In memoriam: Amanda Turner Russell

I had intended no more blog posts for this year, but then Amanda died, and she merits recognition.

Amanda Turner Russell, a labor and delivery nurse at my former hospital, a shining light in so many ways, was declared brain dead of head trauma and spinal chord injury caused by a motorist while she was engaged in one of her passions, training for the next charity run in the Boston Marathon.

A relative on Facebook reported:

In typical Amanda fashion her last wish was to help others. Tomorrow lots of people will be getting another chance at life and a little piece of Amanda will live on.

All who knew Amanda were struck by her good nature and generosity.  She inspired her colleagues to take on new challenges, to develop personally and professionally.  She was a loyal friend. Working in the most optimistic part of our hospital, she saw and delivered joy.  She presented it--almost daily--to the rest of us in the form of a sunrise photograph (that she would label #bidmcsunrise) taken across Boston from the L&D floor.  I'd wake up early, and it was already posted, a gift to start my day.  Sometimes, I'd send her a note, but mainly I just enjoyed her view of the world.  Here's one:

Now, dozens of friends on Facebook are acknowledging her life with #sunrisesforamanda posts, our own sunrise pictures.  Here's mine, from an early morning fishing trip in Cape Cod Bay.

A truly good person, who will be missed by thousands.  Condolences to her family, friends, and colleagues.

Unable to shoot down helicopters here

One last post before the New Year's blogging break:

It doesn't take long after arriving in Australia for an American to be asked, "What on earth is the matter with your country, when it comes to guns?"

These folks are great admirers of the US and close observers of our debate on the issue.  They even know about the Second Amendment to our Constitution and are quick to observe that the Founding Fathers probably had muskets in mind and not projectile weaponry capable of shooting down helicopters.

Speaking of the latter, take a look at this humorous column on this serious subject, "Australia enjoys another peaceful day under oppressive gun control regime." The lede:

Due to the nation’s controversial and oppressive gun restrictions, no one has died as a result of a mass-shooting on Australian soil today, for the 7158th day in a row.  
 
Local cinema attendant, Christina Upton can’t believe it has been a whole 19 years and 7 months since a heavily armed white Australian male decided to shoot at a crowd of unsuspecting Australian civilians for no reason.

An excerpt:

Per 100,000 residents in Australia, less than 1 are expected to be killed by a firearm this year. This is heavily contrasted to the 10.5 in 100,000 who will be killed in America.

But what they really can't understand here is why politicians would be so afraid of losing the next election that they would forego enacting a law that would help eliminate mass shootings by banning assault weapons and that would help reduce unintentional deaths and suicides by putting in place thorough protections around the acquisition and storage of single shot weapons.

John Oliver covered these topics in a series for the Daily Show a few years ago, where he interviewed the politicians responsible.  There are three episodes.  If you only have time to watch one, watch the second one, but the first and third ones are "on target," too.

"The NFL made a calculated attempt to exterminate me."

Check out this fascinating interview between Eric Topol and Bennet Omalu, the pathologist who made the connection between football and brain damage in the Mike Webster case.  This is the story that forms the basis for the new movie Concussion.  It's worth watching the interview before you see the movie.

(Note:  The combination of poor Skype fidelity and Dr. Omalu's Nigerian accent may make it hard for some to understand the audio.  Just read along with the text as the interview proceeds if you need help.)

The toilet paper on your shoe

Whether here in Australia or anywhere else I've traveled over the last decade to review and assist in the health care world, I've seen a growing desire to engage patients more in the design and delivery of care.  As I noted back in 2013:

[P]atient-driven care does not mean foregoing the expertise, judgement and experience of clinicians.  Nor does it suggest the abdication of their clinical responsibilities. But we must go beyond patient-centered care, in which the doctors and nurses decide what is best for the patient.  Patient-driven care, in contrast, is based on a partnership between the provider and the customer.

And, as my friend Danny Sands noted in a comment to that blog post:

Healthcare is a collaboration around the health of the patients. Consequently, I think this appreciation and understanding needs to go both ways. 

As we know participatory medicine is based upon mutual respect: the clinician respecting the self-knowledge, experience, and wisdom that the patient brings to the collaboration and the patient respecting the knowledge, clinical experience, wisdom, and technical skills that the clinician brings.

All of which brings us to a notable address delivered by Jen Morris at a Health Services and Policy Conference here in Melbourne earlier in December.  Jen is a patient perspectives consultant, advocate and researcher (@JenWords on Twitter.)  Here are some excerpts from a summary of the talk, called “Patient innovators: tapping the most underused resource in healthcare."

[Morris] outlined a broad range of benefits arising from consumer engagement in healthcare. This includes introducing what she termed “constructive unease” into the culture, methods, processes and structures that comprise the healthcare system.

Morris argued that the healthcare system desperately needs an injection of what one might call “transformation by transparency.”

She described this as “a sense that learning about one’s faults – like having somebody quietly tap you on the shoulder and mention the toilet paper on your shoe – might be momentarily painful, but it is far more helpful in the long term. Because you can do something about it.”

Health services use many great initiatives, both compulsory and voluntary, to gather data on patient experience in an organised fashion, such as standardised patient experience questionnaires and surveys and clinical data on readmission rates and waiting times. While these are highly valuable, Morris argued that they are not sufficient.

She said that in healthcare, as in life, the worst kind of blind spot is the one you don’t realise you have, because then there is no hope of fixing it or even making an informed decision about whether to fix it.

This means that even health services that show real commitment to measuring patient experience, or care quality and safety will only really collect and analyse data on factors and patterns they are already looking for – the things that they think are important.

The result of this is that a health service’s greatest weakness becomes such not because of deliberate neglect of the issue, but because the issue has not even entered their scope of awareness, much less been pegged as something important.

One counter measure to this is to encourage freer-form patient input, released from the constraints of forms and random surveys and structured feedback schedules, as this can shine a light on the blind spots that health services don’t even realise they have.

Patients can make a unique contribution to healthcare safety because they are uniquely placed to observe risks in care. They can offer crucial clues and information on factors that contribute to clinical risk and adverse events, which might never otherwise come to light, and even come up with ideas about how to reduce them.

In particular, patients are best placed to provide perspectives on contributing factors leading to adverse events, such as those relating specifically to patient experiences. These may go unnoticed if investigations focus only on practitioner-centred issues, such as inadequate staffing or poor consultant handwriting.

Morris discussed a common approach to patient engagement whereby health services identify problems to solve and then seek consumer input on a specific solution they have already devised. She argued that this approach can miss much of the potential contribution consumers can make to service improvement.

Instead of ‘narrow’ consultation with consumers, Morris advised services to regularly ask the most open questions possible, such as:

How could our service be improved?

What is good about our service?

What could be better about our service?

What do you wish was different about our service?

If you could give one piece of advice to the service, what would it be?

Think

Here's a lovely article by David Silbersweig about the importance of liberal arts training for those in the medical profession.  Of course, his argument would apply to any profession, but it has particular relevance in this one, where the tendency to rely on the "hard sciences" is emphasized even in the undergraduate years. Excerpts:

[M]y thoughts returned to my sophomore year at Dartmouth, when I went back to my childhood dentist during a school break.

In the chit-chat of the checkup, as I lay back in the chair with the suction tube in my mouth, he asked: “What are you majoring in at college?” When I replied that I was majoring in philosophy, he said: “What are you going to do with that?”

“Think,” I replied.

And what a continuously giving gift philosophy has been. While it seemed impractical to my dentist, it has informed and provided a methodology for everything I have done since. If you can get through a one-sentence paragraph of Kant, holding all of its ideas and clauses in juxtaposition in your mind, you can think through most anything. If you can extract, and abstract, underlying assumptions or superordinate principles, or reason through to the implications of arguments, you can identify and address issues in a myriad of fields.

--

The ability for a single person to have access to a broad array of disciplines within his/her own brain-mind [allows] for certain insights and nimbleness of thought. Collaboration among such multidisciplinary individuals can take ideas and methods to the next level, resulting in new, unforeseen possibilities.

--

If we are to remain at the forefront of knowledge creation in this changing, globalizing world, then our students must be the next generation of explorers. We have a sacred obligation as educators, role models and mentors to ensure a system that promotes the attributes conducive to their success. A broad yet rigorous education will best equip them to go forth into uncharted territory to address issues of import to humanity in a creative fashion.

Rocked? Really?

It was with some dismay that I read Modern Healthcare's article called, "The 30 events that rocked healthcare's world in 2015."  I jumped into the piece, confident that I would, indeed, find some developments that have made a difference in the quality and safety of patient care, that would introduce transparency, and that would encourage a greater partnership between clinicians and patients and families.

What I found instead was a version of The Nightly Business Report--a series of stories mainly about the corporate and financial interests of pharma, insurance companies, big hospitals, and big government.  These stories have nothing to do with what actually happens on the floors and units of America's hospitals or in the offices of local physician practices.  There is nothing in the stories that is motivational to the doctors, nurses, and other health care professionals who have devoted their lives to taking care of us.  There is nothing in the stories that presents an empathetic view of what happens to us when we interact with the health care system as patients or families.

More importantly, there is nothing in the stories about the things that have really moved aspects of the health care world, like cooperation among over 80 pediatric hospitals expanding from Ohio and moving nationwide that slowly and sustainability improve the quality and safety of care.  Or like the campaign that leads to a persistent growth in knowledge about diagnosing and treating sepsis.  Or the expansion of the Lean philosophy through more places, improving the quality of the workplace and the delivery of care. Or the systematic engagement of patients and caregivers in learning from one another.

Oh, I know these things are boring compared to the transfer of billions of dollars among multi-billion-dollar entities.  But those entities, mainly cost structures in search of revenue streams, are not where the action occurs.  It occurs on the ground, where clinical, admininstrative, and governance leaders make a constant commitment to improvement, are modest about what they know, and are not afraid to experiment for the public good.

Harry and Harvey send a message from Oz

I'll be writing from Melbourne, Australia for the next several weeks.  I've been invited to be a "Thinker in Residence" at Deakin University, which has campuses here and in Geelong several miles to the south. Beside participating in university activities, I'll be offering advice to the Victorian Managed Insurance Authority (VMIA), which provides liability and other insurance to the various state agencies, including those involved in health care and infrastructure. And also to GMHBA, a non-profit private health insurer based in Geelong.

I'm hoping my regular readers--and maybe some new ones--will enjoy some observations from here in Oz.  Given the reach of the Internet, I'll still be watching things back home, but maybe my observations about them will also benefit from the perspective that distance offers.

In commemoration of the Christmas holiday and its emphasis on kindness, I want to start with one story from Dr. Kate Cherry, an infectious disease specialist here.  Several years ago, she was treating a patient named Harry for AIDS, and he had entered the palliative care unit at Alfred Health, housed in a separate structure from the main hospital.

Harry was near death, and Kate asked him that all-important question: "Is there anything else that I can do for you?" Harry mentioned that he would like to have the company of a cat.

Kate went to the charge nurse in the palliative care unit, a person known for being a stickler about rules and also for being a bit gruff.  She asked about bringing in her own cat, Harvey, to visit Harry.  The charge nurse paused and thought and responded, "Well, I guess if you brought in a cat, we'd be unlikely to notice it."  Give this authorization, Kate brought in Harvey and put him on the bed with Harry, at which point Harvey relaxed and started purring loudly.

Harry, though, could no longer hear very well and could not detect the purring. So Kate took his hand and put it on Harvey's back so he could feel the purring. Harry's face lit up and his body relaxed.

Kate asked Harry if she could share the picture, and he insisted that she do so, and widely.  I'm happy to help honor his request.

Two good gifts that do good

Here are two excellent ways to reward your friends and loved ones with something pleasant to view, while helping good causes.  Warning: Note strong relative and friendship bias!

First, for dancers and dance lovers in your life, a stunningly beautiful 2016 calendar produced by the Jacksonville Dance Theater.  JDT is a recent start-up that has added considerably to the cultural life of northern Florida and has also appeared at modern dance concerts throughout the US.  Proceeds from the sales go to support this budding non-profit arts organization.

Second, a lovely picture book called What are Mothers For by Janice Lynch Schuster. A portion of the proceeds will go to Reading Partners Baltimore, which has volunteers working one-on-one with thousands of children ages 5-8 who are unable to read. Janice notes, "In my mind, pushing children through school despite their illiteracy is a form of prison, now and in the future."

About the book, Janice adds, "Beyond the desire to show off my beautiful little book and do good, I would love to inspire others to try something new. The benefits are remarkable."

Santa's sled is stuck in traffic

Sometimes seasonal doggerel contains universal truth.  Here's an example about a Boston-area infrastructure issue from James Aloisi, a former state transportation official.  Like me, he can't figure out why the Massachusetts body politic can't get their collective heads together around the truism that a strong--and expanding--mass transit system is the difference between a city and a world class city.  He also recognizes that a failure to invest in such infrastructure assesses a hidden tax on the many people in a metropolitan area--in the form of longer commute times, a need to purchase cars, and limitations on employment--and on the businesses in that area--in the form of a reduced labor force pool and congestion of roads that adds to the cost of transporting goods.

Excerpts:

To commuters and riders

With a simple request:

For transit mobility,

Why not the best?

And history repeats itself

Many times over

As voices of retrenchment

Get bolder and bolder.

More yappy than beagles

They shouted “for shame!

We won’t raise more revenue

And we won’t take the blame”.

“Reform without revenue” –

The slogan sounds pretty

Until you get down to the

Nitty and  gritty.

And then you can see

As you look at the facts

That we’ve shortchanged transit

Through a series of acts

That over the decades have

Caused this decline

Through lack of investment

Without reason or rhyme.

As I started to type

My thoughts flowed like honey:

The T needs investment.

The T needs more money.

More funding for fixing

Systems old and quite broken.

More funding for maintenance -

Much more than a token.

More funding to innovate

So we keep up the pace -

Embracing the future

Means winning the race.

When a "good news" story can be cruel

There is an understandable tendency for the public to take great interest in the health issues of our former national leaders.  Once they are out of office, political animosities die away, and we want to think about them more as people and, indeed, to express our concern for their well-being. That's a gracious and lovely sentiment.

A problem can arise, though, from the media's coverage of such a beloved figure--a tendency to overstate good news surrounding that person's medical treatment. Harold DeMonaco over at Health News Review offered an excellent synopsis of such coverage in a recent article, "What the media got wrong about Jimmy Carter’s cancer 'cure.'"

The lede:

If you watched or read the news this week, you probably heard a story about former President Jimmy Carter’s ongoing battle with metastatic melanoma. . . . On Sunday morning, he told his bible class, “My most recent MRI brain scan did not reveal any signs of the original cancer spots nor any new ones.”  For Mr. Carter and his family, this is wonderful news. . . . Technically, Mr. Carter is in remission. We can all hope that his continued treatment with Keytruda will prevent additional lesions from appearing. Importantly, Mr. Carter did not use the word “cure.”

He then notes:

The media picked up on the news very quickly and with the usual unfortunate headlines. “How a new therapy kicked Carter’s cancer “ from CBS News, Here’s a look at Keytruda, the drug Jimmy Carter said made his tumors vanish from NBC News, “Jimmy Carter is ‘cancer free': Miracle or just science?” from CNN, and former President Jimmy Carter Says He Is Free of Cancer from The New York Times.

Offering a dose of realism, Harold reminds us:

[T]he bottom line is that 18/81 subjects in this clinical trial had a response (partial or total) that lasted from 6 to 36 weeks. Seventy-six percent did not respond. The results that Mr. Carter has achieved, unfortunately, are not necessarily representative of what the typical patient can expect.
What’s more, as NBC pointed out in its coverage, there’s no way of knowing whether it’s the drug or the radiation therapy and surgery that cleared all detectable traces of President Carter’s cancer. 

He concludes:

[It's] possible that some of these headlines represent a willful misrepresentation of the truth by the media in order to boost readership. Nigel Hawkes, a freelance health reporter, hinted as much when he spoke at  The Lancet Health of the Nation Summit in 2009.

“It is not our job to satisfy you [meaning those on the podium representing medicine] but to keep our readers reading and our viewers viewing,” he said. “The more responsible the press becomes, the less readers seem to like it.”

The NPR commentary by Barbara King referenced earlier should be read by every journalist who posted a story about Mr. Carter’s treatment and by every editor who insisted on a using a headline that did not match the reality.

As King, a cancer survivor, points out, the “celebratory responses built around Carter’s cancer being ‘gone’ are in real danger of swamping an accurate understanding of cancer biology and of what many patients experience as they cope with cancer or cancer recovery.”

I hope that reporters and editors will learn that a good news story about a particular celebrity can inadvertently be a cruel story to others reading it.

Do as I say, not as I do

We've all seen stories in the press describing how inappropriate it seems for doctors to accept funding from drug manufacturers and other participants in the health care marketplace to attend conferences and the like.  In fact, federal rules now require doctors to disclose many types of such payments.  Well, here comes a story from Trudy Lieberman at Health News Review about reporters accepting invitations from industry sponsors to do the same.

The title--"Is it ok for journalists to attend Bayer-funded training on new cancer treatments?"--buries part of the lede, in that it is not just Bayer who is behind the scheme.  Trudy notes later in the story:

The Mayo Clinic is the money behind February’s obesity training in Phoenix, where Mayo has a branch operation. 

But it goes deeper.  Trudy quotes Lauren Sausser, a reporter at the Charleston S.C. Post and Courier,

[S]ometimes, Sausser told me, “The conflicts are hidden and sometimes they are just not clear.”

That was the case with one of the speakers at the obesity training Sausser attended—James O. Hill, executive director of the Anschutz Center. In August  the New York Times reported that Hill also headed the front group, Global Energy Balance Network, funded with a $1.5 million donation from Coca-Cola to start the organization. In late November the AP broke a story showing through emails it had obtained that Coca-Cola helped pick the group’s leaders, edited its mission statement, and suggested articles and videos for its website. . . . Sausser says none of his industry ties were disclosed to participants attending the program although she said, “it became clear over the course of the conference that he had industry ties. He made a point of saying they deserve a seat at the table to figure out how to solve the obesity problem.” 

I have trouble understanding how any editor would allow a reporter's participation in such an event.  Trudy nails the issue here:

When journalists attend events such as the NPF’s on the sponsor’s dime, they are taking a gift, plain and simple. As innocent as that may appear, a gift implies reciprocity. How does the receiver repay? Favorable treatment for the giver; a reluctance to ask tough questions; directly or indirectly promoting their points of view; or a nod to their products and services when it’s appropriate for a story? And that, it seems, is the real danger lurking in those NPF programs designed to help corporations train journalists to fit their business strategies.

Indeed, Trudy notes:

The NPF’s website soliciting new sponsors isn’t shy about what’s in it for them if they cough up the cash.

“Work with us to find the right blend of training and education of journalists to fit your strategy. A literate journalist is a smarter journalist, and that’s a win-win for everyone.”

For everyone?

Not quite. The public is left in the dark.

Diagnostic vagabonds and other problem solvers

Please check out this new article I've published over at the athenahealth Leadership Forum.

Let's start with these

With all the highfalutin talk about the Triple Aim, payment reform, ACOs, population management, and the like, wouldn't it be nice if hospital administrative and clinical leaders focused on these categories of harm that have been identified by the patients and families who have experienced a medical error.* Instead, our "leaders" and their governing bodies focus on building their networks to gain market power and minimize competition, expanding their risk pool, minimizing corporate risk, and fighting over who should share the surplus or deficit from capitated contracts.  They are truly cost centers in search of revenue streams. This is the corporatization of American health care.

--

*Yes, these are Massachusetts numbers, but they are duplicated in other jurisdictions.

What would Isaac say?

Wikipedia summarizes:

The Three Laws of Robotics  are a set of rules devised by the science fiction author Isaac Asimov. The rules were introduced in his 1942 short story "Runaround", although they had been foreshadowed in a few earlier stories. The Three Laws, quoted as being from the "Handbook of Robotics, 56th Edition, 2058 A.D.", are:

1. A robot may not injure a human being or, through inaction, allow a human being to come to harm.
2. A robot must obey the orders given it by human beings except where such orders would conflict with the First Law.
3. A robot must protect its own existence as long as such protection does not conflict with the First or Second Laws.

Now comes a practical application and a query by Eric Schwitzgebel in the Los Angeles Times:

It's 2025. You and your daughter are riding in a driverless car along Pacific Coast Highway. The autonomous vehicle rounds a corner and detects a crosswalk full of children. It brakes, but your lane is unexpectedly full of sand from a recent rock slide. It can't get traction. Your car does some calculations: If it continues braking, there's a 90% chance that it will kill at least three children. Should it save them by steering you and your daughter off the cliff?

This isn't an idle thought experiment. Driverless cars will be programmed to avoid collisions with pedestrians and other vehicles. They will also be programmed to protect the safety of their passengers. What happens in an emergency when these two aims come into conflict?

The author raises a real concern and discusses how such things should be regulated.  He notes:

Google, which operates most of the driverless cars being street-tested in California, prefers that the DMV not insist on specific functional safety standards. Instead, Google proposes that manufacturers “self-certify” the safety of their vehicles, with substantial freedom to develop collision-avoidance algorithms as they see fit.

But he says that's not good enough:

That's far too much responsibility for private companies. Because determining how a car will steer in a risky situation is a moral decision, programming the collision-avoiding software of an autonomous vehicle is an act of applied ethics. We should bring the programming choices into the open, for passengers and the public to see and assess.

I wounder how the public would assess this issue?  Let's take the same case today, with a person driving the car.  How many people would say that they would go over a cliff to avoid killing pedestrians?  It's actually a harder question than you think, and you might have a different answer in real time than in the abstract.

I'm guessing that, in real time, the instinctive action for most of us would likely be to swerve to avoid the children, not realizing fully than in doing so, we'll go over the cliff.

In contrast, if we had a chance to calmly consider the scenario in advance, we might have mixed emotions.

For example, you might say, "Well, even if I go over a cliff, the car will protect me from harm; whereas if I hit the children they'll likely die. So, I'll take my chance with the cliff."

Or, you might say, "My obligation is to my own child first, and I'm not going to risk killing her by going over a cliff. I'm not violating the speed limit, and it's not my fault if there's gravel on the road. I'll do my best to stop, but if I can't, so be it. These things happen."

Eric offers the following thought:

Some consumer freedom seems ethically desirable. To require that all vehicles at all times employ the same set of collision-avoidance procedures would needlessly deprive people of the opportunity to choose algorithms that reflect their values. Some people might wish to prioritize the safety of their children over themselves. Others might want to prioritize all passengers equally. Some people might wish to choose algorithms more self-sacrificial on behalf of strangers than the government could legitimately require of its citizens.

Lest you think this provides too much freedom of choice, Eric reminds us that today's drivers also engage in implicit moral choices:

There is something romantic about the hand upon the wheel — about the responsibility it implies. But future generations might be amazed that we allowed music-blasting 16-year-olds to pilot vehicles unsupervised at 65 mph, with a flick of the steering wheel the difference between life and death. 

He notes:

A well-designed machine will probably do better in the long run. That machine will never drive drunk, never look away from the road to change the radio station or yell at the kids in the back seat.

What would Isaac say?

Here's what I worry about, more than this ethical question.  As we've seen in the medical world--e.g., with regard to robotic surgery, femtosecond lasers, and proton beam therapy--there is an inexorable push to adopt new technologies before we determine that they are safer and more efficacious than the incumbent modes of treatment.  Corporations have a financial imperative to push technology into the marketplace, employing the "gee whiz, this is neat" segment of early adopters to carry out their marketing, leading to broader adoption. All this happens well before society engages in the kind of thoughtful deliberation suggested by Eric. Meanwhile those same corporations take advantage of the policy lacunae that emerge to argue for less government interference. Unnecessary harm is done, and then we say, "These things happen."

Let's remember what Ethel Merman said in the movie when Milton Berle reported in that manner on a terrible traffic accident, "We gotta have control of what happens to us."

Seeing things clearly in NYC

Check out this site from the New York City hospitals, an excellent example of clinical care transparency with regard to HIV treatment. In a simple graphic we can see the proportion of patients in care with suppressed viral load, and the trend from 2011 to 2014.  Congratulations to Dr. Demetre Daskalakis, the head of New York City’s Bureau of H.I.V./AIDS Prevention and Control in September, for his leadership in this arena--and to his staff for their accomplishments.  (Did I mention he was a resident and chief resident at BIDMC several years ago?)

That's BS!

As we watch many participants in today's political debates--and the public's reaction to them--it can be useful to consider the lessons set forth in this blog post and the article to which it refers,  "On the reception and detection of pseudo-profound bullshit".

Key findings:

We focus on pseudo-profound bullshit, which consists of seemingly impressive assertions that are presented as true and meaningful but are actually vacuous. These results support the idea that some people are more receptive to this type of bullshit and that detecting it is not merely a matter of indiscriminate skepticism but rather a discernment of deceptive vagueness in otherwise impressive sounding claims. Our results also suggest that a bias toward accepting statements as true may be an important component of pseudo-profound bullshit receptivity.

The authors' suggestion that a type of cognitive bias is at work is interesting. To whatever extent that is true, I would argue that society's inclination to accept bullshit as true is also a function of our inadequate system of education. Many people simply don't understand the basics of physics, biology, mathematics, and statistics.  Therefore, they have an insufficient level of BS detection.

Unfortunately, in health care this is a rampant problem in stories written by reporters about the latest diagnostic and therapeutic "advances."  Indeed, our friends over at Health News Review make a living by demonstrating the inadequacies of media coverage in this field.

But back to politics, it is the disrespect for science that I find most troubling in the current environment.  Let's acknowledge that scientific conclusions are often off the mark: That's the nature of the scientific method and the long-term pursuit of knowledge. No, more dangerously, what we see is the political driven tactic of denigrating the role of science. When scientific illiteracy is promoted as a virtue, bad things happen in the body politic.

In memoriam: Robert Schuneman

Bob Schuneman, one of several dozen men and women in and around the suburbs of Boston who have been playing soccer together for many years, just passed away after a long bout with cancer.  As our colleague Margot noted recently,  "Our soccer relationships are interesting.  We spend a lot of time together.  We really enjoy each other's company.  We have a ton of fun together.  Yet we know very little about each other."

So for our group and for others, let me tell you a bit about Bob. I fortunately had a chance to visit with him just a few days ago, and I've found these end-of-life conversations to be remarkable in the level of honesty that occurs.  I asked, "How are you thinking about things?"  He said, "I've had an unbelievable 81 years.  Sometimes I can't believe that I've deserved such a good life."  And then I got his personal history, and learned a ton of things I hadn't known.

For one thing, he was a very accomplished musician and music publisher--not something you would ever have suspected as he deftly slipped in left-footed shots if you mistakenly permitted him to be undefended in front of the goal! This article from 2012 gives some details. An excerpt:

After a career which included working with narcotics addicts in Brooklyn; being a church musician in Fort Wayne, IN, Glens Falls, NY, Chicago and Boston, MA; choral and orchestral conductor in Cambridge, MA; and teaching at Oberlin Conservatory, Boston Conservatory of Music, New England Conservatory of Music, and Westminster Choir College, Schuneman gave up all except choral conducting to buy the company that he worked for part-time as editor, E.C. Schirmer Music Company. Since 1985, and contrary to popular opinion, he has not gotten rich as President and principal owner of ECS Publishing Company, the parent company of E.C. Schirmer Music Co., Galaxy Music Corporation, Ione Press, and Highgate Press. Committed to the composers of new art music, he has also mastered and produced over 200 recordings on ARSIS and other labels, and he continues as the conductor of Philovox Ensemble of Boston.

The article notes that Bob grew up in Pittsburgh.  He expanded on this fact with me, noting that when he grew up in Pittsburgh, it was still an immensely polluted city.  He related a vivid childhood memory: From a hill overlooking town, you could see the glow from the steel blast furnaces. The air was so choked with pollution that cars needed to have headlights on during the day.

Bob's wife Cynthia was raised on her parent's wheat farm in Scobey, Montana, where they had been homesteaders.  Also trained as a musician, she later worked with him at the music publishing company. When Cynthia died in 2012 (also of cancer), they spread her ashes on the farm, and there is a marker for her near her parents' gravestones. Bob told me about this as he related that he decided a few weeks ago that he wanted the same to be done with his.  

Bob's last game with us, he reminded me, was July 1.  When I asked if he had any messages for our soccer group, his immediate response was, "Play on!"  Then, "I miss you."  We will play on, Bob, but there will be a hole in our hearts, as we miss you, too.

Why do you have to do this?

As a student of politics and public affairs, I find it interesting how the mileau in which events occur so dramatically affects the public's perceptions of individuals.  I was reminded of this while watching Bridge of Spies, in which the protagonist James B. Donovan is asked by the Court and his law firm to take on the defense of a man accused of being a Russian spy.  As the story takes place during the Cold War and the American public's panic about anything named "Communist," Donovan is roundly criticized--and worse. Indeed, at one point, his daughter 's peaceful viewing of 77 Sunset Strip on television is interrupted by gunfire through the living room window. A policeman arriving at the scene blames Donovan. "Why do you have to do this?" asks this officer sworn to uphold the Constitution, including the right of an accused person to competent counsel.

John Adams faced similar censure when he took on the defense of the British soldiers who shot civilians during the 1770 Boston Massacre. It was an era of intense anti-British fervor.  David McCullough notes:

Adams accepted, firm in the belief, as he said, that no man in a free country should be denied the right to counsel and a fair trial.  As lawyer, his duty was clear.  That he would be hazarding his hard-earned reputation, and in his words, "incurring a clamor and popular suspicions and prejudice" against him, was obvious.

Imagine making this argument in the midst of that environment:

Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passions, they cannot alter the state of facts and evidence: nor is the law less stable than the fact; if an assault was made to endanger their lives, the law is clear, they had a right to kill in their own defence.

What may not be obvious to the general public in such situations is the degree to which the controversy reaches into one's family life. As in Donovan's case, the protagonist essentially puts his family at risk to stand for a matter of principle that is essential for the society to maintain protections for all. As in Donovan's case, too, the spouses' views are not always consistent with one another. His wife raised serious objections to his decision to represent the alleged spy.

I don't want to overstate the case or put myself in the category of these great men, but I had a chance to get a sense of what this feels like when I was running the Massachusetts Water Resources Authority.  Under a Federal Court order, the agency was carrying out the $4 billion Boston Harbor Cleanup. A relatively small part of the project involved building a landfill to receive what are termed "grit and screenings" from the wastewater stream.  These are waste products in the sewage that cannot be recycled or reused: They must be placed in a sanitary landfill.

After an extensive site selection, thorough technical analysis, and detailed environmental review process--approved by state and federal regulatory agencies--we determined that a practical and appropriate place to build the landfill would be in Walpole, MA, near the state prison in that town, and near the border of the neighboring town of Norfolk.  As you might expect, this engendered intense local opposition.

Well, the organizers of the opposition decided that the fight would be more effective if it were presented as a personal attack against me.  It did not help that everyone running for governor (in both parties) at that time said that the landfill should go to that as yet undiscovered town called "Someplace Else."  That's OK and to be expected--just part of the job--but the mood at the time permitted things to get out of hand.

Soon I was receiving persistent and continuous calls on my home telephone line, many of which contained death threats and other threats against me and my family.  Pickets showed up at the house, timed not to coincide with my presence but rather with the arrival of my two little girls as they came home from elementary school.  We'd wake up in the morning to find trash thrown on our front lawn.  Some kind of chemical was spilled on portions of the grass, killing it.  And in one case, a decapitated squirrel was tossed in the front yard for effect.  The phone calls continued: "Watch your back" was a favorite theme.  This was before telephones had caller ID, and when the telephone company investigated the origin of the calls, there were so many hundreds that the particular messages could not be traced to specific individuals.  Because of the threats, we were forced to employ a 24-hour police guard in front of our house for many weeks.

It was during this time that my wife, always supportive of my public service, felt compelled to say, "I didn't sign up for this, to have our children threatened by a mob."  I responded, "But if you give in, you've let the fascists win."  We went to our rabbi for advice at the time, and he remarked that it was the age-old debate and conflict that families have faced in similar situations:  How you balance the legitimate needs of family protection with the imperative to protect the societal need for lawfulness?

Fortunately, in our case, things settled down.  No one was hurt.  Issues were resolved.

For me personally, the experience created a type of resiliency and willingness to dive in again in other settings; but I could certainly see how the opposite might occur.  Who could blame someone for withdrawing from public life and such controversy in the face of threats against you and your family?

As I watched the movie, I felt deeply for both Mr. and Mrs. Donovan. They both were American heroes. The country is a stronger place for what they went through together.

What enviromental radical said this?

As the world leaders meet to dicuss climate issues, it is illustrative to remember these quotes:

For generations, we have assumed that the efforts of mankind would leave the fundamental equilibrium of the world's systems and atmosphere stable.  But it is possible that with all these enormous changes (population, agricultural, use of fossil fuels) concentrated into such a short period of time, we have unwittingly begun a massive experiment with the system of this planet itself.

And:  

We must have continued economic growth in order to generate the wealth required to pay for the protection of the environment.  But it must be growth that does not plunder the planet today and leave our children to deal with the consequences tomorrow.

We should always remember that free markets are a means to an end. They would defeat their object if by their output they did more damage to the quality of life through pollution than the well-being they achieve by the production of goods and services. 

Answer:  Margaret Thatcher, address to the Royal Society in September 1988, and another speech to the United Nations General Assembly in November 1989.

Don't get angry . . . and don't get even.

Watching the recent angry back-and-forth between Russian President Putin and Turkish President Erdogan has caused many of my friends in the medical world to wonder: Why do high ranking national officials stoop to apparently immature approaches in their disputes, approaches that might lead to an expansion of a conflict to something that neither party wants?

And then I remind them of behavior they have witnessed between senior doctors in their hospitals' operating rooms, intensive care units, and treatment floors. Sheepish looks quickly follow.

There is a school of thought that suggests that your effectiveness as a negotiator is enhanced when you display anger. Professor Alison Wood Brooks at Harvard Business School presents the alternative view in a recent HBR article:

[T]here’s a body of research . . . that documents the consequences of feeling angry while negotiating. This research shows that anger often harms the process by escalating conflict, biasing perceptions, and making impasses more likely. It also reduces joint gains, decreases cooperation, intensifies competitive behavior, and increases the rate at which offers are rejected. Angry negotiators are less accurate than neutral negotiators both in recalling their own interests and in judging other parties’ interests. And angry negotiators may seek to harm or retaliate against their counterparts, even though a more cooperative approach might increase the value that both sides can claim from the negotiation.

Or, as Lucius Annaeus Seneca put it:

Anger: an acid that can do more harm to the vessel in which it is stored than to anything on which it is poured.

In her article, Brooks offers some strategies that can be employed to help people tamp down unproductive anger, both in themselves and in their negotiation counterparties.  Most of her advice relies on a party's emotional intelligence.

Coincidentally, Dr. Gene Lindsey devotes a portion of his most recent weekly newsletter to this issue of emotional intelligence in the health professions. His focus is on the importance of this attribute in enhancing the value proposition for health care delivery, but the topic is also relevant in simple face-to-face clinical relationships.

Many of the points seem self-evident.  For example:

Emotional intelligence — plays a significant role in determining how effectively physicians communicate and establish relationships with patients, as well as with their colleagues.

Effectively leveraging emotional intelligence requires an understanding of how emotional intelligence manifests itself, as well as tools to help understand an individual's emotional intelligence in a healthcare context.

Emotional intelligence has four components: self-awareness, social awareness, self-management and relationship management. EQ is the ability to perceive, evaluate, understand, respond to and influence emotions. 

Having spent many hours in offering negotiation training to residents and medical students over the past four years, I have seen first hand how often these latter four components are missing. Even in classroom simulation exercises, I've seen anger and its close ego-driven relatives--stubbornness, aggressiveness, and passive aggressiveness--employed as negotiation strategies.

More sadly, while working in the medical field, I found myself mediating and moderating such behavior among highly experienced attending physicians.

Linda Pololi, in Changing the Culture of Academic Medicine, explores the environment in medical schools and finds precursor behavior among the faculty that likely influences medical students, to wit, "feelings of dehumanization [and] erosion of trust . . . within an environment where competitive individualism was rewarded and collaboration undervalued."  If their teachers present such an example, is there any wonder why young doctors carry it along through residency and beyond?

But there is hope. As educators we can create a safe learning environment to help young professionals develop aspects of self-awareness, social awareness, self-management and relationship management.

Here's a story from two students who learned some key lessons during a simple negotiation game in one of my classes at Telluride. Derek summarizes what he learned: "The frantic pace of a situation [can] overwhelm you into making irrational decisions.  Once we’ve jumped to a diagnosis, and confidently shared it with others, we are too prone to cling to it beyond rationality. Our ego gets in the way of us re-evaluating, asking what we may have missed, and being open to different opinions."

Note, too, Sam's comment: "I’m not going to lie – my ego still stings a little bit, but what a great lesson, and what a good way to learn it. I hope that stings stays with me so that I don’t make the same mistake again when it matters, when it can affect a patient."

A home for orphan wearables

How many people do you know who've bought a Fitbit or similar device to track their exercise patterns--who have then let the whole venture lapse? The Fitbit now resides comfortably and peacefully in their drawer!

Well, there's a useful way to recycle them, offered by Tufts University professor Lisa Gulatieri. As noted in this article:

Gualtieri started RecycleHealth in April with the goal of giving unused activity trackers — mostly Fitbits so far, but RecycleHealth accepts all devices — a second life. The company has collected about 20 devices so far and has plans to donate them to the Montachusett YMCA in Fitchburg, Massachusetts, where they will be used to help older and lower income individuals have access to devices, as well as to learn about how those populations interact with activity trackers.

Check out the Facebook page for stories on how the idea is spreading, plus more information, including how to get free mailing labels.

Ancient grains are not just old plants!

Just in time for Thanksgiving preparation, I ran into Maria Speck the other day, and we started talking about ancient grains.  She published her second cookbook on the topic a few months ago, and I've now had a chance to look through it.

Beyond some really beautiful pictures by Erin Kunkel, there's lots to view in this compendium.  Of course there's background information from amaranth to wild rice, with stops along the way for freekeh, millet, sorghum, and more.  We learn, too about the absorption method of cooking, contrasted with the pasta method and others.  Should we rinse?  Soak? Toast?  How do we know when it's done?  There are handy charts with cooking times, so we can be more secure about planning ahead.

And then, of course, the recipes. By the dozen, in all kinds of categories.

This encyclopedia is a joy to read.  I'm looking forward to sampling its contents.

"They really need to know"

In her day job, Susan Hackley is chief administrative and financial officer for the Harvard Program on Negotiation, but her prior experience in a variety of public policy and other positions offers her a crisp view on many issues facing the country and the world.  She decided to devote her observational skills to a new project, "A Child's Guide to War," when she realized that for American children aged 13 and younger, we have been at war their entire lives.

As noted:

A Child’s Guide to War is a documentary film project that is helping to bridge the civilian–military divide in the United States.

A wide gulf exists in America between those who have served in the military and their families and those who haven’t. While respect for the military is high, real knowledge is not.

Through the film, a public television program, teaching materials and public meetings we are hosting, we will help Americans better understand the role of the military in our democracy and the role of civilians in understanding, respecting and appreciating the service of those who solemnly swear to protect our country.

This is a work in progress, but you can see some tidbits in this short video produced in Indiana, where Susan and crew interviewed children whose mom or dad has been to war and asked: "What is it like?"  "What do you worry about?"  "What makes you proud?"

There's something compelling about the straightforward answers given by these children.

"My dad's not a killer."

"I just put my thoughts aside."

"They really need to know."

 Take a look and, if you feel moved, please support this effort.

Serendipity is allowed

How's this for a lesson plan?

Serendipity is allowed . . . and even encouraged.

It is a philosophy set forth by Ed Moriarty, an instructor at MIT's Edgerton Center.  Opening the doors of the strobe lab for "that Saturday thing," as it is called by the students, Ed provides mentorship and asks challenging questions of children and adults of all ages who drop by to play and experiment.

Here is learning at its most creative, combining physical manipulation of electrical components with thoughtful observation.  There is no syllabus, just the joy of learning.

We were giving some friends a tour of MIT and we had explained that the philosophy of play is an important component of life at MIT.  We walked by the strobe lab at an opportune moment and were immediately hijacked by Ed. He said, "Hey, come in here. I want to show you some stuff."

He borrowed a circuit that eight-year-old Amelia had constructed and asked us, "What kind of shadow is created when you have three small diodes shining red, blue, and green and put a finger in front of one of them?"

"What if you hold up several fingers and the shadow falls on someone's face?"

Or as above, "What happens when water comes out of a sixty cycle-per-second pump and is illuminated by a sixty flash-per-second strobe?"  This little boy learned that the stream of water is actually composed of droplets, not a continuous stream.

As noted on the Edgerton Center website:

Always willing to follow students’ lead and to let them discover their own voice, Moriarty offers the intellectual and emotional support that enables students of all ages to learn to engineer by doing.

What do we do in classrooms?  Well, for the most part, we throw away spontaneity and and shoehorn students into tightly constrained curricula.  They learn the facts, but they often lose the creativity and joy of learning that comes from impulse and experimentation.  They soon forget the surprises that serendipity can bring.

A leadership lesson learned?

As turmoil continues around the world, back here in Massachusetts there's been a kerfuffle surrounding Governor Charlie Baker's remarks about limiting Syrian refugees' access to the state. Several of us, including me, we appalled by what he said. Among those was US Representative Seth Moulton.  Moulton's criticism was, in turn, deemed partisan by the Governor, an accusation Moulton roundly denied. The Governor, too, said that his remarks had been taken out of context, and he appeared upset that he had been accused of a lack of compassion. Indeed, he declined to sign a letter from other Republican governors asking President Barack Obama to suspend efforts to resettle Syrian refugees in the U.S.

A friend on Facebook noted, with regard to this last item:

At least our governor is intelligent enough to listen to his constituency. And it shows we can push him on things, which is a good thing. Bravo Baker for listening and learning from your people.

The question that I ask today is what lesson was learned and how might other leaders also learn from this episode.  If the only lesson Charlie learned from the events was that he had gotten out too far in front of an issue relative to public sentiment and that therefore he had to backtrack, that's just a lesson in politics.

If, however, he learned another leadership lesson, then there is a better result for him personally and for the state.  You see, what Charlie did in his initial comments was to fan a spark of fear, resentment, and xenophobia among at least some people in the state. It does not matter whether Charlie's words were taken out of context. He grabbed the moment and became a lightning rod.

For example, here's one comment from Michele that I received on my blog post:

So if I don't like what this government is doing or the people that are running this country, I should pack up a couple tiny things, my very small children and move to another country? I joined the Navy. I was honored to work beside the Marine Corps. So instead of trying to fix my country I should move and expect everyone else to take care of me? My Grandfather remembers the government coming to his father's house to offer aid to farmers hit by the depression. He proudly refused. Where is the working through adversity attitude? Why is everything "give me help"?

I replied:

Michele, please take a look at some of the pictures and read the stories from these folks. This is not about working through adversity. This is about having your community destroyed, losing your housing and possessions, with threats of bombs every day.

She answered:

I know. I sobbed when their stories started coming through. My concern is my children, Paul. As is their concern I am sure. I am not willing to sacrifice my children's safety as they are not either. We are making decisions based on the same priorities. 

We should in no way discount people's fears when bad things happen in the world. But acknowledging that fear is not the same as fanning it.

Charlie doth protest too much when he claims his words were taken out of context.  The overall context was that a slew of mainly Republican governors were saying approximately the same thing at the same time.  The Governor needs to understand that the moral stature of an elected official is such that his job during times of stress is to bring people together, to appeal to their better instincts and values, and not to their fears.

When he says that "my job is protect the people of Massachusetts," he is both saying too much and too little.  Too much because no one person can protect six million.  Too much because, on this issue, he has no jurisdiction in any event.  Too little because his job is to help maintain a sense of community during a period of unrest.  Too little because his job is to remind us of our underlying values and shared history.

The question for Governor Baker is whether he learned that leadership lesson, not just a passing lesson in politics.

How to secure more block time

While I hate to promulgate stereotypes about any particular group of medical specialists, this short video is too good to leave without broader dissemination.

Blog roll revisions

I've just finished editing the blog roll on the right hand side of my blog's home page.  I've deleted sites that have been inactive for six months or more.  If yours is no longer listed and you think it should be, please let me know.  Likewise, if you have a new (or old) blog to which I've not linked, please let me know.

Blind science

Thanks to Brian Klepper for alerting me to this:

Here's a poignant personal story about modern medicine from my friend Michael Millenson. Michael is a journalist who has played a significant role in ushering in the quality and safety movements in American health care.

The lede:

When I was a newborn — a preemie struggling to survive in a hospital nursery’s incubator — an article deep inside The Washington Post saved me from becoming blind.

The article — on Page A22 — discussed research showing that too much oxygen in an incubator could cause babies to lose their sight. When my worried parents phoned the hospital, they were told doctors had also seen the piece and promptly adjusted the incubator’s air mixture. What none of them knew was that the sight in my right eye had already been destroyed by what is now called retinopathy of prematurity, or ROP. Fortunately, the vision in my left eye remained intact, saving me from a lifetime in the dark.

That was way back in 1953. Yet just a few months ago, a federal judge dismissed a lawsuit involving premature babies enrolled in a study of what incubator oxygen level was best. The infants’ parents said they hadn’t been fully informed of all the risks to their infants. I was stunned. In 2015, how can the oxygen level in incubators still be endangering babies?

A gift from Monique

As we approach the Thanksgiving holiday here in the US, I'm reminded that it is almost the anniversary of Monique Doyle Spencer's death.   Here's a repeat of a post from 2013.  I just found a few more copies of the book.  If you'd like one, free, just leave a comment with your full name and snail mail address.

When Monique Doyle Spencer wrote The Courage Muscle, A Chicken's Guide to Living with Breast Cancer, she couldn't find a publisher willing to take the book on.  It was funny, you see, and all the publishers thought it was inappropriate to have a funny book about cancer.  She showed me a draft, and I said that our hospital would publish the book, and we did.  Since then, it has brought good-humored hope and advice to patients and families around the world.  As one reviewer said:  "It should become a textbook for the medical professions and a guidebook for all who must confront, or support those who do, breast cancer. It is a beautiful book, beautifully written, that sweetly balances gravitas, zaniness and one person's truth. The author's humanity is in full, accessible display for all to see, share and learn from."

Monique died on Thanksgiving weekend in 2011, and along with our fond memories of her, the book remains.  I happen to have several dozen copies, as does her husband Michael.  We have decided to offer them at no cost to the readers of this blog.  First come, first served, until we run out.  Just submit a comment with your name and snail mail address, and we will send one off to you in a few days.

To whet your appetite, here is a story about Monique's humor.  It occurred a few months before in 2011.  Michael tells it:

Bobby McFerrin gave a marvelous concert, showing his voice as an instrument, to a packed house at Symphony Hall.  Afterwards he came to the front of the stage and sat, legs dangling, to answer questions. After a bit, Monique plunged in, without being acknowledged, and asked about whether he was asked to do "Don't Worry Be Happy."  I could feel the audience cringe.  McFerrin gracefully answered the question and said he does not perform the song and was sorry to disappoint.  Monique shot back, "I did not say I liked it."  The audience broke out laughing and McFerrin fell to the floor and lay down on the stage, doing the same.