The stories we tell ourselves
I have been thinking a lot about this article from Wired by Jonah Lehrer (the author of the wonderful book How We Decide) since I read it two weeks ago, and even had a couple of discussions about it over the holidays. It is extremely interesting and thought-provoking, and raises a number of important questions: from how pharmaceutical companies work, to the use of the scientific method, and the general state of medical decision-making and care in the modern world.
To me, one of the more intriguing concepts brought up is the idea of cause and effect, and what Lehrer refers to as "the story we tell ourselves" about what happens between point A (cause) and point B (effect). As science and medicine work on ever-smaller bits (past cells, down to molecules and atoms) we think that what we know to be true about the larger whole will continue to hold up. But that seems to not be the case all the time, and yet we don't want to admit it. I was reminded of the book In Defense of Food by Michael Pollan while reading this article, as the main portion of the beginning of that book also revolves around reductionism and the errors it has created. An example from In Defense of Food is baby formula, and how major, vital components were missing from manufactured formulas when they were first introduced, resulting in many sick babies. We often think that knowing the component parts is the same as understanding the whole, and as Lehrer's examples of cholesterol and back pain show, that is not always true.
I dislike the title of this piece and I think it's a little too incendiary (more than likely an editor's choice and not the author's), because I don't think science is "failing" us. And I hope that the title doesn't turn too many people off from the points being made in the article. Because at some point we do need to face that breaking down the nutrients in our food, or the human brain or body, or whatever, into incrementally tinier pieces isn't going to teach us much that is new. (Obviously if you're a particle physicist that isn't the case, but the idea that human health and well-being is akin to particle physics seems rather problematic and maybe that's where we're going wrong.)
I read passages like this:
Although the scientific process tries to makes sense of problems by isolating every variable—imagining a blood vessel, say, if HDL alone were raised—reality doesn’t work like that. Instead, we live in a world in which everything is knotted together, an impregnable tangle of causes and effects. Even when a system is dissected into its basic parts, those parts are still influenced by a whirligig of forces we can’t understand or haven’t considered or don’t think matter. Hamlet was right: There really are more things in heaven and Earth than are dreamt of in our philosophy... And yet, we must never forget that our causal beliefs are defined by their limitations. For too long, we’ve pretended that the old problem of causality can be cured by our shiny new knowledge. If only we devote more resources to research or dissect the system at a more fundamental level or search for ever more subtle correlations, we can discover how it all works. But a cause is not a fact, and it never will be; the things we can see will always be bracketed by what we cannot. And this is why, even when we know everything about everything, we’ll still be telling stories about why it happened. It’s mystery all the way down."
And I, like countless others, wonder what we can do about it. He gives the example of the field of public health, which continues to make strides in a wide variety of areas: vaccines and immunizations, infectious diseases, nutrition, women's health, sex ed, STIs, and so on. Public health advances in water and sanitation, for instance, have helped increase the lifespan by close to 25 years, so what are they doing right? Is it that they look at the big picture, the biopsychosocial landscape, and track human behavior thusly? Is the focus of public health growing ever broader, while that of pharma is shrinking ever smaller?
I don't know the answer to that, or to any of the issues raised by Lehrer, but I can promise that I will continue to mull over the points he raises for a long time.
New social media tool for students and surgeons
Surgery Theater is the first online social media educational portal for all surgical procedures. The site can be used to watch live surgical procedures and conferences, medical document sharing, exploring new surgical techniques, and receiving information on the most up-to-date surgical innovations. This is a great medical education resource for students but can also be used for patients looking to get more information on upcoming surgical procedure. This is a great new educational tool for surgeons, students, and patients.
Allowing patients to see their EHR data..?
Over the last two days I was involved in a meeting regarding health care data - data for and about physicians, and data for and about patients. A lot of that data overlaps of course, and our discussion revolved mainly around what kinds of information health care professionals need to see about themselves in order to facilitate lifelong learning and improvement. Other aspects of the discussion included how to assure the data is accurate, timely, secure, useable, and wanted; how to incorporate quality feedback with resources and tools for learning; and how to try to create culture change around the use and availability of high-quality health care data.
Today the discussion veered into the realm of patients: how to get them actively participating in decision-making, how to get them engaged in their own health and care, and what kinds of data should patients be able to see. For example, when a patient is choosing a provider or hospital, what kinds of data would help inform their decision? Should patients be able to see certain metrics or assessments regarding their physicians? Which ones should be public, and which private? I doubt patients and doctors will ever agree on these matters, but as the openness and availability of information grows every day, they aren't soon to go away.
Today I came across this article regarding a JAMIA review of why patients can't readily see their own EHR data. It touches on many of the topics we discussed this week, and it doesn't seem to get to any firmer ground than we were able to. The author points out that research suggests sharing a patient's health data with them, when integrated with education and clear communication, tends to improve efficiency, quality and patient satisfaction. However, there are also a number of obstacles and issues regarding sharing EHR data with patients. These include:
- data fragmentation
- privacy implications and legal concerns
- when should data be shared?
- which portions of the EHR should be shared?
- whether doctors should be able to screen certain things first (like lab results)
- whether patients can understand much of what they would read, and if doctors have the time or resources to translate it for them, and
- who actually controls or owns the EHR data?
This last point is very intriguing to me, as again, I think there is a great deal of disagreement about it. As a patient, I believe that my data is always mine and should be available to me whenever and however I want it (besides, as was mentioned today, the EHR may contain incorrect information that I would want the opportunity to check over and fix if possible). However, I know that many physicians and health care systems (let alone EHR vendors, insurers, etc.) may disagree with that. This debate is bound to go on for the foreseeable future, with many different sides weighing in. And despite the fact that I am a patient and not a doctor, I can see both sides of the issue.
It will be very interesting to see where this conversation goes, and how it ends up.
Integrating the humanities into medical education
Hand and Leaf Vasculature, by Ryan James Bender
At the AAMC annual meeting this year, I attended a session put on by two faculty members from the Anschutz School of Medicine at the University of Colorado in Denver. They were discussing the integration of humanities education into their med school curiculum: the required and elective courses, sample lesson plans, and examples of the students' writings and projects. My interest in this topic was twofold: first, I have a personal love for the arts and humanities; and second, I had never heard of a med student who would gladly and gratefully take a required art, film or creative writing course. But they convinced me that such students exist, and that they are both talented and prolific!
Many of the lesson plans discussed had only peripherally to do with medicine; but instead focused on teaching the students how to deal with difficult emotions, how to craft quality narration and self expression, how to continue to develop their imaginations well into adulthood, and how to craft a set of core values based in humanism and compassion. When framed in that way, how could anyone doubt that the humanities have a place in health care? At its core, medicine is the interaction of two or more humans, with the goal of health or healing. A more human experience can scarcely be imagined, and the in-depth exploration of the intellectual, emotional and creative facets of that experience should not be ignored.
You can read a summary of the Anschutz Humanities program here. Some other links worth checking out:
- Some examples of stories written by Anschutz med students, based on their Anatomy course cadaver as "first teacher"
- An open lecture series involving the arts in medicine
- The school publishes a journal entitled the Journal of Medical Humanities, which you can read online
- They publish an annual curated anthology of medicine-related art and writing
- The medical school library includes a collection of medical humanities books and film
- Lists of the elective and required humanities courses
As a patient, I would be pleased to find a doctor who had studied this kind of curriculum in medical school, and if I knew there were a number of humanities-oriented doctors out there, I may even seek them out. I can imagine that a physician who thinks about patients and medicine in this way would be an innovative, creative and thoughtful provider.
Medical training needs more focus on prevention and public health
Focusing on Public Health
Our healthcare system focuses mostly on treating illnesses and diseases after they occur, forgetting to focus on preventing them from occurring. Recent experts published in the American Journal of Preventative Medicine (AJPM), stated that focus needs to be shifted on medical education emphasizing public health and prevention methods. Focusing on prevention strategy prevents people from becoming ill and from carrying the burden of health costs.
Reducing residents work week, increases or decreases medical errors?
In 2003, the ACGME recently set standards restricting residents from working more than 80 hours a week. The purpose was to provide residents with more time to rest and study for the improvement of training as well as decreasing medical errors resulting from fatigue. The University of Mississippi conducted a study that found that after the enforcement of the 80 hour week rule, residents have been performing much less procedures, resulting in less experience and training.
While it seems ridiculous to most of us to work 100 hour work weeks or to go days without sleeping, the findings of the study suggest that residents are not getting enough exposure to observations and training to become an expert physician at the end of their programs. While the standards were set to reduce medical errors due to exhaustion, who is to say that the medical errors will not increase due to insufficient training. Both concepts are very much debatable and are open 80 hour work week to study and experimentation.
Improving Doctor-Patient Relationship
An experience with an arrogant physician which prompted a bad experience at a medical center, motivated a couple to donate $42 million to the University of Chicago to create a new and developed institute to improving the education of doctor-patient relationship as much as science and technology. This new approach teaches the importance of listening, understanding, and empathizing with patients, which builds a doctor-patient relationship and encourages patients to be engaged in their treatment as well engaging in preventative measures.
While this seems like a great approach and really has potential to restore patient-physician interaction, how can one integrate this in their medical schooling curriculum and actually assess this type of behavior, whether it is during the training years or down the line? There is no doubt that medical student’s need ethics and patient-physician interaction training; however it’s difficult to assess how this would play out.
Cool Job Alert!
At the intersection of Hollywood and science. I love that people can do things like this for a living (or, for part of their living)!
Dip & Squeeze
Can I just declare that THIS is innovative. It took a long time (30 years?) to redesign the condiment packet system, but it was worth the wait. Three times the amount of delicious, delicious ketchup in a package that can be squeezed out or used to dip. GENIUS, I say!!
Greetings from Mayo’s 2011 Transform Symposium
Today I dusted off my avatar and joined our host Svea Morane (Mayo staff) and guide Panacea Luminos (Southern Tier HealthLink NY) for some breast cancer awareness education. Unfortunately, much of my time was spent reaquainting myself with getting around in Second Life, so I only tagged along toward the end. I didn't dare look for a new outfit; I showed up in the white coat previously donned for an earlier demonstration of an emergency appendectomy in a virtual world.
The session included a virtual tour of the Mayo Clinic, including the Center for Innovation--I'd sure like to have a pass to take my colleagues through that virtual tour, as my in-person tour yesterday was quite interesting and informative.
Might be a good time to take a fresh look at the promise of virtual worlds and simulations for medical education.