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.

Health Should Be the New Tech

I saw that Kaiser Permanente just named its first Chief Digital Officer, and I was reminded of the belief that all companies are now tech companies.  For example, online retailer Stitch Fix 's CEO Katrina Lake recently said in podcast with Kara Switzer:

But if you want to still exist in a decade, I think everybody’s going to have to be a tech company and figure out what is the thing that is going to be lasting about their company.

Now, Ms. Lake isn't exactly breaking new ground with this thought -- a quick search found similar quotes from others going back to at least 2015 --  but the point remains valid.  Still, though, maybe we should be thinking: in ten years, every company is going to be a health company.

I don't mean in the way that employers' healthcare obligations are forcing them to treat health as part of what they do (e.g., the auto manufacturers realizing they paid more for healthcare than for steel, or in the way Amazon/Berkshire Hathaway/JP Morgan Chase founded Haven).  I don't mean in the way that tech companies are looking to see how they can move into health in order to get their piece of the $3 trillion healthcare pie.  I don't even mean in the way that medical marijuana, CBD, or, God help us, Goop are trying to convince us that they can play an important role in our health.

No, I mean in the way that every company would think about, and compete on, how their products contribute to our health and well-being.

Oh, no!

Take our homes.  Fast Company's Katherine Schwab reported on a new study that found that a plurality of traumatic brain injuries among children and teenagers came not from sports or recreation but from things we buy -- especially home furnishings and home features (each 17%), as well as nursery equipment and toys.   There are already numerous safety regulations, and children/teenagers are going to be reckless, but design plays a key role as well. 

How many home furnishing, home construction, or toy companies think of their mission as helping ensure our health?  If they did, we might live in different kinds of houses.  One that is safer and less likely to lead to us getting hurt.

Fast Company also reported on a Chinese house based on a new model of the future of housing: "homes designed not just for able-bodied, nuclear families, but for the different needs that span multiple generations."  It tries to balance privacy with ease of access and mobility for each of the generations, and consciously plans for different stages of our health.

Well, you might say, that's just China, but a related story found that more Americans are living in a household with two or more adult generations.  Although still in the minority, trends like "cohousing" or "intergenerational home-sharing"  may help both address the affordability of both retirement and homeownership, as well as reduce isolation.  One expert told Fast Company: "There’s been so much emphasis on independence and on privacy that we really designed community right out of our lives without knowing it," with all sorts of adverse health consequences. 

Take food.  The food industry has focused for the last 30+ year on making food tastier and cheaper, but usually not healthier, and our obesity/diabetes rates have reflected that.  It's been good for our wallet and terrible for our health, Trader Joe's and Impossible burgers notwithstanding.  We're not all going to stop eating meat or only organic fruits and vegetables, but we could eat better, and the food industry could help.

Suggested supermarket layout Credit: RSPH and Slimming World

In the U.K., the Royal Society for Public Health and Slimming World issued a report critical of how grocery stores are encouraging poor food choices, urging that public health experts help design their stores.  They went further, opening up a pop-up store called Nudge to help illustrate their principles.  Slimming World's Carolyn Pallister asserted:

Supermarkets will argue that they are giving their customers the choice; and we haven’t removed those choices at Nudge, all we’ve done is made it easier for customers to choose healthier alternatives and put less emphasis on promotions of foods likely to cause weight gain.

Or consider, say, airplanes.  They're built to deliver as many people as quickly as possible, and, while they actually have an admirable record for rarely crashing, they're not really designed for our optimal health.  The air is bad and the surfaces are, well, you really don't want to know how dirty things really are.  Where are the airplane manufacturers/airlines that promise not only to get you to where you are going safely but also no less healthy than how you boarded? 

Many companies might argue that they don't directly make products for consumers, but that doesn't mean they don't impact our health.  Think about short and long term health impacts of pollutants and carbon releases, and then think about why those impacts get borne by other entities, such as our health insurance.  More direct fees and taxes on such by-products of production would bring drastic changes, or at least new funds to help address their effects. 

Concern has been raised about the apparent discrepancy between tech's "move fast and break things" mindset and healthcare's "first, do no harm" directive (although the latter is hard to justify with, for example, the industry-inflicted opioid crisis or the well-known level of medical errors).  The truth is that all industries, including healthcare, should be thinking more about the actual health impacts of what they do.  If they did, Facebook and Twitter might not support so many toxic users, and Google would not allow such pervasive health misinformation. 

Don't even get me started on gun manufacturers or the tobacco industry.

Yes, tech is sexy, tech seems futuristic, and tech is loved by investors.  It's no wonder Ms. Lake and others think about being considered tech companies.  But we have to remember that tech is not the goal; tech is never the goal.  Tech is a tool, and what better to use tools for than to make us healthier?

 Almost two years ago, Steve Downs called for us to build a Culture of Health into all we do, and that call is more needed than ever.

Scramble the Healthcare Red Team!

France's Defence Innovation Agency (DIA) -- its equivalent of our DARPA -- wants to set up a team of science fiction writers and futurologists to help them plan for the future.  This so-called "red team" is intended to "propose scenarios of disruption" that the traditional military strategists might not envision, in order to not be caught off-guard. 

As Futurism put it:

Basically, it seems France wants the creatives to imagine how the future could go really wrong so that the nation can stay one step ahead of any trouble — and really, who better to envision dystopia than a team of science-fiction scribes?

It made me wonder: do CMS, United Healthcare, CVS, Kaiser Permanente, HCA, or Pfizer have their red teams of science fiction writers?  If not, why not?

Now, I have to admit that I am a science fiction fan (I am currently in the middle of reading Neal Stephenson's latest opus, Fall; or, Dodge in Hell), so this idea appeals to me.  Science fiction writers have been making some pretty good predictions for a while now, from Jules Verne sending rockets to the moon, H.G. Wells blowing up things with atomic bombs, Arthur Clarke using satellite communication, or William Gibson's cyberspace. 

Of course, they've been wrong much more than they've been right, which is why we're not all using jet cars, teleporting, or taking fast-than-light trips to the stars.  The point is that they imagine a future that is different than what we're used to, and the great science fiction writers imagine the technologies mostly to draw out the implications for what they might mean for society.

The DIA said: "The work of this cell will be to construct valid strategic hypotheses, ie likely to upset the capability plans, " and added that the team would also be "reflecting on the strategic consequences of the arrival of disruptive technologies.”

Bruno Tertrais, deputy director of France's Foundation for Strategic Research, told The Telegraph that the red team was supposed to challenge "any certainties that we may have and hypotheses about the future outside the usual bureaucratic procedures.”  However, he clarified:

It is certainly not the Red Team that will decide France’s military strategy and still less its defence policy. Its role will be to help the Defence Innovation Agency think about future technologies and their impact on strategies.

I can understand not delegating a country's military strategy to a bunch of science fiction writers, although some critics might argue that France could scarcely do worse.  😉

Healthcare organizations aren't about to turn their strategy over to a team of science fiction writers either, nor should they.  But the DIA's notion that science fiction writers might picture possibilities that an organization's leaders and usual consultants might never think of seems very valid, and this is where healthcare should be paying attention. 

We talk a lot of looking for solutions that are out-of-the-box," but we typically have a hard enough time realizing the boundaries of those boxes, much less picturing topologies that don't even include boxes.  That's the kind of thing that science fiction writers try to do. 

Healthcare is already getting into territories that, not that long ago, would have been considered science fiction.  We've got robotic surgery, nanobots, 3D printing for tissues and prescriptions, and an increasing number of applications for artificial intelligence, to name a few.  But we're still trying to graft them onto our existing delivery and financing systems, and, at some point, that is going to fail. 

My favorite example is with artificial intelligence.  We've had telemedicine, with human doctors, for some 20 years now, and we're still trying to make state licensing and reimbursement work.  So when we get A.I. that can fill many roles of those human doctors, and which make decisions in ways that we don't and probably can't understand, how are we going to solve those same state licensing and reimbursement issues?   

That's the kind of thing that science fiction writers may be better at than most healthcare executives. 

It's easy enough for a science fiction writer to just assume really smart healthcare AIs or nanobots that can deliver pinpoint fixes within our bodies.  But I'm not sure that's where we need their kind of imagination the most.  Where we may need it most are in some of the nuts-and-bolts of the healthcare system, where things work, just not very well.

For example, here are some of the grubbier aspects of healthcare that need reimagination:

• Eligibility: how does everyone in healthcare agree that Person A is Person A?  Right now, we have NPIs that change seemingly willy-nilly, health insurance IDs that change with every change of health plan, and often multiple IDs for the same person.  It's amazing we ever get it right.
• Billing: we spend way too much time and effort trying to get billing "right," the definition of which healthcare professionals and health plans would not agree on.  With ICD-10, we're taking an already incomprehensible coding system and ramping it up still further.  We mix billing with diagnosis/treatment in ways that don't serve either purpose well.  Billing isn't supposed to be the point, but, in many ways, it is.
• Claims payment: Few of us understand our health plan benefits.  Few of us ever really know how a specific medical encounter is going to get paid.  Payments are often less than we expected, and many denials get reversed upon appeal.  Despite health plans' best efforts to automate, many claims end up needing a human to adjuticate.  It is to health plans as billing is to healthcare organizations -- vital to get right, hard to explain, and hugely expensive.
• Financing:  Despite just about every variation experts can think of, no country that I know of is happy with how health care is financed, nor how health care services are paid.  People grumble about taxes, complain about health insurance premiums, and worry that we're incenting the wrong kinds of health behaviors and treatments.  As we spend ever more on health care, this will all get worse.  

Imagine healthcare systems that solves those, and I'll be impressed.

A lot of very earnest, knowledgeable people are working on these and other healthcare problems.  More power to them, but it's not clear to me that they can see over their own biases.  This is where we need fundamental rethinking.  This is where we need daring speculations.  This is where we need wild imaginations to describe a very different future.

This is where healthcare could use science fiction writers.   

The Other Amazon Effect

I was keen to write about how Amazon Prime Day related to healthcare, but my esteemed colleague Jane Sarasohn-Kahn beat me to it, so I'll turn instead to another set of headlines that Amazon has been generating lately: their "Upskilling 2025 initiative to retrain a third of its workforce.  The company plans to spend some $700 million to retrain 100,000 workers by 2025. 

I wonder if healthcare is prepared to make the same kind of upskilling/retraining investments.  Because it is going to need to. 

Not everyone is wowed by Amazon's initiative.  As Peter Cappelli, a professor at Wharton, told The Wall Street Journal: "It’s not altruistic.  There’s some hard-nosed business-decision-making behind this.”  Or, as Marc Perrone, the president of the United Food and Commercial Workers Union said: 

Jeff Bezos’s vision is clear – he wants to automate every good job out of existence, regardless of whether it’s at Whole Foods, Amazon warehouses, or competing retail and grocery stores.

Let that charge sink in: "he wants to automate every good job out of existence."

As it happened, on the same day that Amazon made its announcement, the McKinsey Global Institute released its report The future of work in America: People and places, today and tomorrow. The report illustrates the trends that Amazon is trying to address, including its finding that: "Nearly 40 percent of US jobs are currently in occupational categories that could shrink between now and 2030." 

Equally important, they point out:

Previous MGI research has found that less than 5 percent of occupations can be automated in their entirety, but within 60 percent of jobs, at least 30 percent of activities could be automated by adapting currently demonstrated technologies.¹ What lies ahead is not a sudden robot takeover but a period of ongoing, and perhaps accelerated, change in how work is organized and the mix of jobs in the economy.

 McKinsey rated health care professionals as among the lowest whose jobs faced displacement (but still around 10%), while "health aides, technicians, and wellness" had higher but still below average displacement risks.  Still, "Office support" workers had the highest displacement likelihood, and I wonder how many "healthcare" jobs would truly fit into that category. 

Credit: McKinsey Global Institute

If your healthcare job does not entail being directly involved in actual patient care, you should probably be thinking about that upskilling (and even those giving direct care may need some).

Let's face it: for all the expensive technology, our healthcare spending mostly goes to people.  U.S. healthcare's administrative costs are rightly criticized as being much higher than in other healthcare systems, and those administrative jobs seem to be growing much faster than clinical ones.  We have complex processes that often don't make sense to patients, and that require constant intervention from people to execute them.  We have many clinical decisions based on personal preferences, not empirical evidence.

None of that can last.  None of that is good for our health.  And none of that should reassure anyone about their healthcare job. 

Three things are clear to me:

1. Administrative processes are going to continue to become more automated, as we seek efficiencies and as technologies continue to facilitate them;  
2. Robots are going to help care for our aging population, as demographic trends overwhelm our labor force;
3. Artificial intelligence will become an integral, even primary, part of clinical decisions and care, as Big Data and A.I. grow more powerful.

All of those spell fewer healthcare jobs.  The bull market in healthcare employment that we've seen for the last 20 years is not going to last much longer.  

Amazon's mantra has always been to focus on the customer, not on profits, but that mantra often seems more observed in words but not actions in healthcare.  Healthcare organizations are certainly looking at their costs, but patients often feel that budget cuts seem to adversely impact the people dealing directly with them instead of all those mysterious people in the back offices.

Technology is going to help change that.  For example, an article in blockdelta describes 15 trends in "medical robots disrupting healthcare," including robotic surgery, endoscopy bots, companion robots, nanobots, and AI diagnostics.  Similarly, John Nostra predicts that "AI will be smarter than the clinician. It will even become compassionate."   He believes clinicians need to focus on owning the compassionate domain rather than the cognitive one.

Whenever I am in a care setting, I try to talk to whomever I'm dealing with about the technology they're using, usually the EHR.  The stereotype often holds true: the older the person, the more they grumble about it, the harder they seem to find it to use.  The thing is, the technology is not going to go away (although hopefully it continues to get better); their job might be.  

In its press release, Amazon noted that its fastest growing jobs have been data mapping specialist (832% growth), data scientist (505%), solutions architect (454%), security engineer (229%), and business analyst (229%).  Few believe they're going to upskill many warehouse workers to data scientists, but, as Ardine Williams, Amazon's vice president of people operations, told The New York Times: 

When automation comes in, it changes the nature of work, but there are still pieces of work that will be done by people.  You have the opportunity to up-skill that population so they can, for example, work with the robots.

So needs to happen in healthcare.  

Healthcare has been focused on finding enough people, and is belatedly realizing it needs to finds more of the right people, with new skills and approaches.  The harder part, though, will be to upskill its current workers to the healthcare system that we're going to soon have.   As Ryan Carson, founder and CEO of Treehouse, told The Journal, 

The big secret is there is no lack of talent.  We just haven’t been looking in the right spots. That talent is often at your own company. They literally already work for you.

Maybe med techs or nursing aides aren't going to become data scientists either, but healthcare needs to figure out its upskilling strategy before it faces a jobs apocalypse. 

Our Dunning-Kruger Healthcare System

Psychologist David Dunning, originator of the eponymous Dunning-Kruger effect, recently gave an interview to Vox's Brian Resnick.  For those of you not familiar with the Dunning-Kruger effect, it refers to the cognitive bias that leads people to overestimate their knowledge or expertise.  More importantly, those with low knowledge/ability are most likely to overestimate it. 

Does this make anyone else think of the U.S. healthcare system?

Credit: drschat

Professor Dunning proposed the effect in 1999, in a paper in Journal of Personality and Social Psychology, along with then-graduate student Justin Kruger.  Since then, it has become widely known and broadly applied (not always accurately, as Dr. Dunning explains in the interview). 

Their paper had a chart that summarized their findings:

Credit: Dunning-Kruger, Journal of Personality and Social Psychology

Dr. Dunning believes that we tend to think that this effect only applies to others, or only to "stupid people," when, in fact, it is something that impacts each of us   As Dr. Dunning told Mr. Resnick, “The first rule of the Dunning-Kruger club is you don’t know you’re a member of the Dunning-Kruger club.  People miss that.” 

Or, as Dr. Dunning characterized it in a 2014 Pacific Standard article, "We are all confident idiots."

So, how does this relate to our healthcare system? 

We brag about our excellent care, our great hospitals and doctors, and all those healthcare jobs powering local economies.  Yet we have by far the most expensive healthcare system in the world, which is expensive not because it delivers better care or to more of its population than health systems in other countries, but because it feels it is justified in charging much higher prices.  Our actual outcomes, quality of care, and equity are all woefully mediocre on a number of measures. 

Credit: Kaiser Health News

How many of you live in an area that has at least one hospital system claiming to be one of the "best" hospitals in the country?  I've lived a lot of places, and each of them had one or more hospitals making that claim.  Your local hospital(s) may as well.  I hate to break it to you, but, in most cases, that claim is not likely to be true. 

Similarly, how many of us like to believe that our doctors are "the best"?  Perhaps they even have "best doctors" plaques in their offices to support this claim.  Again, it's possible that they are, but, in most cases, those beliefs are not likely to be true. 

Statistically speaking, most of us receive average care, and some of us receive sub-standard care.  We don't live in Lake Wobegon.  We can't all be getting the best care, or even above-average care. 

Just look at how few hospitals earn high ratings from The Leapfrog Group.  Look at nationally or even internationally known hospitals like UNC Children's or Houston Methodist, both of which had embarrassing revelations about the quality of some of their programs uncovered by investigative journalism.  Look at how even problem doctors often evade our vaunted medical licensing system. 

They all probably thought they were much more capable than they were. 

In the Vox interview, Dr. Dunning referred to a 2018 paper he co-authored, which found that beginners don't start out displaying the Dunning-Kruger effect, but often soon manifest it:

Although beginners did not start out overconfident in their judgments, they rapidly surged to a "beginner's bubble" of overconfidence."...Hence, when it comes to overconfident judgment, a little learning does appear to be a dangerous thing.  

I think about how uncertain medical school students turn into nervous residents and ultimately become the uber-confident physicians we're used to.  Dr. Dunning discussed how we need to do better distinguish facts and opinions, and be more willing to admit "I don't know."  How often does your physician admit they don't know something -- and would that give you more, or less, confidence in them if they did?  

In The Atlantic, Olga Khazan reported on a new study that suggests that, despite all their supposed superior knowledge, doctors don't really make better patients than the rest of us.  They get C-sections about as often, and about as unnecessarily as we do, they get about the same amount of unnecessary/low value tests, they're not better at taking needed prescriptions.  

As Michael Frakes, one of the authors told Ms. Khazan, the doctors "went through internships, residencies, fellowships. They’re super informed.  And even then, they’re not doing that much better."  Professor Frakes speculated that even physicians tended to be "super deferential" to their own physicians, despite their own training and experience.  

They're underestimating their own knowledge, and their doctors may be overestimating theirs.  A new meta-study found almost 400 "medical reversals" -- common tests or procedures that are not supported by research data.  As one of the co-authors told The New York Times: "You come away with a sense of humility.  Very smart and well-intentioned people came to practice these things for many, many years. But they were wrong."  

It is widely accepted that as much as a third of our healthcare services are unnecessary or inappropriate -- even physicians admit that -- but, of course, it is other physicians doing all that.  No one likes to believe it is their doctor, and few doctors will admit that they are the problem.  

Dunning-Kruger, indeed.

Much as they'd like us to, it is not enough for us to always assume that our healthcare professionals and institutions are qualified, much less "the best."  It is not enough for us to trust that their opinions are enough to base our care recommendations on.  It is not enough to believe that local practice patterns are right for our care, even when they are at variance with national norms or best practices.

"Trust" is seen as essential to the patient-physician relationship, the supposed cornerstone of our healthcare system, but trust needs to be earned.  We need facts.  We need data.  We need empirically-validated care.  We need accountability.  

Otherwise, we just fall victim to healthcare's Dunning-Kruger effect.  

In Defence of Ignorance

You may not realize it, but there is something wrong with your body.  Perhaps you have a mutated gene.  Maybe some cells are misbehaving.  Your body chemistry may be out of whack.  Some of your microbiota could be changing from a mutual benefit, or at least a stalemate, with your body to battling it.  It could be lots of things.

If you had a computer program as sophisticated as your body's code, thrown together over as long a time by as many programmers, you'd expect some bugs.  If you had a piece of machinery as complex, and used as hard as your body, you'd expect a few things to be constantly breaking down.  Yet somehow we seem surprised when we're told something is wrong with us.

Let's face it: past your early/mid-twenties, what we politely call "aging" should more realistically be called "deteriorating."   We just don't always realize it, and that's not necessarily a bad thing. 

Credit: Shutterstock

A few weeks ago I saw a primary care doctor.  Almost as an afterthought, she suggested one more scan.  I suspected I was being upsold, but I didn't want to be difficult and it wasn't particularly expensive, so I agreed.  Much to my surprise, the results indicated I might have a serious condition -- not life-threatening, but certainly life-altering.   There were treatments for it, but they were lengthy, unpleasant, and expensive.  Moreover, they could only slow the progression of the disease, not cure or even halt it.

I was not a happy camper.

She sent me to a specialist.  More tests, more scans, and he confirmed her suspicions.  He sent me to an even more expert specialist, who did more tests and scans, with some surprising conclusions.  There was some damage, he agreed, but nothing too serious, just something to watch.  I didn't yet have the disease in question.  Come back in a year just so we can keep an eye on it.

All this took several weeks, which I'm sure is very short compared to what others have had to endure, but which seemed interminable to me.  I kept thinking about all those treatments, all that money, and how my life would be different as the disease had progressed.  All for naught, as it turned out.

I'm kind of wishing I had turned down that original scan. 

We're detecting problems ever earlier.  CTs, MRIs, PET scans can pick up cancer cells at early stages.  We're already using "liquid biopsies" or fecal samples to find tiny traces of cancers, in minimally invasive ways, and are on the cusp of detecting early stage cancers and other problems through even more refined blood tests. 

The trouble is that not all the findings are important.  For example, many scans pick up abnormalities that should be considered "incidentalomas," researchers found last year.  “We know that the diagnosis of incidentalomas can cause patient anxiety and is likely to lead to further investigations and treatment, some of which will be unnecessary, and some of which will cause harm,” said lead study author Dr. Jack O’Sullivan of the University of Oxford. 

Credit: MedPage Today

As H. Gilbert Welch, MD, a professor at the Dartmouth Institute for Health Policy and Clinical Practice and author of a related study, told MedPage Today: "The human body is full of small anatomical abnormalities.  The more we look, the more we find, and the more we intervene. And that’s generally not in our patients’ interest."

Similarly, those new blood tests may have only a 1% false positive rate, but: "One percent in a patient population of 5,000 is manageable.  With 1 percent in hundreds of thousands or millions, you quickly get into different dynamics,” Joydeep Goswami of Thermo Fischer Scientific said in an interview with MedCity News at the recent annual meeting of the American Society of Clinical Oncology.  

It's cool that the Apple Watch can give us 24/7, real-time monitoring of irregular heart beats, and who knows what kinds of such monitoring we'll be able to do next.  But we're also going to turn up apparent issues that aren't really issues, getting lots of people needlessly worried and subject to subsequent tests/procedures/expenses.  

We can get findings.  Lots of them.  More all the time.  We just don't always know what to make of them.  As Dr. Welch said, "the more we look, the more we find."  Sometimes it might be better not to look. 

I think back to my early days in health policy, when there was much discussion about the supposed rationing in the U.K.'s National Health Service.  For example, it was widely believed in the U.S. that no one over 65 could get dialysis through the NHS.  A study -- and I can't recall the authors -- found that, in fact, there were no explicit prohibitions or even guidelines about it.  It was just that physicians were reluctant to order it for seniors.  As one physician put it, "well, at that age we're all a bit crumbly, aren't we?"

Indeed, we are all bit crumbly, and the trouble is we don't always know which of our many flaws are "normal" and which need action.  

We don't have the right baselines.  We don't know what "normal" should look like, for which people, at which ages.  We don't know which of what Dr.Welch called our "small anatomical abnormalities" will never manifest as real issues, and can be safely ignored.  No, give us a finding, and someone will want to take action on it. 

Should we stop trying to find ways to find and diagnosis potential issues at earlier stages?  No, of course not.  But we need to spend at least as much time and money understanding what they really mean.  Sometimes a flaw is just part of who we are.

Should we stop trying to treat issues once identified?  Well, maybe.  Most of us freak out when given a serious diagnosis, but part of physicians' job is to help us understand when action is necessary and when waiting or even ignoring something is the best course of action.  Part of their job may be not to put us through that at all.

Sometimes ignorance is, in fact, bliss.