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Tuesday, July 12, 2016

Movement from informal to formal processes in medicine

I have had a robust exchange with colleagues regarding how one should acknowledge another physician's opinion in the medical record. I am of the mind that the only opinion that one should write in the record is your own. I have no desire for any of my colleagues to record my opinion in their notes, unless they forward those for me to sign or write an addendum.
However, my opinion on this activity is not held universally, not by a long shot. Within other fields, especially radiology and pathology, there is a long tradition of bedside clinicians visiting and consulting these specialists, in their "houses". Rounds used to start in radiology and there would be extensive discussions with care teams, resulting in radiologist opinions being paraphrased in the medical record. Whether what the radiologist intended to communicate routinely ended up in the notes on the floor is not so clear.Similarly, glass slides routinely circulate in Pathology departments and colleagues are called upon to render inter-departmental consults, ranging from formal to very informal. The language incorporated into various reports may include a host of concurrences from physicians whose signature never appears on the final report.
Historically, critical decisions in medicine, especially in the most challenging of cases, were often made after generating a form of consensus, whether that consensus was derived from Grand Rounds, tumor board, or informal solicitation of opinions. The transcripts from these conferences and informal activities were generally non-existent and the consensus recorded tended to be ephemeral and biased through the lens of whomever wrote something in the chart. It may have been heavily influenced by one or a few strong and charismatic clinicians who would sway the audience based upon their confidence and experience. 
All of these activities were highly informal processes. Individual attendees tended to take away what they wanted to take away and the patients cared for had little or now idea what actual conclusions were drawn and how they were arrived at. They were simply informed that we had a conference and the agreement of the group was, whatever. Individual accountability and hard evidence was not something on the radar. 
Looking back nostalgically, we believe that these activities enhanced patient care, irrespective of the actual outcomes. They certainly made the care teams feel better and there was a certain simplicity and finality which appeared to be achievable which does not appear to be achievable now.  While the human contact did unquestionably facilitate communication, the model was not scalable. It depended on small groups who were familiar with everyone involved. The decision trees were not so arborized. The information to be managed was on a much more limited scale.
It is a different world now. We aspire to do more, much more which requires much more complex systems to manage. The teams are larger and the workloads more specialized. Communication becomes even more essential under these conditions and when communication fails, we ascribe those failures to leaving the informal systems behind. However, when systems become more complex, informal communications will not suffice. Each decision branch point, which may be dependent upon particular fidelity on terms of information transition, becomes a possible pitfall. A process with three steps has a much lower failure rate than one with five, or ten, or fifteen. Informal verbal communications are fraught with error and should not serve as the foundation for critical information flow.



Sunday, July 10, 2016

People can be strange and unpredictable

I am reading a book titled "Heaven's Ditch: God, gold, and murder on the Erie Canal". It is quite an interesting story, about the best of humanity, the worst of humanity, and the weirdness of humanity, all wrapped up in one nice package. The best is the fact that in the early part of the 19th century, the Erie canal was built. It took vision, chutzpah, drive, and incredible people. It was an engineering marvel which fundamentally changed the course of history in the US. The worst is that many of those involed were simply awful people who did awful things to other people.

However, it is the weirdness background which simply blows me away. The canal was built in western New York during a time of great religious revival. It was not just religious revival but all forms of spiritual, mystic, and magical thinking. It was where Joseph Smith's family ended up before the trek west. People became wrapped up in all manner of superstition. Joseph Smith, before he found the gold tablets and launched the Mormon sect, was one of may people who used special stones he placed in his hat to see the future. People, including Smith, were using divining rods to find casks of money buried in the ground.

While among my peer group currently, the acceptable facade to display is one of rationality and linear thought (sort of Mr. Spock like), I think this is not how many (most?) people really operate. Beneath the facade there are a jumble of emotions which can drive some peculiar behavior. Most of the peculiar behavior likely can be characterized as quirky and some of it as annoying. It then can go on to move into the territory of very odd, strange, really strange, and then downright disturbing. With enough concentration of people, likes can link up and amplify the quirkiness and strangeness. The internet has been very conducive to this. The fun end of this spectrum is where things like DragonCon reside. At the less benevolent end you might find congregations of people with more sinister motives.

I don;t think there has been any real fundamental change in the underlying DNA. There have always been people who have been at the fringes, did not play well with others, and/or simply had evil motives. If they were charismatic and could convince others to team up and do nasty acts, they could cause great destruction. However, individual actors were very limited in their reach. With great effort they could harm to a few others. Weirdness did not translate to far reaching effects.

Technology has greatly leveraged human capabilities. However, it has also leveraged the ability of individuals to cause great harm to many people. Anarchists more than 100 years ago began this using bombs to target populations. We were distracted for a while from this by wholesale slaughter by state actors and then the cold war and worry about state mediated thermonuclear annihilation. Now, this same phenomena is back.

It is hard to believe that single person human capability in terms of destruction can be scaled back. States may do their best to control armaments in the hands of their populace (with or without the second amendment), but progress in terms of miniaturization and energy concentration is not likely to stop. Research efforts to place more powerful and easily used tools in the hands of soldiers will invariably mean that the fruits of these endeavors ends up in the hands of ordinary people. It has happened with granola bars and it will happen with weapons.

I think this has happened to some degree in the past.  Throughout history, various parties have held monopolies on violence and those monopolies were disrupted by transitions of power and weapons into other hands. No state power means anarchy and chaos, while nothing but state power means totalitarianism. We do not want the constant war of every person against every other person but we do not want to cede total control to a unilaterally armed state because a few bad actors don't realize they are better off by giving up the right to annihilate those around them.

And what we are back to is the realization that people can be strange and unpredictable and we have to live with that.


Saturday, May 21, 2016

I am incedulous that this activity has not received more attention!

From the Washington Post today(Link). This is an op-ed piece from Nicholas Quinn Rosencranz regarding the Justice Department's settlement with various large banks which included the requirement for donations to various community development groups.
What is less well known is that some of this money — amounting to hundreds of millions of dollars — is designated for “donation” to various “community development” organizations that were neither parties to the case nor victims of the alleged wrongdoing. Investor’s Business Daily has characterized these payments as “political payoffs to Obama constituency groups,” and Congress is now considering banning this practice with the Stop Settlement Slush Funds Act of 2016.
How bizarre!  The constitutional issue is obvious. The settlement represents money paid to the Federal government which is then appropriated to pay another party, without any Congressional approval. What we are seeing as the discretionary portion of the Federal budget essentially disappears is the use of DOJ shakedowns of private entities for cash then used to repay politically connected.

How can we better the world?

Deirdre N. McCloskey published what I consider a spot-on piece today in the WSJ. (Link) It is titled "How the West (and the rest) got rich". It is well worth reading in its entirety and I will almost certainly pick up a copy of her new book, “Bourgeois Equality: How Ideas, Not Capital or Institutions, Enriched the World,” .


I am fascinated by why certain systems work well while other systems do not and I have come to believe that functional complex systems develop not because of intelligent design, but because of innumerable trials resulting in many failures and few successes. Thus the great enrichment is described by Dr. McCloskey. The essay is eloquently written and I thought it useful to highlight some of the most pithy parts.
Nothing like the Great Enrichment of the past two centuries had ever happened before. Doublings of income—mere 100% betterments in the human condition—had happened often, during the glory of Greece and the grandeur of Rome, in Song China and Mughal India. But people soon fell back to the miserable routine of Afghanistan’s income nowadays, $3 or worse. A revolutionary betterment of 10,000%, taking into account everything from canned goods to antidepressants, was out of the question. Until it happened.
Why did it happen? McCloskey goes on to write:
But none of the explanations gets it quite right.
What enriched the modern world wasn’t capital stolen from workers or capital virtuously saved, nor was it institutions for routinely accumulating it. Capital and the rule of law were necessary, of course, but so was a labor force and liquid water and the arrow of time.
What appears to have catalyzed this were ideas and liberty:
The capital became productive because of ideas for betterment—ideas enacted by a country carpenter or a boy telegrapher or a teenage Seattle computer whiz. As Matt Ridley put it in his book “The Rational Optimist” (2010), what happened over the past two centuries is that “ideas started having sex.” The idea of a railroad was a coupling of high-pressure steam engines with cars running on coal-mining rails. The idea for a lawn mower coupled a miniature gasoline engine with a miniature mechanical reaper. And so on, through every imaginable sort of invention. The coupling of ideas in the heads of the common people yielded an explosion of betterments. 
Power hungry statists and control freaks on both the left and right have been suspect of both liberty and change and have repeatedly attempted to vilify commercial interests which have been the drivers of growth and change:
Not everyone was happy with such developments and the ideas behind them. In the 18th century, liberal thinkers such as Voltaire and Benjamin Franklin courageously advocated liberty in trade. By the 1830s and 1840s, a much enlarged intelligentsia, mostly the sons of bourgeois fathers, commenced sneering loftily at the liberties that had enriched their elders and made possible their own leisure. The sons advocated the vigorous use of the state’s monopoly of violence to achieve one or another utopia, soon.
Intellectuals on the political right, for instance, looked back with nostalgia to an imagined Middle Ages, free from the vulgarity of trade, a nonmarket golden age in which rents and hierarchy ruled. Such a conservative and Romantic vision of olden times fit well with the right’s perch in the ruling class. Later in the 19th century, under the influence of a version of science, the right seized upon social Darwinism and eugenics to devalue the liberty and dignity of ordinary people and to elevate the nation’s mission above the mere individual person, recommending colonialism and compulsory sterilization and the cleansing power of war.
On the left, meanwhile, a different cadre of intellectuals developed the illiberal idea that ideas don’t matter. What matters to progress, the left declared, was the unstoppable tide of history, aided by protest or strike or revolution directed at the evil bourgeoisie—such thrilling actions to be led, naturally, by themselves. Later, in European socialism and American Progressivism, the left proposed to defeat bourgeois monopolies in meat and sugar and steel by gathering under regulation or syndicalism or central planning or collectivization all the monopolies into one supreme monopoly called the state.
McCloskey summarizes:
Rep. Thomas Massie, a Republican from Kentucky, had the right idea in what he said to Reason magazine last year: “When people ask, ‘Will our children be better off than we are?’ I reply, ‘Yes, but it’s not going to be due to the politicians, but the engineers.’ ”
I would supplement his remark. It will also come from the businessperson who buys low to sell high, the hairdresser who spots an opportunity for a new shop, the oil roughneck who moves to and from North Dakota with alacrity and all the other commoners who agree to the basic bourgeois deal: Let me seize an opportunity for economic betterment, tested in trade, and I’ll make us all rich.
I agree with McCloskey that political entities may create the necessary framework for betterment but there are limits as to what politics can accomplish. You cannot fix a fine watch movement with a ball peen hammer. Some might argue that enrichment is not a desirable end. I would suspect most of those making those claims do not live in abject poverty.  
 

Sunday, May 15, 2016

How do we know who is a good doctor?

I am a following "the Incidental Economist" (Link) and Healthcare Triage News. Aaron Carroll blogged on pay for performance programs and wrote a commentary late last year on measuring quality (Link).  There was also an article in today's NYT examining narrow networks and limited access for patients to providers outside of their designated networks (Sorry, we don't take Obamacare - link). What do these items have in common? What they have in common is the need to be able to measure quality. Who care if you are locked into a narrow network if it delivers what you need well? We all sort of lock ourselves into narrow networks when we end up selecting specific physicians to deal with our health care problems.


As I see it, we have a very basic problem in that more often then not, those needing services are really not in a position to discern whether a given physician (or other health care provider) is really good at what we need them to be good at. (When I use the term physician, please view it as a short hand for health care professional delivering a service). Obviously for those physicians who do very specific life saving or function saving targeted interventions, we may be able to sort through who is at the top of the heap v. those at the bottom. Even that can be tricky. A good set of outcomes for an orthopedic surgeon who replaces hips may be due to the fact they are in a position to cherry pick or a less than optimal set may be due to them being the go-to person for difficult cases.


Even more challenging may be within the larger universe of providers who do deliver services where it is difficult to impossible to define what quality is? One can march through the different specialties in medicine and it is the exception rather than the rule that clear criteria can be defined which allows any given person to identify who delivers high quality care.  How does one determine whether a gastroenterologist is good at colonoscopy? Yes, one can look at complication rates but the primary purpose of the exam is not simply to avoid trouble. You can always avoid the complication of the procedure by not doing it. How can one determine if a thorough exam was actually done? Are more biopsies better than fewer? What are the actual deliverables? A similar situation may be relevant for dermatologists? What represents a good skin exam? How can this be measured?  For primary care physicians, what constitutes a good or excellent annual check up? Who is doing the best pelvic exams? Who is the best pathologist? Is it the ones who diagnose the most or the least cancers? How can one discern who are the best pediatricians?
Those with great technical skills may have less than optimal judgement, work ethic, or interpersonal skills. What problems do given physicians within specific specialties actually solve and just how good a job do they do in solving these problems? What information do we have at our disposal to address these issues? We do have the annual best doctors issues for local publications for most major cities. However, the selection process for these is a popularity contest which reminds me of elections for class president when I was in high school. It takes into account essentially no quality data. Furthermore, does any actual quality data linked to a given doctor or other provider reflect the physician competence or other aspects of the team over which they have little control?


It is not an unusual circumstance where I am asked by a friend to make a recommendation for care within my system. I know a number of my colleagues on a personal level but truth be told, I really have very limited insight into what type of physician they actually are. I have basically little or no access to hard numbers in terms of whether they solve the problems of patients who they see. There are exceptions (primarily those who I work with every day)  but for the most part I have not directly and consistently witnessed the bedside manner of most of my colleagues or have clinically significant knowledge regarding the quality of their problem solving skills.


Then move into a domain where people have marginal medical knowledge, experience, and insight and imagine how they make these determinations. They simply are flying blind. Patients and their families can determine if someone spends time with them, listens, and makes an attempt to communicate. These observations are important but may not track with the ability to fix whatever problem that needs to be fixed. The may be especially true when the services delivered are done so for goals which may be realized well in the future. Patients can be very impressed with the quality of a service delivered that they did not actually need. One can generate impressive numbers if one is in the business of delivering preventative care for diseases that never or only rarely happen.


This brings us back to the original question; what can we measure to determine who is the best? Perhaps even more important is what can we measure to determine who is simply good enough? Not everyone can access the best and always spending money to get the best may be a bad investment of someone's scare resources, especially if the stakes are not so high.  How can patients tell if the providers available within their networks will likely be able to meet their basic needs and goals?  I believe the path to being able to address this problem will require inputs from both those delivering care and those receiving care. It will mean looking at both high stakes environments and lower stakes environments. It will unquestionably require that we better define what the specific goals of care are. Service delivery without goals can never fail. As the saying goes if you have no destination anywhere you end up should be fine. Similarly service delivery without measurable goals can also never fail and service delivery where the measurements are not aligned with the patient goals will almost always fail.


The fact that measuring what is expedient has ended up not getting us to where we want to be should not come as a surprise and should not prompt us reject striving for measuring outcomes. For us to sink more and more money into an industry which has dismal quality control is simply not an option.

Tuesday, April 26, 2016

Intergrative health and CAM- delivering what people want as opposed to what we think they need

I colleague sent me a link to a blog from the British Medical Journal written by Timothy Caulfield entitled "The straw men of integrated health". Link


In this blog Tim Caulfield pretty much completely debunks the defenses proffered for CAMs in general However, it may not really matter because Mr. Caulfield perhaps misses the point. Mr. Caulfield, whose most recent book "Is Gwyneth Paltrow wrong about everything", believes we are mislead by celebrity and deceived by pseudo-science. He is probably right about the science but he is misled but what the actual deliverables are.


His book appears to be written to target people like me. (I have not yet read it but probably will). I use my plodding and non-reptilian brain to  sort through evidence and make plodding and thoughtful decisions. However, the target for his blog and book are people who make decisions to randomly avoid gluten and do cleanses because it makes them feel good about themselves. They could give a rip about any double blind control trials. They do a veggie purge which gives them a terribly satisfying sense of control and they feel great, at least for a while.


Human brains are complicated things and emotions are even more complex. The scientific basis of medicine and the deliverables in the health care realm used to be hard stops, literally. We intervened so that people would not die. It is a relatively easily measured endpoint and snake oils and witchcraft did not move the needle much. When modern antibiotics and modern acute care techniques came on the scene, these interventions quickly rendered less effective (or not effective) approaches to the dustbin of history.


We now have moved into a totally different realm of health care deliverables. People have the luxury of taking living for granted and have moved on to feeling good, feeling in control,  and worrying about the future. We in the scientific realm have not moved the needle much regarding making people happy. There are entrepreneurial sorts who peddle all sorts of compounds which some people crave and make them "happy" albeit for a brief period of time. There also are all sorts of downsides to many of these compounds.


Much of the population is either depressed, insecure, anxious, worried, or somewhat unfulfilled. This is a huge market and nature, abhorring any sort of vacuum, fills this will any number of people with a host of interventions. Some are activities (running, swimming, Lladro collecting, civil war reenactment, mission trips to Haiti), some are spiritual endeavors (praying, meditation, chanting), some appear to be deviant (cross dressing, pedophilia), and others dance around medical interventions. Many seem to make people feel better. None really make any scientific sense.


However, this is not a scientific issue, at least at this point. Perhaps at some point in time someone may be able to connect the dots and demonstrate how any particular activity or behavior makes a given person feel good. We are not likely close to that now.


I guess my point is Gwyneth Paltrow and the CAM crowd should not drape their decisions with the mantle of scientific legitimacy. However, the scientific community should stop telling people what they should or should not do to make them feel good about themselves.


This also has implications regarding what is defined as health care and what insurance pays for. In his Atlantic piece, he dove deeply into the movement of healthcare from addressing acute illnesses to addressing lifestyle concerns and risks of future disease link. The insertion of CAM into this discussion is a natural evolution of this trend. Will we end up requiring payment for CAM by third party payers?





Sunday, April 17, 2016

Shorting health care

Within the world of finance, people and organizations can make very bad bets and invest huge sums of money in very bad investments. Look at the 2008 housing bubble collapse. Massive sums of money went into building homes for people who could not afford them. Certain very astute investors saw the mismatch and placed bets against where most of the money was going. As the movie "The Big Short" showed, they were viewed initially as crazy and then as visionary. They ultimately served an important function in redirecting investment away from poor investments.


Within health care, we are also investing huge sums of money into a variety of investments. I am not talking about specific stocks or equipment but instead I am referring to our investments of specific clinical care delivery activities with the idea that these investments will result in better health returns for individual patients. For example, does the investment of time, money, and effort on every patient over age 50 years of age getting an annual physical have any real tangible return on this investment? If not, why is this investment of resources not like buying penny stocks? My question is, how can I short the annual physical?