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Sunday, December 7, 2014

Intentions are only part of the picture

I am no great fan of empowering the police to intervene in our citizens lives. I look at the current wave of outrage regarding police killing with a great deal of ambivalence. The deaths are a culmination of a host of circumstances and addressing police over reach will not be fixed easily. Drawing attention to these killings using protests is a step toward holding those responsible accountable. However, I believe it is reasonable to consider taking a broader view of who is accountable.

We need to remember who the police are and why they are employed. They are agents of the state and employed to enforce the law. The more laws and rules we have, the more we will need to employ police to enforce them. The more we desire to the state to micromanage the affairs of its citizens, the more intrusive the it becomes, through the actions of its enforcement agents which include the police.

At the most simple level, we need to understand that not all undesirable behaviors should be prohibited using the power of the law. However, that concept seems to be ignored as we increasingly embrace the view that many if not all undesirable actions should be curbed primarily via the use of state force.

Attempts to curb the use of alcohol resulted in an unmitigated failure which are understood under the term Prohibition. Prohibition (capital P) resulted in expansion of state powers, corruption of law enforcement, and creation of powerful crime syndicates. While prohibition of alcohol has all but ended, we have not abandoned a variety of other prohibitions (small P) including various drug prohibitions. They have has the same effects as alcohol prohibition and have been equally unsuccessful and perhaps even more destructive in terms of unintended consequences.

Prohibitions in general have resulted in resulted in expansion of police powers (all in the name of the war on drugs) and have served as the basis for civil seizure statues (blogged on earlier). The death of Eric Garner would not have happened if not for the state of NY heavily taxing cigarettes and creating incentives for creation of an underground economy.  Professor Stephen Carter is cited by Ilya Somin (Professor of Law at George Mason University) in the Washington Post (Link):
On the opening day of law school, I always counsel my first-year students never to support a law they are not willing to kill to enforce. Usually they greet this advice with something between skepticism and puzzlement, until I remind them that the police go armed to enforce the will of the state, and if you resist, they might kill you.
I wish this caution were only theoretical. It isn’t. Whatever your view on the refusal of a New York City grand jury to indict the police officer whose chokehold apparently led to the death of Eric Garner, it’s useful to remember the crime that Garner is alleged to have committed: He was selling individual cigarettes, or loosies, in violation of New York law…..

The problem is actually broader. It’s not just cigarette tax laws that can lead to the death of those the police seek to arrest. It’s every law. Libertarians argue that we have far too many laws, and the Garner case offers evidence that they’re right. I often tell my students that there will never be a perfect technology of law enforcement, and therefore it is unavoidable that there will be situations where police err on the side of too much violence rather than too little. Better training won’t lead to perfection. But fewer laws would mean fewer opportunities for official violence to get out of hand.It’s not just cigarette tax laws that can lead to the death of those the police seek to arrest. It’s every law. Libertarians argue that we have far too many laws, and the Garner case offers evidence that they’re right.

As Carter notes, “activists on the right and the left tend to believe that all of their causes are of great importance. Whatever they want to ban or require, they seem unalterably persuaded that the use of state power is appropriate.” But we should always remember that “[e]very new law requires enforcement; every act of enforcement includes the possibility of violence.” If we really want to curb police abuses, we should think carefully about whether all the laws we have on the books are really worth killing for.

All powerful tools have the potential to do great good or great harm.  

Politics, transparency, and appealing to our emotional brains

"It is hard to reason someone out of belief they did not reason into".  I am not sure where I heard this quote. I know it was not mine but I do not who to credit it to. However, it really summarizes what I observed in the last political season.

When the campaigns began, candidates for the most part tried to take the high road, appealing to the voters on the basis of intellect and reason. I came to realize that these appeals were directed to what Kahneman and Tversky called system two, our cognitive brains. However, as the campaigns progressed and became more competitive, the focus of ads changed. The term often used by the commentators was "going negative". I realized that going negative simply meant changing from focusing on the cognitive brains of voters to their emotional brains or what Kahneman and Tversky called system one.

It only makes sense to do this given the role that our emotional brains play in decision making. Politics will always ultimately be decided by emotion. We are emotional creatures. Move something into the political realm and this is what you should expect. Don't be surprised when this happens.

Recognizing that voters respond at an emotional level to issues they may not fully comprehend on a cognitive level may be interpreted as believing that voters are stupid. The world is so complex and the amount of information out there to assimilate to understand the huge universe of issues is beyond the comprehension of any given human. When we run into situations where we do not have all the information to make deliberative decisions, we default to using our emotional brains.

The arrogant pricks out there use these circumstances to call the public stupid. I use these circumstances to highlight why certain decisions should not be moved into political spheres.

Truth and Error - Tragedy in Charlottesville

I am reading a book by Kathyrn Schulz entitled "Being wrong: adventures in the margin of error". The chapter I am reading now is Chapter 4: Our minds, part one: Knowing, not knowing, and making it up. At the same time I have been listening to and reading about the accounts from the campus of the University of Virginia that first appeared in Rolling Stone magazine. I have realized that what is in Schulz's book is relevant to the events in Charlottesville.

Everyone who has read the accounts was mortified by just how awful the events described were. I have to admit that when my wife first told me about this and read me excerpts, I was very disturbed but there were elements to this story which began to remind me of the fantastic accounts of preschool molestations (nicely summarized in Wikopedia http://en.wikipedia.org/wiki/Day-care_sex-abuse_hysteria). When the preschool molestation cases broke, which were high profile stories for more than a decade and resulted in likely innocent people spending substantial time in jail, I had a difficult time how people could report such stories, which were ultimately found to be false.

The UVA rape story now also appears to be coming unravelled. The account provided by "Jackie" turns out to be riddled with inconsistencies, so many that it is hard to fathom how a magazine such as Rolling Stone could have released such a story, without what appears to be very basic due diligence.

An explanation for these events may reside in our brains and how we remember. Our brains are much less than perfect in terms what and how we remember things. For example, in her book Schulz describes a woman who was literally blind to her own blindness. When asked to described an object placed in front of her, she would described it in detail. The problem was she was blind, literally. Despite this reality she created a detailed description of what she thought she saw and fully believed that object was there. She was blind to her own blindness. While these examples represented an extreme case of blindness to error and current state, we all seem to exhibit blindness to our own realities and errors. As Schulz notes:
In sum: we love to know things, but ultimately we can't know for sure that we know them; we are bad at recognizing when we don't know something; and we are very, very good at making stuff up.
Which now brings me back to the controversies in Charlottesville. It seems that what people recall, particularly the details of especially traumatic events in their lives, is almost always wrong when examined later in their lives. Schulz tells the story of Ulric Neisser, who vividly remembered the day the Japanese bombed Pear Harbor (oddly enough 73 years ago today). The narrative he carried with him was that of a radio announcer interrupting a professional baseball game, telling the story of the surprise attack. Only later did he realize that the details of the story he carried with him were wrong.  Professional baseball is not played in December.

Neisser went on to become a psychology professor and study memory failure, calling into question dogma about the veracity of recalled memories. As it turns out, our recollections of events such as the Kennedy assassination, the Challenger disaster, and the Twin Towers disaster may seem vivid but are almost always wrong, despite feeling so right. The numbers are pretty staggering. Neisser studied the Challenger disaster, asking students details the day after it happened and then three years later. Less than 7% of the second reports matched the initial reports. 50% were wrong in 2/3 of their assertions and 25% were wrong in every major detail.

How does this relate to what has happened in Charlottesville? The story broke two years after the events happened, although even the timeline must be called into question. When something happened is simply another detail which may or may not be recalled correctly. How does one call into question the recollections of someone who suffered a traumatic event without accusing this individual of lying or making things up? It seems that the norm is to recall things with many errors and it should not come as a surprise that her account has serious inconsistencies. All accounts of events in the past will have errors and we will be blind to them.

Truth can only be verified by some sort of recording which is done at the time of the event which ideally can be done independent of human filtering. That is a reality we have to live with. We will be frequently wrong but unfortunately often not in doubt, even when we might be completely wrong.

Saturday, October 11, 2014

Civil Asset Forfeiture

I was trolling my usual set of blogs and came across this video of John Oliver (John Oliver). It is truly frightening. I am not sure how we have gotten to the current state, but it seems that we have empowered various law enforcement entities to take our property without cause. The stories he tells, which are similarly recounted in recent stories written in the New Yorker and the Washington Post (washingtonpost asset forfeiture), are strangely reminiscent of tales of local speed traps, only much worse.

As noted in the New Yorker article published by Sarah Stillman a little more than one year ago (Taken), what we are seeing now is due to the unintended consequences of laws passed in the 1970's.
"Forfeiture in its modern form began with federal statutes enacted in the nineteen-seventies and aimed not at waitresses and janitors but at organized-crime bosses and drug lords. Law-enforcement officers were empowered to seize money and goods tied to the production of illegal drugs. Later amendments allowed the seizure of anything thought to have been purchased with tainted funds, whether or not it was connected to the commission of a crime. Even then, forfeiture remained an infrequent resort until 1984, when Congress passed the Comprehensive Crime Control Act. It established a special fund that turned over proceeds from forfeitures to the law-enforcement agencies responsible for them. Local police who provided federal assistance were rewarded with a large percentage of the proceeds, through a program called Equitable Sharing. Soon states were crafting their own forfeiture laws.
Revenue gains were staggering. At the Justice Department, proceeds from forfeiture soared from twenty-seven million dollars in 1985 to five hundred and fifty-six million in 1993. (Last year, the department took in nearly $4.2 billion in forfeitures, a record.)..."

 The power to take down the likes of Pablo Escobar has been transformed into the power to terrorize innocent people. Numerous examples of local police using routine traffic stops to  seize (steal) cash from people who have committed no crime, only the indiscretion of carrying cash or other valuables in their cars. The seizures did put a dent in the activities of criminals. However, they also provided a tool for law enforcement to steal of the innocent public without due process or recourse.

Sunday, September 21, 2014

Lack of price transparency and the normalization of deviance

I am confident that the story is not going away. Again on the front page of the Sunday Times today is yet another story about the lack of transparency in health care billing which is accompanied by a litany of comments from people who reinforce the message. (NYT- Billing surprises)

The story itself is about a young man who had the acute onset of a neck injury; a herniated set of disks which resulted in pain and neurological dysfunction. He thought he had his ducks lined up and had properly researched his options and the costs. However, he was blindsided by a bill from an assistant surgeon who he did not recall actually meeting. The bill for the assistant surgeon...$117K. What did this surgeon do to justify such a fee? That was not so clear and oddly enough the payment to his primary surgeon ended up being less than 1/10th of this amount.

The stories from those who wrote in that followed the Times story showed a consistent theme. Providers who swooped in during a medical stay, delivered some sort of perfunctory service (or not?), and dropped some sort of outrageous a bill. How common is this? Who knows but perhaps this is not such a rare event.

In my opinion, this phenomena can be traced back to two fundamental issues. The first issue is the widespread and apparently expanding gaming of the billing system. There is no question that the current system has opportunities for exploitation. In the earlier part of my career, the relative lack of financial pressures and the anchor of professionalism served as a brake on such activities. As individual actors identified and leveraged opportunities and their financial windfalls became more apparent to the broader medical communities, the brake exerted by professionalism weakened and the outrage previously expressed over outrageous billing practices disappeared. Why be a chump and "leave money on the table?"

We rationalize such beliefs by looking at all the activities we engage in which provide no or insufficient financial compensation and do some balancing math. However, once you have made that transition and are comfortable with accepting payment not commensurate with activity and value you  added, it becomes a slippery slope. There may be no upper limit on what some will ask for, especially when third parties pay the fee and insulate the patient from the bill.

However, the other issue is no one is really in charge. Patients are cared for a "team" of people who operate in different silos and who are not coordinated in their efforts. There is no big picture person who has the incentives to make team roles explicit. One might think that the lead surgeon would be this person but that is generally not the case. Review a chart of a patient hospitalized for a particular intervention and look for specific orders regarding consultations. You are not likely to find them and if you do you are not likely to find anything specific of what the actual deliverables might be. There we have it; no defined team, no defined roles,  no one in charge, and little or no accountability.

Creations of well functioning teams would go a long way to solve this problem. A team leader should be accountable in terms of everything that happened before, during, and after surgery. Before this person would make sure that the patient was aware of  who was on the team, what their roles would be, and what the costs should be. However, this would require a change is how we are paid since at this point in time, there is no financial value associated with this type of activity, even though there might be tremendous value brought to the patients involved.

I believe we either fix this issue or we undermine the trust of patients to a point where it becomes irreparable.


Sunday, August 24, 2014

Continued disruptions in health care

The New York times published a piece this morning titled " Blood Industry Shrinks as Transfusions Decline". The story contains multiple elements reflective of the changes and disruptions affecting the health care industry.

What is more fundamental in medicine than blood transfusions? There is some controversy regarding the first transfusion. It has been reported that Pope Innocent VIII received the blood of three ten year old boys in 1492 although it is not clear when the blood was infused or ingested. Jean Denis transfused lamb blood into a young woman in 1667, a procedure complicated by a hemolytic reaction which fortunately for the patient, she survived. Unfortunately for Denis, reactions in subsequent reactions were not so benign, resulting in madness and death. The practice was dropped and not undertaken at all for the next 150 years.

In the 19th century, various attempts to revive the practice lead to variable successes. However, it was not until Karl Landsteiner began to define human blood groups in 1900 that more widespread deployment of human to human transfusions could be undertaken. Blood group characterization was then refined over the next 100 years. In addition, a host of other technological breakthroughs including anti-coagulants, preservatives, refrigeration, sterile (or clean)  technique, material science (plastics), and screening for infectious diseases made the practice safer and more effective. It was during war that the much of the practical improvements were driven with life saving impacts.

As noted in the NYT piece, blood banking and the American Red Cross moved to an industrial scale after WWII, about 70 years ago. However, the heyday of transfusion medicine may be behind us. The demands for transfusions are down a almost by a stunning one third in the past five years. This appears to be due to multiple factors including the use of minimally invasive surgery, substitute products, and changing indications for use of transfusions.

Regarding the last factor, decision support tools linked to electronic health records may be having a profound effect. While changing recommendations regarding medical indications may have limited effects if deployments are dependent upon individual physicians embracing the changing recommendations, the same recommendations tend to be adopted more readily if reminders and prompts are embedded in computerized physician order entry systems (CPOE). Orders entered which are at odds with guidelines require some sort of physician action to override the defaults which are also tracked. This has changed the use of transfusions and discouraged what is now viewed as inappropriate use.

The drop in use has prompted a host of consolidations and cost savings activities. The industry is shrinking in terms of employment footprint. As noted in the Times article (emphasis mine):
The change has come as a shock to workers. Marjorie Krueger, the administrative director of the Communications Workers of America for the area including Virginia, West Virginia, Maryland, Pennsylvania and Delaware, said that when the Red Cross began laying off union-represented workers in 2010, “We honestly didn’t know how it would work, because no one ever expected to have layoffs.” The layoffs have been few, but the hours of many full-time workers have been involuntarily cut to part time, she said.
Basically, transfusion medicine is 100 years old. In some sense the history of transfusion medicine tracks the history of recent modern medicine. Changes comes both rapidly and slowly. None of us practicing now has any recollection of what practice of medicine was like without transfusions, creating the illusion of a practice which has always been with us. However, the reality is it is a very recent addition to the ancient practice of caring for the sick and injured. Because of our biases, we are surprised when technology disrupts our world changes what we view as a practice which will be with forever.

The truth may very well be that use of blood is an expensive and labor intensive approach to care where the public will be best served if it can be replaced by approaches which are safer, cheaper, and simpler. Come to think about it, this sounds like the current health care system in general. Be prepared for change. Be prepared for disruption. Don't be surprised.


Friday, August 22, 2014

Would I want to be in GI training now?

First came the paper suggesting that flexible sigmoidoscopy (average cost $500-$750)  perhaps was as effective as  colonoscopy (10x the cost) in preventing colon cancer deaths. The FDA has recently approved the Cologuard test (FDA story) and Medicare wants to fast-track the approval of coverage. The estimated cost will be around the same as the cost for flexible sigmoidoscopy.

In the clinical trial Cologuard detected 92% of colorectal cancers (8% false negative rate) and 42% of precancerous lesions. The trial involved over 10,000 patients scheduled for screening colonoscopy, which subsequently identified colorectal cancer in 65 patients and advanced precancerous lesions in 757. The test reportedly has an approximately 13% false positive rate of diagnosis. Doing the math, this means that the test detected 60 of the 65 cancers and 325 of the adenomas. However, it was found to detect almost 70% of the adenomas believed to be most likely to progress to cancer. With a 13% false positive rate, this means that about 1300 people were found to be positive for the test who were clear on colonoscopy. 

How does this compare to fecal occult blood testing? Fecal immunological testing (FIT)  was 73% sensitive detecting only 48 cancers. However, it had only a 5% false positive rate.

Of course there are questions and doubters. In the LA Times, they quoted the head of the endoscopy unit at UCLA:
Dr. Bennett Roth, a professor of gastroenterology at UCLA, took a more measured approach to Cologuard. He said the test is still a work in progress, "but it's a move in the right direction." Roth said, is that it could encourage more people to have a colonoscopy, which remains the gold standard for diagnosing and treating colon cancer. "Maybe if you get a positive test with Cologuard, you'd be convinced to have the more definitive test," he said. "It doesn't replace the need for a colonoscopy."
I am not so sure I would interpret the results this way.  Colonoscopy is not without its issues. There is reported incidence of serious adverse events of 2.8/1000 procedures. Eight people per 10,000 patients screened will have a perforation. Hemorrhage occurs in 1-6 per 1000 colonoscopies.

Furthermore, colonoscopy is far from perfect (reference). The cancer miss rate (false negative) is reported to be as high as 6% and the adenoma miss rate for tumors greater than 1 cm is 12-17%. Perhaps some of the false positives detected by DNA testing may not be false positives at all?

I have news for Dr. Roth. Perhaps your position heading an endoscopy group has clouded your thinking about value. I cannot help but think that if I were to go and ask a president of a life insurance company about the value of life insurance, I might get a similar skewed perspective. Of course everyone should have life insurance!

I have had my colonoscopy when I was around age 50 and  soon enough someone will raise this with me again. Hmmm... let me think about this? There is a test available which is nearly as sensitive, with no prep, no anesthesia, no invasive risks, and it can be obtained at a fraction of the cost....Can you say no-brainer!

Let me do some additional math. This test roughly may eliminate the need to do over 80% of the $14 billion colonoscopy market. As Dr. Roth noted, perhaps this test may convince selected people to undergo colonoscopy, since 1/3 of the targeted screening group (50-75 year olds) are not screened. Even capturing this entire group, you would only expect perhaps 10% of these people to undergo colonoscopy.

I think any way you look at this this test represents a likely disruptive technology which will change the economics of GI medicine. Perhaps there are aesthetic medicine opportunities. Everyone else is doing it!