Making sure that everyone is rowing and in the right direction

I really enjoy courses I get from the Teaching Company. The two most recent ones I have listened to (and am currently listening to) are the courses on Behavioral economics delivered by Dr. Scott Huettel (Duke) and Why economies rise and fall taught be Peter Rodriguez (Princeton/UVA). These course have given me additional insights into the challenges I face personally and the challenges we face in aggregate in getting people motivated to create a better world for all.

In Dr. Rodriguez's presentations, he reflects upon human history to identify when and why specific peoples have thrived or failed. Improvement of our circumstances over time is completely dependent upon effective human action to increase productivity. It is through human action that we have lifted ourselves from abject poverty and misery. The more people who are working productively, the more wealth comes into existence, and the better off we are in aggregate.

When human operated primarily singly or in small groups, it was likely  not particularly hard to motivate individuals toward productive behavior. Without being individually productive, people went hungry, were exposed to the elements, and likely were miserable. However, as we moved more and more toward labor specialization and working in groups, it became easier for people to not be productive and potentially get away with this. Imagine a giant galley ship with millions of people all rowing. Suppose one stops rowing. Is that a big deal? What about if 1000 stop rowing? What about 100,000? At what point does the ship stop moving? At what point does the behavior of those not rowing entice a critical mass of those still rowing to stop?

Dr. Huettel's presentations in behavioral economics are focused on what motivates people to do things, including being productive and how cooperative behavior came to be and can be effective. Unlike the simple concept of productivity, human motivation and the tools to drive human action are extremely complex since they involve motivating people who are not entirely rational. Remarkably, we will engage in behaviors which will hurt ourselves if we perceive they will hurt potential free-riders even more (Altruistic punishment). Furthermore, this is not a unique human behavior and can be found in animals such as fish.

Understanding human motivation is devilishly complicated and just when you think you know how to manage a situation with a person or persons, everything changes. While human motivations is not just about money, money is a huge human motivator.  It occurred to me that the real function of money is it simply functions as a reasonably good marker of those who engage in productive behavior. Granted it is an imperfect marker but it perhaps is the best marker we have. Is it important for people to be engaged in productive activity? I would suggest it is critical since the aggregate well being of a population is directly related to the ability of those within the population to produce goods and services needed to make the lives of people better. There is a huge moral hazard associated with the widespread ability of people to game a system which allows them access to the products of the labors of others without needing to be productive themselves.


For those who decry those of us within affluent societies that feel driven to work hard and be productive, think of the alternative. We avoid misery and abject poverty because a critical mass of the population feels obligated to some degree to engage in activities which provide value to other people. To undermine the incentives which motivate that segment of the population is to undermine the foundations of the institutions that lift people out of poverty. The default mode in the world is still life on the edge.

Being blind to human wants

I do not watch much television but there are a few programs that capture my attention. A few years ago I got

hooked on "Deal or no deal". I was fascinated by the decisions made by contestants and their reasons for decided as they did. I saw it as a trove of data which would ultimately serve to someone's doctoral thesis in behavioral economics. Now I am fascinated by "Shark Tank" and what draws me to this is the laser focus of the sharks, the venture capitalists and how any given product or service will meet the wants of the public. Whatever you might feel about any of the sharks as people, you have to admit they are gifted in terms of seeing what the public might desire and spend their own precious treasure to acquire.

The last episode I watched highlighted a pair of inventors who developed what I thought was a remarkable

product, one that converted boiling water into electricity. I thought it was an extremely cool technology. However, most of the sharks were not so turned on to it because they thought the markets in the US would be limited. Most of them really disliked the idea of camping and thought their views were representative of the public at large. I could not help but think of my experiences in Haiti where such a device would be extremely useful and the discussion ultimately focused in on this. Mark Cuban asked about whether the inventors had considered developing world applications, which they had. Everyone on the panel thought that people in these circumstances would use this device primarily to charge small battery operated devices such as cell phones This was also the initial thought of the inventors. However, they were surprised to discover that when they inquired, their potential customers desired something else; they wanted the capacity to generate electricity to produce lighting. They were less concerned about charging their cell phones and more interested in prolonging daylight. Everyone on the panel thought they understood what their customers wanted until they asked them.

There is a lesson here for those of us to are in health care. One characteristic of the current delivery system is that our patients, our customers, baffle us by not doing what we recommend. We call this non-compliance. There are impressive numbers floated regarding the scope the problem: 20-30% of prescriptions are never filled and around half are not taken as prescribed. The knee jerk reaction among those of us within the medical fraternity (sorority) is that this behavior is a marker of some sort of  basic human character flaw which warrants remedial training. I would suggest that it may me more indicative that we are trying to sell a product which our patients for which they detect little value.

There are data which support this contention. It has been demonstrated that reducing the copays on medications increases patient compliance. This is consistent with the value theory I propose. If the interventions proposed by us cost substantially more than nothing, patients make the assessment that even at nominal cost they do not provide sufficient value to their lives to make the investment of their own resources.  The articles in the medical literature for the most part make it a given that the interventions we recommend are slam dunks and no one but fools would decline them. Of course you want a parachute when you jump out of an airplane! Duh!  I would suggest the data are not so compelling.  The truth may be substantially more nuanced. As noted in a NYT blog piece by By DANIELLE OFRI, M.D. (Orfri blog, Nov 2012):

“It’s an immense oversimplification” to reduce compliance to whether or not a patient swallows a pill, says the author, Dr. John Steiner, a researcher at Kaiser Permanente in Colorado.
To illustrate his point, he constructed a chart for a theoretical 67-year-old patient with diabetes, hypertension and high cholesterol and tabulated what it would take to be “adherent” with all medical recommendations.
Besides obtaining five prescriptions and getting to the pharmacy to fill them (and that’s assuming no hassles with the insurance company, and that the patient actually has insurance), the patient would also be expected to cut down on salt and fat at each meal, exercise three or four times per week, make it to doctors’ appointments, get blood tests before each appointment, check blood sugar, get flu shots – on top of remembering to take the morning pills and then the evening pills each and every day.
Added up, that’s more than 3,000 behaviors to attend to, each year, to be truly adherent to all of the doctor’s recommendations. Viewed in that light, one can see how difficult it is for a patient to remain fully compliant.

This perspective does not even begin to touch upon the question of whether patients are even close be being convinced they derive value from any of this.  Like the sharks described above who thought they knew what wants motivated their target populations, we are often clueless as to what wants drive our patient decisions. However, unlike the sharks who generally have proven masterful in understanding human wants and have become wealthy because of this, the culture of health care delivery has historically tended to ignore what patients want and focused primarily on what we think they need. In some sense it is remarkable we get as much buy in from our patients as we do. While 20-30% of patients may not fill their prescriptions, that means that 70-80% fill them.


In order to better get our hands around these issues, let's take a hypothetical example from outside of the health care industry. Imagine that you find that your old computer is slow and runs on Windows XP, no longer supported by Microsoft. You have heard about security risks and decide to investigate whether a new machine is in order. You go to a big box retailer (Best Buy) to look into the purchase of a new computer and try to explain to the sales associate what you think you need. The salesman immediately directs you to the highest end machine they sell and also tries to sell you an extended warranty. When you balk, believing that the high end investment does not actually bring you the value you need, the salesman suggests that you are ignorant and calls you "non-compliant". He points out to you that you obviously don't understand the risks involved in buying a cheaper machine or sticking with an obsolete XP operating system. There is much at stake here with your valuable photos and financial records which all could be lost if you are not covered with an extended warranty. People lose their valuable data every day! We will just mark your Best Buy customer record with the "Non-compliant" check mark.

We in health care are involved a service industry. We need to realize that recent history has placed this service industry within a very peculiar  financial environment which has insulated many if not most of its customers from many of  the actual costs of service delivery and thus has created a perverse set of incentives and a skewed set of perspectives on the value placed by patients upon the services we deliver. However, as the cost of the medical services becomes increasingly transferred on to patients, it appears patients perhaps value the services we offer much less than we thought they would or should.  This comes as a surprise to those of us delivering the services since our impressions of value have formed by seeing demand within an environment of almost no cost to those demanding the service. Raise the price just a little and oh how the demand seems to evaporate. Perhaps we should try harder to convince patients that what we offer really does bring them value, convincing them to sped their time and resources on what we recommend. That can be viewed as education and/or marketing but the onus is on us, not on our patients. We should work hard to ask them what they they view their needs to be, where their priorities are, and what they want. We will need to be prepared for answers we do not expect or want to hear.

Physician as craftsman

Physicians operate as craftsmen. We are organized into guilds and use the power of the state through licensing laws to keep competitors out. We train new practitioners using the apprentice model. We link our pay to directly touching our products, one at a time, whether it be in the operating room, the exam room, and less so in the lab or reading room.  We understand that people love craftsman and are suspect of things that are mass produced. We resist mass production in medicine.  However, we tend to lose sight of the fact that our standard of living and life expectancy has improved remarkably over the past 300 years because we have moved from craftsman produced goods and services to mass produced items. We can value craft items now only because mass production has made us wealthy enough to have the disposable income to acquire such luxuries.

Still we maintain medicine as a craft industry and place the most expensive craftsman (us) in the center of delivery. Can we afford to continue to do this? We have deployed increasingly complex sets of interventions and recommendations where the yield from the complexities are marginal. The increase of complexity has been
underwritten by insurance which has for the most part has insulated the consumer from the cost increases, until now. Obviously patients have liked this situation because they are insulated from costs. Deliverers of care have liked this situation because it has allowed them to deliver increasingly complex and expensive (high margin) care without the risk of sticker shock. Furthermore, this could all be delivered without disrupting the craftsman model of care, until now.

Throughout history fields controlled by craftsman have evolved away from the craft model. The major transitions and disruptive innovations were generally not driven by craftsman. It is hard to imagine that medicine will be any different. Craftsman, including physicians, are loathe to drive innovation which will disrupt their status and livelihoods. Furthermore, physicians tend to value their services to patient more than patients value them. In contrast, patients value convenience and cost more than those delivering the services. This disconnect in terms of value has been hidden due to a payment system which insulates those receiving the services from the full costs.

The time and convenience value issue is coming to the forefront. The use of various surveys of patients probing their impressions of the experience of care delivery almost invariably highlights convenience issues. It appears that patients may value convenience and cost more than they value quality. Patients can be just as happy or happier with cheap and good enough as opposed to the best.  Our responses as medical professionals historically has been like the old phone company, "We don't care because we don't have to". Addressing patient priorities has not been our priority because, unlike our patients, we value quality of the care we deliver more than convenience of delivery. What will happen when other non-craftsman parties who get into the health care delivery business have priorities which align more closely with what patients want more (cheaper, good enough, and convenient) than what we physicians believe they should desire (the best quality possible)? I believe the results are predictable.

Furthermore, the craft model of health  care delivery looks increasingly like a trap. The exploding cost of care now exerts substantial price pressures which physicians have responded to by increasing volume and through put. However, there are limits to how fast one can run the craft model. It is not particularly scalable and by insisting we touch every patients, we become bottlenecks, and expensive ones at that. The product we attempt to deliver becomes more and more divorced from what the public desires.

What is a craftsman to do? Should we remain true to our ancient craft or should we embrace new non-craftsman based care models recognizing different priorities?  If we have interventions and delivery approaches which can reach more people at lower cost and make lives better, we should strive to deploy them in ways which are affordable and scalable. However, our training programs are based upon the legacy of apprenticeship of the craftsman and guilds. Should training programs be the bastions of past, are we preparing our trainees for a world which is not likely to exist in the future with skills sets that the public is not particularly interested in using? The key question becomes, will physicians lead movements driving change, be dragged kicking and screaming into new models, or simply be bypassed and left behind?

What is science without replication?

Dr. Mina Bissell published a commentary in Nature in November (Reproducibility Risks) which was in response to questions raised by a study by Amgen scientists where they could only reproduce 11% of work published in high impact journals. She took what I view as a very peculiar tack on these observations. Her major concern was that the drive to improve the reproducibility of research findings could serve as a stumbling block to  promising research and researchers. She believed her concerns were justified based upon the time required and the technical difficulties associated with reproducing studies:

"People trying to repeat others' research often do not have the time, funding or resources to gain the same expertise with the experimental protocol as the original authors, who were perhaps operating under a multi-year federal grant and aiming for a high-profile publication. If a researcher spends six months, say, trying to replicate such work and reports that it is irreproducible, that can deter other scientists from pursuing a promising line of research, jeopardize the original scientists' chances of obtaining funding to continue it themselves, and potentially damage their reputations."

"Many scientists use epithelial cell lines that are exquisitely sensitive. The slightest shift in their microenvironment can alter the results — something a newcomer might not spot. It is common for even a seasoned scientist to struggle with cell lines and culture conditions, and unknowingly introduce changes that will make it seem that a study cannot be reproduced."

My question is how biologically relevant are observations if they are only reproducible under very narrow and difficult to replicate (impossible to replicate?) circumstances? Shouldn't one's reputation be somewhat dependent upon doing and reporting scientific studies which others can replicate? Substitute the term magic for science and wizard for scientist. Magic and alchemy became discredited because it was not reproducible and it was dependent upon special proprietary talents held as secrets by the purported practitioners. Where have we gone if our models begin to resemble magic tricks or at best difficult to duplicate scientific parlor tricks?

What brought this to light was the biotech company Amgen invested a huge sum of money and the product of their investment was not what they expected (Begley). The rest of us in the biomedical establishment should understand what they uncovered. Prior to their work, we had no way of measuring the quality of biomedical research work in terms of a metric which is central to research in general: reproducibility. One must assume that when they undertook this endeavor, they were not intentionally testing the reproducibility hypothesis. I can only imagine this was believed to be a given since it is so central to research activities.

To be faced with a reproducibility percentage which almost reached into single digits must have been staggering to the Amgen scientists. How can this be?  The assumption that scientific work is self correcting does not appear to be valid.  Thus, Dr. Bissell's response to this is to find all sorts of reasons that under the current circumstances with complex systems that reproducible findings are hard to generate. She misses the point. If we have arrived at a place where only one in ten studies published in the most reputable journals can be reproduced, we have an awful quality control problem in science. It is likely worse than these numbers reveal since these results come from the most reputable journals.

Given the extent of the problem highlighted by the Amgen work, one must also wonder how much of this problem may be due to scientific fraud. I came across a report of an investigation in Germany published in 2000 (Hermann and Brach) regarding two cancer scientists who operated in Germany in the 1980's and 1990's. The commission that investigated them and found rampant issues. However, little structural action has been taken to address the underlying problems. It is sad to admit but humans functioning in science will be representative of people in general. If money, fame, power are involved, some will stretch the rules and in the absence of mechanisms to identify undesirable activities, the culture will devolve into whatever it takes to be successful in the increasingly competitive funding climate.  The Wikipedia page on scientific misconduct continues to expand (WIKI).

This is simply unacceptable. The fact that any attempt to address these observations will be disruptive of current operations should be taken as a given, not as a barrier. How valuable is this multi-billion dollar enterprise if the models only work is a few hands and there are no consistent quality control tools? The arguments placed are highly reminiscent of the points put forth when the safety and quality movement came on the scene in health care delivery. Prior to the late 1990's it was difficult to track quality in health care delivery. Thus, consistent with the mantra that if you can't measure it, you cannot improve it was operational. Since there are few incentives to measure reproducibility in biomedical sciences, few focus on this. What the field values in general is productivity, whether valid and reproducible observations are made or not is of secondary value. I fear that the absence of  reproducibility feedback loops has taken us to a very undesirable place from the stand point of those investing financial resources in the research.

Dr. Bissell offers a few anecdotes from her lab to refute the concerns. When sophisticated scientists in industry spending hundreds of millions of dollars cannot duplicate your work, they might have a problem in that they burned through resources that could have been better invested elsewhere. However, if they cannot reproduce your results you have a bigger problem.  The fact that under the current system that this issue can be viewed as someone else's problem is a HUGE PROBLEM. One cannot and should not deflect the onus on someone else. Magicians and wizards can resort to secret spells and incantations. That is not science.