I am a great fan of the Great Courses company (http://www.thegreatcourses.com/). The courses are of consistent high quality and cover a range of subjects. One of my favorite lecturers is Dr. John McWhorter from Columbia University. I just finished the series titled Myths, Lies, and Half-Truths of Language Usage. In this lecture series, I was introduced to differences between spoken and written language and that until relatively recently in human history, the written languages used by learned people were generally different from the spoken languages used. He also introduced me to the concept of formal and informal language. Spoken English may be either formal or informal and recently, written language has expanded into informal uses, especially with newer forms of communication such as texting.
This course made me think about language and communication in health care delivery. I realized that for the most part, physicians value spoken communication over written communication. We interact via rounding. We have conferences and tumor board where cases are discussed. If there are problems with communication we emphasize that the best way to address these issues is to meet of call someone. I agree that the spoken word is valuable, but what are the limits of the spoken word in medicine?
All one needs to do is sit through one deposition to understand issues with spoken communication in medicine. What is said is almost never really translated with real fidelity into the written record in healthcare. We use the written record to justify billings and to cover our assess (and assets). However, the real value of the written word in healthcare should be to communicate with as little ambiguity as possible. The written record rarely does this.
Part of the problem is cultural. We have not been trained to value written communication. However, there are system issues as well. Our workflows are also not conducive to capturing the richness of discussions which happen on rounds or in clinical conferences. We may have very pithy discussions regarding specific challenges we face in the management of specific problems in specific patients. However, by the time that someone is responsible for generating a written product of those discussions and it gets into some written form which should be translated into actionable items, the nuance is generally gone and message is garbled. That is the problem with spoken communication. What is spoken may be different from what is heard, which is also different from what is remembered. It is ephemeral.
All of this may have been less of an issue when the number of moving parts inc are delivery were limited and the size of the health care teams was very limited. We are much more ambitious in what we aim to accomplish and the people involved in any give care pathways may get into the dozens if not hundreds. The number of tasks involved is similar. No single person can keep it all straight in their heads. However, in the absence of formal written communication and coordination tools, traditional spoken communication approaches and tools can't scale to meet current demands.
We need a culture change in medicine and need to recognize the personal relationship driven, verbal communication mode of coordination of care needs to change to a system complemented by structured written tools that help better define clear roles, responsible parties, care teams, and team leaders.
Saturday, December 23, 2017
Tuesday, December 19, 2017
Right to bear arms
I just want to make a small observation. The words guns or firearms do not appear anywhere in the second amendment.
I am not one to completely place my trust in the inherently benign projection of state power and there are inherent concerns when the power differences between citizens can muster and what a state can deploy grows too large. However, why can't we recognize that that we can honor the second amendment while simultaneously place restrictions on the type or armaments that citizens can own and deploy?
A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.The amendment refers to "Arms". No one that I am aware has construed this to mean that the second amendment protects citizen's rights to own all types of armaments. There appear to be accepted limits such as prohibitions on owning thermonuclear devices, nerve gas, or death rays. There are limits.
I am not one to completely place my trust in the inherently benign projection of state power and there are inherent concerns when the power differences between citizens can muster and what a state can deploy grows too large. However, why can't we recognize that that we can honor the second amendment while simultaneously place restrictions on the type or armaments that citizens can own and deploy?
Saturday, December 16, 2017
Problems with the state
I colleague of mine sent me a link to a Washing Post article regarding a rather heavy handed approach of the Trump administration to control the flow of information out of the CDC, with lists of forbidden words to be purged from websites and documents. It is appalling. However, I would argue it is both no more appalling that multiple other heavy handed practices that have received much less attention from the mainstream press, and to be completely anticipated based upon the expansion of state power.
For those of you who have been readers of my blog over the past six years, you are likely very aware of the influence of the legal scholar Richard Epstein on my thinking and world view. In his conceptual framework, human actions can be simply viewed as happening in three different domains; acting as individuals, acting as parts of groups of individuals who join together voluntarily, and acting as groups within the context of legal entities where they are bound legally to belong - state actors. The existence of state actors requires that individuals give up some liberty in order to gain something more, presumably gaining more than they give up.
Individuals clearly gain hugely from working with others to fulfill their needs. Each of us operating on our own are very limited in terms of what we can accomplish and the ability to collaborate has resulted in transformational gains, over a very long period of time. The history of enhancements in human collaboration goes back tens if hundreds of thousands of years and the vector of progress has been far from linear. Collaborative groups started small but evolved into larger and larger cadres using ever evolving rules and conventions. The current world at its best involves massive networks of people who generally never meet who make each others lives better.
An integral part of these networks involves rules which we embrace which foster trust and cooperation. Some but not all of the rules are codified into law. We could codify everything but we have not and I would argue that would be a very bad idea. We can and should have a different relationship with state entities than we do will other groups where our participation is voluntary.
State entities have powers over us that non-state actors do not. State actors hold the power of law, the power to coerce and force individuals. These are powers not to be trifled with. Our government was created to provide for needs which could not be met for private actors with specific limited powers enumerated with an explicit understanding that state power was dangerous. We have somehow lost sight of these dangers, until recent misbehaviors of the current administration.
Todays announcement of Trump administration should not come as a surprise, not because of any specific aspect of this administration, but because of the gradual loss of skepticism of what state actors are capable of and motivated of doing. Concentration of power and cultivation of power monopolies tends to attract people who like to exercise power. Furthermore, governments are political entities and power to influence policy within state actors will tend to be move toward those who control political power. Winning elections means you control governments. The more power which is placed in the hands of political actors, they more those actors will want to use that power.
Technical experts who work for state entities can find themselves placed in very precarious positions. When working in the private sector, your relationship with employer is set by contract. You are free to criticize the government and protected by the Bill of Rights. However, you are not necessarily protected by the Bill of Rights if you publicly criticize your private sector employer. However, working for a state actor can get complicated in a hurry. If you work for a Federal or State agency, just what can you say regarding your employer? What protected rights do you have? If you work for a particular agency and have a policy disagreement with your boss, what exactly can (or should) you say in a public forum? How much control does your political boss have over what you can say without getting fired?
When state functions were limited and the size of the "state" was small, this really was not much of an issue. However, as the size of the state grows and the influence of state funding permeates to a larger and larger segment of the economy, these issues loom larger and larger. With the previous administration, they did not overtly tell Federal employees to not use specific words. However, they tried to play games with dear colleague letters which had similar chilling effects on those of us who were indirectly supported by Federal $'s.
All of these trends point to a growing ability of state actors to coerce a wider and wider swath of the population of the US. We need to understand that empowering state actors, even for what seems like laudable goals, has real dangers. We can not take it as a given that good and wise people will be at the helm of entities that can hold a gun to your head.
For those of you who have been readers of my blog over the past six years, you are likely very aware of the influence of the legal scholar Richard Epstein on my thinking and world view. In his conceptual framework, human actions can be simply viewed as happening in three different domains; acting as individuals, acting as parts of groups of individuals who join together voluntarily, and acting as groups within the context of legal entities where they are bound legally to belong - state actors. The existence of state actors requires that individuals give up some liberty in order to gain something more, presumably gaining more than they give up.
Individuals clearly gain hugely from working with others to fulfill their needs. Each of us operating on our own are very limited in terms of what we can accomplish and the ability to collaborate has resulted in transformational gains, over a very long period of time. The history of enhancements in human collaboration goes back tens if hundreds of thousands of years and the vector of progress has been far from linear. Collaborative groups started small but evolved into larger and larger cadres using ever evolving rules and conventions. The current world at its best involves massive networks of people who generally never meet who make each others lives better.
An integral part of these networks involves rules which we embrace which foster trust and cooperation. Some but not all of the rules are codified into law. We could codify everything but we have not and I would argue that would be a very bad idea. We can and should have a different relationship with state entities than we do will other groups where our participation is voluntary.
State entities have powers over us that non-state actors do not. State actors hold the power of law, the power to coerce and force individuals. These are powers not to be trifled with. Our government was created to provide for needs which could not be met for private actors with specific limited powers enumerated with an explicit understanding that state power was dangerous. We have somehow lost sight of these dangers, until recent misbehaviors of the current administration.
Todays announcement of Trump administration should not come as a surprise, not because of any specific aspect of this administration, but because of the gradual loss of skepticism of what state actors are capable of and motivated of doing. Concentration of power and cultivation of power monopolies tends to attract people who like to exercise power. Furthermore, governments are political entities and power to influence policy within state actors will tend to be move toward those who control political power. Winning elections means you control governments. The more power which is placed in the hands of political actors, they more those actors will want to use that power.
Technical experts who work for state entities can find themselves placed in very precarious positions. When working in the private sector, your relationship with employer is set by contract. You are free to criticize the government and protected by the Bill of Rights. However, you are not necessarily protected by the Bill of Rights if you publicly criticize your private sector employer. However, working for a state actor can get complicated in a hurry. If you work for a Federal or State agency, just what can you say regarding your employer? What protected rights do you have? If you work for a particular agency and have a policy disagreement with your boss, what exactly can (or should) you say in a public forum? How much control does your political boss have over what you can say without getting fired?
When state functions were limited and the size of the "state" was small, this really was not much of an issue. However, as the size of the state grows and the influence of state funding permeates to a larger and larger segment of the economy, these issues loom larger and larger. With the previous administration, they did not overtly tell Federal employees to not use specific words. However, they tried to play games with dear colleague letters which had similar chilling effects on those of us who were indirectly supported by Federal $'s.
All of these trends point to a growing ability of state actors to coerce a wider and wider swath of the population of the US. We need to understand that empowering state actors, even for what seems like laudable goals, has real dangers. We can not take it as a given that good and wise people will be at the helm of entities that can hold a gun to your head.
John Cochrane article
John Cochrane articulates the pro-market case for health care delivery better than anyone else I have read.
After the ACA
After the ACA
Sunday, August 27, 2017
Understanding Donald Trump
After speaking to my oldest child last week (and he is not a kid anymore), I believe I have gained some insight into Donald Trump. What Andrew observed was that it seems that Trump is critical of anyone who is critical of him and furthermore, Trump is incapable of being critical of anyone who is supportive and uncritical of him. It is a very simple principle of tit for tat and very consistent with the reasoning of a man who does not appear to be especially capable of any deep and reflective thought.
After thinking about this observation, it brought to mind the writings of Jonathan Haidt and his work "The Righteous Mind". This work is nicely summarized in 2011 article in Scientific American (Link)
Comey did not get it. To Trump, loyalty is much more important than honesty. Trump's mind is likely equipped with all of the same six social receptors, but he applies a different emphasis on particular receptors. Haidt showed that this differential emphasis is a characteristic of people with certain patterns of emphasis associated with particular political leanings. One can take a test to see where your individual leanings might be and which moral senses you might emphasize at (http://www.yourmorals.org/). Haidt has noted that liberals and conservatives tend to place emphasis on different priorities, where liberals placing great emphasis on care and fairness and conservatives placing more emphasis on sanctity, authority, and loyalty. Surprisingly, there seems to be an inherited component to this differential weighting that goes beyond environment. Thus, our moral intuitions may be driven by genetics to some degree.
Although I realize this is rank speculation, I believe if Donald Trump took this test his results would be skewed toward a single minded emphasis on loyalty. His focus on loyalty is so strong and so single minded, it is hard for the rest of us to comprehend. Yet, it does seem to explain what otherwise defies explanation. Donald Trump becomes quite understandable once you realize that no other principles are in play.
After thinking about this observation, it brought to mind the writings of Jonathan Haidt and his work "The Righteous Mind". This work is nicely summarized in 2011 article in Scientific American (Link)
"To understand what constitutes these moral matrices Haidt teamed with Craig Joseph from the University of Chicago. Building on ideas from the anthropologist Richard Shweder (with whom they both had studied), they developed the idea that humans possess six universal moral modules, or moral "foundations," that get built upon to varying degrees across culture and time. They are: Care/harm, Fairness/cheating, Loyalty/betrayal, Authority/subversion, Sanctity/degradation, and Liberty/oppression. Haidt describes these six modules like a "tongue with six taste receptors." "In this analogy," he explains in the book, "the moral matrix of a culture is something like its cuisine: it’s a cultural construction, influenced by accidents of environment and history, but it’s not so flexible that anything goes. You can’t have a cuisine based on grass and tree bark, or even one based primarily on bitter tastes. Cuisines vary, but they all must please tongues equipped with the same five taste receptors. Moral matrices vary, but they all must please righteous minds equipped with the same six social receptors."It may appear that he is thoroughly unprincipled but that is not the case. Trump values loyalty beyond all other principles. His earlier dealings with Jim Comey provides support for this. Recall that in his initial dealings with Comey what he asked for ( LA Times link)
President Trump demanded "loyalty" from former FBI Director James B. Comey and asked him to drop at least part of the bureau's investigation of former National Security Adviser Mike Flynn, Comey plans to testify to Congress Thursday. In a prepared statement posted on the Senate Intelligence Committee website, Comey says that in a private dinner with Trump on Jan. 27, the president asked him if he wanted to remain as head of the FBI and told him “I need loyalty, I expect loyalty.”"I didn’t move, speak, or change my facial expression in any way during the awkward silence that followed. We simply looked at each other in silence," Comey says. He told Trump that he could promise "honesty," he says.
Comey did not get it. To Trump, loyalty is much more important than honesty. Trump's mind is likely equipped with all of the same six social receptors, but he applies a different emphasis on particular receptors. Haidt showed that this differential emphasis is a characteristic of people with certain patterns of emphasis associated with particular political leanings. One can take a test to see where your individual leanings might be and which moral senses you might emphasize at (http://www.yourmorals.org/). Haidt has noted that liberals and conservatives tend to place emphasis on different priorities, where liberals placing great emphasis on care and fairness and conservatives placing more emphasis on sanctity, authority, and loyalty. Surprisingly, there seems to be an inherited component to this differential weighting that goes beyond environment. Thus, our moral intuitions may be driven by genetics to some degree.Although I realize this is rank speculation, I believe if Donald Trump took this test his results would be skewed toward a single minded emphasis on loyalty. His focus on loyalty is so strong and so single minded, it is hard for the rest of us to comprehend. Yet, it does seem to explain what otherwise defies explanation. Donald Trump becomes quite understandable once you realize that no other principles are in play.
Monday, August 21, 2017
The Promises and Perils of AI - Artificial Ignorance v. Artificial Ignorance
AI - New Yorker
There is a buzz out there in the health care delivery world about the promises of artificial intelligence (AI). There are fears among physicians that they might be replaced by computers. There is excitement and there is fear and there is hype. In my opinion, at this point there is mostly hype. The reason I believe that what we have most is hype is that for most of the important tasks we can delegate to AI, we are missing one key element. AI is not something programmed. It is something learned and in order to learn a computer needs validated data sets which contain unambiguous right and wrong answers. There lies the rub.
The recent article in the New Yorker by Siddhartha Mukherjee (AI - New Yorker AI v. MD) describes studies done by Stanford where they trained computers using images taken from patients diagnosed with melanoma.
In a recent paper published in the British Medical Journal by Elmore et al (BMJ) the reproducibility of histology in melanoma diagnosis was examined. The results are a bit concerning and call into question the gold standard status of anatomic pathology and its ability to "prove" anything. The best concordance found was about 80% for lesions believed by experts to be frankly malignant. That means any training set the computer viewed likely had at least a 20% error rate built in. For the more subtle lesions, the concordance rates hovered around 50% (and some lower). How about comparing this to coin flips?
Training machines to learn to make diagnoses by using flawed teaching sets will generate AI; perhaps more likely to generate artificial ignorance than it is to generate artificial intelligence.
There is a buzz out there in the health care delivery world about the promises of artificial intelligence (AI). There are fears among physicians that they might be replaced by computers. There is excitement and there is fear and there is hype. In my opinion, at this point there is mostly hype. The reason I believe that what we have most is hype is that for most of the important tasks we can delegate to AI, we are missing one key element. AI is not something programmed. It is something learned and in order to learn a computer needs validated data sets which contain unambiguous right and wrong answers. There lies the rub.
The recent article in the New Yorker by Siddhartha Mukherjee (AI - New Yorker AI v. MD) describes studies done by Stanford where they trained computers using images taken from patients diagnosed with melanoma.
Thrun, who had maintained an adjunct position at Stanford, enlisted two students he worked with there, Andre Esteva and Brett Kuprel. Their first task was to create a so-called “teaching set”: a vast trove of images that would be used to teach the machine to recognize a malignancy. Searching online, Esteva and Kuprel found eighteen repositories of skin-lesion images that had been classified by dermatologists. This rogues’ gallery contained nearly a hundred and thirty thousand images—of acne, rashes, insect bites, allergic reactions, and cancers—that dermatologists had categorized into nearly two thousand diseases. Notably, there was a set of two thousand lesions that had also been biopsied and examined by pathologists, and thereby diagnosed with near-certainty.......
...Thrun, Esteva, and Kuprel then widened the study to include twenty-five dermatologists, and this time they used a gold-standard “test set” of roughly two thousand biopsy-proven images. In almost every test, the machine was more sensitive than doctors: it was less likely to miss a melanoma. It was also more specific: it was less likely to call something a melanoma when it wasn’t. “In every test, the network outperformed expert dermatologists,” the team concluded, in a report published in Nature.So should our dermatology brethren be afraid that Watson and its prodigy will supplant the mole spotting workforce in dermatology? Perhaps, but there is a flaw in this work. What does it mean to use "biopsy proven" images? What exactly does a biopsy prove? It may not prove anything and there lies the problem. The teaching sets upon which machine learning is based may be validated (or not) by a not so shiny gold standard.
In a recent paper published in the British Medical Journal by Elmore et al (BMJ) the reproducibility of histology in melanoma diagnosis was examined. The results are a bit concerning and call into question the gold standard status of anatomic pathology and its ability to "prove" anything. The best concordance found was about 80% for lesions believed by experts to be frankly malignant. That means any training set the computer viewed likely had at least a 20% error rate built in. For the more subtle lesions, the concordance rates hovered around 50% (and some lower). How about comparing this to coin flips?
Training machines to learn to make diagnoses by using flawed teaching sets will generate AI; perhaps more likely to generate artificial ignorance than it is to generate artificial intelligence.
Sunday, August 20, 2017
Civil War Reconstruction continued
I have been a bit quiet for a while. I, like much of the country, have been appalled by the antics of President Trump for a number of typical and also contrary reasons. I do not disagree with everything that he is attempting to accomplish, just because embraces awful positions on other issues. In some sense, I am even more deeply resentful of his appalling white supremacist and neo-Nazi apologist statements. They are appalling in and of themselves, but also because these statements also can prejudice others against anything else Donald Trump may embrace. They poison his entire agenda, good and bad.
When one looks into the history of Confederate memorials, it presents a not so virtuous justification of erecting them in the first place. The great surge in erecting these monuments coincides with the promulgation of Jim Crow laws and of Lost Cause mythology. The Old South prior to the Civil War was built upon a foundation of racism at its worst. It was an economic system where people owned other people. The Lost Cause mythology attempted to soften that ugly fact and revise history to make the actions of those who led the rebellion, to preserve the system which allowed certain people (whites) to own other people (blacks), to appear more virtuous than they really were. It also attempted to have the oppressors and former slave owners assume the roles of victims.
The monument building occurred at the same time that Washington DC was resegregated by Woodrow Wilson, the KKK membership spiked, and many gains African Americans garnered in the South after Reconstruction were rolled back through enforcement of Jim Crow laws. The nation put in place immigration laws at that time that were blatantly racially exclusive. The monuments to the Confederacy were erected for a purpose, and a not so benevolent one. We need to recognize that was part of the plan.
Do the statues need to come down? I like the idea that they need to come down only after a period of reflection and education. Here they are in plain sight, where some have been for more than 100 years. Many of us simply ignored them as empty and boring markers of distant history no longer relevant to our lives. However, the history involves events which happened not so long ago and we need to be more aware of what happened then because it is relevant to what is happening now. I believe they were erected with malice intent with an agenda focused on fear and intimidation. Some people in current times share this same agenda. There is nothing benign about this. I believe that once the truth about these statues becomes widely understood, they will come down because they will be a source of embarrassment.
In my opinion, it is not justified to honor people whose behavior and actions were neither heroic nor morally sound. They likely were people with many virtues (or at least some virtues) but their decisions to fight for a way of life predicated on human enslavement put them on the wrong side of the moral divide. It might be said that our founding fathers (Washington and Jefferson) should also be viewed in this light but I would like to make a basic distinction. Washington and Jefferson were hypocrites in that they were slave holders, but they did not mount a rebellion based upon preservation of a morally unjustifiable tenant of slavery. Their monuments were erected to celebrate their accomplishments in creating a Republic which, although imperfect, has been a remarkable accomplishment.
Confederate leaders led a rebellion primarily motivated by the desire to preserve this abhorrent institution. We do need to recognize that their views were not unique for the times. Slavery was the norm for thousands of years and these men and women who embraced it in the early and middle part of the 19th century represented the tail end of slavery acceptability, at least in the developed world. Their lack of insight may be explainable given history, but it is not morally justifiable and clearly does not warrant any monuments celebrating their lives and actions. In the end, they accomplished essentially nothing. What is there to celebrate about their lives and accomplishments?
This series of events also highlights the perils of focusing on moral equivalencies. At the most basic level, everyone is flawed and everyone makes mistakes. This creates the opportunity to level all moral transgressions, elevating minor infractions to major status and lowering major one to minor status. We need to recognize that some transgressions are simply worse than others. Yes, I understand that this can lead one into another slippery set of slopes but we can for our work on the ends of the spectrum and not in the middle. Advocacy of Nazism and White supremacy has no middle way aspects. The philosophy is poison and has recent history marked by brutal violence and mass murder. We would be absolutely mortified if current day Germany started erecting statues honoring Adolf Hitler and Herman Goering.
The monument building occurred at the same time that Washington DC was resegregated by Woodrow Wilson, the KKK membership spiked, and many gains African Americans garnered in the South after Reconstruction were rolled back through enforcement of Jim Crow laws. The nation put in place immigration laws at that time that were blatantly racially exclusive. The monuments to the Confederacy were erected for a purpose, and a not so benevolent one. We need to recognize that was part of the plan.
Do the statues need to come down? I like the idea that they need to come down only after a period of reflection and education. Here they are in plain sight, where some have been for more than 100 years. Many of us simply ignored them as empty and boring markers of distant history no longer relevant to our lives. However, the history involves events which happened not so long ago and we need to be more aware of what happened then because it is relevant to what is happening now. I believe they were erected with malice intent with an agenda focused on fear and intimidation. Some people in current times share this same agenda. There is nothing benign about this. I believe that once the truth about these statues becomes widely understood, they will come down because they will be a source of embarrassment.
In my opinion, it is not justified to honor people whose behavior and actions were neither heroic nor morally sound. They likely were people with many virtues (or at least some virtues) but their decisions to fight for a way of life predicated on human enslavement put them on the wrong side of the moral divide. It might be said that our founding fathers (Washington and Jefferson) should also be viewed in this light but I would like to make a basic distinction. Washington and Jefferson were hypocrites in that they were slave holders, but they did not mount a rebellion based upon preservation of a morally unjustifiable tenant of slavery. Their monuments were erected to celebrate their accomplishments in creating a Republic which, although imperfect, has been a remarkable accomplishment.
Confederate leaders led a rebellion primarily motivated by the desire to preserve this abhorrent institution. We do need to recognize that their views were not unique for the times. Slavery was the norm for thousands of years and these men and women who embraced it in the early and middle part of the 19th century represented the tail end of slavery acceptability, at least in the developed world. Their lack of insight may be explainable given history, but it is not morally justifiable and clearly does not warrant any monuments celebrating their lives and actions. In the end, they accomplished essentially nothing. What is there to celebrate about their lives and accomplishments?
This series of events also highlights the perils of focusing on moral equivalencies. At the most basic level, everyone is flawed and everyone makes mistakes. This creates the opportunity to level all moral transgressions, elevating minor infractions to major status and lowering major one to minor status. We need to recognize that some transgressions are simply worse than others. Yes, I understand that this can lead one into another slippery set of slopes but we can for our work on the ends of the spectrum and not in the middle. Advocacy of Nazism and White supremacy has no middle way aspects. The philosophy is poison and has recent history marked by brutal violence and mass murder. We would be absolutely mortified if current day Germany started erecting statues honoring Adolf Hitler and Herman Goering.
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