Free-range thinkers create Foo for thought

I cite this favorite quote from Max Planck in my book (and every chance I get):

A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.

I think this applies to all walks of life, not just science. Yet sometimes an argument so compelling comes along that, though reluctantly at first, one by one the old guard drop at its feet. This is what happened to me this weekend at the Health Foo Camp in Cambridge, MA.

First, what is Health Foo? Well that was my first question when I received an invitation to attend this strangely named meeting. A Foo Camp is something put together by O'Reilly, the pioneering digital media group. Started 12 years ago, these meetings are thematic gatherings of "Friends of O'Reilly," hence "Foo," intended to bring together a diversity of thought about a specific field. The camp that I attended was the second such gathering in the healthcare space, supported in part by the Robert Wood Johnson Foundation, and held at Microsoft's New England Research and Development Center in Cambridge. How can I ever thank O'Reilly, RWJF and Microsoft for this mind-shifting event?

As I mentioned in my previous post, the attendee roster was so full of luminaries that I frankly wasn't sure that the invitation had not ended up in my Inbox by mistake. But mistake or not, what a privilege to attend! I spent the weekend getting to know the faces and the substance behind such familiar names as Regina Holliday, Paul Levy, Alan Greene, Ted Eytan, Susannah Fox, Gilles Frydman and others. And what still has my mind spinning is my conversations with people I don't normally interact with -- computational scientists, game designers, food advocates and international public health movers and shakers.

The most risky aspect of this meeting was the very essence of its success: we were to free-range. No agenda was set; space, food and company were provided. The resulting sessions ran the gamut from the usual nerd porn of probability to such far-reaching topics as memory and the role of faith, poetry and the arts in medicine (my personal favorite, where I got to play in the sandbox of participatory painting led by Regina. Take that, left brain!)

I have to say I spent a part of the weekend in a bit of a fog. What is gamification of medicine? What does "deep modularity" mean? But the full impact of such diversity of knowledge did not hit me until I was heading West on the Turnpike away from the meeting in the direction of home. It felt like a deep air pocket, and for a moment I couldn't catch my breath.

My epiphany was this: I have been sitting in my office and analyzing, writing and thinking about how to slow down this juggernaut of digitalization in healthcare. My logic has been to identify the problems, particularly the overdiagnosis and overtreatment and the attendant harm, all in the context of an obscene price tag, and to say that not only does medicine not need the radical digital revolution that is being imposed on it, but the very definition of medicine needs to change. What I failed to consider is that medicine is a module that needs to fit into the rest of what we call our modern life. So, slamming on the brakes in hopes of stopping this locomotive before it squashes the medical system is the wrong approach.

I can hear what you are thinking. "There goes another one." "She drank the Kool-aid." "If she gets all starry-eyed about technology, there is no hope for the rest of us." Well, I am not a fan of Kool-aid, but I do like Shakespeare. My realization is as follows: If we don't start thinking about what we want medicine to be, we will continue getting medicine that looks and works like a Rube Goldberg machine, a conglomeration of unrelated levers that may or may not achieve the desired results. The stakes are too high, stakeholders too many, and the resources being used staggering.

The digital revolution will continue its break-neck pace regardless of my opinions. In its quest to take over the world, it will continue to advance into every aspect of medicine. But instead of positioning it as a confrontation between Godzilla and King Kong, I have decided that a more constructive way is to start to imagine what medicine can and should be in the future. The current model is moribund, if not altogether dead. Nature abhors a vacuum, and unless we fill it with something that heals and nurtures that has come out of a concerted multidisciplinary blueprint, it will continue to grow into a hydra that will eventually swallow us.

I know, I miss the slide rule too. But we did not get to be on Twitter by chaining ourselves to the old paradigms. Regina Holliday taught me, among so many other things this weekend, the word "chaordic." It is a neologism that combines the ideas of chaos and order into one force of nature. I think there has been enough chaos in the relentless penetration of technologies into medicine. I am tired of screaming at at the back of the digital monster like a crazy lady. We need to get ahead of it with an open mind and even some excitement, and start imagining where we can direct it for the better health of the public. Our magical thinking will not change the fact that this tidal wave will destroy us if we lack the imagination to ride it. A gathering like the Health Foo Camp is what fuels that imagination. Let's grow and harness it!


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Three central questions about medical technologies

Every day my inbox gets filled with announcements for and invitations to attend all kinds of conferences. While many of them are of the traditional medical education sort, more and more I hear about meetings where new technologies and gadgetry in healthcare are the focus. And while the former feature healthcare professionals speaking medicalese from the stage to rapt audiences of other healthcare professionals in dimly lit halls, the latter capture their audience' imaginations with the promise of the future, in all its glitter and glory. And naturally, the latter are what attract techies and patients alike, steamrolling over our staid medieval medical conventions. I heard that the HIMSS conference in Las Vegas last month attracted 37,000 attendees! And the excitement was palpable even through Twitter feeds. This is clearly the preferred way to effect public engagement with healthcare.

But here is the thing: medical advances happen much more slowly than the speed of technology development. That is why, year after year, we go to our professional society meetings and have deja vus all over again. Year after year we hear the same people present the same studies, sometimes, if we are lucky, with a slightly different twist. The last group of breakthroughs I heard about at one of our critical care meetings was over a decade ago. And we have had to backpedal from that quite a bit with the removal of Xigris from the market, and with the realization that tight glucose control had to be used with extreme caution, so as not to kill more critically ill patients than it was meant to save.

This disconnect between the glacial pace of true progress in the clinical sciences and the lightening speed of technological progress raises some obvious questions about our assumptions. If we are not making dramatic breakthroughs in medicine every day, what is this breakneck pace of technology innovation delivering, save for the glitter and a seductive promise of health and wealth? Is there evidence supporting this promise? You might counter by saying that we have years, maybe even decades, of translational catching up to do, bringing all the advances from the bench to the bedside. I would have to say that the magnitude of such advances, as well as clinicians' resistance to them, may have been overstated. You might also point out that the vast advances in computing capabilities have not penetrated sufficiently into our healthcare system, and there I cannot disagree. But whether bringing these advances into clinic without careful planning will improve our health or our healthcare finances remains in question.

Moreover, I see numerous downsides to rushing ahead without thinking through what we are rushing toward. Ostensibly, the light at the end of this bright technological tunnel is better health. What concerns me is that the journey has become a sort of an end in itself: the sheer beauty of the tunnel has itself become the prize. To regain our compass, we need to ask three tough questions, each of them central to understanding the impending advent of too much out-of-context information:
1. Do we really want to walk around with sensors (pdf document, see page 16)? Personally, I find 24/7 monitoring of our vital functions to be a depressing prospect. Furthermore, I sincerely doubt that this is a better (or more cost-effective) way to achieve health than through focus on public health and socioeconomic equity.
2. What is the use of having your genome in your pocket?
How is that going to help us at the stage where all we can do is identify certain levels of risk (bracketed by broad intervals of uncertainty) in isolation from all the influences that modify that risk?
3. Do we want an epidemic of false positive findings and pseudo-disease?
We have enough trouble interpreting positive findings from medical screening tests. Do we really want the public falling prey to the anxiety and over-testing that false positives bring? As a healthcare system, can we sustain such an avalanche? As clinicians are we able to mange these screening snafus?
(I have done so many posts on this issue that you can barely navigate this site without stumbling over their debris).

All of the above is not sexy or shiny, and it brings in the ugly four-letter word "risk" to balance the discussion of the holy grail of benefit. So, how do we sell it to people so hypnotized by technology? I am asking this question quite seriously. I, and many of you out there, really would like people to become more cognizant of these nuances, but how do we accomplish this? Do we need to change our byzantine approach to medical meetings to start attracting a broader audience for our messages? If so, let's get started. Perhaps other forums that are already exceedingly successful can teach us how. I commend TEDMED (which I am attending as a Front-Line Scholar) for starting to bring this important viewpoint to their audiences. Now, how about having HIMSS, Health 2.0 and others join to clarify this other edge of the medical sword? Perhaps we can prevent the wild pendulum swings by thinking things through now. And think how much more credibility we all will have if, by thinking and debating now, we minimize the unintended consequences later?                            

Tinkering with health is not a laboratory job

Do you love Brussels sprouts? I do. And broccoli, chard and kale, too. Why do I ask?

Well, last week my friend Kent Bottles did a blog post on what the future of medicine may look like according to two of our prominent medical futurists, David Agus and Eric Topol. It left me scratching my head, so I went to find Agus on the interwebz, and came upon his 2011 TEDMED talk, which can be found here. The Brussels sprouts were just the beginning of nearly 20 minutes of bewilderment. I will get to the meat (ahem) of it momentarily, but I just could not get past his assertion at around 3:48, where he states that people in their 90s do not take up healthcare resources -- no mechanical ventilation, no weeks in the ICU -- and that they "die with dignity from whatever process ails them at that point." Really? In what country?

Here is the reality -- you can consult the Dartmouth Atlas for a lot of this info, but many other sources exist as well. There are approximately 2.5 million deaths in the US annually. Fully 1/3 of them occurs in the hospital, more that 1/2 of which involve ICU care. And incidentally, not to get all cost-conscious or anything, but 80% of all of the associated costs were due to ICU care. But wait, you say, this is not necessarily people in their 90s, right? OK, let's take it down a layer.

Among the 1/3 of all the annual deaths that occur in the hospital, nearly 3/4 are among the Medicare population, or those who are 65 years old or older. Furthermore, according to none other than the Dartmouth Atlas, up to 1/4 of all Medicare enrollees spend 1 week in the ICU in the last 6 months of life. OK, then. So, where are the data that old age is associated with low medical costs? Not here, that's for sure.

After this dubious beginning, Dr. Agus states the undeniable: humans are complex systems, and we need to think of them as such. Additionally, he advocates skepticism because much of what is done in medicine is not based on "true" data. OK, I can certainly go along with that. Then he goes astray. Here is how.

At around 10:30 he gets into technological solutions. You may be surprised that I do not fundamentally disagree with technology as the answer to disease. No, I disagree that technology is the answer to health -- this is where Brussels sprouts come in. At about 11:00 he starts to talk about aspirin and all the fantastic health benefits that are associated with it -- here is a screen shot of his slide:

And he suggests that aspirin should be mandatory, and that society should not have to pay for these diseases that develop due to what? Aspirin deficiency? Now, as veteran readers of my blog, do you see something funny about this slide? Is there something missing? Yes, you are right, where are the references for these statements? No, I did not cut off the bottom -- there are no studies referenced. One other critical piece of information is missing: whenever data on benefit are presented, data on risks must also be presented. Where are they? So, yes, be very skeptical. One more picky point: he brings up Michael Dell at 11:30 or so, telling the story of how his employees who smoked had to pay higher insurance premiums. By extension, Dr. Agus contends that we should charge higher premiums to employees who do not comply with aspirin. Unfortunately to get into the full controversy about the role of aspirin in these conditions is way beyond the scope of this post. But do let me give you a taste of what a balanced discussion of aspirin as a prevention for heart disease looks like -- here the Mayo Clinic web site is exemplary in providing a well-informed approach. Around 12:00 Agus builds the same argument for statins. And then he knocks down vitamins and supplements and suggests that people who take them should be penalized with higher premiums. OK, in my humble opinion this branch of inquiry has always been a fool's errand in a society that is fairly well fed, but higher premiums? Come on. I will not belabor this. And finally he sprinkles his comments with a few words on the microbiome. 

So what does Dr. Agus seem to say overall? My impression is that he thinks that we should tinker with maintaining our health by looking to manufactured drugs, such as aspirin and statins, as well as whatever we learn from the microbiome (more drugs?). What is missing here is the discussion of the risks vs. the benefits of such tinkering in healthy people. What is also missing is data to back up some of his fundamental assertions (see above). 

So, final words? Technology is not the enemy. If used correctly it can help us understand and cure disease. Tinkering with the healthy human is the job of evolution, not the laboratory. The potential "unintended consequences" of such tinkering are too colossal to ignore.  

          

    

How technology can help contain H1N1

It makes sense to put a lot of resources into trying to prevent at least some of the estimated 46 million cases, 2.7 million hospitalizations, 300,000 cases of respiratory failure and 200,000 deaths expected this flu season from H1N1 in the US. I believe that technology can be leveraged to mitigate this epidemic. Here is how.

The obvious solutions are already here. We are using social media outlets, Twitter, Facebook, to keep up with the galloping epidemic. Making sure that the majority of the population has access to this relevant information could help local health departments to broadcast latest recommendations. The availability of remote learning and work environments should make it much easier to make sensible decisions about work and school closures without major adverse consequences to the economy, at least in the non-production sectors. Webcasting technology can be a good substitute for remote meetings, thus obviating the need potentially for many people to travel across the country or the world.

And there are other, less obvious ways, in which technology can be useful. We can leverage the thriving possibilities of geographic information systems (GIS) not only to track the epidemic as it spreads, but to plan sensible triage on the ground. Another engineering approach, discreet event simulation, can be used to help avoid the much anticipated bottlenecks in the hospital emergency departments and ICUs. And I am sure there are other opportunities that this vast web of communication can offer us that I am not even aware of, but someone is! I sure hope that we are firing up these technologies and learning how to simulate this epidemic, so that we have at least a little more idea of what we are doing when it descends upon us full force. It is heartening to me that the Department of Health and Human Services has commissioned a count of all the mechanical ventilators in the US hospitals -- this basic activity will certainly help. What I have not heard anything about is what efforts are underway leveraging the sophisticated 21st-century technologies to optimize our approach. My guess is that these efforts, if they exist, happen at the local level and are quite fragmented and haphazard.

I think that it now takes very little imagination to foresee the potential fall out from this virus. So, let's use our imagining energy on how we can mitigate the epidemic. The DHHS, if it has not done so yet, should convene a panel of docs, EMS professionals, engineers and IT experts to develop contingencies and test them virtually. This way, when the full epidemic strikes, we will not have to blame our collective lack of imagination for not preventing a catastrophe.