Is using the term microaggression a microaggression?

We had a training session this week focusing on cultural competency. It was a great experience and generated a good mix of discussion and reflection, something that the practice of medicine needs dearly. We are so focused on hard metrics (meaning $'s and volumes) that we forget that getting care right means thinking, being humble, and being aware of what is important to people from amny different backgrounds.

At one point during the session, one of the speakers used the term "microagressions" and I cringed. I simply find this word annoying and frankly insulting. I admit this is a visceral and emotional response to the term, being triggered by the insinuation that I am perpetrating aggressions against vulnerable people who I interact with on regular basis.

The definition of microagression is variable. I trolled the internet for definitions. From Wikipedia:

Psychologist Derald Wing Sue defines microaggressions as "brief, everyday exchanges that send denigrating messages to certain individuals because of their group membership.Sue describes microaggressions as generally happening below the level of awareness of well-intentioned members of the dominant culture. According to Sue, microaggressions are different from overt, deliberate acts of bigotry, such as the use of racist epithets, because the people perpetrating microaggressions often intend no offense and are unaware they are causing harm.^[13] Microaggressions are known to be subtle insults that direct towards the person or a group of people as a way to "put down".^[14]

Also from the Urban Dictionary:

Acts or words that are perceived to be insulting by a person who is looking to be insulted, whether or not that was the intent of the transgressor.

I do not belong to the "have-nots" by any stretch (unless I can claim this as a consequence of not having height).  However, within the University environment in which I function, I am not part of the dominant culture. Although I have a leadership position, I hold a number beliefs and values which may be at odds with the dominant culture, some of which are the subject of thoughtless ridicule.

I know the session leaders who organized and gave the cultural competency session are motivated by the highest ideas and have no desire to insult me personally. However, I am a member at some level of a non-dominant culture within my workplace and profession. The dominant culture uses a term that I find insulting.  By the definition of the term microagression, I cannot be wrong in how I perceive any given act and my perception defines the act. By using the term microagression, they are commiting a microaggression.

We need to come up with a different term.

Hyperbole and Denial

The first week of the Trump presidency is behind us and for those who expected a moderated tone, I guess your expectations are not going to be met. Get ready for governance by Tweet. For reasons which are obscure to me, he is glomming on to the cause of election fraud. I guess he is basically insecure and that it still galls him that, although he won the election, he did not win the popular vote.

For whatever reason, this debate will be front and center for at least a while. I had not given this issue much thought for a while. The history of American elections is one marked by various high profile and perhaps isolated instances of fraud which may have altered the outcomes of selected elections. Robert Caro's biography of Lyndon Johnson describes the likely ballot fraud which perhaps stole the election of Governor Code Stevenson. Much has also been written about Mayor Daley and the 1960 presidential election of  John Kennedy. Earlier time periods were likely marked by more systematic and widespread vote manipulations.

I did read John Fund's "Stealing Elections" book (2004) and his book identifies a number of irregularities. I read it almost a decade ago and had not given it much additional thought until today. He describes the different emphasis given to vote fraud and vote suppression given by the Republican and Democratic constituencies and emphasizes the former in a number of specific instances. I have to admit I took his data at face value when I read the book.

I read an Oped piece in the NYT (the-voter-fraud-fantasy) today which essentially discounted any possibility of systemic voter fraud. It got me to thinking. How could the Times claim no evidence of systemic fraud when work such as Fund's are out there? I decided to do some more digging and came across a report from the Brennan Center at NYU authored by Justin Levitt (The Truth About Voter Fraud). Many of the examples identified by Fund were analyzed and found to be orders of magnitude lower than thought and due to a host of database and clerical errors.

Allegations of widespread voter fraud, however, often prove greatly exaggerated. It is easy to grab headlines with a lurid claim ("Tens of thousands may be voting illegally!"); the follow-up - when any exists - is not usually deemed newsworthy. Yet on closer examination, many of the claims of voter fraud amount to a great deal of smoke without much fire. The allegations simply do not pan out.

The Brennan Center report was very convincing. John Fund does not accept this dismissal and presents data contrary to the Brennan Center conclusions voter-fraud-real-and-dangerous - National Review 10/7/2016:

J. Christian Adams, who previously worked in the Justice Department’s Voting Rights Section and attended the 2009 Fernandez meeting, now heads the Public Interest Law Foundation. He has forced several counties in states such as Mississippi and Texas to clean up their voter rolls. But in many other states, his efforts have run into outright obstructionism. He was able to get voter-registration records from eight of Virginia’s 133 cities and counties, and found 1046 illegal aliens who were illegally registered to vote. In the decade between 2005 and 2015, a number of those aliens had voted some 300 times. Their presence on the voter rolls was only discovered if, in renewing their driver’s licenses, they corrected their past false claims of citizenship.

There is an element of denial in terms of whether the systems in place are porous and at least prone to voter fraud. John Fund wrote in the National Review in January 2014 a story which describes various successful attempts to cast fraudulent votes:

... New York City’s watchdog Department of Investigations has just provided the latest evidence of how easy it is to commit voter fraud that is almost undetectable. DOI undercover agents showed up at 63 polling places last fall and pretended to be voters who should have been turned away by election officials; the agents assumed the names of individuals who had died or moved out of town, or who were sitting in jail. In 61 instances, or 97 percent of the time, the testers were allowed to vote. Those who did vote cast only a write-in vote for a “John Test” so as to not affect the outcome of any contest. DOI published its findings two weeks ago in a searing 70-page report accusing the city’s Board of Elections of incompetence, waste, nepotism, and lax procedures.

Issues are not isolated to New York City and identified by others in addition to Fund. A Pew Trust study in 2012 (pewupgradingvoterregistration) identified nationwide systemic problems.

Our democratic process requires an effective system for maintaining accurate voter registration information. Voter registration lists are used to assign precincts, send sample ballots, provide polling place information, identify and verify voters at polling places, and determine how resources, such as paper ballots and voting machines, are deployed on Election Day. However, these systems are plagued with errors and inefficiencies that waste taxpayer dollars, undermine voter confidence, and fuel partisan disputes over the integrity of our elections. 

Similarly, a study published by Jesse Richman at Old Dominion University pointed to evidence of non-citizen voting. His work was highlighted in a Wired article (Trumps-favorite-voter-fraud-study-says-everyones-wrong):

"...Over the last three years, Richman has grown weary of what he describes as the partisan distortions of his research. “We’re perpetually fighting a two-front war,” he says. “One against people, mostly coming from the left, who want to claim on generally quite flimsy grounds that the study is completely invalid, and on the other hand people on the right who want to pretend this study is much more than it is or says much more than it does.”

What is my take on all of this? What characterizes the discussion is a general intellectual laziness. While Trump takes intellectual laziness to new extremes, he is not unique in terms of being intellectual lazy. The NYT is lazy. While they use more than 140 characters, the content of NYT contains scarcely more information than the Donald's tweets. His claims that voter fraud cost him the popular vote are pants on fire wrong. However, to fail to acknowledge flawed voter registration systems and the possibility of widespread and systemic issues which may affect election results undermines confidence in the electoral system and provides fuel to demagogues like Trump. 

Russian meddling in US affairs

We appear to have entered a new phase in international relations, with likely intervention of the Russian intelligence services in our recent Presidential elections. However, I would argue that this is nothing new. The Russians have been meddling in our politics for decades and similarly, we have been meddling in their politics and the politics of a host of countries for at least 70 years.

I must admit that the approaches to influencing events have changes but the underlying goals are the same; to influence political leaders and their constituencies in order to create environments more favorable to Russian goals. There is overwhelming evidence of efforts during the Soviet era dating back at least to the pre-WWII Stalinist regime. The US government cracked the Soviet encryption of communication in the early 1940's. This was kept secret until the early 1990's but the information was released under the name of Venona papers.

Additional supporting evidence of Russian attempts to influence American politics also came from the Mitrokhin Archives compiled by Vasili Mitrokhin, a KGB archivists who smuggled a vast trove of materials from the KGB archives over the span of decades. There is also substantial evidence of Soviet backing of pacifist movements post-WWII until the fall of the Soviet Union in 1990. The highest profile organization supported was the World Peace Council but monies were purportedly directed to a host of organizations. How successful their efforts were in terms of influencing events is another story.

The US also has deployed efforts to influence politics and elections in a host of countries, both within and outside of Russian and nations making up the former Soviet Union. This was detailed in a Paul Musgrove commnetary in the Washington Post from last summer (Musgrove):

The United States also has a long and active history of interventions in other countries’ politics. We have toppled governments by supporting coups, fueling revolutions and sending in our troops. We have employed more subtle tactics, too, to influence the outcome of elections.
In 1948, U.S. policymakers feared that Soviet-backed communists would win power in Italy. In response, as John Lewis Gaddis discusses in “The Cold War: A New History,” the role of the newly created CIA was extended beyond intelligence-gathering to allow the agency to funnel money and organizational support to pro-U.S. parties. American assistance may have included forging documents to discredit the Communist Party.
After Washington’s favored party won the Italian elections, such interventions became a staple of global-power politics. Political scientist Dov Levin estimates in International Studies Quarterly that Washington and Moscow intervened in a third country’s elections 117 times between 1946 and 2000. Sometimes, those interventions were overt, as when U.S. officials went out of their way to show favor to Chancellor Konrad Adenauer in West Germany’s 1953 elections. At other times, the interventions were kept secret, as with American support for Thai political parties in 1969.
The United States and Russia (or the Soviet Union) have meddled in elections because it has served their national interests and because the inherent risk has often paid off. Levin estimates that an overt intervention by a superpower yields a tilt toward its desired outcome equal to about 3 percent of the total vote. In a close election (such as West Germany’s in 1972 or Israel’s in 1992), that effect could easily be large enough to tip the balance.

There is a certain irony in our present circumstances in that the tables have been turned. During the latter part of the 20th century, it was the conservative right which highlighted potential Soviet influence over US and western European politics and it was the left which discounted their concerns. Now it appears to be just the opposite.

Foreign governments and other non-political entities will always try to influence events in the US to their advantage. To expect otherwise is foolish. Similarly, our government and US corporate entities will also try to use their resources to influence events. I would hope that US entities, both state and non-state, are more constrained in terms of what they will try to do and will draw the line before they cross into political assassinations (although we have gone there before). We simultaneously celebrate our own hackers and are dismayed when we are hacked.  The new cyber domains and cyber attacks will likely require development of new diplomatic rules or engagement, which we should expect to be broken when it appears to be in the best interests of parties to do so.

Fallacy of misplaced concreteness

I was introduced to a concept this week referred to as "Fallacy of misplaced concreteness". According to Wikipedia:

According to Alfred North Whitehead, one commits the fallacy of misplaced concreteness when one mistakes an abstract belief, opinion, or concept about the way things are for a physical or "concrete" reality: "There is an error; but it is merely the accidental error of mistaking the abstract for the concrete. It is an example of what I will call the 'Fallacy of Misplaced Concreteness.'"

This has substantial implications in the practice of medicine, especially in terms of diagnostic concepts and diagnostic tools. Let's say a patient has some sort of discrete and observable finding such as a growth on the skin or a subtle finding on an imaging study. These represent concrete findings in that there is something observable. That lesion may undergo biopsy which might reveal some other morphological observations. The lump on the skin may reveal it's structure as being a cyst or a solid mass of cells. A lesion seen on mammography similarly may consist of a cyst or a collection of cells. These are concrete findings.

However, almost invariably, the pathologist who examines the tissue goes beyond simply describing the findings under the microscope and goes on the apply some sort of label. The label represents an abstract concept which implies a host of properties and future behavior (or risk of future behavior). The physical reality is still the lump or cyst which represents the current "concrete" reality. The diagnosis is not a concrete thing but instead is prediction of what future reality might be.

There are times where the current reality is not simply some subtle clinical and microscopic finding and the label used by a pathologist is more concrete. A patient may present with hemoptysis and found to have a large lung mass on chest x-ray. Further evaluation may show multiple nodules of the bone and biopsy shows features diagnostic of lung cancer. The abstract concept of a malignant tumor diagnosed by the pathologist aligns with the concrete current reality of multiple invasive tumors.

I guess my point is cancer is characterized by a concrete functional impact of malignant biological behavior. This can only really be defined by the behavior itself. All other markers are surrogates. We have gradually and falsely substituted morphological observations, many increasingly subtle, as a substitute for biological behavior in defining disease. The problem is we have started using the same terms, previous reserved for something very concrete (disease states previous characterized by concrete illness and morbidity and very high risk of death), but use them to describe states without overt illness. There is nothing concrete about the so-called illnesses of people who by almost all measures are symptom free and whose disease states fail to progress.

Defining health care - a fundamental but thorny problem

There are two articles published in this week's NEJM highlighting the importance of caregivers in the outcomes of health care delivery (NEJM1) (NEJM2). The come on the coat tails of and NAS report titled "Families caring for an aging America" (NAS report). They should be required reading for anyone interested in getting our arms around the health care delivery monster we have created.

In some sense these reports state the obvious. What those of us involved in health care delivery accomplish in our offices represents a miniscule fraction of what goes into the production of good health outcomes. Our interactions with patients are transient and many respects trivial. The vast majority of patient's lives are experienced in the vast swaths of time outside of our care delivery environments, either inpatient or outpatient clinic based. Few if any of our transient office or hospital encounters are likely to result in meaningful impact if patients are sent out into environments that do not facilitate enduring support of our common goals.

The NAS report delivers a series of recommendations as to how to address these current and looming expanding problems as the population ages. There are host of recommendations touching upon additional data collection, legal and policy supports, and changes in funding mechanisms. It is hard to argue with any one of these recommendations, but they tend to miss a larger point.

Once one gets outside of what has been defined as health care delivery over the past 100 years, it will become almost impossible to define the boundary between what is health care delivery and what represents everything else. One hundred years ago, it was relatively easy to draw this distinction. For the most part, people did not engage physicians unless they were extremely ill. The time and money directed toward health care was substantially less than our current fraction of GDP (18%), estimated in 1929 to be around 4% (1). This percentage of GDP remained relatively stable for more that 40 years. Once expansion of social insurance was injected into the health care economy, we experienced massive expansion of cost.

At least part of this expansion was due to a change in was health care delivery entailed and what goals were embraced. No longer were interventions primarily short term to address acute illnesses, the end result being either resolution or death. Care delivery needed to account for the management of chronic conditions over extended periods of time, something that previously made up only a trivial portion of health care expenditures. This transition occurred during a time of unprecedented wealth and productivity gains in the US and the world and the costs of delivery of the expanded scope was absorbed into the these gains, if not effortlessly, with limited economic disruption that was observable.

The current papers cited above are calling for another redefinition of what health care entails. To be fair, there is no clear discontinuity here and the transition proposed is a natural extension of trends which have been ongoing for the last 50 years. I have no quibble with where these various authors want our care delivery to move toward. We need to cultivate mechanisms which facilitate continuous care and enlist caregivers closer to where patients live. My concern is the idea that we need to expand the current payment mechanisms to cover the costs.

I am an unabashed supporter of market based mechanisms to meet human needs. No other mechanism in history has been nearly as effective in allocation of scarce resources to meet human needs. In my humble opinion, the looming bankruptcy of the health care delivery system in the US can be traced directly to the injection of third party payment into an ever growing segment the health care economy and the overall economy in general. This injection disrupted effective market based pricing mechanisms and have tended to both distort resource allocation and insulate the public from many individual instances of these distortions. To expand the scope of what entails health care services while simultaneously remove market discipline and expanding third party payment in even larger segments of the broader economy is a recipe for disaster.

Ultimately meeting the health needs of people as they age cannot be done via command and control approaches and will require what meeting human needs and wants always requires; efficient allocation of scarce resources, continuous improvements in productivity,  understanding that there are tradeoffs involved, and that no matter what system is in place, it will be imperfect in that some legitimate wants and needs will go unfulfilled. Health care goods and services for the most part is no different from and cannot not inherently be distinguished from services in general. Deploying a terribly flawed payment system to an ever broadening segment of the economy in general will create the unintended consequence of making all of us poorer and shrinking the pool of resources which we can tap into to improve the lives of those who need help. 

1. Paul Starr. 1982. The Social Transformation of American Medicine. New York: Basic Books, pp. 261-62. Quoted in Greg Scandlen, 2003. 100 Years of Market Distortions.

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.