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Tuesday, April 26, 2016

Intergrative health and CAM- delivering what people want as opposed to what we think they need

I colleague sent me a link to a blog from the British Medical Journal written by Timothy Caulfield entitled "The straw men of integrated health". Link

In this blog Tim Caulfield pretty much completely debunks the defenses proffered for CAMs in general However, it may not really matter because Mr. Caulfield perhaps misses the point. Mr. Caulfield, whose most recent book "Is Gwyneth Paltrow wrong about everything", believes we are mislead by celebrity and deceived by pseudo-science. He is probably right about the science but he is misled but what the actual deliverables are.

His book appears to be written to target people like me. (I have not yet read it but probably will). I use my plodding and non-reptilian brain to  sort through evidence and make plodding and thoughtful decisions. However, the target for his blog and book are people who make decisions to randomly avoid gluten and do cleanses because it makes them feel good about themselves. They could give a rip about any double blind control trials. They do a veggie purge which gives them a terribly satisfying sense of control and they feel great, at least for a while.

Human brains are complicated things and emotions are even more complex. The scientific basis of medicine and the deliverables in the health care realm used to be hard stops, literally. We intervened so that people would not die. It is a relatively easily measured endpoint and snake oils and witchcraft did not move the needle much. When modern antibiotics and modern acute care techniques came on the scene, these interventions quickly rendered less effective (or not effective) approaches to the dustbin of history.

We now have moved into a totally different realm of health care deliverables. People have the luxury of taking living for granted and have moved on to feeling good, feeling in control,  and worrying about the future. We in the scientific realm have not moved the needle much regarding making people happy. There are entrepreneurial sorts who peddle all sorts of compounds which some people crave and make them "happy" albeit for a brief period of time. There also are all sorts of downsides to many of these compounds.

Much of the population is either depressed, insecure, anxious, worried, or somewhat unfulfilled. This is a huge market and nature, abhorring any sort of vacuum, fills this will any number of people with a host of interventions. Some are activities (running, swimming, Lladro collecting, civil war reenactment, mission trips to Haiti), some are spiritual endeavors (praying, meditation, chanting), some appear to be deviant (cross dressing, pedophilia), and others dance around medical interventions. Many seem to make people feel better. None really make any scientific sense.

However, this is not a scientific issue, at least at this point. Perhaps at some point in time someone may be able to connect the dots and demonstrate how any particular activity or behavior makes a given person feel good. We are not likely close to that now.

I guess my point is Gwyneth Paltrow and the CAM crowd should not drape their decisions with the mantle of scientific legitimacy. However, the scientific community should stop telling people what they should or should not do to make them feel good about themselves.

This also has implications regarding what is defined as health care and what insurance pays for. In his Atlantic piece, he dove deeply into the movement of healthcare from addressing acute illnesses to addressing lifestyle concerns and risks of future disease link. The insertion of CAM into this discussion is a natural evolution of this trend. Will we end up requiring payment for CAM by third party payers?

Sunday, April 17, 2016

Shorting health care

Within the world of finance, people and organizations can make very bad bets and invest huge sums of money in very bad investments. Look at the 2008 housing bubble collapse. Massive sums of money went into building homes for people who could not afford them. Certain very astute investors saw the mismatch and placed bets against where most of the money was going. As the movie "The Big Short" showed, they were viewed initially as crazy and then as visionary. They ultimately served an important function in redirecting investment away from poor investments.

Within health care, we are also investing huge sums of money into a variety of investments. I am not talking about specific stocks or equipment but instead I am referring to our investments of specific clinical care delivery activities with the idea that these investments will result in better health returns for individual patients. For example, does the investment of time, money, and effort on every patient over age 50 years of age getting an annual physical have any real tangible return on this investment? If not, why is this investment of resources not like buying penny stocks? My question is, how can I short the annual physical?

The imperfections of simplicity and the perils of complexity

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

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

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

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

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

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

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

Step one....listen