. Yet on Capitol Hill, this system has always had its staunch defenders, for obvious reasons."

Reinhardt, Uwe E.. Priced Out (pp. 145-146). Princeton University Press. Kindle Edition. September 2016 Princeton interieww.
The Worst Patients in the World
Americans are hypochondriacs, yet we skip our checkups. We demand drugs we don’t need, and fail to take the ones we do. No wonder the U.S. leads the world in health spending.

…For years, the United States’ high health-care costs and poor outcomes have provoked hand-wringing, and rightly so: Every other high-income country in the world spends less than America does as a share of GDP, and surpasses us in most key health outcomes.

Recriminations tend to focus on how Americans pay for health care, and on our hospitals and physicians. Surely if we could just import Singapore’s or Switzerland’s health-care system to our nation, the logic goes, we’d get those countries’ lower costs and better results. Surely, some might add, a program like Medicare for All would help by discouraging high-cost, ineffective treatments.

But lost in these discussions is, well, us. We ought to consider the possibility that if we exported Americans to those other countries, their systems might end up with our costs and outcomes. That although Americans (rightly, in my opinion) love the idea of Medicare for All, they would rebel at its reality. In other words, we need to ask: Could the problem with the American health-care system lie not only with the American system but with American patients?...
Yeah. Recall my prior post "Can medicine be cured? Some views from across the Pond"

More to come...

Sunday, June 9, 2019

Exploiting Doctors and Nurses

Danielle Ofri, MD, in the New York Times:
…If doctors and nurses clocked out when their paid hours were finished, the effect on patients would be calamitous. Doctors and nurses know this, which is why they don’t shirk. The system knows it, too, and takes advantage.

The demands on medical professionals have escalated relentlessly in the past few decades, without a commensurate expansion of time and resources. For starters, patients are sicker these days. The medical complexity per patient — the number and severity of chronic conditions — has steadily increased, meaning that medical encounters are becoming ever more involved. They typically include more illnesses to treat, more medications to administer, more complications to handle — all in the same-length office or hospital visit.

By far the biggest culprit of the mushrooming workload is the electronic medical record, or E.M.R. It has burrowed its tentacles into every aspect of the health care system.

There are many salutary aspects of the E.M.R., and no one wants to go back to the old days of chasing down lost charts and deciphering inscrutable handwriting. But the data entry is mind-numbing and voluminous. Primary-care doctors spend nearly two hours typing into the E.M.R. for every one hour of direct patient care. Most of us are now putting in hours of additional time each day for the same number of patients.

In a factory, if 30 percent more items were suddenly dropped onto an assembly line, the process would grind to a halt…
Read the entire piece. I've cited Dr. Ofri on numerous occasions and have read her books and articles.

The E.M.R. is now “conveniently available” to log into from home. Many of my colleagues devote their weekends and evenings to the spillover work. They feel they can’t sign off until they’ve documented all the critical details of their patients’ complex medical histories, followed up on all the test results, sorted out all the medication inconsistencies, and responded to all the calls and messages from patients. This does not even include the hours of compliance modules, annual mandates and administrative requirements that they are expected to complete “between patients.”
According to their latest available IRS 990 (2017), the CEO of the Health Information Systems Management Society "non-profit" trade association (HIMSS) is paid about $1.25 million a year. I'm sure he's a very busy person.
As must also be the CEOs of Johnson & Johnson and Pfizer, each of whom earn close to $30 million annually.
The average primary care doc makes about $225k, according to Medscape.


Yeah, it's a decade old. I'm confident that the trend has neither flattened nor reversed.


Monday morning rounds. Saw this cited at The Incidental Economist:

What makes us healthy?

We have an intuitive sense that things like what we eat, how much we exercise, the quality of our water and air, and getting appropriate health care when sick all help us stay healthy, but how much do each of these factors matter?

Studies have also shown that our incomes, education, even racial identity are associated with health — so-called “social determinants of health.”

How much do social determinants matter? How much does the health system improve our health?
Certainly worth following. 'The Drivers."

More to come...

Saturday, June 8, 2019

How good is Kaiser's Medicare Advantage plan?

Cheryl and I are fixin' to find out first-hand.

What are the Pros and Cons of Switching to a Medicare Advantage Plan?

Medicare Advantage, also known as Medicare Part C, makes it possible for people with Medicare Part A (hospital insurance) and Part B (medical insurance) to receive their Medicare benefits in an alternative way. Medicare Advantage plans are offered by private insurance companies contracted with Medicare and provide at least the same level of coverage that Medicare Part A and Part B provide.

You may be wondering which is the better choice: sign up for a Medicare Advantage plan or Original Medicare. There isn’t a simple answer because Medicare Advantage plans have key features that many people find attractive and other characteristics that may not match with your personal preferences and/or lifestyle…
Among the upshots of our recent move from the CA Bay Area to Baltimore was being involuntarily disenrolled from our SilverScript Medicare Part-D Rx coverage ("out of service area"), and seeing a huge premium increase in our high-deductible MediGap Part-F plans (mine was about 30% compared to last year).

During the Christmas holidays, through our future daughter in Law Eileen, we'd come to know Dr. George Brouillet, orthopedic surgeon and former President of the Maryland Medical Association. He provided us with a list of area internal med docs to check out.

None of them were taking new patients. So much for "unrestricted choice of doctors" vs "HMO."

We discussed taking a closer look at Kaiser Permanente. I'd covered a number of their HIT Conference presentations across the years, and then we got caregiver in-your-face close-up looks once Danielle was diagnosed in March 2017 (she'd signed up for KP the year before via "Covered California")

We attended a KP pitch presentation, and watched a version of this:

We ran the comparative numbers once home. No longer need Rx Part-D or our Humana Medigap monthly premiums. Net financial benefit, though, quickly becomes inscrutable.
Our KP sales rep was candid to say that we could compare their plan to that of their principal competitor--Johns Hopkins.
Kaiser is on Epic, as is Muir (where I've been a patient since 2013), so records interop transfer should be "relatively" straightforward.
BTW, KP's Maryland Advantage plan is essentially a hybrid Staff + Network "capitated/risk" HMO model. No "medical underwriting."
After a rough initial start (incompetent, indifferent Primary who should count herself lucky I didn't come after her license), Danielle's KP care was uniformly top-shelf, notwithstanding that Kaiser lost their shirts on her.

We signed up. We shall see how our experiences shake out. Stay tuned.

More to come...

Thursday, June 6, 2019

Uh-oh, someone's "feeling dark lately."

Margalit is at it again. Cross-posted.

For over a decade Washington DC has been busy with fixing health care. For over a decade, the same government bureaucracy, the same advocacy (read lobbying) organizations, the same expert think tanks, the same academic centers, the same business associations, with the same people hopping around from one entity to the next, have been generating and applying the same “innovative solutions” differentiated solely by their aggrandizing names. The result? Health care is more expensive than ever. More people than ever can’t afford to seek medical care. More doctors are disheartened, to the point of committing suicide. All this while the illustrious transformers of health care are accumulating fame and riches, probably exceeding their own expectations, with no end in sight.

It is no secret that back in 2016 many of us voted for Donald Trump hoping that he will “drain the swamp” or at the very least blow it all up into a spectacular artesian fountain of filth. He didn’t and he won’t. The swamp won. Our special health care swamp is deeper and wider than most, and the Trump administration is making it deeper and wider than ever before.  The single payer lobby is simply proposing to move the existing health care swamp to a bigger and more noxious location, so it has plenty of room to expand in the future. The swampy strategy for fixing health care has always been, and by the looks of it will always be, a game of hot potato. The potatoes are us.

At the core of the guileful verbosity of health care transformation there is nothing more than an elaborate effort to shield corporations, and the governments that serve them, from financial risk. It’s really that simple. We pay our premiums and our payroll taxes, month after month, year after year, and when the time comes, if it comes, they’d much rather not pay the medical bills they are contractually or statutorily obligated to pay. Blame sick people for being sick. Blame the sick for not shopping the clearance aisle. Blame doctors for treating the sick. Blame hospitals for admitting too many sick people, too often and for too long. Punish them for the errors of their ways. Teach them a lesson or two. And most importantly, make them pay until it hurts.

Managing the Health Care Consumer
The most blatant attempt to throw people under the bus is the insanely brazen effort to remake medicine into a consumer industry. Patients, according to the narrative, are empowered when they spend their own money on health care. Increasing deductibles for health insurance, while also increasing premiums and limitting choice of service providers, is how we weaponize sick people in the war against rising health care prices. If enough diabetics choose to die rather than overpay for insulin, prices for the drug will surely go down eventually, because Southwest Airlines will come up with a disruptively innovative version of insulin that will not be as fancy, but it will be cheap enough to spur increased market participation and push Eli Lilly into bankruptcy. Any day now.

The return to pre-1965 days of consumerism in health care for the first $6,000 of medical expenditures was a good step forward, but the road to fully optimized profitability is long and full of terrors. Consumers are like goats. If left to their own devices, they will destroy your landscape in five short minutes. However, with proper guidance and supervision, they will clean and protect your property from the dangers of random wild fires. Managed Care insurance plans, coupled with high deductibles, ensure that consumers do not eat into your nice profits, while consuming enough garbage to keep your bottom line from going up in smoke.

From Volume to Value
Offloading risk to sick consumers is working relatively well by all accounts, but it is not working well enough, and it is not working for beneficiaries of public insurance where the consumer lever is rather short and limp. And so, we push the “provider” lever next. Once patients became consumers, their doctors, naturally, became providers. And just like empowered consumers, empowered providers should have some financial skin in this game. In the current system, you see, providers are just sitting there, placidly watching the register go cha-ching every ten, fifteen minutes like clockwork. If the consumer gets better, fine. If not, also fine. As long as there are no malpractice lawsuits, and the cash keeps flowing, providers are surely satisfied. How do policy makers and garden variety health care experts know this? Simple. It’s called projection.

Moving “from volume to value” does not mean moving from indiscriminate overconsumption to eclectic consumption of excellence. It means moving from lots of variably priced stuff to small amounts of cheap stuff. It means moving from assumed abundance to assumed scarcity. If you can find excellence at the Dollar Store, good for you. If you can’t, well, whatever. Saks Fifth Avenue is out of bounds. And your provider is supposed to enforce those boundaries, at his or her own risk. If you manage to sneak into Saks, your provider will be punished. If you stay where you belong, your provider will be rewarded. Simple. It’s called stewardship.

Global Budgets
This is not fair. Obviously. These very clever risk levers are based on wealth, and since we have massive wealth inequality, the levers are largely discriminatory. Wealthy providers couldn’t care less about adding or removing a dollar from each patient visit. Poorer providers can be driven out of business by a fifty cents difference in “reimbursement”.  Wealthy patients don’t have to become consumers at all. For patients who are not wealthy enough (or poor enough), even the Dollar Store is cost prohibitive. There is too much privilege at the top. The only fair solution is to shut down Saks Fifth Avenue completely. If everybody is forced into the Dollar Store, eventually the Dollar Store will get better. It will become as good as Saks, but at $1 prices, because the wealthy will demand it. Right.

Shuttering the Saks Fifth Avenue of health care is hard. You can’t just show up at Bayonne Medical Center one morning with a wrecking ball and have at it. Fortunately, the Medicare For All aficionados have a solution: Global Budgets. Once the Federal government controls all health care dollars, they give Saks Fifth Avenue a fixed amount of money to service all their customers for the year. The amount of money is calculated based on Dollar Store costs, with a little markup perhaps, so we don’t appear overly vindictive. Within a few months, you won’t be able to tell the difference between a Saks store and a Dollar Store, except maybe the crumbling façade from a bygone era. That’s how we rid ourselves of inequality and excess privilege, of course.

Remember when Paul Ryan and his evil acolytes proposed replacing the open-ended Medicaid financing model with block grants to States (i.e. fixed amount of Federal money to service all their Medicaid beneficiaries)? There is a one hundred percent overlap between the people who screamed about millions dying in the streets if Medicaid moves to block grants, and the people now climbing the Medicare For All barricades in support of global budgets. Rationing medical care for the poor, or “by ability to pay”, is immoral. Rationing medical care for everybody, regardless of ability to pay, is righteous. Simple. It’s called justice.

A Permanent Solution
It is not surprising that health insurance companies would look out for their bottom line at customers’ expense. After all, these are insurance companies, like home insurance or car insurance, which are notorious for continuously devising innovative ways to minimize current and future payouts. Perhaps it is also not too much of a shocker to see that government is at its best when working to eschew commitments made to its citizens. What should however give you pause is that both government and health insurers seem to have finally found a good way to coopt physicians into doing their bidding. Not all physicians, of course, but more than enough to make a permanent difference in the practice of medicine. Either due to misplaced fear or newfound conviction, your doctor’s prime directive now is to do no harm to the United States Treasury and the corporations for which it shills. 
Trump. Agghhh...


apropos of nothing. But, yeah, this is us. Notwithstanding our having rid ourselves of another 3/4ths of our hardcopy books prior to the Baltimore move.

More to come...