Wednesday, May 25, 2011

Remember: Social media is social

A few days ago, several news outlets reported on Newt Gingrich's unfortunate turn of phrase about our President. In a speech in Georgia he referred to Obama as "the most successful food stamp president in modern American history." Promptly, David Gregory of NBC News called Newt on the potential racist connotations of this remark, thus precipitating a maelstrom of "liberal media" accusations from the usual suspects (here and here). And so it goes, possibly a careless figure of speech, possibly racially charged code, but everyone is now yelling and screaming about whether or not it was OK to say and subsequently to accuse.

There is a much bigger issue at stake than just the utterance of these words. While they offend me and make me think that they were spoken deliberately to elicit racial tensions, the point is that, in an obtuse sort of a way, they can be defended as non-racial in nature. Unfortunately, the speaker's intention is not the issue any longer, so much as the fact that these words can easily be construed as racially inciting by large swathes of the population. And this is an important point: once squeezed out, much like the toothpaste from its tube, these words cannot be forced back. They will exist in perpetuity and continue to elicit visceral reactions.

Such is the nature of public discourse. Which brings me to the discussion on Bryan Vartabedian's site about the etiquette of healthcare professionals on Twitter. The example of the particular Twitter stream from a healthcare professional who tweets anonymously under a nom de plume, precipitated a spirited discussion (see over 100 comments) about the propriety and professionalism of her messages in this public forum. While many saw her behavior as at the very least undesirable, some MDs and, more concerning, medical students, did not see a thing wrong with her eructations. Furthermore, she responded via Twitter that she was quite surprised by this tongue lashing and did not know what was so offensive in her messages.

But that is just it! Enough readers saw her words as being disrespectful and even contemptuous of patients, regardless of her intent. And this is the crux of the matter: the distance between the output, and its intent, and its interpretation by the listener or reader can be vast, especially when the message is reduced to 140-character snippets. This is why when people lament that communication is the biggest obstacle in all human relations, they are right. And different types of communication deserve different levels of scrutiny.

So, here is my bottom line. Whether we intend to be hurtful or disrespectful in our tweets or racially divisive, as in our political discourse, is immaterial. In an open forum, if we are concerned with being empathic and careful of others' feelings, we should think twice (or more) about what we put out there. Because extending this blogger's thought to all communications, Twitter, like a tattoo, is forever. And everyone is looking.  

Monday, May 23, 2011

All harm and no benefit: Wake up and smell the pus!

Ideas are a little bit like a pimple: There needs to be enough pressure that builds up to cause one to erupt into consciousness. So it has been with my thinking around value of certain consumables. And the more I think about it, the more I am convinced that the law of diminishing returns is scowling at us from its perch. Here are 3 examples that I hope will drive this point home.

Take cigarettes. They cost money to manufacture, they cost a boat load of money to buy, yet what do they produce that is of value? A rise in the teen's coolness quotient? A brief relaxation effect? Appetite control? Sultriness? A tax base? All of this is so squashed by the sheer size of the risk of disease and death that cigarettes cause as to make any of these potentially perceived "benefits" infinitesimally small, thus bringing the harm in the harm-benefit ratio into the range of infinity. So, huge investment, personal and societal, for a negative return.

Next comes food. I am sorry, but I am going to stop wringing hands and apologizing for being convinced that there is in fact unequivocal scientific proof (yes, I did say "scientific proof") that our gargantuan and infinitely dysfunctional food production system is poisoning our public. Obesity is but one manifestation of this diseased production. The potentially more catastrophic consequences include accelerated deforestation with the consequent extinctions and climate change, which is rapidly moving from the realm of abstract future into the concrete present. Many have written about the science behind all this, and I will not belabor it here. Yet it is clear that this is another example of ever-increasing investment and subsidies made at the peril of environmental and public health. So, again, we have a cigarette-like situation, where the numerator of harm overwhelms the denominator of benefit to such and absurd degree that it threatens to stamp us out, like a drunken Godzilla strolling down a city street, pulverizing everything to dust.

And of course, we must bring in "healthcare." I put it in quotes because there is so little health in this healthcare paradigm. It is striking to me how the "prevention" conversation has been hijacked by the vocabulary of "screening." And don't you practically feel like a criminal refusing some screening test or another, or worse yet, refusing to comply with your annual check-up? At the same time, every day we hear about harm due to overzealous search for what is wrong with us. Healthy people walk into a place of "healthcare" delivery and walk out at best with a handful of pills and a bunch of ICD-9 codes attached to them, or at worst end up dead (or so close to it that they wish the job had been completed). I am sure you all remember the paper in the Archives of Internal Medicine that precipitated this post, where a healthy woman ended up needing a heart transplant because of the dogged search for a diagnosis that did not exist. More recently, several lay press articles, including this one, have highlighted data on an increase in potentially life-threatening post-biopsy infections among men undergoing a prostate biopsy. And the kicker is that the PSA test, which is what usually leads to a biopsy, has been so convincingly characterized as completely unreliable that it is difficult to believe that anyone still submits himself to it. And to top it all off, Archives of Internal Medicine has just published this paper on screening for heart disease in asymptomatic people (this means schmos like you and I who hang out in our offices without any heart symptoms). And, not surprisingly, they found an increase in the diagnosis and treatment of heart disease among those screened compared to those not screened, and absolutely no impact on the outcomes! All harm or potential harm and no benefit! We should be outraged, but instead we demand more intervention.

Given our peaceful acceptance of pushing (yes, pushing) harmful stuff on the public without any pretense at benefit, just as the brazen strategies of the tobacco and monocultured foods have done for so long, it is not surprising that we are willing to dive head first into this quicksand of harm. It attests to how effective the PR industry's brainwashing is. But really, isn't it time to wake up and smell the pus?      

Friday, May 20, 2011

In praise of not knowing

Recently I had the occasion to tell my 10-year old an old secret: until I was into my forties, I had a strong belief that the rest of the people in the world knew something I did not know. I don't mean just about stuff I do not know, but about everything! It was unnerving, anxiety-provoking and self-defeating. Until one day I had the epiphany that most humans feel this way, not just me. So, be humbled by not knowing and move on.

Yet even more recently this line of self-examination has led me to the conclusion that I end up saying "I don't know" a lot. I read a definitive tweet from someone I respect, and I say to myself "I don't know"; I read a new paper in a journal and say, "Gee, I don't know", I hear a political speech, and I walk away saying, "I just don't know." Is it that I am an idiot, or intellectually lazy? Perhaps. But what is occurring to me more and more lately is that what we are convinced of today will be much less certain and obvious tomorrow, barring some truly sacred cows. This is called growth, and as far as I can tell is a desirable development.

On the other hand, saying "I don't know" sometimes means that it just does not make sense to take sides. I know that we have to apply current knowledge and not wait for perfect information, but I still do not see getting all polar about stuff. Most of the time we act like there are only two possibilities, and they are diametrically opposed to one another. Well these are false dichotomies promoted by our educational system, which drills into us the idea that there are only two answers to any question: the right one and the wrong one. What if this is untrue? What if we change the way we think about the world, and instead of seeing only the black and the white, the left and the right, the correct and the incorrect, we start really seeing the entire continuum of possibilities? What a fantastic variety of solutions we might stumble upon to our perennial questions!

A nice mind game could be trying to think about stuff without using words. Can we do that? It is thoroughly difficult, yet it is language that seems to bracket our conceptual understanding of the world within and around us. Take the word "race" or "gender", for example. These are human-made and defined terms, which are meant to distinguish rather than merge. Yet just think how uncomfortable we can be made by a person with an ambiguous gender identity, say. Why? Because he/she does not fit into our preconceived dichotomy? Uncertainty is uncomfortable, and dichotomies cure uncertainty. But I am not sure that nature is all that into dichotomies.

The human brain is wired for "belonging." I believe it is for this reason we gravitate to our respective extreme corners of thinking and being, instead of meeting somewhere in the isle. The isle is an uncomfortable place, yet that is where we must aim to be. All the borders we have created are imaginary separations. Instead we can reposition them as the glue that unifies that which lies to either side.

Here is to not knowing more!

Thursday, May 19, 2011

Of pigs, Babel and totalitarianism

Here is a weird thought: Our current food production is closer to the Soviet collectivization than to the free enterprise model. Outrageous? Not really.

I had avery interesting weekend. As some of you may know, I am finally going back to Odessa (no, not the one in Texas) after a 35-year hiatus -- we left when I was 13. Since I am only spending 3 days there, I have been doing a lot of soul-searching to figure out what I need to get out of the trip. Serendipity struck last Sunday, when in the midst of a gloomy morning I went online to search for something to do in the Valley, indoors, and came upon this. Now, although most of you probably have never heard of Babel, he was a very well known and respected author of the Soviet era. A Jew in peri-revolutionary Odessa, he was a master story teller, best known as the bard of the colorful life of the Moldavanka, a district of Odessa particularly rich in poverty and Jewish gangsters. My father was a great scholar of Babel, and I remember hearing his stories from a very young age. I also remember passing by his house in the streets of Odessa, with a modest plaque marking its historic lineage.

But Babel became personal for me when in 1996 my parents brought me a gift from their trip to our home town, a book of Babel's short stories with an inscription from my cousin's family. This inscription pointed me specifically to page 19 of the tome. As my eyes focused on the small print, and as I started to skim the text, I shortly came upon the following sentence: "None other than Dr. Zilberberg operated on him..." Yes, my great-grandfather was a fairly well respected surgeon in Odessa at the turn of the 20th century, and Babel in fact mentions him in several other of his works, including this autobiographical sketch. Unfortunately, most of what I know about that Dr. Zilberberg has been passed down through the idealized prism of the family lore. Yet I am thoroughly intrigued by the claims that his professional ethics forbade him from turning anyone away, and he cared for the rich Jewish ladies alongside the mafiosi of Moldavanka with the same level of professionalism. And for this, the legendary gang leader Mishka Japonchik, who incidentally is rumored to be related to me on my mother's side, but that is a story for a different time, is known to have afforded him protection from the rogue elements of his gang. The story is well told by my father in this essay, albeit in Russian.

But I digress. So I immediately got myself out the door to get to the program and sat, along with about 100 other attendees, riveted by Andrei's reading of his grandfather's work. After the intermission he read the story that features my great-grandfather, and of course in the Q&A I came out as the great-granddaughter of the great surgeon. Because of this I was invited to join a group of locals and Andrei for a memorable dinner. It was at this dinner that an insightful comment from the brilliant hostess clarified the mindset for my trip. And it was at this dinner that Andrei started to remind us about his grandfather's journalistic work about the collectivization movement in the nascent Soviet Union. It is at this dinner that I got a very clear picture of how our current food production is eerily totalitarian. Imagine if you will being a small farmer at the turn of the 20th century in Russia. You are by no means well off, and all you have is the land and what it gives you after hours and hours and hours of backbreaking loving tending. Imagine now that in comes a new regime, claiming to be for the workers and peasants, and now considers you a land-owner, a kulak, a member of the bourgeoisie, and takes away your farm (the term used is "raskulachit'" or de-kulakize) and puts it in the hands of the collective. Now the big whole owns your meager part and you are left with nothing.

Now let us think about what has transpired in the US over the last century. Let us look at the meat industry specifically. Its deplorable practices at the turn of the 20th century were chronicled brilliantly by Upton Sinclair, and I will only mention that, according to Eric Schlosser's writing, in 1917, 5 largest meatpacking companies owned 55% of the market. On the heels of Sinclair's book, and prompted by the appalling confirmation by the government investigation of Sinclair's claims, the government embarked on a regulatory voyage culminating in the 1920s with the anti-trust legislation, meant to ensure that no monopoly (or oligopoly) would control any market in our nation, thus precluding companies from getting big enough to control our free markets. Well the result of this was a sharp decline in the market share for each of the giants. Yet this was transient, and, as Schlosser points out on page 162, today the top 4 meatpacking giants control over 80% of the market. What happened? Well, we call it "deregulation." But is it really all that different from collectivization? Not that much -- it is still the few controlling the many, and the many going bankrupt and having no leverage to improve their lot. But, you say, it is not the government, but private interests that are at play, so this makes it all better, right? Well, are you sure about that? Who is pilling the strings of our congressional representatives? And these strings are only going to get stronger, thanks to Citizen's United decision from the Supremes. So, while the politicians are foaming at the mouth calling Obama a socialist and a communist, we are careening head first away from democracy and into that social structure we contemptuously call totalitarianism.

Simplistic? I don't think so. Think about it: a pig with lipstick on is still a pig.    

Tuesday, May 10, 2011

When do diagnostic tests improve mortality?

I thought this post, originally published last May, was worth revisiting apropos this paper that came out in this week's Archives of Internal Medicine. Below I discuss some of the data in the paper, as they were presented in an abstract at a meeting last year, as the context for understanding various mortality statistics. 

The question the title of this post poses is well worth asking, particularly as we argue about the merits of mammography screening. The USPSTF has really stirred up the hornet's nest with this one, and the politicians cannot help but get on their populist pulpit, ignoring the facts completely. Oh well, what else is new?

But the question remains: do screening or diagnostic tests that are more sensitive save lives? A great talk on pulmonary embolism detection and outcomes by a recent graduate from the Dartmouth group at the American Thoracic Society last week prompted me to clarify this. We all hear that mortality from many diseases has decreased over the last few decades. But is this true? In order to answer this question, one has to ask what is meant by mortality. Even people well versed in epidemiology and biostatistics occasionally blur the lines between mortality and case fatality, and to our question the distinction is critical. Case fatality is defined as the proportion of patients with the disease that dies, while mortality is a population-based measure, a proportion of all of the population at risk for the disease that dies. The difference lies in our old friend the denominator, which will always keep us honest.

Let's go through a simple example to illustrate this concept. Let's pretend that the total number of cases of disease D diagnosed using stone-age test T 30 years ago was 100 in a population of 10,000 people. Of these cases, 90 died, giving us the case fatality of 90% and mortality of 9 per 1,000 population. Now, we have a new test for D, a super-Doppler-MRI-PET-cyberscan called über-T, a much more sensitive test than the old "gold standard" test T. And now we detect 1,000 cases of D in the population of 10,000 people. Of the 1,000 cases detected by über-T, 90 have died. The case fatality now has decreased dramatically from 90% to 9%, and we can pat ourselves on the back for a job well done, right? Not so fast, the population mortality from disease D has remained a steady 9 per 1,000 population!

So, what does this mean? Does it mean that über-T, which costs 2 orders of magnitude more than its predecessor, is worthless? Well, decide for yourselves. What it means to me is that the additional cases detected by über-T, though finding earlier stage disease, thus increasing the denominator for the case-fatality calculation, has had no impact on the numerator and therefore has not in fact improved the only mortality that matters: population mortality related to the disease.

So, next time a politician tells you how well we are doing with technological innovation in disease management, ask this simple question: Has all the money and innovation really altered the important outcomes, or is this all smoke in mirrors, a mirage created by our irrational belief that technology is our salvation? This may be an uncomfortable epiphany for some. But think about the 900 excess cases of the pseudo-disease diagnosed in our example above -- how many people could have been saved becoming a chronically ill person, how many complications of follow-up procedures could have been avoided, and yes, how much money could have been spent on something other than healthcare? And asking these questions may help us to identify technological advances that actually improve our lives, as opposed to those that merely create attractive business opportunities and stimulate the economy.            

Friday, May 6, 2011

How many diseases does it take?

It is not a secret that I dislike tobacco companies. Intensely. I do not see the point of allowing them to sell a product whose value is all in the negative. I am appalled that we are looking for expensive ways to diminish lung cancer mortality before considering a complete ban on this disease promotion apparatus. Yet this story in the LA Times got my goat. Briefly, a woman who has smoked for years and has had smoking-related obstructive lung disease since 1989 decided to sue tobacco companies after developing lung cancer in 2003. The suit has been making the rounds in various levels of courts, since the defendants asserted that she had exceeded the 2-year statute of limitations following the onset of her smoking-caused disease, referring to the 1989 COPD diagnosis. However, the California State Supreme Court has ruled that she can still sue the manufacturers, since she filed her suit within two years of the lung cancer diagnosis. So, why am I bothered?

Well, here is the thing: once you develop lung disease, followed by periodontal disease, as this woman did, had she really remained unaware that cigarettes are bad? That they cause problems? Is it really possible to live in our world and NOT be aware that tobacco kills? And if she was aware and continued to smoke, whose responsibility is it that she developed lung cancer, hers or the manufacturer's? Well, you say, but the tobacco companies are unethical and lied about making cigarettes more addictive by adding undisclosed ingredients. So, how are we, the consumers, to know? Well, this is pretty simple: We have free will, don't we? And if you have the free will, you have to exercise some will power, no? Is this not what the human condition is all about? Consider what would happen if we just let all of our desires run rampant. At the simplest level, who would want to get up early and do back-breaking work to produce food for our communities? And why contain anger at town hall meetings, when my humanity tells me to get into a brawl? These are basic ways in which we conquer our instincts and do what we need to do to live in a society with human beings and other organisms. But what is peculiar is that we have not extended these exercises of will to the area of consumerism. In other words, it seems to me that whichever way the market, and more importantly marketing, goes, so goes the perceived need for personal will and responsibility. Ergo, smoking despite warnings of its dire effects is OK, since the poor soul is addicted, and she can always sue on the back end, while the murderous tobacco CEOs and investors walk away with the profits. I don't know, I think it is embarrassing to give up your will that way personally.

There are two nuances to this view that I want to express. First, I do believe that cigarette companies are unethical, cruel and in debt to us, but the debt that needs to be paid is to the society, not to individuals. It is a debt to our public health that requires complete withdrawal of their product from the market and a large monetary compensation to promote healthy habits among human beings. Second, I believe that there are shades of this personal vs. societal responsibility balance that are important. Take, for example, food options for an inner city youth who lives in poverty. He may want to exercise his free will to get better nutrition than a $1.25 meal at McDonald's offers, or spend his $1.25 on an apple instead of a bag of potato chips, but for this he has to go across town, a trip that he does not have the means to undertake. This, folks, is where this young man's personal responsibility needs to be supplemented with societal commitment to equity.

So, should this unfortunate smoker with severe and life-threatening sequelae of tobacco abuse be able to sue the producer of the poison, even if she knowingly took the poison? I guess as a society we have decided that this is OK, but as an individual I am dubious. Yet it really is in the interest of our common health and wealth to punish and eliminate producers of such poisons as a society. Relying on individuals to do this job is just a perpetuation of the idea that we are not responsible for our actions. And furthermore, this becomes but a small pimple on this giant's ass, a nuisance, and not a necrotizing fasciitis that is required to kill it once and for all.