Trusting in Magical Fairy Dust

This isn't going to be about artificial intelligence (A.I.).  I promise.  There have been a raft of cautionary articles lately about A.I. in general and in healthcare in particular -- David Shaywitz did a nice job of summarizing several of latter in Forbes recently -- but I only want to reference it in order to borrow a great suggestion from Tim Hwang, director of the Harvard-MIT Ethics and Governance of AI Initiative.

In an article in IEEE Spectrum about how to separate hype from reality, Mr. Hwang:

...suggests mentally replacing all mentions of “AI” in an article with the term “magical fairy dust.” It’s a way of seeing whether an individual or organization is treating the technology like magic.

That seems like good advice for lots of claims in healthcare, because healthcare has a lot of magical fairy dust - and not just with A.I. or even technology.

What started me thinking about this, oddly enough, was an expose in The Wall Street Journal about Amazon.  According to the investigation, Amazon has "thousands of banned, unsafe, or mislabeled products" on its site.  It compares Amazon to a flea market, exercising limited control over what third party sellers are selling or how they describe products.  

After calling attention to 4,152 problematic products, Amazon changed or took down the listing for 57% of them, although at least 130 had reemerged within two weeks.  Amazon defended itself in a blog post, citing its various efforts to monitor products on its site and to protect customers, but admitted: "There are bad actors that attempt to evade our systems."  

No kidding. 

The Journal sees this as not a problem for Amazon, but a problem for tech companies generally: 

Amazon’s struggle to police its site adds to the mounting evidence that America’s tech giants have lost control of their massive platforms—or decline to control them. This is emerging as among the companies’ biggest challenges.

The lack of control over tech platforms is why many think we're living in an era of misinformation.  Dr. Claire Wardle, co-founder of First Draft, argues in Scientific American that we're living in a "new world disorder" due to the influence of misinformation.  Technology, she believes, has helped remind us "...that humans are wired to respond to emotional triggers and share misinformation if it reinforces existing beliefs and prejudices."  

Credit: Jen Christiansen, from Wardle/Derakhshan

She distinguishes misinformation, which is false information spread by people who do not realize it is false, from disinformation, which is false information shared to cause harm, or malinformation, which is true information spread in a way designed to cause harm (e.g., leaked emails).  

Dr. Wardle is no Luddite, but she points out: "In a healthy information commons, people would still be free to express what they want—but information that is designed to mislead, incite hatred, reinforce tribalism or cause physical harm would not be amplified by algorithms."

Our world of "disorder" is, unfortunately, our "new normal," Dr. Wardle fears, and suggests: "Understanding how each one of us is subject to such campaigns—and might unwittingly participate in them—is a crucial first step to fighting back against those who seek to upend a sense of shared reality."

And, unfortunately, healthcare is a major victim of misinformation, as the anti-vaxx movement has shown.  We're always looking for that magical fairy dust that will improve our health, and all-too-often we end up trusting misinformation.

People like Dr. Jen Gunter or epidemiologist Gid M-K, Health Nerd spend much of their time trying to debunk health misinformation, Dr. Gunter usually on women's health issues (Goop is a favorite target) and Gid M-K pointing out out flaws in studies/reports of studies.  

Dr. Gunter recently issued a "call to arms" about medical misinformation and the internet, describing her personal journey through misinformation and her subsequent efforts to combat it.  She laments:

It is hard for people to wade through the quagmire that is the medical internet. Bad information is everywhere, fear sells, and the lure of the cure is real. In our 24/7 news cycle a misleading medical story can spawn many erroneous articles. Sometimes the content is actually accurate, but the headlines are incorrect. And let's face it many of us, doctors included, don't always read to the end of a story. 

We also all mistake repetition for accuracy, a phenomenon called the illusory truth effect. And social media, with retweets and reposts, is the very model of repetition.

She urges medical professional to do their part in fixing the medical internet, such as by guiding patients towards good medical information, sharing it on social media, even creating it.  Dr. Gunter urges:

"We in science are the people who developed surfactant, the measles vaccine, and safe blood transfusions...We know how to do great things with science. Helping people have access to quality information so they can make informed decisions is also one of those great things, because you can only be empowered with your health if you are accurately informed.

Credit: Axel Pfaender/The Atlantic

The really scary thing is that misinformation in healthcare is not always easy to discern.  It's not always obviously false, or even widely agreed to be false.  Austin Frakt, of The Incidental Economist fame, reminds us that a 2013 study of thousands of medical treatments found only 40% were had actual evidence to support them.  At least 3% were believed to be ineffective at best and harmful at worst.  Most surprising: "But a whopping 50 percent are of unknown effectiveness. We haven’t done the studies."

They are, in essence, magical fairy dust. 

Professor Frakt says of the fight against this kind of common health misinformation:

It’s an uphill battle. Even when we learn something doesn’t make us better, it’s hard to get the system to stop doing it. It takes years or even decades to reverse medical convention. Some practitioners cling to weak evidence of effectiveness even when strong evidence of lack of effectiveness exists.

It's important to do the science, as Professor Frakt says, to analyze it correctly, as Gid M-K strives to ensure, and to get the word out widely, as Dr. Gunter urges.  It's important not to blindly believe in something that might be misinformation.  But when it's our health, or the health of one of our loved ones, on the line, the temptation to put our faith in unproven claims, new technologies, or alternative treatments is easy to do.  

Just try to make sure you're not believing in magical fairy dust. 

Hey, Healthcare: Just Do the Right Thing

How about that: it appears that big corporations have a social conscience after all. 

The Business Roundtable (BRT), which primarily represents large corporations, issued a statement earlier this week that steers away from its previous stance that a corporation exists to serve the interests of shareholders.  Now, 181 member CEOs agree, corporations must seek to serve all stakeholders.  Corporations must, they say, help promote "An Economy That Serves All Americans."

As soon as I saw this I started thinking about healthcare.

Credit: Getty Images

Jamie Damon, Chairman & CEO of JP Morgan Chase and the current BRT chairman, said:

The American dream is alive, but fraying.  Major employers are investing in their workers and communities because they know it is the only way to be successful over the long term.

The key commitments outlined in the BRT statement are as follows:

1. Delivering value to our customers
2. Investing in our employees
3. Dealing fairly and ethically with our suppliers
4. Supporting the communities in which we work
5. Generating long-term value for shareholders

The Washington Post described the reaction by corporate critics as "cautiously optimistic."  Robert Hockett, a Cornell Law School professor who also advises the Presidential campaigns of Bernie Sanders and Elizabeth Warren (no lovers of corporations!), told The Post: 

It’s almost astonishing.  They’re in effect coming right out and saying, ‘We’ve been wrong for the last 20 years"...some folks in the BRT are recognizing there’s something unsustainable about an economy that’s all about shareholder primacy.

Steven Pearlstein, a professor at James Madison University, told The Post:  "Rather than thinking of them of as bad people with bad motives, it’s probably more correct to think of them as reasonably good people in a bad system."

Credit: Sophia Foster-Dimino

"Reasonably good people in a bad system" may well describe people working in corporations, but it definitely applies to our healthcare system.  Our healthcare system is filled with good people, most of them trying to do the "right thing," but beset by a Kafkaesque system filled with perverse incentives.

It is worth noting that CEOs of for-profit health companies Abbott, Anthem, Baxter, Bayer USA, Bristol-Myers Squibb, Cigna, CVS Health, Johnson & Johnson, McKesson, Medtronic, Pfizer, Stryker, and Walgreens all signed the statement.  It is also worth noting that Kaiser Permanente Chairman and CEO Bernard Tyson was one of only 7 BRT CEOs who did not sign the statement; a spokesperson indicated Kaiser agreed with the principles, but as a non-profit did not have shareholders.

Healthcare is filled with "non-profits," some of whom manage to generate a lot of surplus nonetheless and to pay their executives quite a lot of money, or are small corporations (or LLCs).  It's time for healthcare -- from the smallest solo physician practice to non-profit health systems to the largest for-profit corporations -- to step back and consider a new set of commitments as well.  

Here are my suggestions:

1. It's the patient, stupid: In theory, of course, healthcare has always been about the patient, but that's getting harder and harder to believe.  No one who sits in a waiting room for hours, gets shocked by a large (and usually incomprehensible) bill, has difficulty getting enough time and attention from their healthcare professional, or has to pay more in cases of medical errors or bad outcomes can believe that. 

Healthcare organizations and professionals have to stop being about what they do to patients and focus on what they do for them. 

2. Fair pricing, always.  Drug companies up the prices of longstanding drugs (insulin, anyone), or reformulate them to maximize pricing.  Hospitals maintain chargemasters that have prices that would embarrass defense contractors.  Physicians send out "surprise" bills to patients who had no opportunity to even choose who treated them.  Commercial prices are multiples of Medicare prices, and prices for those without insurance are even higher.

Healthcare organizations and professionals should charge a fair price, one that allows them to make a reasonable return but which does not depend on the kind of insurance one happens to have (or not have) or how skillful they are at upcoding.

3. Share and share alike: Repeat after me -- patient data is theirs.  It is not the property of those treating the patients.  It shouldn't be resold without their explicit consent, and it should be easily accessible to them and to any others they choose to share it with, even if that includes competing healthcare organizations.    

Healthcare organizations and professionals should stop treating patient data as a siloed asset, and look to the business opportunities of interoperability.

4. Health does not happen in a vacuum: Yes, people can be prescribed a pill or given a procedure, but most of what influences their health happens outside healthcare settings.  It matters where they live, how well they eat, what kind of social support they have, how much they exercise.  Sending patients off with instructions they can't understand/can't follow/can't afford, or to settings where they are not safe, just invites bad outcomes and more care.   

Healthcare organizations and professionals need to deal with patients in the world in which they actually live, not in the cloistered healthcare world.

5.  Unhealthy communities mean unhealthy people.  Physicians were once always community leaders, just as hospitals used to exist as community institutions.  Not so much anymore.  Healthcare remains a leading employer in many, if not most, communities, but that is not enough.  Public health matters.  The overall economic health of the community matters.  Taking leadership roles in civic issues matters.  Communities that do not thrive usually have fewer people who thrive.  

Healthcare organizations and professionals must be community leaders with a broad view of the health of that community.

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It's great that the BRT is at least paying lip service to a broader purpose. I'll be more impressed when they do something about executive compensation, tax loopholes, and pollution, or take proactive positions on controversial issues like climate change or gun violence.  Most will not change overnight and some will not change at all.  

But we should expect more from healthcare organizations and professionals.  Lip service to the Hippocratic Oath is not enough, especially when it only is applied to physicians.  We need to stop pretending that too many in healthcare aren't driven primarily by their own economic interests or personal preferences.  We need to start acting with a higher set of principles.

The above five commitments is my proposed set.  What are yours?  

You Want to What?

I love an idea that seems to come out of the proverbial left field.  I love it when an idea seems so novel that you think, "wow, that's an interesting idea."  I especially love it when an idea borrows a practice from one industry and applies it in another. 

Take, for example, the proposal to require liability insurance for gun owners as a solution for gun control. 

Gun control is one of the social issues, much like abortion, where compromise has been increasingly hard to find.  Although a majority of Americans do support some kind of restrictions on gun ownership, a very vocal minority fiercely oppose them, citing their 2nd Amendment rights.  We've wavered through repeated efforts to impose various restrictions, but even in the wake of a number of mass shootings we still don't seem able to get consensus on bipartisan legislation to truly address it.

Mayor Sam Liccardo.  Credit: San Jose Spotlight

San Jose Mayor Sam Liccardo thus got national attention with his recent proposal for a city ordinance to reduce gun violence and its cost on the public.  It's not uncommon for cities to adopt restrictions on firearms, but what makes Mayor Liccardo's proposal newsworthy is the requirement for all gun owners to carry liability insurance (or pay a fee if unable to purchase such insurance). 

Mayor Liccardo says:

We require motorists to carry automobile insurance, and the insurance industry appropriately encourages and rewards safe driver behavior. We tax tobacco consumption both to discourage risky behavior and to make sure non-smokers are not forced to subsidize the substantial public health costs generated by smoking-related illnesses and deaths,

The proposed insurance would apply to any accidental discharge of a firearm, as well as any intentional acts of others who might borrow or steal the gun, but it would not cover intentional discharge. 

Naturally, color the NRA unimpressed.  "Criminals are already ignoring California's more than 800 gun laws, so it's doubtful many of them would rush out and get liability insurance. But, even if they did, liability insurance won't cover criminal acts," said NRA spokesperson Amy Hunter.

The Mayor admits it is not a complete solution and would not end gun violence, but at least it is doing something.  "A mayor doesn't have the luxury of just offering thoughts and prayers... we have to solve problems," he said in a statement.

There have been similar proposals before.  In fact, in early August lawyer Michael Vargas wrote an op-ed in the San Jose Spotlight calling for this very approach, and referenced examples of proposed state and federal legislation that had included it.  Mr. Vargas said:

This raises an important question: why should the cost of gun violence be shifted to gun owners? The answer is simple. Gun owners, like car owners, are the ones who control these dangerous instruments... 

Good public policy demands that we shift the burden of these costs to those who control the instruments (i.e. the guns) of gun violence. Good economic policy demands that we spread the costs among them, so that the costs are born fairly and evenly. 

Mr. Vargas agrees that the proposal would not address illegally obtained guns, but notes that many times guns used in mass shootings are legally obtained. 

Since the analogy to auto insurance is being used, it worth noting that nearly 13% of drivers are estimated not to have such insurance.  And there are drivers who don't register their car, or who drive with no license or on a suspended license.  So having requirements licensing, registration, and insurance only get us so far. 

A bigger problem may simply be that such insurance does not exist and insurers may be reluctant to get into this particular war.  “I would be lying if I said to you that the insurance companies are enthusiastic about this,” Mayor Liccardo told The New York Times.  

Still, to gun control advocates, there must be something delicious about the prospect of gun owners having to deal with the industry that everyone loves to hate.  The insurance industry is already often seen as the bad guys, so let them be the bad guys that strong-arms gun owners.  Those people we especially don't want to have guns probably would not get very good rates from insurers, and owning an assault weapon would be like owning a very expensive sports car when it comes to the cost of its insurance.  

It is financial services solution to a very real public health issue, and that makes it interesting.

Look, I don't think this approach is going to take off.  Nor do I think it would end up being particularly effective even if it did.  But I think it is an audacious approach, an example of non-linear, out-of-the-box thinking applied to a problem that seems to resist more straight-forward approaches.  So, even if it fails, it might help stimulate thinking about approaches around which we might gain consensus.  

Healthcare has developed a wide array of carrots and sticks to try to motivate behavior.  We mandate having insurance (or tried to), we give higher benefits for using preventive services or in-network providers, we charge higher premiums if you smoke or don't participate in wellness programs.  Some of them sort of work, although none of them seem to work anywhere near as well as expected.  

So what's healthcare's version of requiring liability insurance for owning a firearm?

I'm not being literal.  We already have a malpractice liability system that everyone seems to hate, which manages to hamper the way physicians practice without either improving the quality of care or rewarding most of the people who actually suffer from malpractice.  Maybe instead of a liability approach to address sub-standard yet expensive care we should be borrowing from some of the approaches that manufacturers have developed to improve quality, reduce costs, and speed the supply chain. 

You get the idea.

I often write about interesting things happening outside healthcare and then try to apply those lessons to healthcare, because I think too often people in healthcare are too insular.  Most think healthcare is unique, and many tend to look to what others in healthcare are doing for "new ideas.  When it does borrow ideas from elsewhere, its versions rarely delight.  It needs all the outside ideas it can get.

So, to whomever came up with this idea about requiring liability insurance for gun ownership: have you got any other ideas for healthcare?  

New Paradigms for Patients

Three articles particularly struck me this week: Eric Topol's Why Doctors Should Organize, Jonathan Tepper's The Doctor Monopoly Is Killing American Patients, and Farhad Manjoo's Abortion Pills Should Be Everywhere.  They come from vastly different perspectives, and seek different ends, but I think there is an underlying problem that they all agree on.

Too often the healthcare system is looking out for itself, not us.  The existing paradigms aren't working.

Dr. Topol laments what is happening to physicians.  Long hours, too much data entry, deteriorating patient-physician relationships, and physician burnout.  When physicians try to speak up on social issues, even public health ones, they're told to "stay in their lane," as happened when some spoke up about gun violence. 

He wonders: "But there have been no marches on Washington, no picket lines, no social-media campaigns. Why not? Why aren’t doctors standing up for themselves and their patients?"  

Dr. Topol notes that the physicians' professional organizations could represent these interests, but "there is no single organization that unifies all doctors. The profession is balkanized."  Even more concerning, he adds:  "The power and impact of medical organizations is further diminished because their priority—supporting their constituents—is often at odds with the needs of the public."  He describes medical societies as "primarily a trade guild centered on the finances of doctors."

Dr. Topol calls for a different future:

It’s possible to imagine a new organization of doctors that has nothing to do with the business of medicine and everything to do with promoting the health of patients and adroitly confronting the transformational challenges that lie ahead for the medical profession.  Such an organization wouldn’t be a trade guild protecting the interests of doctors. It would be a doctors’ organization devoted to patients.

Now, there's a radical idea. 

Mr. Tepper concern is the impact of physician shortages has on our care.  They are a problem for our care, and for our health.  However, they did not happen by chance.  He charges:

U.S. doctors operate as a cartel to restrict trade and reduce competition. The American Medical Association (AMA) artificially limits the number of doctors, which drives up salaries for doctors and reduces the availability of care.

As a result of the physician-run accrediting bodies control over medical schools and state licensing, he believes "becoming a practicing physician requires navigating a maze of accrediting, licensing, and examining bodies."  Mr. Tepper calls for breaking the "the monopoly that current accrediting bodies hold over graduate medical education." 

Mr. Tepper is not the first to call licensing boards, including medical ones, cartels.  A few years ago, Aaron S. Edlin and Rebecca Haw Allensworth wrote a paper Cartels by Another Name: Should Licensed Occupations Face Antitrust Scrutiny, followed by an op-ed in The Wall Street Journal.  They believe that, as the result of a Supreme Court ruling, "Many professional boards in the U.S. will be vulnerable to antitrust suits for anticompetitive regulations."

So Dr. Topol and Mr. Tepper are not fans of physician organizations.  What does that have to do with abortion pills? 

As abortions have become harder to obtain -- some states, like Missouri and Mississippi, are down to only one clinic -- the so-called abortion pill RU-486 is increasingly an alternative for women needing an abortion.  It is both very safe and very effective. 

But it is not easy to get, at least not legally.  According to Mr. Manjoo: "It can be prescribed only by doctors who meet certain qualifications, and can be dispensed only in clinics licensed to provide abortions, not retail pharmacies."  Many other, riskier drugs are not subject to similar restrictions.

However, we live in a digital world, so, as Mr. Manjoo says, "restrictions on abortion pills are becoming increasingly difficult to enforce. Despite the F.D.A.’s restrictions, activists have created a robust online market that makes getting pills surprisingly easy."

As a test, Mr. Manjoo ordered the pills from four different online pharmacies, usually with success.  He marveled: 

Each time I got a pack of pills in the mail, I was increasingly bowled over: If this is so easy, how will they ever stop this? I’ve been watching digital markets for 20 years, and I’ve learned to spot a simple, powerful dynamic: When something that is difficult to get offline becomes easy to get online, big changes are afoot.

The point I was particularly struck by was this:

For providers and users, legal risk is also relatively low. Regulators have little capacity to enforce restrictions on foreign distributors. In March, the F.D.A. sent a letter to Aid Access demanding that it cease operations immediately. The organization sent a letter back saying, essentially, nope. What happens next is anybody’s guess.

I'll take a guess.  The center cannot hold.  The cartels cannot maintain power.  The healthcare system cannot survive if it is more about the people profiting from it than the people who are supposed to be served by it.  Not in the 21st century.  Not in a world where technology gives us many options and where there exist healthcare professionals who do still care primarily about patients.

Dr. Topol thinks physicians should organize to give them a more powerful voice in issues not about the business of medicine but rather the practice of medicine.  I say, more power to him and to such organizations.

Meanwhile, some of my Twitter friends say, that's all fine and good, but what we really need are patient organizations to give us more agency about health issues -- personal and societal -- that impact us.  And to them I say, more power as well.

But what Mr. Manjoo brings up poses perhaps the biggest change.  The parochial nature of our healthcare system, largely overseen by these various existing physician organizations, is already breaking down.  

Xiaoyi passed the Chinese national medical exam (China Daily)

We can order pills from overseas.  More importantly, we could do online consultations with overseas physicians, and soon enough we'll be able to consult with, and get treatment from, artificial intelligence and robots.  Who is going to license them, how?  

As I've written before, we can't even decide if human physicians should be educated and licensed as M.D.s or D.O.s, so how the heck are we going to deal with A.I. "physicians"?  We're still struggling with human telemedicine across state lines.

Time to rethink everything.  Time to move from healthcare's parochial, self-serving interests to a system that empowers and supports each of us in our health.  Time to get back to healing, helping, and caring. 

Time for new paradigms.