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Sunday, November 24, 2013

Putting things in perspective

One of the challenges we face a physicians is to both understand risk ourselves, and communicate risk to our patients. We are hamstrung by basic human foibles, most notable being our inability to grasp the difference between how different a risk of one in one thousand might be from a risk of one in one billion. Our ancestors developed in a world where understanding such differences in size were simply not relevant. Unless particularity trained, our brains do not ascribed significant differences to these differences.

The Teaching Company course on Big History taught by Dr. David Christian is a great resource for beginning to grasp how significant these differences and scales are. The scope of this course is to cover the history of the universe, startling with the big bang and moving to contemporary history; 13 billion years in 48 lectures. The entire first lecture is a discussion of nothing more than understanding the size of the universe and the time scale to be addressed, looking at orders of magnitude (powers of ten). He gives a quick Ted Talk summarizing this in 18 minutes.

I recently saw a piece posted on the Big Picture blog by Barry Ritholz which provided a good visual representation of this (Big Picture link). I also tracked this back to another nice blog  ( I really like authors who dwell upon these concepts since I see this as a major shortcoming of human cognition and decision making. Our fascination with critiquing and judging events in a moment to moment fashion, is destructive. This when combined with our other tendencies to create stories out of random chatter prompts us to act hastily and value action over reflection.

While we physicians (and other health care professionals) do not work on universe life-time scales of time, we still are called upon to understand phenomena occurring within huge a spectrum of probability, needing us to understand quantitative concepts which we are ill suited to grasp. This may all seem to be an pointless intellectual distraction except for the fact that it is not. As our scope of work in health care has moved to assessors of risk and providing advice to patients regarding events that might affect them in the future, it is absolutely essential that we are able to understand orders of magnitude and furthermore, be able to communicate this understanding to patients.

My training failed to prepare for this task. Given what I read of the medical literature, the preparation of my colleagues was equivalently inadequate. Our rights of passage required us to do and survive all sorts of things in our training. It did not require us to understand risk and probability in any sort of real quantitative fashion. Whatever appreciation I have developed regarding perspective, size, risk, and orders of magnitude has for the most part developed as a consequence of reading and listening out side of the medical field.

I hope this is changing.

Tuesday, November 19, 2013

Let the games begin!

OMG... What an angle. I am always amazed at the resourcefulness of humans....

Nudges or shoves? Voluntary or guns to your head?

What is voluntary and what is coercion?  Interesting video....

Michael Munger at MTSU

Sunday, November 17, 2013

Hooray for Tyler Cowen

Tyler Cowen wrote a great piece in the NYT:
More Freedom?

It reminds me of Richard Epstein's seminal work Simple Rules for a Complex World.

The limits of the reach of the law

Let us go back to the Spring of 2010 after the ACA had passed Congress and had become the law of the land the previous fall. As referenced in a previous blog linking to a particular David Cutler letter (Cutler letter), David Cutler wrote to Larry Summers and expressed the following concerns:
I am writing to relay my concern about the way the Administration is implementing the new health reform legislation. I am concerned that the personnel and processes you have in  place are not up to the task, and that health reform will be unsuccessful as a result...........My general view is that the early implementation efforts are far short of what it will take to implement reform successfully. For health reform to be successful, the relevant people need a vision about health system transformation and the managerial ability to carry out that vision. The President has sketched out such a vision. However,I do not believe the relevant members of the Administration understand the President’s vision or have the capability to carry it out.
The events since October 1 of this year provide evidence that David Cutler was spot on in his assessment. Furthermore, the most recent responses of the Obama administration underscore a crucial point. It appears to me that there is a mindset which views the public deliverables as the law, and that the product of political process, that being new law conceived, is sufficient to improve the lives of citizens. The events of the recent past should serve to dissuade anyone of that notion.

Even the most recent response to the website meltdown is illustrative of the almost delusional faith in the power of the state. Delivery of health care services involves a complex web of people, products, and services. The availability of insurance products is only one element of this matrix. Having a well functioning insurance market is an necessary but not sufficient element for health care delivery to thrive. In this limited but essential domain, there is remarkable complexity and the systems which have developed over many years are the product of evolving and adapting complex systems. For these entities to survive and thrive, they require robust IT systems, actuarial data, rules required to adjudicate claims, people management systems, marketing systems, and management know how that allow them to plan, budget, and respond to a changing and challenging business environment.

In any event, either no one understands or wants to understand that when  passing a law does not equate with making things happen. Congress can pass a law mandating that everyone should be happy but even the most delusional Pol understands that this is simply not possible. However, many legitimate desires to improve the lot of people are pushed into the political arena with the hope that near Utopian aspirations can be realized by passing a law. It is a simple and seductive concept which has ended up transferring money and power to various state capitals and most importantly Washington, DC, the latter now being the richest city in the country.

The business of Washington is government and the product for the most part is regulation and law. From the Washington insider and activist perspective, the deliverable is the law itself, not the implementation. Which again brings us back to David Cutler's prescient letter where he goes on to warn specifically:
Above the operational level, the process is also broken. The overall head of implementation inside HHS, Jeanne Lambrew, is known for her knowledge of Congress, her commitment to the poor, and her mistrust of insurance companies. She is not known for operational ability, knowledge of delivery systems, or facilitating widespread change. Thus, it is not surprising that delivery system reform, provider outreach, and exchange administration are receiving little attention. 
Not that no one else saw this happening. Scott Gottlieb wrote in Forbes in March of this year in his article titles "Who's in charge of implementing  Obamacare and why it matters (Forbes link):
I wrote more almost three years ago, in the New York Post, that many of the Obama Administration’s economic centrists were leaving the White House. Left behind were some of the most progressive staffers. They would be the ones implementing the law.
That transition now seems to be complete. The few remaining centrists thinkers inside the White House, mostly scattered across the National Economic Council and Treasury, are gone – or largely marginalized when it comes to issues around implementation. The people drafting and reviewing the regulations are mostly centered in the White House and its Domestic Policy Council — and they mostly work for Jeanne Lambrew.

It seems that many people recognized that placing someone with operational savvy in charge of ACA deployment was not a priority. Not surprising for a President who had almost no operational experience prior to ascending to the Presidency.  He then appeared to condone the purging of HHS of those with operational expertise, perhaps to maintain philosophical purity and Federal control of the products to be marketed on the exchanges.

Now that it is becoming increasingly clear that the foundation upon which the health insurance exchanges were built cannot be supported given the probable number of enrollees, the response of both Congress and the Obama administration is to rule by decree. In both case each entity is looking to change the rules precipitously without regard to the actual timetables which fall under the category of "the possible". In the case of the White house, they also appear to ignore whether their actions fall under the category of "the legal". That has not stopped them in the past, however. Why bother changing the law when one can rule by Executive decree.

I am reminded of recent events happening in Venezuela where President Maduro has decided that prices for consumer goods are too high. His response has been to decree that he will set profit limits in all sectors of the economy. Toilet paper is in short supply. They have had to deploy troops to control crowds at consumer electronics retailer Daka. Sounds like a great idea to make greed disappear by decree. Why bother with markets or rule of law or needing to cooperate with messy institutions such as elected governing bodies. They are just obstructive when good leaders are trying to get something done to help the people like getting them free stuff.

In the same sense, why bother with trying to understand how insurance markets actually work when you think you can manipulate them like a puppeteer controlling a marionette. Push for a law which is fatally flawed? No problem! Mandate others fix it by decree and them blame them for any ensuing disaster. Just ignore the inconvenient reality of state insurance commissioners, actuaries, and the planning required to make sure entities charged with paying health care bills are fiscally solvent. Such petty and boring operational details are not the stuff of genius. That should be someone else's job and it is not material which gets anyone elected for higher office.

However, it just the heart of what makes the world work. We should not take this for granted.

Sunday, November 10, 2013

The origins of irrational exuberance for cancer screening

Every day I wake and I am here, wherever I might be. I operate using a set of assumptions, most of which I do not think to question. While we constantly exclaim that the pace of change is scary, on a day to day basis we perceive very little change. Given that background, I read articles like the one that appeared in the Health section of the New York Times on October 17th which remind me that the world that we presently experience is not the world that has existed for time in memorial (NYT- Bowery study).

The article is by Gina Kolata, one of my favorite writers for the Times and her piece was about a study done more than 50 years ago by Dr. Perry Hudson, a urologist who was a researcher working out of Columbia University.  For those of you who follow my blog, you realize I have more than a little skepticism when it comes to cancer screening programs. In the present time, I am the outlier, expressing essentially little or no faith in the ability of our tools to accurately predict who will die from malignancies. I was intrigued to read in Dr. Arnowitz's piece (Aronowitz)  that early in Dr. Hudson's career, the position that I currently hold was more the norm for the medical profession.
At mid-century, there was also a backlash to the optimism-promoting “do not delay” public health campaign in other cancers. Physicians were increasingly skeptical that existing means of prevention and treatment were effective because the mortality from most site-specific cancers had not improved. This skepticism led to a group of self-identified physician “predeterminists” who argued that at the time of a cancer diagnosis the fate of most individuals was outside of medical care, determined by the poorly understood tumor characteristics and the individual patient’s immune status.
Enter Dr. Hudson. He was motivated to dispel the cancer fatalism which permeated the medical community and it only made sense to him that early detection and treatment was a promising approach.  He begins to test his ideas on homeless men living in flop houses in the Bowery of New York City. He provided inducements to coax them into participation in gruesome diagnostic and "therapeutic" interventions, inflicting untold harm upon ill informed subjects. His work was accepted by the medical powers that were at the time, passing peer review and receiving funding from NIH.

The damage is not limited to the poor souls from the Bowery, but extends to to current times. As Dr. Aronowitz  states in words that I cannot improve upon:
There has been a disturbing continuity between the Bowery series and our current paradigm. The Bowery studies were prematurely deployed, crude technopractices that anticipated and followed a similar logic undergirding many subsequent incremental developments in prostate cancer. These studies, forgotten perhaps because they reminded later practitioners of the violence and dubious ethics of subjecting men to invasive procedures without good evidence of benefit, are a window into the long halting history of how we have come to accept as efficacious a set of very invasive prostate cancer practices, developments that are themselves part of an ever larger quest to control cancer and our fears of cancer and that have brought millions of American men into state of prostate cancer risk.
The message is clear. We tend to be blind to the very things that the future will be appalled by. The medical profession has a long history of caring for the sick and relieving suffering. However, it also has a long history of doing terrible things to other people with inadequate disclosure and without their consent, often justified by lofty goals for humanity in general. We cannot forget specific humans in particular.