Regarded

BY SUHAS GONDI

The Trump administration’s recent announcement to end the Deferred Action for Childhood Arrivals (DACA) program instilled fear and outrage in communities across the country. As a medical student with friends and classmates with DACA status, I am particularly disappointed in the poor and compassionless judgment of our nation’s leader. I fear for my peers who have worked incredibly hard and overcome the most daunting of obstacles to get where they are today, and who now could see it all taken away from them. Their now tenuous situation is unimaginable to me. But I also fear the impact of this decision on my non-DACA classmates, on our training, and on our futures. There is certainly a moral case to keep DACA alive, but the effects of its repeal on the healthcare system writ large make apparent that it’s also a bad idea for all Americans.

The American Medical Association (AMA) letter to Congress spells out many of the reasons why. Study after study has shown that, due to multiple demographic changes, physician demand will far outpace supply over the next decade. By 2030, the US will face an estimated shortfall of up to 104,900 physicians. Even now, we are witnessing how a lack of doctors in rural and other federally designated Health Professional Shortage areas results in inadequate access to care for too many, and directly contributes to worse health. As AMA CEO James Madara wrote in the letter, “the DACA initiative could help introduce 5,400 previously ineligible physicians into the U.S. health care system in the coming decades,” and work towards alleviating this persisting issue.

Less easily quantifiable is the potential for tremendous loss of academic and economic productivity. DACA protects hundreds of medical students, PhD candidates, residents, post-doctoral scientists, and others who contribute their time, skills, and intellectual capacity towards the advancement of science and the relief of suffering. As if that were not enough, the economics student inside me can’t help but also think about all the publicly and privately invested resources that, through either explicit sponsorship or indirect subsidies, went into the schooling and training of these bright, promising young adults. Deportation eliminates the chance of any “return” on that investment – probably in the form of productive careers of science and service with immeasurable benefits to society.

But the value that medical students and residents with DACA status add to the healthcare workforce and patient care is far understated by numerical estimates and productivity losses. Many of these trainees are multilingual and come from diverse ethnic backgrounds – attributes that are underrepresented among today’s doctors, but are critical in caring for the patient populations that most sorely need effective and compassionate care. Immigrant and minority populations face myriad barriers to accessing healthcare, with difficulties in communication and distrust of the medical establishment chief among them. Having more providers who share a language and culture with these patients can help close these gaps. And for the thousands of undocumented immigrants with pressing medical needs, my classmates with DACA status offer a level of connection and shared experience – foundations for a strong doctor-patient relationship – unlike any the rest of us can offer.

The unique experiences and backgrounds of these individuals enrich the education and development of their colleagues, as well as the care of their patients. Their stories are both inspiring and instructional to those of us with more traditional or more privileged upbringings who hope to serve the most vulnerable patients in our communities. For at least ten years now, evidence has accumulated in the literature of the importance of diversity in medical schools – it builds stronger, more confident, more empathetic doctors who are better prepared to provide culturally competent care and promote health equity. My future patients will benefit if I can learn alongside and from these peers of mine.

Now is not the time to scale back. The deportation of trainees with DACA status would constitute an irrecoverable loss of diversity from our schools and the entire profession. I can say with confidence that my clinical development, and that of my classmates, would be hurt by such a loss.

In the coming days, medical students and trainees at my institution and others across the country will assemble in protest of this executive decision. We do so not only for our classmates with DACA status but also for our future patients and the future of American healthcare.

Clearly, revoking DACA protection isn’t just antithetical to our core beliefs as Americans – it’s also decidedly detrimental to the public interest. While we await the details of a tentative agreement struck between President Trump and Democratic leaders in the Senate, advocates seeking to influence policymakers should draw on both the remarkable stories of individuals protected by DACA and the strong economic and public health cases against repeal.

Congress now faces the opportunity to prevent this blunder and solidify protection for children of illegal immigrants – it’s time to make DACA the law of the land. Our representatives can seize this moment to update our immigration policies to match our nation’s economic goals for the 21^st century and our public health needs for the next decade.

“Dreamers” are our friends, our peers, our lab partners, and our teachers. What we can learn from them can’t be learned from a book or a computer, but what they can teach us will make us better doctors. In more ways than one, they make our healthcare system – and our country – stronger.

Suhas Gondi is a medical student at Harvard Medical School.

By AMELIA EDWARDS

Imagine if I told you that there was a pool of close to 600,000 individuals in New York City who were ripe for innovative health technology integration. You probably wouldn’t believe me and say that it sounded too good to be true. This said pool does in fact exist and can be found concentrated within the city’s public housing.

While entrepreneurs, governmental leaders, and healthcare officials constantly speak of innovation and disruption, there seems to be a major disconnect between these words and actual creativity. This large, untapped pool of individuals who fall under the New York City Housing Authority’s (NYCHA) umbrella is one example of the lack of creative, and truly disruptive practices, that I see in today’s early stage ecosystem.

In health tech, we have all too readily accepted the Silicon Valley model of startups and attempted to force healthcare to fit within this mold. Startup mythology has encouraged us to look at disruption as a four step model:

1. Develop a pitch deck and product
2. Raise Money
3. Experience success, a TechCrunch article, and wealth
4. Exit out with acclaim and glamour

Time and time again this method has been shown not to work in the field of health tech, yet we continue to see entrepreneurs approach the ecosystem with this mindset.

Health tech has a huge opportunity to impact the quality of life of countless individuals. It however, still needs to learn how to differentiate itself from the massive amount of convenience technology out there amongst the general startups and carve out its own niche. I believe that this niche should be one of creativity, affordability, and equal access.

Reimagining the health tech space

Many of the current public systems in the United States are poised for improvement and health tech has the ability to make said changes. You may say that I am simply echoing the 2008 Obama-era mindset of anything is possible, but I truly believe that by using a creative, and yes perhaps slightly paternalistic, perspective these systemic issues have potential solutions that are already sitting in the market. These pieces are just waiting to be combined into the right mix.

For a second, let’s just take a look at our often, and rightly criticized, public housing system.

In a 2017 survey by the Center of Budget and Policy Priorities, it was found that over 5 million low-income households are users of federal rental assistance. NYCHA itself houses 1 in 14 New Yorkers. While recipients and users of these programs are better off than those stuck in a cycle of homelessness, these affordable housing projects and developments are not exactly pristine safe havens. Public housing over the years has become synonymous with concentrated poverty, crime, and inner-city struggles. Numerous studies have also demonstrated that there are correlations between poor public housing, housing insecurity, and negative health outcomes.

The money for large, physical development overhauls to help alleviate these symptoms does not seem to be appearing anytime soon due to overtaxed city and federal budgets. This however, does not mean that we need to continue accepting this systemic cycle of poverty and poor health. This is an opportunity for digital health companies to step-in and benefit both the greater community and also their own self-interests in terms of need for proof and engagement data.

One of the great things about technology is that aside from time, much of the hard material costs of development are incredibly low. Easy downloads and online platform access can allow a singular entity to impact thousands with the click of a button. Taking this into consideration, what if there was a way to meaningfully impact the health of the individuals in public housing simply with the adoption of affordable tech-centric programming?

A theoretical healthy living prescription

For this test case, I would like to purpose a theoretical “healthy living prescription”, that would involve 2 free digital applications and 2 Medicaid covered doctor visits, as a demonstration of the ability for creative health tech adoption to have large scale, cost-saving impact.

Public housing is one area that has the potential to be used as a platform for supportive services, which could be provided in part by digital health program integration. Right now, there seems to be a state existing where those of lower socioeconomic statuses are viewed only as disadvantaged, not as viable consumers. I would like to push back against that as even if you are on a restricted income, you still are a participant in the economic market, albeit on a smaller scale than those of unrestricted wealth. In my opinion, public housing provides health tech both a large pool of consumers and a real opportunity to invest in the public good.

Currently, NYCHA lists on their website their community health opportunities as being:

1. Citi Bike Discounts
2. Shape Up NYC exercise classes
3. Connecting residents to a hotline and partnering health agencies for health insurance information

The detailing of these opportunities is by no means an attempt to call out NYCHA, as they truly are doing work for the greater good, but what if their interventions were expanded? Could you imagine if instead of simply connecting individuals with phone numbers, healthcare technology was brought directly to the homes of public housing residents as part of a comprehensive solution?

This is not some rose-colored glasses dream, but something that hypothetically could be readily achieved by changing our perspective of the issue at hand into a more flexible, creative one.

If we look at residents of public housing as consumers, this enables us to create a whole list of different jobs that they need completed – from pre- and post-natal health management to better medication adherence methods to substance abuse assistance – with a fairly minimal amount of expenditure. Analysis of each of these jobs, and associated needs, could enable the development of holistic programs, like the proposed healthy living prescription, that utilize digital health products as a means of affordability, access, and scalability.

Say a pregnant, single mother enters into a public housing development. Instead of being given a website link to a general health information page, she could be given a “new mom healthy living prescription” upon entrance into NYCHA supported housing. This prescription could detail actions steps to guide her and her family for the next year.

Maybe one aspect of the prescription is giving her a referral to a partner neighborhood clinic, who when she goes in could give her a digital health product to monitor her pregnancy for irregularities and guide her through necessary appointments, so she does not have to take off work if it can be avoided. Maybe this prescription also includes a link to a free smartphone application that will help her with budgeting while participating in the SNAP program, connect her with neighborhood stores that accept SNAP EBTs, and suggest affordable grocery lists to create a healthy meal plan for her and her child.

Really, the opportunities for integration are endless especially since 64% of low-income individuals have smartphones. Then, perhaps, after the year passes and she goes to renew her place in public housing maybe a requirement of the lease renewal, and successful completion of her prescription, is that she and her children undergo their yearly physicals.

The compounding consequences of small changes

The above hypothetical situation is a unique, low-cost intervention involving 2 free digital health products, 2 government covered doctors’ visits, and 1 printed piece of paper with the written prescription. These small steps though could make a huge difference in health, and by consequence the economic outcomes for an entire household. Maybe now our mother misses less work for unnecessary doctor visits, thereby garnering extra wages that could raise her family’s living standard. Her son could have access to more fruit and vegetables since she now has assistance in navigating her use of governmental benefits for food. This could mean that he has more energy, is generally healthier, and in turn misses less school and avoids falling behind in class.

Replicating this with families throughout an entire housing project could have incredible outcomes and opportunities. You may be grumbling about the idealistic nature of this example, and I of course acknowledge that in the real world outside of theoretics, other factors will impact what an actual program designs entail. Perhaps you are instead claiming the existence of such a program is too paternalistic and not the place of the housing system to intervene, so maybe that means that individuals need to opt into this health living prescription program instead of being mandated.

With further work these concerns could eventually all be mitigated, so it should not take away from the glimpse this one case helps provide into what it could look like if health tech begins to creatively focus more on integration into pre-existing systems and structures in need of improvements.

Designing for all of America

It’s great to design boutique health services and flashy applications, but there are over 5-million low-income households who are barely able to afford their own housing. Beginning to put more time, money, and energy into innovations and partnerships that positively impact those on the bottom of our economic and health system is how health tech can develop a niche for themselves and truly unite together the guiding ethos of health and technology. Entrepreneurs in this space should begin to consider bottom-up design with the idea that if those of the lowest means can afford and utilize a product/program, then the compounding positive results will be greater than merely designing for the wealthy and hoping for a trickle down effect. All of American is not of the same wealth level and demographics as Silicon Valley, so we should not treat it as so in our design and our proposed implementation of health tech.

Looking at public housing interventions, and other social programs, may be a great way to begin to accomplish this.

Amelia Edwards is director of marketing at Junto.

BY LEONARD D’AVOLIO

The healthcare AI space is frothy.  Billions in venture capital are flowing, nearly every writer on the healthcare beat has at least an article or two on the topic, and there isn’t a medical conference that doesn’t at least have a panel if not a dedicated day to discuss. The promise and potential is very real.

And yet, we seem to be blowing it.

The latest example is an investigation in STAT News pointing out the stumbles of IBM Watson followed inevitably by the ‘is AI ready for prime time’ debate. If course, IBM isn’t the only one making things hard on itself. Their marketing budget and approach makes them a convenient target. Many of us – from vendors to journalists to consumers – are unintentionally adding degrees to an already uphill climb.

If our mistakes led to only to financial loss, no big deal. But the stakes are higher. Medical error is blamed for killing between 210,000 and 400,000 annually. These technologies are important because they help us learn from our data – something healthcare is notoriously bad at. Finally using our data to improve really is a matter of life and death.

In that spirit, here’s a short but relevant list of mistakes we’d all benefit from avoiding. It’s curated from a much longer list of sometimes costly, usually embarrassing mistakes I’ve made during my dozen years of trying to make these technologies work for healthcare.

1. Inconsistent references to…whatever we’re calling it.  I hard a hard time settling on the title of this piece. I had plenty of choices to describe the topic of interest, including machine learning, big data, data mining, data science, cognitive computing, to name a few.  Within certain circles there are meaningful distinctions between all of these terms. For the vast majority of those we hope to help, using 10 ways to describe the same thing is confusing at best and misleading at worst.

I’d prefer the term ‘machine learning’ since that’s usually what we’re talking about, but I’ll trade my vote for consensus on any name. Except ‘artificial intelligence’. The math involved is neither artificial, nor intelligent. Which brings us to mistake 2.

2. Machine learning is a tool, not a sentient being. It’s a really powerful tool that can help with detection of disease, early prediction of progression, and pairing individuals to interventions. The tool metaphor has real repercussions – not just for cooling off the “AI as doctor” hype but for how we actually put it to use.

For example, the hammer is a great tool. If you know how to use it. If you have a plan to create something value with it. If you are working with wood. If the job, ultimately, is to bang nails. If not, it’s useless. The second we claim otherwise, we’re setting up for disappointment.

3. Ridiculously unhelpful graphics. On a related note, the images accompanying articles on the topic aren’t helping matters. I sympathize with the challenge of visually representing a somewhat intangible approach. However, robotic terminator arms presenting magical pills are not helpful (or even brains) are hilarious* but not helpful.
4. People don’t get excited about being replaced. Yet our references to artificial intelligence, our graphics, and our headlines keep steering their audience back toward this one inevitable conclusion. I get it. Scare sells. But it doesn’t get us to better care faster.
5. Outrageous promises (and belief) of what these tools can do.  For some reason people seem to be upset that IBM Watson hasn’t revolutionized cancer care yet. If I sold you a hammer based on the promise that it can build a house on its own, would you be disappointed if it didn’t?

For that matter, who deserves the blame? Me for selling you the hammer or you for believing it?

No one in their right mind would blame the hammer. Unlike the tools comprising AI, there are not thousands of studies over the past three decades demonstrating the effectiveness of hammers. And yet, inappropriate use, over-promising, and poor project management is causing many to question AI.

Why is it so easy to blame the tool? See above.

6. Measure (and talk about) what matters. Hint: it’s not the predictive performance of an algorithm, the terabytes of data amassed, or grandiose introductions of your data scientists’ degrees. It’s dollars saved or earned, lives improved, time reduced, etc.

If you must describe value in terms of accuracy / statistical performance, best to do so responsibly. Claiming “90% accurate!” doesn’t mean anything without additional context. Accurate at what? Measured how? With what data? Details matter in healthcare.

7. Technology is great. But people & process improve care. The best predictions are merely suggestions until they’re put into action. In healthcare, that’s the hard part. Success requires talking to people and spending time learning context and workflows – no matter how badly vendors or investors would like to believe otherwise. It would be fantastic if healthcare could be transformed by installing software that assumed your workflows and priorities. Just ask those dealing with the aftermath of electronic medical record installed (i.e., most practicing clinicians). Until certain fundamental realities change, invest in understanding, process, and workflow.

I share this partial list of lessons learned not out of frustration but with incredible enthusiasm for what’s to come. These technologies will become an integral part of how we identify patients in need of attention, reduce wasteful administrative overhead, recommend more appropriate pathways of care. I see it happening in small steps, in real healthcare organizations every day. The sooner we reframe the way we speak about and apply these tools, the sooner we can begin using our data to get better.

*Not helpful but hilarious. I started collecting them and tweeting out one new wildly unhelpful AI graphic every Friday. Feel free to send great specimen my way.

Leonard D’Avolio @ldavolio is CEO & Co-founder of Cyft Inc, and also Asst. Professor, Harvard Medical School & Brigham and Women’s Hospital

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By SAURABH JHA, MD

“There are some enterprises in which a careful disorderliness is the true method” – Herman Melville, Moby Dick

Asymmetry of Error

During the Ebola epidemic calls to ban flights from Africa from some quarters were met by accusations of racism from other quarters. Experts claimed that Americans were at greater risk of dying from cancer than Ebola, and if they must fret they should fret more about cancer than Ebola. One expert, with a straight Gaussian face, went as far as saying that even hospitals were more dangerous than Ebola. Pop science reached an unprecedented fizz.

Trader and mathematician, Nassim Taleb scoffed at these claims. Comparing the risk of dying from cancer to Ebola was flawed, he said, because the numerator and denominator of cancer don’t change dramatically moment to moment. But if you make an error estimating the risk of Ebola, the error will be exponential, not arithmetic, because once Ebola gets going, the changing numerator and denominator of risk makes a mockery of the original calculations.

The fear of Ebola, claimed Taleb, far from being irrational, was reasonable and it was its comparison to death from cancer and vending machines which was irrational and simplistic. Skepticism of Ebola’s impact in the U.S. was grounded in naïve empiricism – one which pretends that the risk of tail events is computable.

The U.S. got away lightly with Ebola. It would seem the experts had rebutted Taleb. But the experts were wrong, in fact wronger than wrong, despite being right. To understand why you need to invoke second order thinking. Their error was in failing to appreciate the asymmetry of error. Error is often unequal. The error from underestimating Ebola is magnitudes higher than the error from overestimating its impact. Their error lay in dismissing counterfactuals. Counterfactuals eventually catch up with you.

Imagine you’re hiking in the Mojave desert, which is rattlesnake territory, and a billionaire pays you $10 for lifting rocks.  There’s a chance you could blindly lift rocks without being bitten by a rattlesnake. But the error is asymmetric because the pay off, the outcome, is asymmetric. If you don’t lift the rock, wrongly believing there is a rattlesnake underneath it, you forfeit $10. If you lift the rock, wrongly believing there’s no rattlesnake underneath it, you will be dead. My guess is you will ignore the point estimate and confidence interval of “risk of rattlesnake underneath rock” and not lift rocks blindly.

A “2 % chance of being wrong” is meaningless without knowing what the consequences of being wrong are. A “0.1 % chance of a catastrophic event” is meaningless without acknowledging the error in that point estimate. Some events are so catastrophic that they render both point estimates and their range meaningless.

Tailgating in Extremistan

I found Taleb by chance. My train to New York was late. This was before Twitter, when I still read books, so I went inside the bookshop. I choose books randomly. I bought The Black Swan because the title sounded intriguing. At some point I came across this sentence “…the government-sponsored institution Fanny Mae when I look at their risks, seems to be sitting on a barrel of dynamite, vulnerable to the slightest hiccup.” I realized its significance six months later when Lehman Brothers collapsed, triggering the financial collapse of 2008. I had a “where have I seen you before” moment. I re-read The Black Swan. Taleb had predicted the financial collapse.

After the financial collapse, the prediction merchants, who were conspicuous by their absence during the rise of sub prime mortgages, came out of the woodwork in droves and eloquently explained why the financial collapse was inevitable. Explaining “why” after the event is much easier than explaining “how” before the event, and is a pretense of knowledge. Taleb takes apart our pretensions.

The ancient Greeks looked at the sky, joined the dots and told fascinating tales. Today we ask about the dietary and reading habits of people who have lucked out from the cosmic Monte Carlo simulator. Ten steps to becoming a millionaire are often ten steps to losing a million. The unsung loser, the denominator, is lost to publication bias.

Physicians are also prone to being fooled by randomness. We give a cluster of cases an eponym because we don’t understand chance. Autism’s fallacious link with the MMR vaccine is because we can’t get ourselves to say that bad things happen to good people for no body’s fault.

“Reflection is an action of the mind whereby we obtain a clearer view of our relation to the things of yesterday and are able to avoid the perils that we shall not again encounter,” the satirist, Ambrose Bierce, quipped. An entire industry thrives from our failure to appreciate chance. The industry retrospectively analyzes the event and, with hindsight, sees the problem with even greater clarity. Instead of being humbled, our belief in our predictive, preemptive and preventive powers becomes stronger.

In The Black Swan, Taleb uses the problem of induction as a metaphor for the unquantifiable. Even after seeing thousand white swans the statement “all swans are white” would be an epistemic error, disproven by a single black swan. Einstein put it similarly: “no amount of experimentation can ever prove me right; a single experiment will prove me wrong.”

The world is shaped not by Gaussian laws but outliers. Taleb divides the world in to “mediocristan” and “extremistan.” Mediocristan is bell-shaped, loved by statisticians, predictable, with a tail that is inconsequential. Extremistan is dominated by a single event – the pay offs are large, meaning the tails are fat. Extremistan is unpredictable and consequential.

Book sales are in extremistan. Bill Gates is a product of extremistan. Physician incomes, as extreme as they may appear, are in mediocristan. Black swans rule extremistan and change the world. September 11^th, 2001 was a black swan event, as was the collapse of the financial sector. We live in an interdependent world which is more prone than ever to black swans.

Taleb scorns at experts, particularly in the prediction industry, who he says suffer from the Ludic Fallacy. This is when we think we know the variable, or its distribution, used to derive risk. We confuse risks (known unknowns) and uncertainty (unknown unknowns). Experts are most wrong when it matters the most. The possible gives the probable, and the experts, a thorough hiding.

Fragile systems and Antifragility

Was Taleb lucky or prophetic in predicting the sub prime mortgage crisis? Perhaps neither. He was commenting on the fragility of the system, the subject of his book, Antifragile.

Fragile systems collapse under stress. The opposite of fragile is robust – a system unaffected by stress. Robust systems do not improve. Antifragile systems gain from stress. Antifragile is a neologism coined by Taleb. Nature is antifragile. Hormesis, the long terms gains of the body from small stressors, is a recognized biological phenomenon which illustrates antifragility. The stresses in antifragile systems are like a live attenuated vaccine which protects the body from its more virulent counterpart.

Black swan events can’t be predicted. But systems can be made less prone to outliers. According to Taleb, we should focus on pay-offs, not probabilities; exposure, not risk; mitigation, not prediction. Antifragile is Taleb’s peace offering – an epistemological middle ground where the unknowable compromises with our need to act. The fault lies not in our failure to predict Tsunamis, but in failing to make systems Tsunami proof.

The greatest strength of Antifragile is its domain independence. When read thoughtfully, its relevance to medicine, and evidence-based medicine, becomes clear.

Burden of proof in non linear systems

To understand fragility and antifragility you need to understand non-linearity which, despite the formidable mathematics, is easy intuiting.

The assumption that biological systems are linear may be fundamentally wrong. Biological systems are more likely a continuum between concave and convex functions. When f (x) is concave, the harm from an increment of ‘x’ is more than the gain from a decrement of ‘x.’ This is why less is sometimes more, why the quixotic search for pre-syndromic syndromes, overdiagnosis, can lead to net harm.

When f (x) is convex, not only more is more, but the gain from an increment of ‘x’ is more than that forfeited from a decrement of ‘x.’ In this zone indecisiveness has opportunity costs. If a patient is exanguinating, you must act, not look up Pubmed, even if you forfeit the most optimal action.

The line between the two domains is not precise. In medicine, convex and concave are often separable only by scale. For example, severe hypertension is convex, but mild hypertension is a concave function.  Treating acute myocardial infarction, acute stroke, transplant rejection, and bacterial meningitis are convex functions. Secondary prevention is more convex than primary prevention. Antibiotics for common cold is concavity on steroids.

The twin dogmas of linearity are extrapolation and projection, which lead to errors in non linear systems. Projection, that is assumption a system, f (x), responds ten times at x = 100 as it does at x = 10, underestimates the response at x = 100. The small and uncertain benefits of stenting distal circumflex narrowing in chronic stable angina can’t be transported to left main lesions, which have a different degree of convexity.

Extrapolation, that is assumption that a system, f (x), responds one-tenth at x = 10 as it does at x = 100, overestimates the response at x = 10. The large and certain benefits of stenting proximal left anterior descending artery narrowing in ST-elevation myocardial infarction can’t be transported to distal circumflex lesions in chronic stable angina.

The convexity, or concavity, determines the burden of proof. Naïve empiricists err by assuming a constant burden of proof. The burden of proof for a screening test should be much higher than the burden of proof for a treatment of obstructive left main disease – think asymmetry of error.

The burden of proof ought to be highest when making policy decisions, when developing guidelines, when dictating standards, because if these have errors, conformity scales the error. An example was the conventional wisdom, and policy, which addressed pain control, and introduced “pain is the fifth vital sign” in physicians’ cognition. The error amplified exponentially when opioid analgesia was prescribed without compunction, leading to the intractable opioid crisis.

The challenge in medicine is fine tuning the burden of proof according to the asymmetry of error – a singular failure of evidence-based medicine which seems unable to display epistemic nuance.

Skin in the Game

Taleb has special respect for doctors. He doesn’t call people with PhDs “doctors.” He only calls MDs “doctors.” The respect is rooted in Taleb’s respect for the opinion of people who have “skin in the game.” If you have skin in the game you’re more likely to draw on your local knowledge, use what is important and discard what is irrelevant. To practice is to preach. But not everything that is relevant is articulated and much that is articulated is irrelevant.

I once attended a quality and safety talk where the speaker said “what cannot be measured cannot be improved. Measure, measure, measure!” Taleb might have recoiled at the epizeuxis and might have introduced the speaker to the “green lumber fallacy.”

The “green lumber fallacy”, coined by Taleb, is named after a trader in green lumber who thought  green lumber was literally green, but it is so named because of its freshness, not color. However, this ignorance did not affect his trade. Experts make this fallacy when they mistake the visibility of knowledge for its necessity, and ignore hidden knowledge.

The tendency to dismiss the unknowable or unmeasurable was also described by Robert McNamara. The McNamara fallacy progressively disregards the intangible, that which does not appear extant to the quantifier. First we measure what we can. Then we assign what can’t be measured an arbitrary value. Then we disregard the unquantifiable as unimportant. Finally, we pretend the unquantifiable doesn’t exist. The transparency movement in healthcare may fall prey to McNamara fallacy by mistaking what is disclosed for what is relevant. The sauce may always remain secret.

There is a tension in health policy between the quants and the doctors in the trenches because the experts dismiss the doctors in the trenches, doctors who have skin in the game. Aggregation has become so fashionable that now the expected value, the mean, the net benefits reign, and the signal from variability, from outliers, is ignored. What works in Boston is expected to work in the Appalachia. Technocrats can be more valuable if they modified their models to fit reality. If they wish to preach to those who practice, they must consult the practitioners to whom they wish to preach.

For example, the history of the electronic health record (EHR) could have been different if its developers had paid more heed to the needs of the foot soldiers, the doctors and nurses, rather than the wants of regulators, payers, researchers, dreamers and other utopians. The technology has ended up in a developmental cul-de-sac, where it can’t get better without getting worse.

Optimizing Economies of Scale

Taleb takes apart healthcare’s two most sacred cows – optimization and economies of scale.

Taleb cautions against efficiency or optimization. In an optimized healthcare system – a health economist’s wet dream – all of healthcare is firing on all cylinders all the time delivering the highest quality-adjusted life years for the dollar. Efficiency is flying too close to the wind. Efficiency makes the system more fragile because efficient systems are usually efficient under normal conditions and not so efficient under abnormal stresses. Systems should have redundancies built in them. Perhaps healthcare should incentivize doctors to procrastinate, occasionally, rather than be hamsters on the productivity wheel.

In illustrating how economies of scale could become disasters of even larger scale Taleb hypothesizes what would happen if elephants were pets. When times are good the elephant’s share of the household budget is barely noticeable. During thrift, a “squeeze”, the maintenance costs for the elephant rise disproportionately and irreversibly, much more than they would for a cat.

The obvious elephant in our room is the EHR – healthcare’s very own Fukushima. The larger and more centralized EHR becomes, the costlier it will be to fix errors and privacy leaks; and one will have no choice but to fix them when they occur. The failure of interoperability may, paradoxically, spare us from a larger disaster.

By fiat or necessity hospitals are concatenating. The economies of scale which come with integration make the “Cheesecake Factory” model of healthcare appealing.  But as alluded, elephants are more expensive to maintain than cats, particularly during thrift. Are we setting ourselves up for a supernova when healthcare becomes a red giant?

Complex Systems

Taleb reserves special derision for academic experts whom he calls “fragilistas”, or designers of fragile systems. I’m an academic, though far from an expert at anything. It’d be a mistake dismissing Taleb just because he doesn’t suffer fools gladly. Friederich Hayek opposed central planning because knowledge is too dispersed for the technocrat to know it all. Taleb cautions against too much planning because it interferes with organic growth.

Is our approach in healthcare fundamentally incorrect? After reading Antifragile, I believe so. In the narrative in healthcare, there’s an inordinate love for uniformity and standardization and an uncanny disdain for variability. For unbeknownst reasons, variability is the profession’s most unforgivable sin. But there is signal in variability which is lost in uniformity. And you can’t achieve uniformity without conformity, and forcing physicians to conform loses the valuable insights which come from individualism, the same quality which leads to variability.

Healthcare is a complex, recursive, wicked system. There is a place for Gauss but Gauss can’t be our sole method for analyzing healthcare. Antifragility is another framework for thinking about healthcare. Taleb’s prescription is a “barbell strategy” in which risk minimization and serendipity coexist. Healthcare should be designed, but not so perfectly or uniformly or optimally that it becomes too big to think. Imperfection must not just be tolerated but built into the system so that the system improves, as far as possible, on its own.

About the author:

Saurabh Jha is a radiologist and contributing editor to THCB. He can be reached on Twitter @RogueRad

By STEVEN FINDLAY

Nazis and white supremacists.  Charlottesville.  Immigration policy and DACA.  Climate change.   In the context of these issues, there’s been much discussion of late about moral and ethical principles and American values. 

There is, of course, no moral equivalency between white supremacists and those who oppose and protest them.   People who advocate white supremacy are just plain wrong, on moral grounds. 

And the Trump administration is clearly pursuing a path on immigration policy and climate change that is contrary to the ethical standards and values of the vast majority of Americans. I would add to this list the expansion of health insurance coverage.  If anything is clear after this summer’s failed attempt by Republicans to repeal the ACA it’s that almost all Americans now support universal coverage.  

And, more to the point, people see this increasingly in moral terms. They get it. It took many years—decades—to get to this point.   But this summer’s debate clarified what our values are as a nation on access to health care via the structure of insurance, private and public.     

So, thank you Republicans for triggering the debate.  It was painful but illuminating.  Your plans to go backwards on our nation’s slow but steady expansion of coverage failed.   In the end, 70 to 80 percent of adults—including tens of million of Republican voters—rejected your plans to upend the ACA completely, and thereby erode the coverage expansions at its core.   We can only hope that’s an end to such efforts.  But it appears that some Republicans in Congress are still not fully getting the message.  They are choosing to ignore their own voters and the moral issue at hand, and to pursue a partisan path that is grounded in bad policy and a willful denial of basic insurance principles and the benefits of the ACA to date—imperfect as it is.   

I speak of the renewed debate in the Senate last week, and continuing this week, around fixes to the ACA ahead of this fall’s open enrollment.   There is dissonance once again in Republican ranks that could disrupt, delay or scuttle entirely an emerging bipartisan effort to stabilize the ACA marketplaces, which cover 10 million people.    

The effort is being led by Lamar Alexander (R-Tenn) and Patty Murray (D-Wash), chair and ranking member, respectively, of the Senate Health, Education, Labor and Pensions (HELP) Committee.  They have buy-in on the Committee, in principle, towards a deal to fund the payments insurers get under Obamacare—called cost sharing reduction, or CSR, payments.  These payments (about $8 billion in total this year) compensate insurers for lowering/subsidizing deductibles and co-payments for low-income exchange enrollees.  About 75 percent of exchange enrollees benefit from CSR relief.  (Deductibles in the exchanges are higher than employer-based coverage, averaging above $2,000 for individual coverage and $3,500 for family coverage.)   

Importantly, without CSR payments, premiums will increase by larger amounts.  Insurers have been very clear about this and in testimony before the HELP committee last week, insurance commissioners from 4 states all but begged for continued CSR payments to keep a lid on premium hikes of 20, 30 or even 40 percent for 2018 (on top of an average 22 percent nationwide in 2017).    

In addition, the Committee is considering creating a reinsurance program to help insurers pay for high-cost care.  Such a program operated for three years (2014-15-16) as a provision of the ACA but expired in 2017.   Reinsurance also helps constrain premium increases.   

A deal could also include a Republican goal: easing the path for states to apply for waivers from the federal government to experiment with health insurance expansions, as well as more flexibility for states to bend ACA rules.   Murray and other Democrats have said they are willing to consider more state flexibility as long as it does not undermine coverage.   

Hard right Republicans, however, are beginning to make disruptive noises, as they so often do.   Leading the charge is Orrin Hatch, chairman of the Senate Finance Committee.  In an op-ed in the Washington Post on Friday Sept. 8, Hatch called reinsurance and the CSR payments “insurer bailouts” and said he could not support them.     

This is an example of willful ignorance.  Not only is reinsurance a tried-and-true insurance mechanism, used across the industry, but it’s a tool frequently used in health insurance.   Employers who self-fund their employee health benefits buy it.   And the federal government back-stops the Medicare Part D plans with reinsurance for high expense claims.   In addition, the federal government subsidies the Medicare Advantage program in a way that’s analogous to the CSR payments—not to mention the fact that the government subsidies employer-based health insurance to the tune of almost $300 billion a year in deferred taxes. 

Hatch has also signaled that he would not attach any ACA fix measures to the reauthorization of the Children’s Health Insurance Program (CHIP), a must-pass piece of legislation by the end of this month.   

Along with Hatch, Senate leader Mitch McConnell could derail the bipartisan train on ACA fixes—possibly out of spite.   

And then there’s Trump and HHS Secretary Price.   Trump has played politics with the CSR payments for months, threatening to stop paying them as leverage to get Democrats to the bargaining table on an ACA replacement.  In fact, Trump last week agreed to a path preferred by Democrats on the debt ceiling, and signaled he may work with them on other legislation. 

But that could change at any moment, of course; the Trump administration revealed antipathy to the ACA and mercurial, ever-shifting, chaotic modus operandi again last week when it further reduced funding for the navigator programs that assist people in enrolling in the exchanges.  And, in a series of tweets, he piled on his previous criticism of McConnell and Paul Ryan for their failure to pass an ACA repeal & replace bill.   

Indeed, whether Trump would agree to sign a bill with any form of ACA fix attached is unknown.   He has not yet tipped his hand on that.   And it’s very likely one reason Hatch doesn’t want to attach any ACA fix to the CHIP bill is that Trump would have a hard time vetoing that. 

All of this is a on a very tight schedule if its to be relevant to premiums for 2018.  HHS and state insurance commissioners must lock in exchange premiums by the end of this month—or at the latest the first week of October—to prepare for the start of open enrollment on Nov. 1.   

It’s time for Republicans to realize that their attempt to undo the ACA was and remains quixotic.   More importantly, their clumsy efforts were morally bankrupt and out of step with progress towards the goal of universal coverage that’s now firmly embraced by the public.   

By NIRAN AL-AGBA, MD

Since the birth of our nation, labor unions have existed in one form or another in the United States.  Unions are a force to protect the ‘working population’ from inequality, gaps in wages, and a political system failing to represent specific industry groups.  Historically, unions organize skilled workers in a specific corporation, such as a railroad or production plant, however unions can organize numerous workers within a particular industry.  Known as “industrial unionism”, the union gives a profession or trade a collective and representative voice.  The existence of unions has already been woven into the political, economic, and cultural fabric of America; recent events suggest that it may be time for physicians and surgeons to unionize.

A labor union, is a body of workers who come together to achieve common objectives, such as improved safety, higher pay and benefits, and better working conditions.  Union leadership bargains with employers on behalf of union members to negotiate labor contracts (collective bargaining.) This may include the negotiation of wages, work rules, complaint procedures, and regulations governing hiring, firing and promotion, or workplace policies.

In 2010, the percentage of workers belonging to a union in the U.S. was 11.4%, compared to 27.5% in Canada.  There are strong, causal linkages between a diminished proportion of the workforce unionizing and loss of worker bargaining power.  Obviously, the leadership of corporations prefers workers having less leverage while negotiating; unions allege this employer-incited opposition has contributed to the decline in membership over time. 

However, the popularity of unions is growing, according to a January 2017 survey conducted by Pew which found 60% view unionization favorably.   More than half of young, millennial Republicans are in favor of unions as well, something that would have been shocking a decade ago.  Maybe the time is right for physicians to unionize?

In 1972, Dr. Sanford A. Marcus, a surgeon in private practice formed the Union of American Physicians and Dentists (UAPD).  It has been the most successful physician union and is affiliated with the AFL-CIO.  A quote from their website is apropos, “Hospital administrators easily manipulated physicians, treating them as if they were hired hands.  Insurance companies were dealing with them as if they were employees.  Government programs… controlled key aspects of doctors’ work, told them how much they would be paid, and what procedures they would be paid for.”  This sentiment sounds familiar.

Dr. Marcus saw medicine being ripe for takeover by corporations who were more concerned with profit than ensuring high quality care was provided to patients.  Medical associations were and still are overlooking the needs of front line practicing physicians; Dr. Marcus believed a union was the only organizational structure which could level the playing field.  He met with the AMA and they were ardently against unionizing.  The AFL-CIO initially balked at his suggestion, saying “Come back in ten years”, assuming most physicians would be employees at that point in time.  It has taken more than a decade, but our profession has arrived at the point where the majority of physicians are employed.  Large corporations are stripping physicians of professionalism and belittling our management role.

The Economic Policy Institute recently released a report with objective data supporting the assertion that unionization benefits workers in the long-term.  The EPI report found unions definitively raise wages for both union and nonunion workers.  A worker with a union contract earns 13.2 percent more in wages than a peer with similar education and background experience.  Through establishing wage “transparency”, unions raise earnings of women, black, and Hispanic workers, groups whose pay tends to lag behind that of their white, male counterparts.  Hourly wages for women are 9.2 percent higher than nonunionized women across similar occupations.  Black unionized workers in New York City earn 36.1 percent more than nonunion laborers in the same demographic. 

In addition, unionized workers have better health and wellness because unions ensure employers are held accountable for safe, non-abusive working conditions.  Unions can strengthen families by obtaining better leave policies, retirement benefits, and health insurance, while at the same time, safeguarding that employees have due process in promotions, dismissals, or terminations.  Front line workers often face tangible challenges often overlooked by management; as a result, they have a tremendous knowledge to suggest improvements to the workplace, make it safer, and increase productivity. 

Physicians certainly qualify as an industry sector whose bargaining power has fallen far below the value of their effort.  Labor unions exist to protect workers against imbalance in negotiations.  In a recent Washington Post article, Jared Bernstein posed that collective bargaining should be structured by industry sector instead of by individual corporations.  Interestingly enough, Larry Mishel, President of EPI and the report author, told Bernstein, “We need a design where people have collective bargaining rights as restaurant workers, as opposed to one where they gain those rights one restaurant at a time.”  Physicians may need collective bargaining rights as an industry, not as employees of Everyday Hospital, USA. 

UAPD has survived over four decades because they have offered traditional and innovative approaches to assist physicians with boots on the ground.  While officially opposing unionization, the AMA did try their hand at it during the mid-1990s, when President Clinton was working on universal health care.  After spending $3 million, they brought in 38 physicians, but the effort ended in colossal failure. 

For physicians in private practice, UAPD developed a grievance process when insurance companies unfairly deny reimbursement.  Their organization is run by physicians and for physicians.  They have won battles against large hospital corporations, advanced pro-physician legislation, organized a compassionate strike of physicians, and countered doctor-bashing in the media. 

Dr. Marcus once said, “There are no dinosaurs left…, they were unable to adapt to changing environmental conditions.  We stand a much better chance of preserving our professionalism through the process of becoming unionized workers – admittedly a terribly unprofessional thing to do… But then, that’s just the sort of adaption those dinosaurs were incapable of making, isn’t it?”  As the world becomes more divided, politically, economically, and medically, physicians stand to lose the profession we love dearly.  The moment has arrived for physicians to put aside our differences, of gender, specialty, or political ideology, and support an organized body standing up for the collective voice of physicians. 

Niran al-Agba is a pediatrician in Washington state.

By PAUL KECKLEY

The physician-patient relationship is a bedrock of the U.S. health system. Strong relationships are associated with higher ratings for physicians and better outcomes for patients but there’s a catch.

In Secretary of Health and Human Services’ Tom Price Senate confirmation and many times since, he has vowed his administration will seek to restore that relationship. But what patients associate with a strong relationship is increasingly at odds with how physicians think. And the gap between the two seems to be widening.

Background:

Per the American Medical Association, the physician-patient relationship is a formal or inferred relationship between a physician and a patient, which is established once the physician assumes or undertakes the medical care or treatment of a patient. It is a responsibility physicians don’t take lightly and most believe they do it well.

The physician-patient relationship has been widely studied. A framework developed by Ezekiel and Linda Manuel has been widely used to categorize the four roles physician play in these relationships: guardian, technical expert, counselor, and friend. In interacting with patients, physicians play all four. Researchers have linked a physician’s personality with their bedside manner. Surveys show most physicians lean toward a more paternalistic approach in dealing with patients and the majority think friendships with patients must be approached with caution. Academics have studied the dynamic between physicians and patients, observing that the physician is the ‘power’ figure in most. Studies have linked a physician known to have a prickly personality with more patient complaints and, in some specialties, a higher susceptibility to lawsuits. And physicians routinely compare notes among themselves about problem patients with whom interactions are routinely difficult.

Through the years, the American Medical Association and every major medical organization have opined consistently to the need for strong physician-patient relationships. Physicians understand their importance: they’re pragmatists. They understand that a pleasant bedside manner is not necessarily correlated to clinical competency and skillfulness but both are important. They are sensitive to impressions that their profession attracts smart people with big ego’s and a predisposition toward arrogance. And they recognize that changes in their environment are driving a wedge between how they practice and the expectations patients have for the relationship. Consider:

More physicians are now practicing in larger groups, and one third are employed in hospitals (MGMA). That means the clinical judgement of a clinician often is part of a larger scheme for managing patients consistently (to optimize clinical coordination) and efficiently (to maximize productivity and revenues). Peer reviews, utilization management and comparative effectiveness are now part of their lexicon.

Data about the quality of a physician’s care is increasingly accessible to patients from independent third-parties that sponsor report cards about physician outcomes, practice patterns and ratings by patients. It’s a growing irritant to physicians, especially those that believe the measures used are neither valid or reliable.
The science of medicine—what works, what doesn’t and for which patients—is increasingly accessible to patients seeking information about treatments that might not be recommended by their physician. The democratization of medical knowledge via social media and readily accessible clinical guidelines from reputable sources means patients have more questions and are often armed with inaccurate or harmful information.
Physician income pressures are mounting. Granted, their incomes remain healthy compared to the overall population ranging from 3:1 up to 20:1 but physicians face higher administrative costs and lower reimbursement from employers and insurers. There’s almost universal belief among physicians they’re fairly paid and palpable fear things are getting worse. And they react viscerally to the notion that physician greed is systemic.

And physicians understand that ratings by patients are here to stay. Patients expect to be able to compare the quality of medical care they receive just as they compare every other high-profile profession. And physicians know their ratings matter to payers like Medicare who penalize them for poor patient experience ratings.

Against this backdrop, most physicians believe their relationships with patients are less than ideal due to circumstances beyond their control. The majority think the profession is being compromised by external intrusions that limit their effectiveness as clinicians and compromise their relationships with patients. They want to spend more time with patients but recognize the gap between their wishes and reality is widening.

Patients see a gap, but their perspective is different. They see their physicians in positions of power and trust who are highly compensated and knowledgeable. They do not understand the complexities of modern medical practice nor do they believe them insurmountable. Their wish list is simple:

• Most patients trust their physicians’ judgement but want a second opinion for major treatments and decisions, and they pursue those on their own.
• Most want to learn more about their condition from sources that are evidence-based and independent.
• Most believe they should have complete access to their own medical record without cost or hassle.
• Most think their physicians should leverage online technologies to allow online scheduling, tele-visits, secure messaging and more. (Most practices permit online bill payment and little more).
• Most want their physicians to embrace alternative therapies and lifestyle interventions in their recommendations.
• All want their physician to tell them what a procedure or encounter will cost ahead of time to avoid surprises.
• All want to know their physician’s track record—outcomes, patient ratings, and more.
• All want their clinicians to disclose their conflicts of interest i.e. business relationships influence their referrals.
• All want their physicians to treat them with respect and listen better.
• All think their practices should provide better service that’s convenient, accessible and person-centered.Little wonder half of all patients say they are open to making a change. Most think physicians are focused on their own needs rather than theirs.

What’s Ahead for Physician-Patient Relationships?

Four trends will reshape physician-patient relationships:

Practice settings: Physicians will increasingly be affiliated with larger groups that position themselves around their depth, breadth, service, prices and reputation.

Financial Incentives: Physicians and patients will share financial risks associated with health insurance plans, and Medicare will penalize physicians that do not score at acceptable patient satisfaction levels. In other words, physicians will have an incentive to manage a patient relationship rather than accommodate visits and requests.

Data: An abundance of valid and reliable data will be available to consumers to compare the performance of their physicians about outcomes, practice patterns, financial relationships, patient experiences and costs.

Insurance Design: Patients will have more skin in the game. Employers are shifting financial responsibility to employees via high deductible plans; Medicaid is shifting to managed Medicaid and Medicare is encouraging alternative payment programs.
The combined impact of these means physician-patient relationships will be better coordinated, managed tightly and the basis for differentiating the performance of medical practices. Patients will migrate to practices that put their needs and values first.

The gap in the physician- patient relationship is widening. It’s clear patients want something quite different than they’re getting. Both perspectives are important and neither more than the other. So as Secretary Price and others espouse the centricity of the physician-patient relationship, it’s important it be understood objectively.

By DAVID SHAYWITZ, MD

When you think about tech giants playing in healthcare, you think of Google and the work Verily is doing; you think of Apple and their HealthKit and ResearchKit applications, as well as their rumored plans to organize all your medical data on your iPhone; you may even think of Amazon and their potential entry into the pharmacy market.

When I recently told Might about the mutation-specific Facebook communities, he wasn’t surprised, and told me that he was “impressed by what patients can already do on Facebook” and other “established systems” including Google, Wikipedia and Twitter.

Google, for one, seems keenly interested in asking how its platform could be used to improve health (remember its intriguing and unfairly maligned Flu Trends effort–see thisoutstanding Alexis Madrigal essay). Might suggests Google might help rare disease patients by enabling them to connect with each other (if they want to) “on the basis of search history alone.”

In 2014, Facebook reportedly expressed an interest in nurturing patient communities, yet “we’ve heard nothing more about this” MedCityNews reported last year. The irony, of course, is that because of its features and popularity, Facebook has organically emerged as arguably the most attractive platform for patient groups to organize–despite the far more deliberate efforts of other companies and organizations that offer platforms aimed at bringing patients together. (Addendum: see this fascinating video, pointed out by a reader, featuring a pathologist, Jerad Gardner, describing to peers his experience engaging with patient communities on Facebook.)

If we truly believe what many profess–that the center of power in healthcare will relocate from physician to patient–what better platform for health than a digital community already integrated into the lives of a huge number of patients? (I assume I’m in the minority in not having a Facebook presence–I’ve avoided it out of concern it would become too much of a time sink.)

The point is that for all the work entrepreneurs are now doing trying to create de novo platforms aimed at serving the needs of patients, I wonder if patients would ultimately be better served by Facebook leaders recognizing the incredible opportunity that’s been dropped in their lap, and making a deliberate effort to discover and address the needs of the patients already on their platform. For example, Might suggests Facebook could “implement an opt-in ‘find patients like me’ service.” I can imagine a host of other utilities and applications (including user-friendly medical data import, sharing, visualization and analysis) aimed at better serving the needs of patients, and of patient communities.

Will Facebook take a more serious run at health? Certainly Zuckerberg (the son of a dentist) and his wife, pediatrician Priscilla Chan, have supported a range of health-related initiatives, including upgrades to San Francisco General Hospital (now named after the couple), the Chan-Zuckerberg Initiative (whose science is led by distinguished biologist Cori Bargmann–star of Natalie Angier’s classic Natural Obsessions) and the Breakthrough Prize (which I’ve discussed critically here).

As I’ve long argued (e.g., this Atlantic post, this New York Times op-ed), what many technologists fail to appreciate about healthcare is the importance and value of relationships, of human connection, of community. At its best and most foundational, medicine is about relationships, not transactions. Most of medicine, health and wellness isn’t about showing up with a discrete question and leaving with a discrete answer. Our experience of illness and disease is so much more complex and nuanced, individualized and personal, a process of understanding that unfolds over time. The best physicians and care providers recognize this, and appreciate the importance of listening and the value of longitudinal connection.

Facebook, at its core, is about cultivating relationships–in marked distinction to the transactional core of Google (search) and Amazon (deliver). The core mission of Facebook is to connect people–and to help good things emerge from these connections. What better forum than Facebook to bring patients together–and what better platform for health?