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Saturday, January 20, 2018

Federal budget gridlock

Here we go again. Budget gridlock. Federal Shutdown. Finger pointing. Who is to blame for the current state of affairs?

I believe a bit of historical context is needed. Between fiscal year 1977 and fiscal year 2015, Congress only passed all twelve regular appropriations bills on time in four years - fiscal years 1977, 1989, 1995, and 1997. Between 1976 and 2013, there were 18 times where funding was interrupted because of the inability to pass budgets or continuing resolutions. Government shutdowns occurred after 1980 as a consequence of rulings by then Attorney General Benjamin Civiletti subsequently requiring the Federal government to scale back services without actual appropriations (ref). The budgeting process is completely broken down. We may want to assign proximate blame for the most current shutdown but whatever argument is put forth, it is essentially meaningless in the larger sense.

The discretionary budget represents less than $0.30 on every dollar spent at the Federal level. Congress has essentially no control over more than 70% of Federal spending. While it may seem counter-intuitive, as the discretionary spending constricts, the incentives to play brinkmanship games appears to increase. With less money available to work out compromises, there are incentives to switch from win-win negotiations to winner takes all. And it is only going to get more pronounced as mandatory spending consumes more and more of the Federal Budget. By 2030, government shut downs will be meaningless since discretionary spending will be all be gone away. 

I am concerned that this shutdown may last a while precisely because no one seems to think it will and because Donald Trump is in a position to not back down. Furthermore, much of the government will continue to function (Vox). He does not really care if it blows up the Republican Party.  I will make a prediction. Like all predictions, it could be way off. I believe this will go on for weeks. The DACA issue and immigration were core stances for Trump. He will cater to his base. He has no reason to back down. 

Sunday, January 7, 2018

The complex and evolving relationship

I read the Op-Ed piece in the NYT by Daphne Merkin titled "We say #MeToo. Privately we have misgivings" (NYT). It got me thinking. One characteristic of humans is we really have to work hard to understand historical context and time frames. We have existed in social groups for perhaps 100,000 years, and in larger complex groups for perhaps not more than 10,000 years, since the dawn of agriculture. Our current organizational structures have essentially just appeared over the course of not more than 500 years.

The relationships of men and women have undergone marked changes in recent decades and most of us within the US have little or no concept of how men and women related throughout the overwhelming majority of the course of human history. This relationship is nuanced and extraordinarily complex. Human societies have been grappling with this relationship since the dawn of human history. It cannot be boiled down to one idea or simple rules. However, the fate of humans depends upon how this relationship plays out. Men and women need to interact in a very personal, intimate, and vulnerable way or additional humans will not be made. Yes there are exceptions to this (in vitro fertilization and artificial insemination), but these are rare exceptions, not the rule and they have only been available for the equivalent of an historical blink of an eye.

The drives which motivate humans to mate are powerful and complex and have in some sense bedeviled societies for millennium. Rules were adopted with manage the risks. We look back upon many of these rules as being brutal, oppressive, and archaic, which they are given our present circumstances.  We need to remember that for most of human existence, our ancestors eked out their existence in a world of terrible violence driven by scarce resources. Mixed into this were sexual drives and competition for mates. Some rules worked better than other in terms of fostering success of social groups. It is reasonable to assume that the rules which made it to near contemporary times likely fostered additional social cohesiveness and moderated internal violence.

Fast forward to the past 100 years where there has been an extraordinary revolution in terms of the roles and status of women. No longer is there a huge advantage to size and aggressiveness of men. The industrial and communication revolutions have allowed women to compete for positions of leadership and authority on the basis of merit unlike any other time in history. However, we are still left with the legacy of who we are, complex social creatures whose procreation depends upon almost incomprehensible sexual motivations. Furthermore, sexual drives are to a great degree asymmetric and manifest differently in the two sexes. I understand there are overlapping distributions.

What this translates to is despite the changing roles and incredible changes in the overt trappings of society, we are left with the fate of humans being dependent upon the same personal, vulnerable, and private interactions our ancestors had to deal with. Intimate interactions still happen in private. The paths taken by couples to embark on the journey from casually meeting to intimate encounters has no single guidebook currently. (Older societies did simply this with mates being chosen by parents. We have for the most part discarded this convention). Each individual in the market for a mate needs to somehow successfully signal and then act when they believe they receive signals back. How people signal and what are acceptable signals is context, time, culture, and individual dependent. Some people can get away with certain approaches that others cannot.

This is not a topic handled by the formal educational system, something we should likely be grateful for. However, it leads to an almost infinite myriad of strategies which people use to attract partners. Which ones have historically been acceptable or are currently acceptable or will be acceptable is obviously evolving. No matter where these mores move toward, they will always need to address the reality that what drives these relationships are not rational and when they play out it places parties in vulnerable positions in private. There is no other realm of human existence that will provide a greater challenge to laws and social mores.

There is no EASY button. Beware of the hedgehogs who sell one simple approach.  Good systems will have failures.

Saturday, December 23, 2017

Chasing long tails in medicine

Economics is defined as the study of the optimal allocation of scarce resources. There is a mindset that when discussions of healthcare intersect with those of economics, there is a tendency to imply that health care should be viewed as something very different where if the laws of economics are somehow applicable, they should be applied differently. However, scarcity matters is all realms, every in healthcare.

Forgetting this tends to lead to decisions where resources are misallocated in healthcare, the logic being that money should not be an object when dealing with someone's, anyone's health. This aspiration is hard to argue against, but it is an aspirational statement, not a practical statement. We do not have infinite resources to invest in anything and acting as though we do or should leads to harm.

Once you get people to accept this as a concept, you still run into problems in translating this into action. Those who operate in healthcare are, with the exception of being monetarily numerate, and otherwise relatively enumerate. Expensive, wasteful, and even dangerous interventions are routinely lobbied for based upon anecdote and anxiety. Interventions found to be statistically justified in selected high risk populations are then advocated for in a more general population.

I view this as a long tail problem. Investing modest resources in a given problem may yield substantial results. Doubling the investment may result in additional incremental improvements, but nothing as substantial as the initial investment. Additional investments run into the law of diminishing returns. However, notable cases highlight that the work is incomplete, and serve as blanket justification for investment of additional resources to bring us closer to perfection.

Chasing long tails is baked into medicine at all levels. Physicians use this to justify more expensive and intrusive approaches to diseases and risk of disease. Regulatory entities use anecdotes to drive increasingly onerous regulatory burdens, all on the basis of safety and quality. The problem is that we apply this logic with tunnel vision and are influenced by the myth that scarcity concerns should not enter into health care discussions.

All roads lead to the original sin of healthcare delivery in the US, that being third party payers. All of this would have never happened if we did not raise an entire generation of physicians and patients within the health insurance bubble. Insulating patients from actual costs allowed us to chase long tails for decades without appreciating the waste. It will be painful for virtually everyone to stop this.

Medical Communication - Written v. Spoken

I am a great fan of the Great Courses company ( The courses are of consistent high quality and cover a range of subjects. One of my favorite lecturers is Dr. John McWhorter from Columbia University. I just finished the series titled Myths, Lies, and Half-Truths of Language Usage. In this lecture series, I was introduced to differences between spoken and written language and that until relatively recently in human history, the written languages used by learned people were generally different from the spoken languages used. He also introduced me to the concept of formal and informal language. Spoken English may be either formal or informal and recently, written language has expanded into informal uses, especially with newer forms of communication such as texting.

This course made me think about language and communication in health care delivery. I realized that for the most part, physicians value spoken communication over written communication. We interact via rounding. We have conferences and tumor board where cases are discussed. If there are problems with communication we emphasize that the best way to address these issues is to meet of call someone. I agree that the spoken word is valuable, but what are the limits of the spoken word in medicine?

All one needs to do is sit through one deposition to understand issues with spoken communication in medicine. What is said is almost never really translated with real fidelity into the written record in healthcare. We use the written record to justify billings and to cover our assess (and assets). However, the real value of the written word in healthcare should be to communicate with as little ambiguity as possible. The written record rarely does this.

Part of the problem is cultural. We have not been trained to value written communication. However, there are system issues as well. Our workflows are also not conducive to capturing the richness of discussions which happen on rounds or in clinical conferences. We may have very pithy discussions regarding specific challenges we face in the management of specific problems in specific patients. However, by the time that someone is responsible for generating a written product of those discussions and it gets into some written form which should be translated into actionable items, the nuance is generally gone and message is garbled. That is the problem with spoken communication. What is spoken may be different from what is heard, which is also different from what is remembered. It is ephemeral.

All of this may have been less of an issue when the number of moving parts inc are delivery were limited and the size of the health care teams was very limited. We are much more ambitious in what we aim to accomplish and the people involved in any give care pathways may get into the dozens if not hundreds. The number of tasks involved is similar. No single person can keep it all straight in their heads. However, in the absence of formal written communication and coordination tools, traditional spoken communication approaches and tools can't scale to meet current demands.

We need a culture change in medicine and need to recognize the personal relationship driven, verbal communication mode of coordination of care needs to change to a system complemented by structured written tools that help better define clear roles, responsible parties, care teams, and team leaders.

Tuesday, December 19, 2017

Right to bear arms

I just want to make a small observation. The words guns or firearms do not appear anywhere in the second amendment.
A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.
The amendment refers to "Arms".  No one that I am aware has construed this to mean that the second amendment protects citizen's rights to own all types of armaments. There appear to be accepted limits such as prohibitions on owning thermonuclear devices, nerve gas, or death rays. There are limits.

I am not one to completely place my trust in the inherently benign projection of state power and there are inherent concerns when the power differences between citizens can muster and what a state can deploy grows too large. However, why can't we recognize that that we can honor the second amendment while simultaneously place restrictions on the type or armaments that citizens can own and deploy?

Saturday, December 16, 2017

Problems with the state

I colleague of mine sent me a link to a Washing Post article regarding a rather heavy handed approach of the Trump administration to control the flow of information out of the CDC, with lists of forbidden words to be purged from websites and documents. It is appalling. However, I would argue it is both no more appalling that multiple other heavy handed practices that have received much less attention from the mainstream press, and to be completely anticipated based upon the expansion of state power.

For those of you who have been readers of my blog over the past six years, you are likely very aware of the influence of the legal scholar Richard Epstein on my thinking and world view. In his conceptual framework, human actions can be simply viewed as happening in three different domains; acting as individuals, acting as parts of groups of individuals who join together voluntarily, and acting as groups within the context of legal entities where they are bound legally to belong - state actors. The existence of state actors requires that individuals give up some liberty in order to gain something more, presumably gaining more than they give up.

Individuals clearly gain hugely from working with others to fulfill their needs. Each of us operating on our own are very limited in terms of what we can accomplish and the ability to collaborate has resulted in transformational gains, over a very long period of time. The history of enhancements in human collaboration goes back tens if hundreds of thousands of years and the vector of progress has been far from linear. Collaborative groups started small but evolved into larger and larger cadres using ever evolving rules and conventions. The current world at its best involves massive networks of people who generally never meet who make each others lives better.

An integral part of these networks involves rules which we embrace which foster trust and cooperation. Some but not all of the rules are codified into law. We could codify everything but we have not and I would argue that would be a very bad idea. We can and should have a different relationship with state entities than we do will other groups where our participation is voluntary.

State entities have powers over us that non-state actors do not. State actors hold the power of law, the power to coerce and force individuals. These are powers not to be trifled with. Our government was created to provide for needs which could not be met for private actors with specific limited powers enumerated with an explicit understanding that state power was dangerous. We have somehow lost sight of these dangers, until recent misbehaviors of the current administration.

Todays announcement of Trump administration should not come as a surprise, not because of any specific aspect of this administration,  but because of the gradual loss of skepticism of what state actors are capable of and motivated of doing. Concentration of power and cultivation of power monopolies tends to attract people who like to exercise power. Furthermore, governments are political entities and power to influence policy within state actors will tend to be move toward those who control political power. Winning elections means you control governments. The more power which is placed in the hands of political actors, they more those actors will want to use that power.

Technical experts who work for state entities can find themselves placed in very precarious positions. When working in the private sector, your relationship with employer is set by contract. You are free to criticize the government and protected by the Bill of Rights. However, you are not necessarily protected by the Bill of Rights if you publicly criticize your private sector employer. However, working for a state actor can get complicated in a hurry. If you work for a Federal or State agency, just what can you say regarding your employer?  What protected rights do you have? If you work for a particular agency and have a policy disagreement with your boss, what exactly can (or should) you say in a public forum? How much control does your political boss have over what you can say without getting fired?

When state functions were limited and the size of the "state" was small, this really was not much of an issue. However, as the size of the state grows and the influence of state funding permeates to a larger and larger segment of the economy, these issues loom larger and larger. With the previous administration, they did not overtly tell Federal employees to not use specific words. However, they tried to play games with dear colleague letters which had similar chilling effects on those of us who were indirectly supported by Federal $'s.

All of these trends point to a growing ability of state actors to coerce a wider and wider swath of the population of the US. We need to understand that empowering state actors, even for what seems like laudable goals, has real dangers. We can not take it as a given that good and wise people will be at the helm of entities that can hold a gun to your head.

John Cochrane article

John Cochrane articulates the pro-market case for health care delivery better than anyone else I have read.

After the ACA