A Necessary Departure from the Usual

When this site was first created, it involved examination of many issues other than those involving the performance of music. Over the last few years I have narrowed my focus, simply to keep my plate from getting too full. Nevertheless, I feel that the following opinion piece is one that deserves all the circulation it can get:

https://www.aljazeera.com/indepth/opinion/free-market-deepen-coronavirus-crisis-200408122743522.html

Mind you, there is probably nothing in this article that cannot be found in the writings of Max Weber; but this particularly piece has the advantage of being less opaque!

A Useful Way for the Virtual World to Inform the Physical World

Maggie Fox, Health and Science Editor for Reuters, has an interesting report on how online gaming may be benefiting the real world of epidemiological research. The story is based on the outbreak of an epidemic in a virtual world:

The outbreak was an accidental consequence of a software challenge added to the "World of Warcraft" game in 2005, [Nina] Fefferman and [Eric] Lofgren report in the journal Lancet Infectious Diseases.

The virulent, contagious disease was introduced by maker Blizzard Entertainment Inc. of Irvine, California, as an extra challenge to high-level players. But, just as a real virus might spread, it was accidentally carried out of its virtual containment area.

"Soon, the disease had spread to the densely populated capital cities of the fantasy world, causing high rates of mortality and, much more importantly, the social chaos that comes from a large-scale outbreak of deadly disease," Fefferman and Lofgren wrote.

"When this accidental outbreak happened, players embraced it. Some thought it was really cool," Fefferman said.

The makers did not. They reset the computer game to eliminate the disease, wiping out any data that may have been collected.

However, while this was the end of the story in the gaming world, it was just the beginning for Fefferman and Lofgren:

Fefferman, a medical epidemiologist, immediately recognized human behaviors she had not ever factored in when creating computer models of disease outbreaks. For instance, what she calls the "stupid factor".

"Someone thinks, 'I'll just get close and get a quick look and it won't affect me,'" she said.

"Now that it has been pointed out to us, it is clear that it is going to be happening. There have been a lot of studies that looked at compliance with public health measures. But they have always been along the lines of what would happen if we put people into a quarantine zone -- will they stay?" Fefferman added.

"No one have ever looked at what would happen when people who are not in a quarantine zone get in and then leave."

She will now incorporate such behavior into her scenarios, and Fefferman is working with Blizzard to model disease outbreaks in other popular games.

"With very large numbers of players (currently 6.5 million for World of Warcraft), these games provide a population where controlled outbreak simulations may be done seamlessly within the player experience," she wrote.

There is, of course, the question of whether or not gamer behavior should be taken as a reflection of how they would react to a real-world crisis; but, regardless of how they would act in the real world, it may still be an indicator of how they would think. What may be most important is that these first results have been published in a journal with internationally-recognized authority. As such, it may be one of the first instances of published results in "hard medical science" being based on an analysis of social behavior in a virtual world (recognizing that Fox cites a similar article by Ran Balicer in Epidemiology); and Fefferman and Lofgren deserve recognition for that achievement.

The Cuban Side of the Health Care Story

Since I began the day dealing with the authenticity of the cardboard steamed bun story from China, it is only fair to point out that there is now a question of authenticity regarding Michael Moore's trip to Cuba in search of quality health care. It turns out that Jocelyn Noveck's report for Associated Press on the quality health care that 9/11 workers received in Cuba (as documented in Moore's film SiCKO) may have been a bit more susceptible to Moore's bias than her readers would have anticipated. Writing for Reuters, Anthony Boadle has now pulled together a version from the point of view of the physicians who attended to those workers. This version does not question the quality of the medical care provided. However, it also introduces a new point of view:

Communist Cuba's universal free health system has achieved low child mortality and high longevity rates on a par with rich nations since Fidel Castro's 1959 revolution.

But the hospital where SiCKO's patients were treated is an exception in Cuba, where patients of many other hospitals complain they have to take their own sheets and food.

There is something about that last sentence that resonates with Communist ideology, leaving me to wonder whether it is possible to have health care without either of the ghosts of the capitalist profit motive or the everyone-pulls-their-own of Communism. For all my skepticism about hospitals, I would hate to think that I would have to be responsible for my own sheet laundry while I am being treated; and, while we all have our favorite jokes about hospital food, during my last surgery I certainly did not want to question the judgment of an on-staff dietician in matters of what I would consume during my first 48 hours out from under the knife. My guess is that, as I previously suggested, Cuba saw an advantageous opportunity in playing Moore's rhetorical game; but, at the end of the day, scoring points in rhetoric is not going to fix a broken health care system.

From School of Medicine to School of Health

Maggie Fox, Health and Science and Editor for Reuters, has just reported a new voice in the debate over health care reform:

Dr. Julie Gerberding, director of the Centers for Disease Control and Prevention, stepped into the debate over health care reform with a call for changing the way doctors, nurses, veterinarians, pharmacists and dentists are educated.

Not only are more schools needed, Gerberding said, but these professionals need to start their education all together, to foster cooperation and a sense of common mission.

"I believe that what we really need in this country are schools of health," Gerberding told reporters at the annual meeting of the American Veterinary Medical Association.

"If we are seriously thinking about building a health system, then we need to be training professionals in a collegial and collaborative manner."

My immediate reaction to this new call to arms is whether it involves anything other than changing a name. Fox provides only one example of what Gerberding seems to have in mind:

Gerberding said the system is focused on treating disease and on end-of-life care, with little attention paid to preventing disease and helping people lead healthier lives.

Perhaps Gerberding might think twice about playing the name game if she realized that there already is a label for this alternative perspective: When the words are taken literally, it is called "health maintenance." Had this phrase not been so contaminated by health-maintenance-as-industry, she might have recognized the semantic interpretation it deserves.

However, this little word game gets to a problem Gerberding never bothers to recognize. Whether your call it "medical care" or "health maintenance," the process is about far more than learning how the body works and learning the proper practices of diagnosis and treatment. The real world of health care is now a world of an "industrial complex," chock full of all the negative connotations that Dwight Eisenhower assigned to the "military-industrial complex." The real problem with health care is the dominating mindset of profit-based business thinking; and, unless we can all come up with the right way of casting health care in terms of the sort of customer service problem that those businesses understand, new approaches to training health care professionals will probably not have much impact. Unfortunately, the way most of the business world deals with customer service these days, we should applaud any health care operation with the good sense to avoid that paradigm! However, the real moral of this story, to paraphrase Talleyrand-Périgord once again, is that health care is far too serious a matter to be left to those with the credentials of a Doctor of Medicine!

"The Misue of Science" and Holsinger's Weak Defense

Most of us would probably associate the phrase "faith-based medicine" with Christian Science and the writings of Mary Baker Eddy. It is thus interesting to see the extent to which the White House has changed the connotation of this phrase through its handling of the management of the Office of the Surgeon General. Will Dunham has been covering the Senate confirmations hearings for Dr. James Holsinger, Bush's nominee to succeed Dr. Richard Carmona. Dunham felt that it was important to include, as context for his latest report for Reuters, the fact that "Carmona has accused the Bush administration of preventing him from speaking out on stem cell research and other controversial issues." Carmona felt that the authority of his own professional experience should not be subjugated to the authority of anyone who lacked comparable experience, even his boss. This strength of professional conviction above political expediency casts an interesting light on the current examination of Dr. Holsinger.

The issue at stake was described by Dunham as follows:

Gay rights groups also have opposed Holsinger's nomination to be the nation's top doctor, faulting a document he wrote in 1991 titled "Pathophysiology of Male Homosexuality."

Written to a United Methodist Church panel studying homosexuality, Holsinger offered exhaustive anatomical details to describe anal sex as unnatural.

Democratic Sen. Edward Kennedy of Massachusetts, the committee's chairman, said Holsinger's paper was "ideological and decidedly not an accurate analysis of the science then available on homosexuality."

"The misuse of science gravely concerns me," Kennedy said.

"I did not attempt to write a definitive scientific paper," Holsinger responded, admitting the paper is now outdated.

One does not have to be a seasoned expert in rhetoric to see how Dr. Holsinger evaded Senator Kennedy's concerns about the "misuse of science." Whatever his intent may have been, Dr. Holsinger wrote this 1991 document in the voice of the authority of his profession. One has to assume that the United Methodist Church invited him to write the document specifically for that voice of authority. If that voice was used to "utter" ideology and inaccuracy, then my own opinion is that Dr. Holsinger has committed an act of the "misuse of science." He might offer, as a defense, that, because the paper had not been reviewed by his medical peers, it should not be taken as a scientific document; but I see this as a deliberate attempt to confound the distinction of the role of the writer with the role of the reader. If the United Methodist Church presented Dr. Holsinger as an authority to its community, then that community will not care very much whether or not what Dr. Holsinger wrote had been properly vetted by peer review. If it is good enough for those representatives of the Church that invited Dr. Holsinger to write the paper, then it should be good enough for the entire Methodist Community.

This is perhaps an overly extended way to saying that Senator Kennedy should be concerned about the "misuse of science" and that Dr. Holsinger did not say anything to allay those concerns. It is not an attempt to argue that "scientific truth" should always trump "faith-based truth," however. Rather, it is a conviction that the highest government official responsible for the oversight of medical practice in this country should have sufficient respect for that "scientific truth" that we, as citizens, can view him as an "honest broker" in the decisions he makes and his capacity for oversight.

It's not about the Data (again)!

Last night Julie Steenhuysen filed a report for Reuters about a study just published in the Archives of Internal Medicine on the impact of the move to electronic health records. Her lead paragraphs say it all:

Electronic health records -- touted by policymakers as a way to improve the quality of health care -- failed to boost care delivered in routine doctor visits, U.S. researchers said on Monday.

Of 17 measures of quality assessed, electronic health records made no difference in 14 measures, according to a study published in the Archives of Internal Medicine.

The study by researchers at Stanford and Harvard Universities was based on a survey of 1.8 billion physician visits in 2003 and 2004. Electronic health records were used in 18 percent of them.

In two areas, better quality was associated with electronic records, while worse quality was found in one area, they said.

This story was particularly important to me, as a Lipitor user, since that "one area" of "worse quality" was the prescription of statins for high cholesterol; but it is not just my own ox that is being gored. Indeed, my own interpretation of these results is that, when the quality of health care is left in the hands of "policymakers," rather that practicing health care providers, that quality is bound to suffer.

Fortunately, Ms. Steenhuysen gave some indication of what may have influenced those policymakers:

Electronic health records promise to eliminate errors due to bad handwriting and make it easier for doctors to follow a patient's care over time.

Some systems can also flag dangerous drug combinations, or offer advice about tests or drugs the doctor might prescribe.

However, the question of the extent to which factors such as these impact the overall quality of health care practice were left unaddressed, at least by Ms. Steenhuysen if not the Archives of Internal Medicine. Those who seek a better understanding of the issues behind that question need to consult books like Atul Gawande's Better and Jerome Groopman's How Doctors Think, or at least the comprehensive review of Groopman's book that Richard Horton, editor of The Lancet, published in The New York Review. I already wrote about Ellen Goodman's review of Groopman's book when it appeared on Truthdig, but Horton has now given us more of an insider's point of view.

To try to put the Archives study in perspective, I would like to cite a paragraph from Horton's review concerned with what he calls a "deeper fault line within medical practice:"

On average, about 15 percent of a doctor's diagnoses are inaccurate. Groopman directs a well-aimed arrow at a system of medical training that more often than not fails to investigate why these diagnoses are misses. Doctors are rarely taught to ask how an error could have taken place, let alone how it could be avoided in the future. Most are unaware of their mistakes. Even if patients remain unwell, no systematic effort is made to find out where doctors may have gone wrong. Doctors are uncertain about their own uncertainties. (Although for some doctors, such as radiologists, Groopman cites alarming research that shows the worse their performance, the more certain they seem to be that they are right!)

In this context one has to ask whether, even if practicing physicians were more conscientious about error analysis, having electronic records would make a difference. Anyone who took an undergraduate course in databases (if not the more general area of information systems) would know the answer immediately: It depends on what has been recorded electronically! If the decision about record content was left to policymakers more concerned about the risk of applying the data to support a malpractice suit, then it is unlikely that those records would be of much help when error analysis is required. In other words, at a time when public opinion (now under the influence of Michael Moore) about health care just keeps getting lower, technology is there, once again, with a solution to the wrong problem. This leaves the policymakers scratching their head over what went wrong, as oblivious to the possibility that they, themselves, were what went wrong as are those radiologists that Groopman studied!

Fleshing out the Story

It turns out that the BBC story that provided me with grounds for giving Michael Moore a Chutzpah of the Week award was more than a little bit incomplete. The lacunae do not detract from either Moore or the chutzpah, but they are still interesting. Apparently, Associated Press has been doing a better job of covering Moore; and Jocelyn Noveck can now offer a more thorough account:

Lost in all the publicity over Moore's trip is the reason he went to Cuba in the first place.

He says he hadn't intended to go, but then discovered the U.S. government was boasting of the excellent medical care it provides terror suspects detained at Guantanamo. So Moore decided that the 9/11 workers and a few other patients, all of whom had serious trouble paying for care at home, should have the same chance.

"Here the detainees were getting colonoscopies and nutrition counseling," Moore told The Associated Press in an interview, "and these people at home were suffering. I said, 'We gotta go and see if we can get these people the same treatment the government gives al-Qaida.' It seemed the only fair thing to do."

So the group, which included eight patients — three ground zero workers and five others — headed off by boat towards Guantanamo. From a distance, with cameras rolling, Moore called out through a bullhorn that he wanted to bring his friends for treatment at the naval base. He got no response.

"So there I was with a group of sick people," he says. "What was I going to do?"

The answer: head to Havana. There, the film shows the group getting thorough care from kind doctors. They don't have to fill out any long forms; health care is free in the Communist nation, after all.

But did the American film crew get special treatment because they were, well, an American film crew? Moore and his producer, Meghan O'Hara, insist not. "We demanded that we be treated on the same floor as all Cubans, not the special floor for foreigners," Moore told The AP. Still, the doctors obviously knew they were being filmed, so it's hard to know — although Cervantes [one of the patients] said she went back alone with no cameras and was treated similarly.

If anything, this extended account further justifies Moore's award for exercising chutzpah so outrageously in order to make his point. However he chose to frame the narrative, it is hard to believe that Moore had not anticipated the folly of sailing to Guantanamo with no means of communicating with anyone there other than a bullhorn from a boat. Since his film Sicko pursues the advocacy of a socialized medical system, Moore most likely realized that this would be a provocative way to show his viewers socialized medicine "in action." It was just his rhetorical game, and the Cubans were happy to play it.

The real insight from this story comes back to the reaction of our government and Moore's reaction to that reaction. I suppose that ordinary life has always been the battleground on which opposing propagandas duke it out. We are most aware of it in all the negative advertising that fills the airwaves in the months (now years, apparently) leading up to an election; but we tend to forget that all the advertising we encounter amounts to little more that the progression of skirmishes in a series of propaganda wars. Health care just happens to be one of the bigger battlefields. It is this more general state of affairs that we come to recognize when Moore undertakes one of his muckraking projects. The only real irony is the extent to which the muck-generators serve his cause through acts of opposition that end up shining more light on the very things Moore wanted us to see in the first place!

A World without Reflection

I really appreciate the fact that Truthdig carries Ellen Goodman's columns; but I was particularly impressed with today's piece, "The Benefits of Slow Journalism." Usually I can count on Ms. Goodman to bring my attention to a matter I had not previously considered, but this time she took on a topic that has occupied me for the last several years, the state of the world that the Internet has made (a topic whose significance is now being recognized by other columnists, such as Libby Purves). As always seems to be the case, she did it with a keen sense of perception; and she did it from a pulpit that commands so much more authority than my own meager blogging efforts.

As is often the case on Truthdig, I responded with a comment expressing my own take on these matters. What follows is a somewhat enhanced transcription of what I submitted to Truthdig. The focus of the comment was what I call the how-did-we-get-into-this-mess question, which Neustadt and May analyzed so well in their book, Thinking in Time, about decision-making in times of crisis.

Ms. Goodman's point of departure concerned the problem of inaccuracies in "news" reported through the blogosphere due to the problem of blog time trumping checking time. What made her column most interesting, however, was her recognition of these inaccuracies as a symptom of a much greater problem:

You don’t die from a journalistic mistake. The worst thing you can kill is a reputation. I might not have even noted these errors of speed-blogging (is that redundant?) if I hadn’t been reading Jerome Groopman’s disturbing and thoughtful book of essays on “How Doctors Think.”

It turns out that most mistakes in medicine are not a matter of operating on the wrong leg or leaving a sponge in the stomach. “The majority of errors are due to flaws in physician thinking, not technical mistakes,” writes Groopman. As many as 15 percent of all diagnoses are wrong.

These mistakes in thinking, says Groopman, are mostly due to cognitive shortcuts, what are called “heuristics.” In real life, for example, doctors are likely to judge the case before them by others that come readily to their minds. They are then likely to latch onto a diagnosis, anchor it, and cherry-pick the symptoms that confirm their belief rather than revisiting or expanding the list of possibilities.

Such heuristic thinking is very much a product of the progress artificial intelligence (AI) made in moving from the research laboratory to the "real world." It is an interesting note of history that one of the first "successful" steps in that direction was in the area of medical diagnosis. Now it is important to remember that the AI technology would not have emerged had the researchers not been able to recognize the heuristic element in medical diagnosis and see how that element could then be rendered in software, but the result was the formation of a culture that believed that heuristics were all that you needed. One of the worst parts of that result was the extent to which it reflected back on the practices of the medical community itself. There were, of course, plenty of researchers demonstrating that, in just about any discipline, expertise was not a simple matter of heuristics; but they did not stem the growth of a cottage industry based on translating heuristics into software.

There was another factor that encouraged that growth, though, which was a long-standing preference in the business world for efficiency over effectiveness. The reason was simple: You can always measure efficiency. Evaluating effectiveness requires much more human judgment and often entails considerable disagreement. Software can do wonders for efficiency, but effectiveness will always be a matter of the mind sitting behind the computer terminal. Nevertheless, the world of work has been gulped down and masticated to a pulp by the obsession with efficiency. Health care is now an industry where doctors have to "process" their patients, rather than care for them. Public education has a long history of obsession with efficiency that goes all the way back to the early days of Taylor-style efficiency experts with their stopwatches. Now, thanks to the blogosphere, journalists are as much under the efficiency gun as is the kid who takes your order at McDonald's.

I was once at a trade show at which I heard one of the "knowledge management" gurus talking about the need to "process more knowledge more efficiently." All I could think of was how little this guy knew about knowledge. Ms. Goodman interpreted Groopman's findings with proposition that "the enemy of thinking is speed;" but I would like to refine that conclusion. The point that this guru was missing was that you cannot have knowledge without reflection. RSS can now pour all sorts of sources (even credible and reliable ones) onto your screen at a prodigious rate; but, if you do not reflect on what those sources are asserting, you are no wiser that you would have been had you never seen all that stuff. So, the bottom line is that "the world the Internet has made" is a world in which doctors can no longer reflect on their patients' conditions, teachers can no longer reflect on their students' progress, and journalists can no longer reflect on what they read. Good luck, world!