Uncertainty and how problems and solutions are framed

I would like to direct my readers to a recent piece published in the NEJM entitled "Tolerating Uncertainty" (NEJM). The issue identified and the article has implications well beyond the delivery of health care. We humans love certainty and hate ambiguity. Until recently, medicine didn't really have to address uncertainty since our roles were fairly straight forward. We measured our successes and failures based upon a hard endpoint: were are patient dead or alive within days or at most weeks after we were asked to evaluate and intervene. Because of our successes, the dead or alive bar is no longer the primary goal of our efforts. Simply finding that our patients did not die after we touched them is not adequate to justify our efforts. 

Our metrics and particularly timelines to measure successes or failures have changed dramatically. Our endpoints may be measured years or even decades into the future and that creates all sorts of problems. We are not so good at predicting the future and the longer we try to look out, the more uncertainty we need to face. Some view this problem of prediction as a problem which can be addressed with the application of enough data and enough technology. However, I believe that uncertainty will always be with us and the longer we attempt to peer into the future, the more inherent uncertainty we will need to acknowledge. 

I find myself explaining this to patients every day. People come to me in various states if ill health and it is my role to evaluate their circumstances and provide them with options in terms of intervention. In each case, decisions are made in terms of doing something based upon trying to peer into the future and estimating whether any given course of action is likely or unlikely to leave them better off. For any given decision, there is always a possibility of catastrophe, whether the decision is to act or not act. There are no certain outcomes, just ones we estimate to be more likely to be generate better or worse outcomes. There are always trade offs involved and it is always about probabilities, not certainties. 

The trade off reality is not limited to health care. While there may be uncertainty regarding which particular trade offs will come into play, there is absolute certainty regarding the inherent existence of trade offs. Thus, the blindness to the presence of both uncertainty and required trade offs influences how humans address problems, both current and future. I see this particular problem poisoning thoughtful exchanges in all realms which are potentially contentious, which is basically everything. 

I would like to highlight how the desire for certainty and the blindness to trade offs has totally poisoned any discussion regarding climate science. I am listening to a Great Courses audio course given by Dr. Robert Hazen of George Mason University entitled "The origin and Evolution of Earth". The basic premise of the course is that the geosphere and the biosphere have been interacting for literally billions of years and that life on earth has changed the earth in fundamental ways. These life driven changes have preceded human existence, again by billions of years and have resulted in the modification of rocks and minerals, makeup of the atmosphere, and changes in climate. The earth has varied in the past from being covered with ice to tropical environments at the poles, all without any human intervention. We are only now recognizing this to be the case.  We are also now recognizing that like life forms which preceded us on earth, we are influencing our environment. All of life on earth past and present and future have and will do the same, no matter what we as humans do.

This has set off alarm bells among certain groups on the basis that any change which we might be driving could have catastrophic consequences, and they could. Like we have observed in health care, any time we act we might create serious problems. We also observe that when we act in attempts to prevent one outcome, we can also create unintended problems. It is that trade off thing. However, the discussions regarding climate change and possible outcomes rarely are framed with trade offs involved. How likely are the catastrophic outcomes to happen if we continue pursuing our current courses? Who will these outcomes preferentially affect? Similarly, if we intervene and apply some sort of carbon (energy) restrictive approach, what are the trade offs involved? Who will these outcomes preferentially affect and will these people be different from those affected if we do not change?

Like interventions for disease states which may occur in the future, we need to think about whether we will leave most people better off if we apply any particular intervention. There is often no right or wrong answer but only interventions which are believed to be more likely to leave people better off at a given point in time. Our current knowledge about climate change is that the climate is changing as it has been for billions of years. There is no surprise here. That humans may be altering the climate should also not come as any surprise. Our ancestors back to single cell oxygen producing organisms have been doing the same back to the great oxidation event. The questions are:

1. Are we actually screwing things up to the point of likely catastrophe?

2. Do we have any real idea that we can change our actions such that we are likely to move toward better outcomes? 

3. Specifically, what do the trade offs look like regarding following our current course and any alternative courses?  

We haven't any real clue as to the answers to these questions. As far as I am concerned the predictions made regarding what is going to happen 50-100 years into the future regarding highly complex and poorly understood systems are crazy. In the same sense that we crave certainty in medicine and will be disappointed because there are things which are unknowable until they happen, our world will also not yield to the desires for certainty that we may have. We are just humans, not gods. To think we can predict where chaotic systems will take us in an extended time frame and select interventions which will leave humanity and the earth better off represents arrogance and hubris. 

Our desires and attempts to scientifically change the future have yielded all sorts of Utopian nightmares, whether that be Scientific Socialism and mass murder, or eugenics and mass murder. My experience in the health care realm has taught me that we can always make things worse and create new problems. It is an experience which I believe has provided me with a broader understanding of the world outside of medicine as well. We are not inherently better off when we act than when we do not. 

Best intentions and unintended consequences

I read a story from the New York Times today (Cuban tourism) about an unintended effect of the surge of tourism on the lives of ordinary Cubans. It seems that the Cuban government failed to anticipate the flood of new tourists (3.5 million last year). One might think that in a normally operating economy these arrivals would result in some sort of positive effect on the island economy, with all of the external currency injected into the economy. However, that was not the case.

What happened is that in order to meet the needs of the visitors, goods (especially food) normally which met the needs of ordinary Cubans were diverted to feed the visitors. Cuban citizens were left with empty shelves and soaring prices. The response of the Cuban government was both predictable and maladaptive. The government placed price controls on basic staples which served to make the price on paper affordable but in reality made the unavailable to the average Cuban citizen.

There is an irony here. I suspect that those individuals now most likely drawn to Cuban travel are ones who have an element of good Samaritan motivation.  And yet, the immediate effect has been to make the lives of ordinary Cubans worse, at least in the short term. The market for supplying the tourism sector with what now are luxury goods is giving at least some Cubans an opportunity to better their lives, but not without more unintended consequences. The Times article describes the activities of Leticia Alvarez Canada, a nurse who gave up her job to sell snacks from a cart and increased her income by 10-fold. This does not bode well for health care delivery.

It seems that the tourists who visit Cuba are likely unintentionally undermining the very system they likely hold sympathy for. In contrast, the staunch anti-Castro elements which have successfully lobbied to keep Cuba isolated for more than five decades may very well have helped create an environment of isolation which was necessary to perpetuate the regime.

Picking fights v. solving problems

I have been listening to much of the banter on XM radio since the surprising election results. I toggle between the POTUS channel, MSNBC, CNN, and Fox, trying to take a broad measure of what the Trump election means and how it will translate into specific decisions and course of action.

I did not see this coming, but I was not alone. In fact, the night of the election, I had turned off the TV early in he evening, believing things were essentially baked already and that Hillary would win with a comfortable margin in the Electoral College, that the House would remain under Republican control, and that the Senate was a toss up. As it turned out, we had a family medical emergency which prompted me to go to the Emergency Room around 11 pm and while I was in registration, I overheard the ED staff talking about a NYT prediction that Trump was going to win. I couldn't believe what I was hearing!

I find his words deplorable. He comes across as egocentric, hypercompetitive, and the opposite of reflective. No one has every accused Donald Trump of overthinking, anything.

He is now our president. Will he become any better or more likable as a person? I seriously doubt it but perhaps that is not as important as what his election will translate to in terms of positions, policies, and outcomes regarding the Federal government?  It is anyone's guess at this point. It is hard to hope he will be a disaster, although I have serious concerns. 

I believe we can get some insight into his priorities based upon his 100 day plan, summarized below (taken from  NPR website).   Already there are calls for resistance to anything and everything Trump. I am not into picking fights. Fighting rarely solves any problems. However, current politics is nothing but fighting and confrontation. I propose we attempt to make this into everything but Trump the person.  I suggest we all approach each of these initiatives using the following framework of questions:

1. What problem does this initiative address?

2. Is this a significant problem which warrants an intervention?

3. Do I believe the proposed solution will move toward a solution?

4. What are the likely unintended consequences? Is this approach dangerous and if you believe so, is it much more likely to create problems than to solve problems?

5. Is there a better approach? 

The first 100 days proposed (NPR)

* FIRST, propose a Constitutional Amendment to impose term limits on all members of Congress;

* SECOND, a hiring freeze on all federal employees to reduce federal workforce through attrition (exempting military, public safety, and public health);

* THIRD, a requirement that for every new federal regulation, two existing regulations must be eliminated;

* FOURTH, a 5 year-ban on White House and Congressional officials becoming lobbyists after they leave government service;

* FIFTH, a lifetime ban on White House officials lobbying on behalf of a foreign government;

* SIXTH, a complete ban on foreign lobbyists raising money for American elections.

On the same day, I will begin taking the following 7 actions to protect American workers:

* FIRST, I will announce my intention to renegotiate NAFTA or withdraw from the deal under Article 2205

* SECOND, I will announce our withdrawal from the Trans-Pacific Partnership

* THIRD, I will direct my Secretary of the Treasury to label China a currency manipulator

* FOURTH, I will direct the Secretary of Commerce and U.S. Trade Representative to identify all foreign trading abuses that unfairly impact American workers and direct them to use every tool under American and international law to end those abuses immediately

* FIFTH, I will lift the restrictions on the production of $50 trillion dollars' worth of job-producing American energy reserves, including shale, oil, natural gas and clean coal.

* SIXTH, lift the Obama-Clinton roadblocks and allow vital energy infrastructure projects, like the Keystone Pipeline, to move forward

* SEVENTH, cancel billions in payments to U.N. climate change programs and use the money to fix America's water and environmental infrastructure

Additionally, on the first day, I will take the following five actions to restore security and the constitutional rule of law:

* FIRST, cancel every unconstitutional executive action, memorandum and order issued by President Obama

* SECOND, begin the process of selecting a replacement for Justice Scalia from one of the 20 judges on my list, who will uphold and defend the Constitution of the United States

* THIRD, cancel all federal funding to Sanctuary Cities

* FOURTH, begin removing the more than 2 million criminal illegal immigrants from the country and cancel visas to foreign countries that won't take them back

* FIFTH, suspend immigration from terror-prone regions where vetting cannot safely occur. All vetting of people coming into our country will be considered extreme vetting.

Next, I will work with Congress to introduce the following broader legislative measures and fight for their passage within the first 100 days of my Administration:

Middle Class Tax Relief And Simplification Act. An economic plan designed to grow the economy 4% per year and create at least 25 million new jobs through massive tax reduction and simplification, in combination with trade reform, regulatory relief, and lifting the restrictions on American energy. The largest tax reductions are for the middle class. A middle-class family with 2 children will get a 35% tax cut. The current number of brackets will be reduced from 7 to 3, and tax forms will likewise be greatly simplified. The business rate will be lowered from 35 to 15 percent, and the trillions of dollars of American corporate money overseas can now be brought back at a 10 percent rate.

End The Offshoring Act. Establishes tariffs to discourage companies from laying off their workers in order to relocate in other countries and ship their products back to the U.S. tax-free.
American Energy & Infrastructure Act. Leverages public-private partnerships, and private investments through tax incentives, to spur $1 trillion in infrastructure investment over 10 years. It is revenue neutral.

School Choice And Education Opportunity Act. Redirects education dollars to give parents the right to send their kid to the public, private, charter, magnet, religious or home school of their choice. Ends common core, brings education supervision to local communities. It expands vocational and technical education, and make 2 and 4-year college more affordable.

Repeal and Replace Obamacare Act. Fully repeals Obamacare and replaces it with Health Savings Accounts, the ability to purchase health insurance across state lines, and lets states manage Medicaid funds. Reforms will also include cutting the red tape at the FDA: there are over 4,000 drugs awaiting approval, and we especially want to speed the approval of life-saving medications.

Affordable Childcare and Eldercare Act. Allows Americans to deduct childcare and elder care from their taxes, incentivizes employers to provide on-side childcare services, and creates tax-free Dependent Care Savings Accounts for both young and elderly dependents, with matching contributions for low-income families.

End Illegal Immigration Act Fully-funds the construction of a wall on our southern border with the full understanding that the country Mexico will be reimbursing the United States for the full cost of such wall; establishes a 2-year mandatory minimum federal prison sentence for illegally re-entering the U.S. after a previous deportation, and a 5-year mandatory minimum for illegally re-entering for those with felony convictions, multiple misdemeanor convictions or two or more prior deportations; also reforms visa rules to enhance penalties for overstaying and to ensure open jobs are offered to American workers first.

Restoring Community Safety Act. Reduces surging crime, drugs and violence by creating a Task Force On Violent Crime and increasing funding for programs that train and assist local police; increases resources for federal law enforcement agencies and federal prosecutors to dismantle criminal gangs and put violent offenders behind bars.

Restoring National Security Act. Rebuilds our military by eliminating the defense sequester and expanding military investment; provides Veterans with the ability to receive public VA treatment or attend the private doctor of their choice; protects our vital infrastructure from cyber-attack; establishes new screening procedures for immigration to ensure those who are admitted to our country support our people and our values

Clean up Corruption in Washington Act. Enacts new ethics reforms to Drain the Swamp and reduce the corrupting influence of special interests on our politics.

EpiPen craziness

My attention has been drawn to the Mylan labs controversy regarding its EpiPen product. This story epitomizes what is wrong with the pricing mechanism which permeates much of health care delivery.

The obvious front page story goes something like this:  "Greedy pharmaceutical companies lead by greedy CEO's take advantage of the public to reap out-sized profits."  This in turn leads to a cry for Federal intervention to fix this problem.

Is this really the problem and is the proposed fix going to be effective in solving the problem. I often hearken back to the words attributed to Albert Einstein who has been quoted " If I had only one hour to save the world, I would spend fifty-five minutes defining the problem, and only five minutes finding the solution." (Whether he actually said this is another story but beside the point). If we don't have the problem adequately defined or even worse, incorrectly defined, it is not likely that that the problem can be solved except by the injection of dumb luck.

It should come as no surprise that a profit seeking entity will be motivated by generating a profit and it will do whatever that is legally within its power to maximize its earnings.   Companies that sell any product or service will try to optimize the price structure. Companies that do a bad job at this tend to disappear. There are pressures to keep prices high enough to cover costs, the reasons being obvious. There are also pressures to pressures to keep prices low enough to compete with other parties who seek to take market share by offering the same or similar product or service at a more competitive price.

The case of the EpiPen is one of a failed market, one that has failed because a third party has intervened. That third party is the Federal government in the form of the FDA. The FDA has a mandate to protect the public from unsafe and/or ineffective medications and devices. Who can argue with that mandate? As usual, the devil is in the details and with any intervention targeted to add value to the public, there is always the possibility that the unintended consequences of the best intended actions end up creating new problems.

Epinephrine, the drug platform behind the EpiPen has been around for more than 100 years. It is inexpensive to produce. The delivery device has been around for decades and vastly cheaper earlier versions are sold outside of the US for pennies on the dollar. Multiple Mylan competitors have attempted to bring alternatives to market in the US for years. Mylan, in some sense partnering with the FDA, has done the most reasonable thing to maximize their shareholder value. In the absence of competitive pressure to keep prices low it would be irresponsible not push the envelope on price and fulfill their fiduciary duties to their shareholders.

The FDA combines the worst of the precautionary principle with a blindness to cost. I do not have inside information on the specifics of decisions to impede the deployment of competitive products and I do believe there is a specific conspiracy. It is likely simply to convergence of perverse incentives within the agency which which prompt employees to avoid risks associated with approval of competing products. The net result is the cost of the injector rising from around $50 for a single unit to over $600 for the obligatory two pack.

A second but related element is the role of health insurance in the evolution of this problem. While the EpiPen is in the news, the peculiarities regarding its pricing is fare from unique in health care. Perverse pricing of health care related goods and services are more the rule rather than the exception. The perverse pricing structures are a consequence of the use of third party payment mechanisms which result is large segments (but not all) of the public being insulated from the cost of given goods and services. Her lies the source of so many issues we face in health care. Even in the absence of any competitor, there are limits in terms of how much Mylan could charge for the EpiPen and the presence of a large insured population allowed them to push the price hikes much harder than if the public had to pay out of pocket for the EpiPen.

When going back to define which problems we are facing, I believe the crux boils down to the role of insurance and its effect of shielding the paying public from awareness of the cost of delivery of goods and services. The question should be, should we insulate people from the costs of health care delivery and if so, which ones and when? One reason that the EpiPen cost could rise so steeply is that during the time where the cost increases were going into effect, much of the buying public was insulated from the cost. As Holman Jenkins wrote in his WSJ article (Jenkins):

Well, in the rest of the economy, when a consumer is spending out of his pocket, he has incentive to judge whether the service he’s buying is worth the price he’s being asked to pay.
Now you know why we offer coupons and rebates to individual consumers. This is our way of trying to re-desensitize customers to the price of EpiPen in order to counter the efforts of insurers to re-sensitize them by hitting them with copays and deductibles.
Then why does getting our coupons and rebates involve rigmarole? Because certain consumers won’t make the effort, and then we get to keep the money that would otherwise go to defray their out-of-pocket costs.

Extrapolate the EpiPen phenomena to the entirety of the health care economy. Jenkins goes on to do this...

It’s a great game and we have fun playing it. On average, however, it probably does not increase the health-care industry’s profit margins or the public’s health—but only the share of national income diverted to health care from everything else: beer nuts, wedding presents, automobiles. Our industry’s share of GDP is 17%, up from 13% two decades ago. Hooray, that’s $700 billion a year.

  Obviously, there are catastrophic events where insurance has a vital role. Heck, that is the purpose of insurance.  However, when the desire to insulate the public from the cost of mundane and predictable services they can and should plan for, and to use insurance to meet those ends leads to outcomes which become catastrophic when considered in aggregate. Where well functioning markets are relentless in driving down costs, regulated health care markets drive up costs, even of old products with little or no commensurate value added to the public. Despite the best of intentions, the results are not what virtually anyone desires, unless you are Mylan Pharmaceuticals benefiting from a governmental facilitated monopoly.

Health care costs, mandates, and the changing health care workforce

Health care delivery is both already expensive and also saddled with unsustainable cost increases. The reasons for this are multiple. Just to name a select few, health care historically has operated under the assumption that improvement (or perceived improvement) is worth it, no matter what the cost. In addition, health care is very labor intensive and the labor is very expensive. In addition, it is about to get even more expensive.


I have little doubt that Hillary Clinton will be elected the next president of the US. I also have no regret that the next president will not be Donald Trump. I will derive some degree of satisfaction when the first person looks at him after the election and addresses him as a "loser" and I hope the habit continues for a long time. However, I have some great reservations regarding some of the planks of the Democratic Party Platform, relating to generous paid leave provisions.


For those us who need to balance budgets, legally mandating that employees can take generous time off with paid leave means figuring out how to pay them. For expensive people, this can get very expensive and we have lots of expensive labor in health care delivery. Increasing labor costs will not decrease the cost of delivery services. In fact, the effect is quite the opposite! How will I figure out how to pay the salaries of $100K+ professionals who are not at work? How many people on paid leave can we afford at any given time?


I have little doubt that these mandates will be established but I have to ask, how is this going to work? How are we going to find a way to delivery health care services at steeply lower costs when mandates drive up the cost of the biggest part of our overhead (labor)? I see there are only five options.


Option 1 is to pay everyone less money.
Option 2 is to hire less expensive labor, that is substitute nurses for doctors, health techs for nurses, etc.
Option 3 is to stop hiring people and automate
Option 4 is to stop offering services which are too expensive to deliver
Option 5 is really a hybrid of all the above which is to increase efficiencies and generate more value per unit of labor paid for.  However, there is no way that one can garner efficiency gains from people who are on paid leave.


I believe the pressures to cull the workforce and eliminate workers, especially expensive workers will be huge. Couple this with changing payment patterns and I believe physicians will be in the cross hairs. Physicians bring lots of unmeasured value into care delivery now but the thing that is measured is money. We measure little else. Up to the current time, fee for service has been mostly dependent upon MD's to drop bills. For health systems, doctors are needed for cash flow because doctors can submit bills and allow facilities to operate. When bundled payments go directly to health systems (as proposed under MACRA) and doctors are primarily salaried and are no longer required for billing, health systems will view MD's primarily as the most expensive part of their workforce. Where can costs be cut? Why are we paying these guys so much?

Movement from informal to formal processes in medicine

I have had a robust exchange with colleagues regarding how one should acknowledge another physician's opinion in the medical record. I am of the mind that the only opinion that one should write in the record is your own. I have no desire for any of my colleagues to record my opinion in their notes, unless they forward those for me to sign or write an addendum.
However, my opinion on this activity is not held universally, not by a long shot. Within other fields, especially radiology and pathology, there is a long tradition of bedside clinicians visiting and consulting these specialists, in their "houses". Rounds used to start in radiology and there would be extensive discussions with care teams, resulting in radiologist opinions being paraphrased in the medical record. Whether what the radiologist intended to communicate routinely ended up in the notes on the floor is not so clear.Similarly, glass slides routinely circulate in Pathology departments and colleagues are called upon to render inter-departmental consults, ranging from formal to very informal. The language incorporated into various reports may include a host of concurrences from physicians whose signature never appears on the final report.
Historically, critical decisions in medicine, especially in the most challenging of cases, were often made after generating a form of consensus, whether that consensus was derived from Grand Rounds, tumor board, or informal solicitation of opinions. The transcripts from these conferences and informal activities were generally non-existent and the consensus recorded tended to be ephemeral and biased through the lens of whomever wrote something in the chart. It may have been heavily influenced by one or a few strong and charismatic clinicians who would sway the audience based upon their confidence and experience. 
All of these activities were highly informal processes. Individual attendees tended to take away what they wanted to take away and the patients cared for had little or now idea what actual conclusions were drawn and how they were arrived at. They were simply informed that we had a conference and the agreement of the group was, whatever. Individual accountability and hard evidence was not something on the radar. 
Looking back nostalgically, we believe that these activities enhanced patient care, irrespective of the actual outcomes. They certainly made the care teams feel better and there was a certain simplicity and finality which appeared to be achievable which does not appear to be achievable now.  While the human contact did unquestionably facilitate communication, the model was not scalable. It depended on small groups who were familiar with everyone involved. The decision trees were not so arborized. The information to be managed was on a much more limited scale.
It is a different world now. We aspire to do more, much more which requires much more complex systems to manage. The teams are larger and the workloads more specialized. Communication becomes even more essential under these conditions and when communication fails, we ascribe those failures to leaving the informal systems behind. However, when systems become more complex, informal communications will not suffice. Each decision branch point, which may be dependent upon particular fidelity on terms of information transition, becomes a possible pitfall. A process with three steps has a much lower failure rate than one with five, or ten, or fifteen. Informal verbal communications are fraught with error and should not serve as the foundation for critical information flow.

People can be strange and unpredictable

I am reading a book titled "Heaven's Ditch: God, gold, and murder on the Erie Canal". It is quite an interesting story, about the best of humanity, the worst of humanity, and the weirdness of humanity, all wrapped up in one nice package. The best is the fact that in the early part of the 19th century, the Erie canal was built. It took vision, chutzpah, drive, and incredible people. It was an engineering marvel which fundamentally changed the course of history in the US. The worst is that many of those involed were simply awful people who did awful things to other people.

However, it is the weirdness background which simply blows me away. The canal was built in western New York during a time of great religious revival. It was not just religious revival but all forms of spiritual, mystic, and magical thinking. It was where Joseph Smith's family ended up before the trek west. People became wrapped up in all manner of superstition. Joseph Smith, before he found the gold tablets and launched the Mormon sect, was one of may people who used special stones he placed in his hat to see the future. People, including Smith, were using divining rods to find casks of money buried in the ground.

While among my peer group currently, the acceptable facade to display is one of rationality and linear thought (sort of Mr. Spock like), I think this is not how many (most?) people really operate. Beneath the facade there are a jumble of emotions which can drive some peculiar behavior. Most of the peculiar behavior likely can be characterized as quirky and some of it as annoying. It then can go on to move into the territory of very odd, strange, really strange, and then downright disturbing. With enough concentration of people, likes can link up and amplify the quirkiness and strangeness. The internet has been very conducive to this. The fun end of this spectrum is where things like DragonCon reside. At the less benevolent end you might find congregations of people with more sinister motives.

I don;t think there has been any real fundamental change in the underlying DNA. There have always been people who have been at the fringes, did not play well with others, and/or simply had evil motives. If they were charismatic and could convince others to team up and do nasty acts, they could cause great destruction. However, individual actors were very limited in their reach. With great effort they could harm to a few others. Weirdness did not translate to far reaching effects.

Technology has greatly leveraged human capabilities. However, it has also leveraged the ability of individuals to cause great harm to many people. Anarchists more than 100 years ago began this using bombs to target populations. We were distracted for a while from this by wholesale slaughter by state actors and then the cold war and worry about state mediated thermonuclear annihilation. Now, this same phenomena is back.

It is hard to believe that single person human capability in terms of destruction can be scaled back. States may do their best to control armaments in the hands of their populace (with or without the second amendment), but progress in terms of miniaturization and energy concentration is not likely to stop. Research efforts to place more powerful and easily used tools in the hands of soldiers will invariably mean that the fruits of these endeavors ends up in the hands of ordinary people. It has happened with granola bars and it will happen with weapons.

I think this has happened to some degree in the past.  Throughout history, various parties have held monopolies on violence and those monopolies were disrupted by transitions of power and weapons into other hands. No state power means anarchy and chaos, while nothing but state power means totalitarianism. We do not want the constant war of every person against every other person but we do not want to cede total control to a unilaterally armed state because a few bad actors don't realize they are better off by giving up the right to annihilate those around them.

And what we are back to is the realization that people can be strange and unpredictable and we have to live with that.

I am incedulous that this activity has not received more attention!

From the Washington Post today(Link). This is an op-ed piece from Nicholas Quinn Rosencranz regarding the Justice Department's settlement with various large banks which included the requirement for donations to various community development groups.

What is less well known is that some of this money — amounting to hundreds of millions of dollars — is designated for “donation” to various “community development” organizations that were neither parties to the case nor victims of the alleged wrongdoing. Investor’s Business Daily has characterized these payments as “political payoffs to Obama constituency groups,” and Congress is now considering banning this practice with the Stop Settlement Slush Funds Act of 2016.

How bizarre!  The constitutional issue is obvious. The settlement represents money paid to the Federal government which is then appropriated to pay another party, without any Congressional approval. What we are seeing as the discretionary portion of the Federal budget essentially disappears is the use of DOJ shakedowns of private entities for cash then used to repay politically connected.

How can we better the world?

Deirdre N. McCloskey published what I consider a spot-on piece today in the WSJ. (Link) It is titled "How the West (and the rest) got rich". It is well worth reading in its entirety and I will almost certainly pick up a copy of her new book, “Bourgeois Equality: How Ideas, Not Capital or Institutions, Enriched the World,” .


I am fascinated by why certain systems work well while other systems do not and I have come to believe that functional complex systems develop not because of intelligent design, but because of innumerable trials resulting in many failures and few successes. Thus the great enrichment is described by Dr. McCloskey. The essay is eloquently written and I thought it useful to highlight some of the most pithy parts.

Nothing like the Great Enrichment of the past two centuries had ever happened before. Doublings of income—mere 100% betterments in the human condition—had happened often, during the glory of Greece and the grandeur of Rome, in Song China and Mughal India. But people soon fell back to the miserable routine of Afghanistan’s income nowadays, $3 or worse. A revolutionary betterment of 10,000%, taking into account everything from canned goods to antidepressants, was out of the question. Until it happened.

Why did it happen? McCloskey goes on to write:

But none of the explanations gets it quite right.
What enriched the modern world wasn’t capital stolen from workers or capital virtuously saved, nor was it institutions for routinely accumulating it. Capital and the rule of law were necessary, of course, but so was a labor force and liquid water and the arrow of time.

What appears to have catalyzed this were ideas and liberty:

The capital became productive because of ideas for betterment—ideas enacted by a country carpenter or a boy telegrapher or a teenage Seattle computer whiz. As Matt Ridley put it in his book “The Rational Optimist” (2010), what happened over the past two centuries is that “ideas started having sex.” The idea of a railroad was a coupling of high-pressure steam engines with cars running on coal-mining rails. The idea for a lawn mower coupled a miniature gasoline engine with a miniature mechanical reaper. And so on, through every imaginable sort of invention. The coupling of ideas in the heads of the common people yielded an explosion of betterments. 

Power hungry statists and control freaks on both the left and right have been suspect of both liberty and change and have repeatedly attempted to vilify commercial interests which have been the drivers of growth and change:

Not everyone was happy with such developments and the ideas behind them. In the 18th century, liberal thinkers such as Voltaire and Benjamin Franklin courageously advocated liberty in trade. By the 1830s and 1840s, a much enlarged intelligentsia, mostly the sons of bourgeois fathers, commenced sneering loftily at the liberties that had enriched their elders and made possible their own leisure. The sons advocated the vigorous use of the state’s monopoly of violence to achieve one or another utopia, soon.
Intellectuals on the political right, for instance, looked back with nostalgia to an imagined Middle Ages, free from the vulgarity of trade, a nonmarket golden age in which rents and hierarchy ruled. Such a conservative and Romantic vision of olden times fit well with the right’s perch in the ruling class. Later in the 19th century, under the influence of a version of science, the right seized upon social Darwinism and eugenics to devalue the liberty and dignity of ordinary people and to elevate the nation’s mission above the mere individual person, recommending colonialism and compulsory sterilization and the cleansing power of war.

On the left, meanwhile, a different cadre of intellectuals developed the illiberal idea that ideas don’t matter. What matters to progress, the left declared, was the unstoppable tide of history, aided by protest or strike or revolution directed at the evil bourgeoisie—such thrilling actions to be led, naturally, by themselves. Later, in European socialism and American Progressivism, the left proposed to defeat bourgeois monopolies in meat and sugar and steel by gathering under regulation or syndicalism or central planning or collectivization all the monopolies into one supreme monopoly called the state.

McCloskey summarizes:

Rep. Thomas Massie, a Republican from Kentucky, had the right idea in what he said to Reason magazine last year: “When people ask, ‘Will our children be better off than we are?’ I reply, ‘Yes, but it’s not going to be due to the politicians, but the engineers.’ ”
I would supplement his remark. It will also come from the businessperson who buys low to sell high, the hairdresser who spots an opportunity for a new shop, the oil roughneck who moves to and from North Dakota with alacrity and all the other commoners who agree to the basic bourgeois deal: Let me seize an opportunity for economic betterment, tested in trade, and I’ll make us all rich.

I agree with McCloskey that political entities may create the necessary framework for betterment but there are limits as to what politics can accomplish. You cannot fix a fine watch movement with a ball peen hammer. Some might argue that enrichment is not a desirable end. I would suspect most of those making those claims do not live in abject poverty.  

 

How do we know who is a good doctor?

I am a following "the Incidental Economist" (Link) and Healthcare Triage News. Aaron Carroll blogged on pay for performance programs and wrote a commentary late last year on measuring quality (Link).  There was also an article in today's NYT examining narrow networks and limited access for patients to providers outside of their designated networks (Sorry, we don't take Obamacare - link). What do these items have in common? What they have in common is the need to be able to measure quality. Who care if you are locked into a narrow network if it delivers what you need well? We all sort of lock ourselves into narrow networks when we end up selecting specific physicians to deal with our health care problems.


As I see it, we have a very basic problem in that more often then not, those needing services are really not in a position to discern whether a given physician (or other health care provider) is really good at what we need them to be good at. (When I use the term physician, please view it as a short hand for health care professional delivering a service). Obviously for those physicians who do very specific life saving or function saving targeted interventions, we may be able to sort through who is at the top of the heap v. those at the bottom. Even that can be tricky. A good set of outcomes for an orthopedic surgeon who replaces hips may be due to the fact they are in a position to cherry pick or a less than optimal set may be due to them being the go-to person for difficult cases.


Even more challenging may be within the larger universe of providers who do deliver services where it is difficult to impossible to define what quality is? One can march through the different specialties in medicine and it is the exception rather than the rule that clear criteria can be defined which allows any given person to identify who delivers high quality care.  How does one determine whether a gastroenterologist is good at colonoscopy? Yes, one can look at complication rates but the primary purpose of the exam is not simply to avoid trouble. You can always avoid the complication of the procedure by not doing it. How can one determine if a thorough exam was actually done? Are more biopsies better than fewer? What are the actual deliverables? A similar situation may be relevant for dermatologists? What represents a good skin exam? How can this be measured?  For primary care physicians, what constitutes a good or excellent annual check up? Who is doing the best pelvic exams? Who is the best pathologist? Is it the ones who diagnose the most or the least cancers? How can one discern who are the best pediatricians?
Those with great technical skills may have less than optimal judgement, work ethic, or interpersonal skills. What problems do given physicians within specific specialties actually solve and just how good a job do they do in solving these problems? What information do we have at our disposal to address these issues? We do have the annual best doctors issues for local publications for most major cities. However, the selection process for these is a popularity contest which reminds me of elections for class president when I was in high school. It takes into account essentially no quality data. Furthermore, does any actual quality data linked to a given doctor or other provider reflect the physician competence or other aspects of the team over which they have little control?


It is not an unusual circumstance where I am asked by a friend to make a recommendation for care within my system. I know a number of my colleagues on a personal level but truth be told, I really have very limited insight into what type of physician they actually are. I have basically little or no access to hard numbers in terms of whether they solve the problems of patients who they see. There are exceptions (primarily those who I work with every day)  but for the most part I have not directly and consistently witnessed the bedside manner of most of my colleagues or have clinically significant knowledge regarding the quality of their problem solving skills.


Then move into a domain where people have marginal medical knowledge, experience, and insight and imagine how they make these determinations. They simply are flying blind. Patients and their families can determine if someone spends time with them, listens, and makes an attempt to communicate. These observations are important but may not track with the ability to fix whatever problem that needs to be fixed. The may be especially true when the services delivered are done so for goals which may be realized well in the future. Patients can be very impressed with the quality of a service delivered that they did not actually need. One can generate impressive numbers if one is in the business of delivering preventative care for diseases that never or only rarely happen.


This brings us back to the original question; what can we measure to determine who is the best? Perhaps even more important is what can we measure to determine who is simply good enough? Not everyone can access the best and always spending money to get the best may be a bad investment of someone's scare resources, especially if the stakes are not so high.  How can patients tell if the providers available within their networks will likely be able to meet their basic needs and goals?  I believe the path to being able to address this problem will require inputs from both those delivering care and those receiving care. It will mean looking at both high stakes environments and lower stakes environments. It will unquestionably require that we better define what the specific goals of care are. Service delivery without goals can never fail. As the saying goes if you have no destination anywhere you end up should be fine. Similarly service delivery without measurable goals can also never fail and service delivery where the measurements are not aligned with the patient goals will almost always fail.


The fact that measuring what is expedient has ended up not getting us to where we want to be should not come as a surprise and should not prompt us reject striving for measuring outcomes. For us to sink more and more money into an industry which has dismal quality control is simply not an option.

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?

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

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.

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.

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....

Financials bubble through the ages

Tulip Bubble

South Sea Island Bubble

Home mortgage bubble



And from the BBC news...


http://www.bbc.com/news/education-35343680

Coproduction in health care

I have been introduced to an interesting concept, that of co-production. I came upon this concept when I read an article published in BMJ  Quality and Safety. (Link) It is actually such an intuitive concept that it is hard to imagine why it did not occur to me and everyone else previously. I guess that is just how ideas are.


In manufacturing, those who produce goods such as cars or consumables do not directly rely on those use consume and use those products to produce them. The end users may influence the characteristics of the products but they play little or no role in product manufacture. Consumers do not play a substantial role in the quality of the final product, whether that be automobiles or chicken pot pies.


The service industry is different. Victor Fuchs noted in 1968 that the new service economy was different from the old manufacturing economy in that the producers and consumers of services worked together to create value. Later Alfred Toffler described the next generation of consumers which he referred to as "prosumers", linking the previously separated function of production and consumption to maximize consumer value and minimize producer cost.


For example, one might hire a financial professional to help with retirement planning. No matter how good the advice of the professional, the final product depends upon the consumer. If the consumer does not follow the advice and put away money for the future, the final product will be substandard, no matter how good the advice. Similarly, if one gives your tax professional the wrong data,  the final product of the tax return will not be up to snuff.

This concept is also very appropriate for many aspects health care delivery. For patients who present with a diagnostic problem, if they are not capable or willing to provide accurate or complete histories or reviews of systems, they are much less likely to receive accurate diagnoses. For patients who undergo surgery or other interventions who are then discharged home, if they are not willing or capable of following care instructions (or have not been appropriately educated), the outcomes of the interventions are much less likely to be favorable. For patients with chronic disorders where most of the care happens at home, their contributions and buy in may be most essential to optimal outcomes.

However, the co-production involves not just a given provider and a given patient, but teams of providers and other teams which may include patients, their families, and perhaps other patients.

The current payment system is really incompatible with the co-production model. Furthermore, the proposed incentive changes are still predicated on the assumption that outcomes are based solely upon the inputs of those delivering what is commonly viewed as health care services. If the co-production model has validity, you simply cannot get away from the reality that co-production partners who fail to have the requisite skills or desires to co-produce the desired outcomes will invariably lead to less favorable outcomes.


How do we get better outcomes? You have to first figure out what you are trying to produce and then figure out who are the key players in co-producing the desired outcomes. This is going to take some major culture change, in both patients and professionals with health care delivery.

Assault on research transparency

We all suffer from various forms of isolation, some of it self imposed. I recently read the book, "The big sort" which identifies how Americans are increasingly self sorting in terms of where they live and with whom they associate. The authors come up with a compelling story about the results of that sort, which is we are increasingly unaware of opposing world views and opinions. The New England Journal recently published an editorial which I can only explain on the basis of scientific isolation. In this editorial, the Editor of the NEJM, Jeffery Drazen expresses reservations regarding data sharing and possible unintended consequences. (NEJM). I have to admit that he raises legitimate questions:

However, many of us who have actually conducted clinical research, managed clinical studies and data collection and analysis, and curated data sets have concerns about the details. The first concern is that someone not involved in the generation and collection of the data may not understand the choices made in defining the parameters. Special problems arise if data are to be combined from independent studies and considered comparable. How heterogeneous were the study populations? Were the eligibility criteria the same? Can it be assumed that the differences in study populations, data collection and analysis, and treatments, both protocol-specified and unspecified, can be ignored?

These are difficult to address issues which should be dealt with in the open! If these issues are part of the original data set upon which conclusions are drawn, all of the readers and consumers of the information should be aware of these potential limitations. Putting such data in the hands of an extended set of interested people should do nothing but add value to the original studies.


He then goes on to state:

A second concern held by some is that a new class of research person will emerge — people who had nothing to do with the design and execution of the study but use another group’s data for their own ends, possibly stealing from the research productivity planned by the data gatherers, or even use the data to try to disprove what the original investigators had posited. There is concern among some front-line researchers that the system will be taken over by what some researchers have characterized as “research parasites.”

What? Research work requires an investment of time and money, usually lots of each. The product of that investment may be data and from that are derived publications and hopefully some sort of impact on the world. If smart and motivated people can derive additional value from data derived from the original research teams, that is NOT parasitic. Depending upon who funded the research and who owns the data, the original parties may rightfully expect to derive some compensation and expect that they have a right to some portion of that additional value derived from the original data sets.


Obviously no one is going to make huge investments of time and effort to amass data sets only to have them coopted immediately. However, once one puts a publication in the public realm, the data upon which conclusions were drawn should be available to readers of that work.


The concern that the data could be reinterpreted with different conclusions seems frankly ridiculous. That this was published in one of the most prestigious medical journals in the world by the senior editor is outright embarrassing. Who did he have to critique this? He obviously has sorted himself away from necessary and critical peers who should have provided feedback to him and help him recognized the nonsense that this editorial is, before he published it.

Resisting the Medical Machine - to what end?

There has been a gradual change in health  care delivery which has placed increasing financial pressures on all parties, patients, doctors and other billers for services, and payers. Where we find ourselves is a state where the health system is pressured to find more resources to pay parties more for the services they are delivering while simultaneously health care delivery is consuming a larger and larger proportion of economy.

The temptation is to look for scoundrels driving the cost side of the equation. There is no question that there are scoundrels but the truth is, all of the parties involved are to fault to some degree. We have a delivery system which has been blind to the cost side of the equation for much too long. Operating under the assumption that health care is different and that human lives are more important than money, we have been blind to the reality that there is a limit to this truth and it is a financial limit.

Health  care delivery is an expensive proposition. The more expensive it becomes, the greater the financial pressures created on the parties involved. The articles from the NYT and The Atlantic highlight the difficulties created in the production model of care, incentivizing physicians primarily via production targets.  (NYT)  (Atlantic)  As margins get squeezed for entities that are responsible for meeting payrolls and  paying the bills, they have few options; increase revenues or decrease costs. As much as we might not like this situation, it is an unavoidable truth.As Megan O'Rourke says in her article in the Atlantic:

The hospitalists assured the administration negotiators that their concern had nothing to do with money — that none of this had ever been about money. They preferred to work less and make less to avoid burnout, which was bad for them and worse for patients. At which point the administration responded that money was always the issue, according to several people in the room.

Until payment models are changed, physician payment will be linked to number of patients seen. However, in the absence of other measures than simply patient throughput and $'s generated, these will be the defaults. Whether quality measures can be developed which bear any real relationship to value added to patients and whether payments can be linked to actual value added (or be the driving force) is an unanswered question. The measures don't really exists for most encounters and the payments system still defaults to sheer numbers. I anticipate this will not change any time soon.

What it boils down to is the incentives are screwed up. This has implications not only for current physicians and patients but for future doctors and patients. Incentives now have impact on the decisions young people make about their careers in the future. It is no wonder that the most coveted fields in medicine are the ones that pay the highest now. For anyone who says it is not about the money, they might be right about selected people at selected points in time. However, incentives drive people and financial incentives, although they are not the only incentives,  they are still  the most powerful and ubiquitous incentives in place. Get them wrong and you create havoc.

How are the incentives wrong? It is hard to begin to catalog since  they are screwed up at so many levels. The use of third party payers has created an administrative system setting prices which works as  an accounting tool but loses all of the abilities of prices to coordinate economic activities.  Third party payment has also sufficiently insulated those receiving care from the cost to create all sorts of perverse incentives. Expensive interventions adding nominal to no value to patients become standard of care, a situation which would never happen if patients had real skin in the game. There are stories of financial impact on selected patients  but one thing our current system has done has been to insulate most patients sufficiently from the actual financial impact of how we operate to allow it to continue.

The production model of health care delivery is showing real strains as evidenced by the two articles I highlighted. As one of the comments from the NYT:

This is what happens when you apply a business model to healthcare. People aren't widgets. My great doctor, who spent time with patients and was a careful diagnostician, had her practice swallowed up by one of these hospitals. The last time I saw her, she apologized, but said she just couldn't making in private practice under the new business model for medicine. She was retiring early, she was broken hearted. You cannot put profits before people. 

However, you can put financial survival ahead of almost everything, which is exactly what is happening. Health care requires that a variety of people be incentivized to choose health care careers, get up to go to work, and decide to remain within the health care business. Get the incentives wrong and free people make rational decisions based upon the incentives in place. The doctor-patient relationship, however configured, has to make financial sense which means that physicians get paid from somewhere. I have few if any colleagues who have taken oaths of poverty. Ultimately the cost of physicians is borne by their patients, if not directly than indirectly. For a doctor who works 60 hours per week and makes $200K/year, assuming a 65% overhead, that means their patients need to pay them a minimum of $200/hour. That actually grossly under estimates the actual cost because much of the 60 hours per week devoted to patient care is billable time (time directly with the patient) under the current system. It is reasonable to assume that the cost is more like $400/hour.

However, patients are not aware that this is what the cost of their doctor is to them. They want their doctor and a relationship with their doctor, but I seriously doubt they can afford $400/hour or would be willing to pay this amount if they had to do so with their own money. So much for slow medicine. We also have to ask whether for most medical encounters it makes sense to pay this much for the value received.  When one is gravely ill this cost is likely money well spent. When one is dropping in for an annual social visit, perhaps there are better ways to invest this sum of money. The almost infinite variety of other doctor patient encounters yield a spectrum of value, ranging from great deals to lighting $100 on fire.

What we are left with are different parties all looking at the situation from vastly different perspectives. From the perspective of the doctors, they see environments pressing them to work faster and faster, putting patient's health at risk, and rewarding them for quantity but not quality. If they are to maintain their compensation levels, they are pushed to compromise. From the health care administrator's perspective, they are presented with competing priorities, diminishing revenues, and increasing demands from payers and patients. In order to deliver more with less, you need to get more from current investments, meaning more patients seen per doctor. From the patient's perspective, health care consumes more and more, both in terms of insurance premiums and payments for services, and the ambiance associated with the delivery systems seems more hurried and less caring.

The truth is we are all scoundrels and victims at the same time. We all bear some degree of culpability for the mess we are in and we all have  become victims of it dysfunction. For doctors, we long ignored the essential nature of being aware of how we brought value to our patients and measuring this objectively. We are playing catch up. We can't be the leaders of an industry now consuming what approaches to be 20% of GDP and not be at least nominally concerned about how to make this industry better AND more affordable. We self righteously claim that what we do is more important than profits but will accommodate to the production model  of "fast" medicine to maintain our compensation. For administrators, they are now trying to claim the moral high ground pushing initiatives such as patient access and becoming patient centric. However, they fail to fully comprehend what access means. Access to what? Who are our patients? What are their needs? Are there elements of care delivery that are more important than payer mix? And then there are the patients. They are the reason that the entire enterprise exist. However, patients now enter into the health care delivery morass not understanding that there are always trade offs and that resources that are spent to further some health care goal for them are resources that won't be allocated somewhere else. Truly valuing something means being willing to spend your own resources and the current system seems to more and more intent on defining what patients value with their own resources.

The health care enterprise does truly amazing things but sustaining and expanding its reach without bankrupting the country will require that fundamental changes in how we deliver care, how we pay for care, and how we think about the goals of the care system. The articles in the Atlantic and the NYT identify the symptoms but we simply cannot set the goal to slow the system down. How a meaningful transition to something different happens within such a regulated and risk averse industry is the trillion dollar question.

Flawed testing

I saw a young patient in my practice this past week with a very difficult medical problem. She had a recurrent and painful condition which had defied characterization and treatment. I felt bad for her. Her life has been turned upside down.

My approach to such patients is marked by primarily by being persistent, mostly because effective treatment is often more about trying lots of things.  There is an awful lot of guesswork within present day medicine, whether we own up to it or not. My patient was not happy with my approach. I assured her that we could work through her problems and likely find a solution which resulted in clinically significant improvement of her state. It might take a while but I was optimistic. However, she thought I should do more tests. She simply could not believe that there was not some sort of off the shelf diagnostic tool which when applied would yield a quick fix to her problem.

In my opinion, there is a remarkable faith in the ability of diagnostic tests to sort through diagnostic conundrums. I think much of that faith is undeserved. The public's perception as to the power of "testing" is something those within the health care industry are more than willing to cultivate. The magical powers of examining a sample of tissue or blood and divine critical information which allows us to peer into the future or past gives power to those within the industry.

However, the real power and utility of those tests may not be anywhere close to what the perceptions may be. This is not unique to medical tests. A recent story in the Washington Post (Washington post story) underscores this. The FBI has now admitted that tools it has used to analyze hairs found at crimes scenes may not consistently yield useful information.

The admissions mark a watershed in one of the country’s largest forensic scandals, highlighting the failure of the nation’s courts for decades to keep bogus scientific information from juries, legal analysts said. The question now, they said, is how state authorities and the courts will respond to findings that confirm long-suspected problems with subjective, pattern-based forensic techniques — like hair and bite-mark comparisons — that have contributed to wrongful convictions in more than one-quarter of 329 DNA-exoneration cases since 1989. This included 32 death penalty cases.

Admission that the scientific underpinnings of our work has serious holes is a scary proposition. Information is power. The ability to predict and the ability to look back in the past and define truth is power. Power is money.