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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?

The imperfections of simplicity and the perils of complexity

I know I am not alone in yearning for a simpler world at times. The latest point of contention revolves around "bathroom" laws.

Each of us operates in the world by simplifying many decisions. If we had to reflect deeply about every decision we make, we would become paralyzed and use huge amounts of scarce resources to do what would ideally be done with minimal conscious effort. Central to many of our decisions and routine interactions are the concepts of sex and gender. For the sake of simply being able to function, we have historically adopted simplified rules to facilitate interactions between people, including men and women. However, there is nothing inherently simple about any of this. Don't let anyone convince you to the contrary.

The rules are not perfect and they are evolving over time. Using the simple binary sex/gender model, we have had a very difficult time trying to sort this out as human society has changed markedly over the past 100 years. Moving to a much more nuanced view of sex/gender/sexual preference results in a geometric increase of complexity overlaid on an already complex domain of human interaction.

What we are talking about is defining acceptable rules of human engagement. Even under the best of circumstances, this is extremely difficult and will always be fraught with what seems like less than desirable outcomes. This has also been a moving target.  What I find remarkable about this discussion is how certain parties can be so sure of their positions. We have only recently been medically and surgically intervening to "transform" selected individuals from one gender to another. We have been trying for thousands of years to refine the rules of engagement between man and women and we are still flailing to some degree. There is clearly less than perfect consensus looking out across the world in general and this is based upon a simple binary model (man and woman).

When we inject this new complexity into the sex/gender world, whatever routine we have used to simplify our dealings with sex/gender issues is disrupted. What will replace it? I have no idea. What are the rules of engagement? Again, I have no idea. What rules which have used historically will also work in the new world? I don't know.

This is important but it is not simple. It is not a black and white issue. Desegregation in some respects was much easier to deal with. It actually simplified the rules and removed distinctions where no distinctions were needed. The rules of engagement do not need to be contingent upon the color on someone's skin. Relations between men and women require rules of engagement which are inherently different, at least in great part because of the biology of sexual attraction.

It might be argued that the different rules of engagement are really not dependent upon gender or sexual phenotype but sexual orientation. That might have some element of truth but we have used sexual phenotype as a proxy for this for a very long time for the simple reason is it is a simple and generalizable (but not perfect) rule. Even with this simplification the rules are very complex (VERY COMPLEX). In my opinion (and it is just an opinion), it is not realistic to expect rapid, widespread adoption of new rules governing interactions between sexes/genders to happen without a great deal of discussion and contention. It is not fair or constructive to the parties involved to vilify everyone with opinions which may differ from your own.

Step one....listen

Sunday, March 20, 2016

Uterus transplants and other interventions extending capabilities to those not born with them

The Cleveland clinic's most recent attempt to do a cadaveric uterine transplant did not meet with the desired endpoint. The uterus had to be removed because complications (Link). This was brought to my attention in a blog piece from the MD Whistleblower (Link). He raises some interesting questions but I think his questions should also touch upon implications in a much broader clinical and ethical realm. The circumstances of the transplant were the patient who received the transplant was born without a womb. As it turns out, there are many humans who are born without wombs, approximately half  to be specific.

The Cleveland Clinic experiment seems like a bad idea at multiple levels. It is not as if no other options existed for this specific person. For the transplanted womb option to work, they had to go through the in vitro fertilization anyway meaning those eggs could have been implanted in a surrogate who did not need to take a host of immunosuppressive drugs for the entirety of the pregnancy. Frankly, I do not see how any IRB could approve this protocol. It places the person getting the uterus at great risk and places an unborn child at great risk, all of which is completely unnecessary for generating a child. Yes, it is a clinical trial but I simply cannot see how these types of risks can be justified. It appears to be reckless in my opinion.

The ability or inability to carry a child because of having or not having a uterus is one of basically an infinite set of human functional differences which exist because of inborn or acquired differences. The question I want to pose is what portion of these differences constitute fair game for correction via some sort of medical intervention? What sort of interventions should we strive to develop and which ones of these should be the target of investment of public dollars? As we move inexorably toward a world which defines access and payment for health care as a universal right, what of the inevitable desires of people to use the health care system to enhance functionality beyond what they were born with? Does that too represent an inherent human right?

Think of all the differences in inborn or acquired traits which could become fair game. I am not so tall and always thought it would be great to be taller, much taller. The fact that I am "vertically challenged" likely has had all sorts of impact on what success and failures I have encountered in life. Simple physical attractiveness (perhaps not so simple) has huge functional implications which has major impact on where people end up in the world. At his point height and physical attractiveness are already amenable to some form of rectification. Imagine all of the possibilities for enhancements that other interventions could impact.

Should this be within the realm of heath care delivery? We already have bleed through in terms of training and missions. Physicians trained in plastic surgery and increasingly other fields such as dermatology, are trained as physicians but have moved into realms very distinct from taking care of people with actual illness and sickness. Once we validate the mission to take people who are not sick by any typical definition of disease, and push the mission to create functionality that people were not born with, we are doing something very different. Before we open this Pandora's Box, we should be very intentional about understanding where it will take us.

Saturday, February 20, 2016

The worrisome role of hedgehogs in politics

I am a fan f the work of Philip Tetlock. He has studied the ability of individuals to forecast the future using a very clever approach, the details of which are beyond this specific blog piece. What Tetlock found in his initial work was that the best predictor that and expert was right or wrong was how recognized or famous they were. However, the correlation was negative. The more fame (or perhaps notoriety), the worse their judgement tended to be. Furthermore, the strongest correlation with correct predictions and judgement was related to cognitive styles which he referred to as either "hedgehogs" or "foxes".

Foxes use a cognitive style which is flexible, adaptive, and measured (tentative) while Hedgehogs are
said to "know one thing and know it well" and to focus on a single, coherent theoretical framework in their analyses and predictions. Quintessential Hedgehogs might be found on television or other media and promote themselves as experts. The most successful people in the realm are not tentative or reflective and they rely on the very brief attention span of the public to forget when they are wrong, and they are often wrong and may be worse than chimps guessing at random. However, they are decisive and attractive to the viewing public.

This cognitive style has worked itself into a central place in politics. For some reason, we are now surprised when political candidates with notable hedgehog like tendencies are appealing to the public. Bernie Sanders is an off the chart Hedgehog. His big thing is income inequality and vilifying financial markets and institutions. Is there any nuance in his appeals? I have not seen any yet. For all of the criticism coming Hillary's way, one cannot accuse her of just knowing one thing well.

The Republican may be similar. Donald Trump may be hard to characterize as a typical hedgehog,  but I believe he is. His one big thing is his experience in business allows him to make deals and "Make America Great". It is a simple hedgehog like message. His reality show suggested that one can makes one's organization simply by firing people. He is an odd expert but he fits into the

expert class, holding expertise and information which are proprietary and he implies he will move America back to greatness through his own special will and special sauce. Both he and Ted Cruz push to motivate and unify people by vilifying and mockery, which is one of their big things.

As politics and the entertainment industries have become blurred in terms of where one ends and another begins, it is not surprising that characteristics which make individuals attractive as entertainers and maintain ratings turn out to be the same characteristics which make them attractive to the voters. This is not new. JFK perhaps ushered in this phase of politics. His family links to Hollywood were strong and his father Joe understood the importance of image and simple and compelling ideas, whether they were right or wrong. Ronald Reagan was the master of this domain and he was a hedgehog.

What is worrisome is these same hedgehog like characteristics are also basically markers of bad judgment.  How do we address this? Is it addressable? I suspect it is not and represents a basic human limitation. One approach may be to push to limit the ability of parties to appeal to voters through some sort of legislative or regulatory action. I have little confidence that this will yield results which leave us better off. In my opinion, these observations represent a compelling reason to create limits on what should or can be done via exercise of political power.

Saturday, February 6, 2016

Innumeracy and catastrophizing; partners in creating medicine's anxiety disorder

I am currently reading Richard Thaler's book "Misbehaving". Perhaps I spend too much time thinking about this subject, but I am constantly reminded t hat even the most educated professionals that I work with are blind to how they "misbehave" as Thaler describes. He uses t his term to describe behaviors and decisions made by individuals that are simply not rational.
His path into these studies came from seeing inconsistencies in how the world of economics initially viewed human decision making, before the widespread introduction of concepts of behavioral economics. He noted that from a purely economic sense, people made really crazy decisions. They did not behave like what was referred in the field as Homo economist (or Econs for short). Basically, the numbers did not add up.

These sorts of inconsistencies are certainly not limited to economic decisions. They touch all decisions made by people in all walks of life. They are simply rampant in health care and the misbehaving is certainly not limited to patients and consumers of health care. I would argue that the business model upon which much of current health care delivery is based is very dependent upon getting all actors to "misbehave". The growing consumption of services in the health care arena is driven by almost universal innumeracy displayed by providers and consumers alike, which is leveraged to create widespread catastrophizing of potential consequences. The anxiety created serves as a powerful marketing tool. Those of us within the health care delivery world derive substantial financial benefit from our patients being innumerate and from being innumerate ourselves.
One particular leverage point is we all know what everyone's final fate will be and it terrifies most if not all of us. We can point to the potential for catastrophe and ultimately we will always be right.  While we cannot dismiss that fact that every single one of our patient's lives will be marked by the ultimate catastrophe, that being one's own death, we also must realize that the stakes involved with every medical decision cannot be viewed as tightly linked to this outcome. Like the undesirable outcome for any given person when all of their personal decisions are coupled in their mind invariably to potential catastrophic outcomes, if medical care operates by catastrophizing everything, we will end up with a professional anxiety disorder.
We are already there. The medical profession suffers from anxiety disorder which is brought about and aggravated by our inbred tendency to catastrophize everything. It is dysfunctional.

The problem with free stuff

From the NYT -

Free electricity and Puerto Rico

Note that between the declaration of free and the unwinding took over seventy years....