Physician Payment Sunshine Act: More marginal thinking

It never ceases to amaze me how we gravitate to the margins in our thinking: margins seem to have a centrifugal force that is nearly impossible to overcome in today's political discourse. Yet the truth almost always lies at the center, the place that does not generate Op-Eds or produce votes.

I have said this before, and I will say it again: industry-physician relationship is not all bad or all good, there is no one within this relationship that is all bad or all evil, and it does not always benefit or always harm patients! The truth, of course, is somewhere in the middle. Contrary to Stossel's thesis, there is plenty to worry about with respect to corruption promoted by the big money exchanging hands between Pharma and doctors. On the other hand, just because there are instances of corruption and its consequences, not all interaction, financial or otherwise, is counterproductive. I am the first to admit that the much-touted innovation in medicine is rare, and we have largely given up its pursuit in favor of predictable markets and returns. Yet without a robust and transparent collaboration between industry and practitioners there is not only little hope of innovation, but any innovation that may stand a chance is likely to be irrelevant.

Yes, I agree with Stossel that the new reporting regulation is overly punitive and will inevitably result in undue administrative burden. But it would be disingenuous of me to disagree with the fundamental idea that there needs to be at least some degree of transparency in the financial dealings between industry and clinicians, if only to avoid the appearance by the docs of serving two masters.

As in everything in life, the devil is in the details. And it is these details that get buried by the gravitational pull of peripheral thinking and discourse. The solution? How about we stop paying attention to these marginal fallacies and start putting our heads together for real to solve these significant problems? How about we start a rational discussion about what is best for the people and not for the corporations or the economy or reputations? The discussion has been subverted by extremism. It is time to give in to the centripetal pull of reason.      

Massachusetts' unwinnable gamble

It is ironic how, just a few days following the startling (?) confirmation by the Robert Wood Johnson Foundation-funded research that an ounce of prevention is indeed worth a pound of cure, the Massachusetts legislature with reckless abandon ushered in yet another mechanism for the erosion of public health: legalized gambling. Really, I have nothing against a little gambling. The issue is that this legislative move does not just open the door to a trickle of small local gambling operations. No, what it does is turn the crank to open a fire hose of "big box" gambling establishments descending upon our state. And it is not just anywhere in the state: it is in the Western part, far removed from the back yards of the legislators who are salivating over the projected licensing and tax revenues.

But I don't want to get into the NIMBY aspect of this misguided bill. I would rather stick to the real issue: selling us out to raise short-term revenue. The move projects 15,000 new jobs (menial with no benefits mostly), $40 million annually in tax income, on top of $85 million licensing fees from each of the three casinos, all this in addition to construction investment and the like. Already the bill allocates $50 million to overhauling healthcare reimbursements in the state. As well, there is a $25 million provision to shore up research into and prevention of problem gambling. And even people who are in staunch opposition to legalizing gambling seem appeased by this provision, which they say makes it the best bill of its kind. But we still have to ask, if prevention is better than cure, why settle for good mitigation strategies when we have the best prevention available to us already: keep casinos out!

Some of you will probably say that I am naive. After all, reason fades when we are talking about such big bucks for the state coffers. Well, just because this kind of a trade-off is something we have come to expect from our politicians does not mean that we should tolerate it. Others will bring up the old free will argument. No, I am not against people exercising their personal decision making, but haven't you read "Nudge?" We are all deeply flawed human beings, and in the face of temptation we fail miserably! And since we know that casinos increase the risk of problem gambling, why not just steer clear of them altogether? This is simply not a winnable gamble.

I hope that some of you are hearing echoes of the food-obesity debate. We deem it an individual rather than a societal problem, and look how well we have done mitigating the obesity epidemic! There is no rocket science here, and it is disingenuous to say that we do not understand the causes of obesity. Human physiology has not changed over a couple of generations, no. What has changed is our constant access to high-calorie cheap concoctions that pass for food; what has changed is our limited access to physical activity; and what has changed is the degree to which we as a society are willing to sign on to corporate and political propaganda designed to get votes and make money at the expense of our health.

So, am I shocked that this casino bill is likely to become law? Not at all. Am I surprised that the public is allowing this to happen in a pathetic perversion of personal freedom? Of course not. Am I going to shut up about what a mistake this is? You bet I am not. And in a decade I will say "I told you so." But I am sure that then, not unlike now, no one will be listening.              

Whose perspective?

After a long hiatus filled with travel, work and lack of inspiration to write anything, I have chosen this arguably hottest day of the year to venture forth again. But I will make this brief, as it seems that everything that needs to be thought and said has already been thought and said. Yet who is listening?

Anyhow, to suspend my natural cynicism, I want to talk about perspective. No, not the perspective that makes parallel lines converge in the distance, but the one that gets lost in many of our political, civic, business, and, yes, even scientific discussions. I am talking about my perspective, your perspective, societal perspective, etc. I was inspired to write this because of these tweets by Gary Schwitzer to Kaiser Health News about a story on their web site:

Linking out to the story, I learned that a consulting arm of Disney is teaching hospitals about hospitality. Since there is going to be a financial incentive for these hospitals to deliver good customer service, many are feeling that an investment in this type of training will help them maximize these new reimbursements. Hurrah and ta-da! 

Well, Gary likes to burst these one-sided bubbles, and so he rightfully asked about the costs. What was baffling to me was the response by the KHNews who did not seem to appreciate the importance of reporting the costs or the various perspectives that these costs represent. So, this seemed like a teachable moment, and here is the teaching.

In outcomes research, we are always interested in understanding the perspective for both the costs and the benefits of interventions. In health outcomes these perspectives are broadly represented by the patient, the provider, the hospital, the payer, the employer, the manufacturer, the society, to name a few. These are just some of the examples of the usual stakeholders involved in healthcare decisions. Because our healthcare is such a fragmented disaster, many of these perspectives find themselves at odds with one another. Just think of the patient who wants to get what she perceives as a life-saving treatment that in reality has a 1% chance of helping at a cost of $600,000 per treatment course. From her perspective, since she is insured, this investment is well worth the cost. For a payer, however, this means $600,000 (multiply this by 100 in order to determine the cost to save 1 life) that cannot be spent on something else that can help more people more predictably. And if this payer is the taxpayer, the societal perspective enters the picture, where we have to decide what amount of money is worth spending on possibly saving one life -- is $60 million reasonable? Perhaps. But these are not simple questions, and, as such, do not have simple answers. In addition, all conversations that we hear or engage in have multiple perspectives. This is why a black-and-white approach is so divisive: it generally emphasizes two diametrically opposed perspectives. 

So, next time you hear about death panels or Mickey Mouse teaching hospitals how to maximize their revenue, consider the broader implications from may different perspectives. Chances are you will find yourself agreeing with more than one point of view. And when this happens, you will know that you have learned an important lesson and can now start engaging in more nuanced and thus productive debates, many of which will shape our society's future.

h/t to @garyschwitzer for this KHN story      

Why easy is not always good

My mother-in-law is a typesetter. She will not read a book unless it is not only appealing in its content, but also pleasing to the eye. When I was in medical school, she did quite a bit of work for medical textbook publishers. Comparing books typeset by her to what I was grinding through on a daily (and nightly basis) incensed her: unwieldy tables appearing three pages away from the corresponding text, small letters crammed to capacity onto oversized pages, few illustrations -- all baffling, annoying (and easily fixable) transgressions against readability. Yet, like all budding docs of all generations, I plowed through these morasses of knowledge without giving its readability much thought -- this was just what you did to get to your goal.

Yesterday I was listening to a program where the author Amy Chua was interviewed about her (ahem) embattled autobiography Battle Hymn of the Tiger Mother. Ms. Chua, though evenly humored throughout the interview, was on the defensive nearly the entire time, explaining how the intent of her opus has been grossly misunderstood by the public, thanks to attacks by critics on her parenting style. And granted, looking at the book as a parenting manual through the prism of our Western parenting norms is a bit disturbing. Yet putting its events in a culturally appropriate context, as well as looking at the content as a narrative rather than a guide, leads to completely different conclusions.

Why am I bringing up Amy Chua's interview after talking about my conquest of the unreadable? Well, it seems that ease is what we have come to expect from everything. What I mean by this is that not only do we expect easily readable texts, but we also expect people to present themselves in such a way as to make it easy for us to like them. Why else change your appearance through life-threatening eating disorders and grueling surgeries, get coached on how to make friends and influence people, and comment on how unlikable some of our female politicians are? Is this not a triumph of form over substance?

Amy Chua clearly bucks this trend in her book and is paying the price. But what worries me is that we are all paying a price. By creating another false dichotomy of "she is nice" or "he is nasty", we have eschewed a more realistic view of our human foibles. We are all nice sometimes and nasty at others. Yet this dichotomy has proven supremely fruitful to our political discourse, where for 30 years this new reality has been taking root. And it has born fruit, so that now people who do not hold similar opinions to ours are summarily dismissed as "nasty" or idiotic, and we are satisfied to surround ourselves with "nice" like-minded sycophants. How primitive it renders our political and social interactions!

Ms. Chua's immigrant parents' philosophy resonated with my upbringing. Coming from lands of uncertainty and deprivation, as immigrants, our parents subscribed to Maslow's pyramid and taught us that economic security trumped everything else. This is why only certain career choices were acceptable, while others were relegated to the back burner of a hobby. These choices were not about ease, but about doing what we were taught was the right thing. As John Adams said:

I must study Politicks and War that my sons may have liberty to study Mathematicks and Philosophy. My sons ought to study Mathematicks and Philosophy, Geography, natural History, Naval Architecture, navigation, Commerce, and Agriculture, in order to give their Children a right to study Painting, Poetry, Musick, Architecture, Statuary, Tapestry, and Porcelaine.

We all set priorities, and some of them may not be easy. I myself still read books even if they are not all that well presented; my priorities are content and writing style, though, to be sure, I do not frown upon the beauty of the visual form. I even enjoy characters who in, their multidimensionality, are a challenge to like. And I have learned in the rest of my life to enjoy people who do not necessarily hold easy or quick appeal for me, yet in the long run prove to add unimaginable richness to my life. Nietzsche coined the famous quote "What does not break you will make you stronger." In all aspects of our lives, while, based on Nietzsche's statement, adversity is a sufficient but not necessary road to strength, pushing ourselves a little bit out of our stuporous ease may prove to be one timely remedy.

The beautiful uncertainty of science

I am so tired of this all-or-nothing discussion about science! On the one hand there is a chorus singing praises to science and calling people who are skeptical of certain ideas unscientific idiots. On the other, with equal penchant for eminence-based thinking, are the masses convinced of conspiracies and nefarious motives of science and its perpetrators. And neither will stop and listen to the other side's objections, and neither will stop the name-calling. So, is it any wonder we are not getting any closer to the common ground? And if you are not a believer in the common ground, let me say that we are only getting farther away from the truth, if such a thing exists, by retreating further into our cognitive corners. These corners are comfortable places, with our comrades-in-arms sharing our, shall we say, passionate opinions. Yet this is not the way to get to a better understanding.

Because I spend so much time contemplating our larger understanding of science, the title "Are We Hard-Wired to Doubt Science" proved to be a really inflammatory way to suck me into thinking about everything I am interested in integrating: scientific method, science literacy and communication and brain science. The author, on the heels of doing a story on the opposition to smart meters in California, was led to try to understand why we are so quick to reject science:

But some very intelligent people I interviewed had little use for the existing (if sparse) science. How, in a rational society, does one understand those who reject science, a common touchstone of what is real and verifiable?

The absence of scientific evidence doesn’t dissuade those who believe childhood vaccines are linked to autism, or those who believe their headaches, dizziness and other symptoms are caused by cellphones and smart meters. And the presence of large amounts of scientific evidence doesn’t convince those who reject the idea that human activities are disrupting the climate.

She goes on to think about the different ways of perceiving risk, and how our brains play tricks on us by perpetuating our many cognitive biases. In essence, new data are unable to sway our opinion because of rescue bias, or our drive to preserve what we think we know to be true and to reject what our intuition tells us is false. If we follow this argument to its logical conclusion, it means that we just need to throw our hands up in the air and accept the status quo, whatever it is.

I happen to think that the author missed an opportunity to educate her readers about why we need to come to a better understanding and how to get there. The public (and even some of my fellow scientists) needs to understand what science is and, even more importantly, what it is not.

First, science is not dogma. Karl Popper had a very simple litmus test for scientific thinking: He asked how you would go about disproving a particular idea. If you think that the idea is above being disproved, then you are engaging in dogma and not science. The essence of scientific method is developing an hypothesis from either a systematically observed pattern or from a theoretical model. The hypothesis is necessarily formulated as the null, making the assumption of no association the departure point for proving the contrary. So, to "prove" that the association is present you need to rule out any other potential explanation for what may appear to be an association. For example, if thunder were always followed by rain, it might be easy to engage in the "post hoc ergo propter hoc" fallacy and conclude that thunder caused rain. But before this could become a scientific theory, you would have to show that there was no other explanation that would disprove this association.

So, the second point is that science is driven by postulating and then disproving the null hypotheses. By definition, an hypothesis can only be disproved if we 1). the association exists, and 2). the constellation of phenomena is not explained by something else. And here is the third and critical point, the point that produces equal parts frustration and inspiration to learn more: That "something else" as the explanation of a certain association is by definition informed only by what we know today. It is this very quality of knowledge production, the constancy of the pursuit, that lends the only certain property to science, the property of uncertainty. And our brains have a hard time holding and living with this uncertainty.

The tension between uncertainty and the need to make public policy has taken on a political life of its own. What started out as a modest storm of subversion of science by politics in the tobacco debate, has now escalated into a cyclone of everyday leveraging of the scientific uncertainties for political and economic gains. After all, how can we balance the accounting between the theoretical models predicting climate doom in the future and the robust current-day economic gains produced by the very pollution that feeds these models? How can we even conceive that our food production system, yielding more abundant and cheaper food than ever before, is driving the epidemic of obesity and the catastrophe of antimicrobial resistance? And because we are talking about science, and because, as that populist philosopher Yogi Berra famously quipped, "Predictions are hard, especially about the future," the uncertainty of our estimates overshadows the probability of their correctness. Yet by the time the future becomes present, we will be faced with potentially insurmountable challenges of a new world.

I have heard some scientists express reluctance about "coming clean" to the public about just how uncertain our knowledge is. Nonsense! What we need under the circumstances is greater transparency, public literacy and engagement. Science is not something that happens in the bastions of higher education or behind the thick walls of corporations. Science is all around and within us. And if you believe in God, you have to believe that God is a scientist, a tinkerer, always looking for a more elegant solution. The language of science that may seem daunting and obfuscatory. Yet do not be afraid -- patterns of a language are easy to decipher with some willingness and a dictionary. Our brains are attuned to the most beautiful explanations of the universe. Science is what provides them.

Self-determination is predicated upon knowledge and understanding. Abdicating our ability to understand the scientific method leaves us subject to political demagoguery. Don't be a puppet. We are all born scientists. Embrace your curiosity, tune out the noise of those at the margins who are not willing to engage in a sensible dialogue, leave them to their schoolyard brawling. And likewise, leave the politicians, corporate interests, and, alas, many a journalist, and start learning the basics of scientific philosophy and thought. Allow the uncertainty of knowledge excite and delight you. You will not be disappointed.                   
              

Stupak shtup

Did Stupak finally shtup himself instead of millions of poor Americans, as he had intended to? I think so, and with the Catholic nuns, no less. The man who has been living up to his unfortunate name by trying to derail the healthcare bill because of the non-existent threat of public money funding abortions is now turning on himself, apparently. In a MSNBC interview, as reported here in the NYT, he evidently disparaged the importance of a large and influential group:

"With all due respect to the nuns, when I deal or am working on right-to-life issues, we don’t call the nuns."

Can we hear this again? You don't call the nuns?!!! I think what he meant to say is that we don't call on WOMEN! I for one, though not Catholic, am taking this very personally. I truly believe that it has to do with disparaging the opinions of those who do not hold economic power, particularly the poor women of our nation. "We do not need to listen to them because they are not the ones electing us" is the implication of this stupid stupid remark.

Well, Bart, I do hope that you enjoy the self-stupping that this represents. With this remark, more than any other in the previous few weeks or months, you have shown your true colors. Go back to where you came from and enjoy the fall-out!

Is our political discourse suffering from a psychiatric disorder?

When I was a kid in Odessa my Dad and I went to see The Sound of Music at least 17 times in the span of 3 months. Remember that song sung by the nuns when Maria is late for the vespers, "How do you solve the problem like Maria?" One nun says "She's an angel", another one counters "She's a demon", when the voice of reason from Mother Superior repositions the whole argument with "She's a girl!" I always saw this as a bit of splitting nipped effectively in the bud by the Mother Superior -- good for her!

The press are doing exactly this to President Obama: the right makes him out to be a demon promoting a big government take-over within the US while ruining our reputation abroad, and the left canonizes him as the do-no-wrong president. I am struck by how effective this borderline personality approach has been at overtaking our political discourse. A borderline personality is a psychiatric diagnosis highlighted by a black-and-white view of the world, resulting in splitting behaviors. Sound familiar? Right: Obama bad, we good! Left: Obama good, them bad! I learned in medical school that a borderline personality disorder is a psychosis. Therefore, conservative and liberal alike, in lemming-like fashion we are following a psychotic analysis of reality.

In this grey world, neither the black nor the white bent seems intellectually honest. Granted, everything I understand about politics I learned from the "West Wing", so I am by no means an expert pundit. But I have also learned some valuable lessons from my own life, including that life is all about compromises whenever possible. This, I believe, is what Obama is after, which makes him neither evil nor a saint, but a reasonable leader and diplomat.

Let's take his approach to the Middle East. Yes, he is making an effort with the Iranians, the nation perceived to carry a substantial threat to the US security. Does it not make sense to establish constructive relationships with their leaders so as to avoid a potential nuclear confrontation? You know that expression about "an eye for an eye" and being blind -- this seems like the perfect application for it: time to turn around our eight-year bully posturing on Iran and start exploring real long-term solutions.

Domestically, the biggest sticky wicket is the healthcare reform. And even here Obama is showing himself to be a compromiser. This is not appreciated by the extreme right or left (myself included), but the realist in me understands that this is a chess match with far-reaching implications. And while I would like to see quality single payer healthcare for all Americans in my lifetime, I appreciate that mine is considered to be an extreme point of view.

More important to me than getting my own way is to see our country brought together. We need to get away form the psychotic hegemony and end the divisiveness of the deliberately polarizing rhetoric. We must engage in an honest intellectual exercise and effect changes that are best for all people.