Dr John M

cardiac electrophysiologist, cyclist, learner

Follow-up on my Eight COVID Assertions

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Yesterday’s post generated some good comments.

Two emergency medicine specialists felt that I was both wrong and insulting in saying that hospitals were not overwhelmed.

What I meant in the word ‘overwhelmed’ is the notion of not being able to support a sick patient in the ICU or on a vent. That didn’t happen, but both doctors make important points.

First I mean no insult to my frontline colleagues. It’s the opposite really. As a specialist who deals mostly on the treatment side of things, I’ve held those who must make diagnoses in the highest regard. Their work in the pandemic has only increased that respect.

Second, the point that there were consequences to the “massive and costly” efforts to shift resources is valid. Data in our (cardiology) journals hint at the fact that heart attacks and stroke admissions were way down during the height of the pandemic.

But it’s hard to believe that heart attacks and strokes stopped happening during this stressful period. Post-pandemic reviews will likely show that the efforts to care for patients with COVID19 will have increased unnecessary non-viral deaths due to lack of care. (The counter is that the pandemic also stopped a lot of low-value, potentially harmful care.)

Nonetheless, “overwhelmed,” was a poor word choice. Sorry.

2. My Twitter friend, Dr. Mike Johansen (who is a super-sleuth when it comes to critical appraisal) pointed out that my comparison to NZ and Australia is problematic.

Dr. Johansen’s first point about not using the dichotomy between NZ and the US is well-taken–especially given the surprise of vaccine development.

Response to the pandemic has clearly been on a continuum. As he wrote, countries such as Canada, Germany, Denmark, Finland have done better than the US. And now that we have vaccines, countries that did better with pandemic control will end up with less death due to COVID19.

It’s interesting, too, that the countries mentioned above all have better safety nets than the US. Though, there are many other factors in a country’s response to the pandemic.

This country has to figure out a way to improve our safety net. I realize that people differ on how to get there. But no one can disagree that it is an existential problem.

3. An anonymous commenter pushed back on my assertion #6.

What evidence is there that reductions in IFR are due to masks and distancing?

My thinking is not that masks or distancing affect the IFR directly, but that delaying getting the infection will reduce one’s chance of dying. For two reasons:

It was a novel virus; it took time to learn stuff. So it is clearly better to get the virus in December than in April.

And now there are vaccines.

For a person with risk factors, therefore, it makes sense, now, to stay hunkered down for a few more months. There is an end in sight.

If you have the means, you use online shopping, you avoid weddings and large gatherings, get an N95 mask, do Zoom Christmas and take the vaccine.

But my commenter is right: Social distancing and masks do not affect the severity of illness–though there is a theory that a mask might lower the severity of illness by reducing the amount of virus that gets in your body.

The pandemic forces everyone to think. This is a good thing.

JMM

Doctoring and Activism

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I got myself into a bit of tussle on Twitter today.

In a provocative piece on the newsletter Persuasion, Dr. Sally Satel argued for caution in the matter of doctors becoming political activists.

I retweeted it below:

Most of the replies express extreme disagreement. One question stood out as worthy of a longer reply than Twitter allows.

And then this:

Thank you CC for the calm inquiry. My answer goes something like this:

Dr. Satel and I are both against racism.

But let’s say we objected to being forced to do implicit bias training or white fragility corporate modules. Then let’s say we argued publicly against these policy interventions.

We would likely be fired, or castigated on #medtwitter, or both. Read the timeline for evidence.

This is where my June 7th post comes in: Namely that I am concerned that legitimate debate is increasingly impossible in today’s culture.

Here are a couple more vignettes highlighting the challenges of doctor-activism.

As a cardiologist I see minority patients whose social situations surely play a role in their heart disease. I treat these patients as best I can, taking into account their specific challenges. I practice minimally disruptive medicine.

Like anyone I want the disadvantaged to have better lives. But…how exactly is my medical degree supposed to guide me in crafting solutions to improve the situation of poor people? Is it Bernie Sanders’ approach? Or Elizabeth Warren’s? Or, god forbid, a free-market approach?

I’ve visited a certain eastern European country a couple of times. There I noticed very little homelessness. My hosts added that there was almost no issues with drug abuse. Why, I asked? Their answer was that in their country family structure and religion were very important. My hosts felt that these factors played a central role in limiting societal inequities.

Imagine expressing that view on #medtwitter now. Boom. You’d be gone! So I won’t.

Another example: Dr. Satel cites a Dr. Donald Berwick essay in which one of his calls to action is for doctors to oppose the electoral college. That’s a long way from electrophysiology.

I took some history in college, and I have been an American for a good while, but how is my medical degree relevant to arguing for or against the constitution of the US?

Yes, we can have a discussion about the electoral college, but why would Dr. Berwick think a large swath of the medical profession should advocate on one side of a debatable issue? in the matter of governance, doctors in smaller rural states might feel differently than those on the coasts.

The pandemic has given us another terrific example in the challenges of political activism. The American Academy of Pediatrics initially advocated for getting kids back in school. Others said this was foolish.

Let’s say you are a pediatrician and parent and your spouse is a teacher who happens to have chronic lung disease. Your professional society is advocating for re-opening schools. Your position is different.

Yet the school debate gets even more complex. Keeping kids out of school arguably hurts disadvantaged kids more than rich kids. Thus, on these grounds, could one go so far as to call such a policy, racist? I would not. But perhaps the nuance of advocating for solutions to societal problems comes out?

—

Doctoring is a great job. I love it. But cardiologists have no special expertise in fixing the societal forces that contribute to the higher rates of heart disease in disadvantaged groups.

I’ve written before that we should strive for more diversity in medicine. We should have more women and minority representation. I have no special expertise on how to achieve that. There is likely more than one way.

Trauma surgeons and emergency medicine doctors treat patients with gunshot wounds, but do they have any special insight into the best gun control policy? Yes, you could be for banning guns, but surely there are surgeons and EM docs who would disagree.

—

Doctors like anyone can and should participate in debates over policy solutions.

But, as a group, we have no special wisdom over any other citizen.

To act as if we do shows our hubris.

And hubris is a doctor’s greatest foe.

JMM

Deeper Worries in America

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I worry about the coronavirus. It’s already killed more than 100,000 Americans. The recent protests have created a nerve-wracking public-health situation for the next weeks.

I really worry about racism. Not only racism in police systems but more systemic racism in our culture.

My friend Dr. Andrew Foy sent me this slide and post showing the large disparity in black and hispanic representation in medical education.

There can be no rest so long as a man like Dr. Otis Brawley, a distinguished professor of medicine,

“can get thrown to the ground, handcuffed and questioned at gunpoint for looking suspicious in a nice part of Montgomery County. That would be yours truly a few years ago.

My real offense: standing in the garage of my own home.”

****

But I think there may be another great threat to this country.

Last night I read a story describing a situation in which the writer Andrew Sullivan would not be allowed to publish his column on the protests in the New York Magazine.

Sullivan is not just forbidden from writing for the New York magazine about the riots; his contract means he cannot write on the topic for another publication.

From Wikipedia: Andrew Sullivan is an openly gay Roman Catholic conservative intellectual. He has voted for Bill Clinton, and endorsed Barak Obama. And in 2006, Sullivan was named as an LGBT History Month icon.

The reason I am writing here is that my colleague in cardiology Usman Qayyum asked ….with so many problems right now, how is this important?

This is important because it indicates what could become a dangerous problem: the fall of classic liberalism.

If a sane calm intellectual like Andrew Sullivan can be silenced, what does that say for others?

Then there was the civil war within the NYT about the Tom Cotton editorial. I disagree strongly with the Senator’s view, but as a leading senator, should he not be allowed to make his argument?

Intolerance of ideas also extends into science:

Liz Neporent, the social media director at Medscape, had an important story on how YouTube initially removed a video on coronavirus from British oncologist and former chief of The WHO for violating guidelines. Initial efforts to have the video reinstated failed. It took more intervention from Medscape Medical News to get it put back up.

What was the problem? The scientist dared to express a view of the coronavirus that ran counter to the prevailing “consensus.” As if there could be any consensus with a months-old novel virus.

Hospital-employed doctors and nurses have grown used to not speaking publicly on anything contentious. So have many corporate workers.

But when this degree of illiberalism reaches the opinion pages of media, college campuses or social medial platforms, we have a big problem.

The obvious issue with deplatforming an idea is that if it can’t be debated, it cannot be proven wrong.

The late Christopher Hitchens, who we dearly miss now, once said or wrote: “time spent in argument is hardly ever time wasted.”

If the opposition to the current authoritarian regime, one that seeks to divide us, is an illiberal group that does not tolerate free public debate, I think we should be very worried.

JMM

P.S. After a thoughtful online discussion with Professor Alok Khorana, I have changed my choice of words in the seventh and eleventh paragraphs.

In the seventh paragraph, I changed the wording from ‘even greater ‘ to ‘another’ to define a threat to our country. In the eleventh paragraph, I changed ‘what could become a much more dangerous problem’ to ‘what could become a dangerous problem.’

By expressing my concern over the intolerance of ideas in policy and science, I did not intend to minimize racism.

P.P.S: Another edit. I cut the line “As a doctor, I am always looking for upstream causes of bad things.” I did not mean to imply the intolerance of ideas caused systemic racism.

More on COVID19 Testing and How This Virus Makes Us Use Our Noggins

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My friend Anish Koka, a cardiologist, wrote a beautiful review of COVID testing over at the HealthCareBlog.

The great pandemic is wreaking havoc, we are told, because the nation is not testing enough.  The consensus from a diverse group that includes public health experts, economists, and silicon valley investors is that more testing will allow the country to restart the economy and do it safely. 

No, it’s not quite that easy, Anish writes. You will learn a lot from his long column.

You might wonder why a COVID post from a cardiologist is worth reading. First, since COVID is novel, there are few true experts. Second, COVID tests are similar to cardiology tests in many ways.

Take a stress test; these are not black and white. A young patient with no risk factors and unusual symptoms who has a positive stress test probably has a false positive. A patient who smokes and has diabetes and typical chest pain who has a positive stress test probably has a true positive.

COVID tests are like that too. You have to think about likelihoods. You have to know the viral swab has problems with false negatives–you could have COVID infection and still test negative. The antibody tests have the other problem: you could test positive and not actually have the antibodies.

One of my hopes from this terrible pandemic is that it makes patients and doctors smarter about uncertainty. COVID19 is one giant thinking exercise. And if we think a lot we may collectively become smarter about healthcare.

The next time the doctor says you “need” some test, you might think about asking about the rates of false negatives or false positives. You might think what if I don’t get this test?

And since your mind is so sharp from all this thinking, you might think: what are the potential downsides, the unintended consequences of having this test? I have seen a simple $25 dollar ECG lead people into an odyssey of healthcare folly.

Dan Morgan, MD and I wrote about the pitfalls of cascades from testing in the open access journal JAMA Network Open.

JMM

Can We Discuss Flatten-the-Curve in COVID19? My Eight Assertions

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On Telehealth, an older couple asked me a tough question about COVID19. They asked whether this virus would either be gone or less dangerous in 6 months to a year.

It was a curious question. I replied, Why do you ask?

Doc, we have a big family with many children and grandchildren, most of whom live nearby. We miss them. We’ve been isolating, but it’s hard; we did it for 6 weeks. Doing it for a year or more would be miserable.

We saw on the news today that the battle with the virus would be long. A man called it a cruel new normal.

So doc, if you tell me the the virus will be gone in a year or it will be less dangerous to get infected later, then it makes sense for us to keep isolating. But if the situation will not be much different a year from now, we would just as soon see our family and take the risk. Of course, doc, we would still be sensible. We’d not visit if someone was sick; we would wash our hands and wear masks.

Indeed my patient was correct. Dr. Scott Gottlieb writing in the WSJ, did not mince words:

Hospitals and public-health systems will have to contend with persistent disease and death.

In essence, my couple asks whether flatten-the-curve policies save lives. Buried in that question are three other questions: namely, in one year, will the virus be 1) gone, or 2) less contagious, or 3) less deadly? If any of those three are true, then my couple could rationally decide to stay lonely for a year or more.

I study this new virus and this once-in-a-lifetime-situation every day.

I don’t think flatten-the-curve policies will change any of those issues. Let me explain my reasoning. I may be wrong; tell me if you disagree in the comments.

Flatten-the-Curve Purpose

You now know the famous curves–one with an early surge of disease, and the other flatter curve that spreads the infections over time. The y-axis is number of COVID19 cases.


In early March the COVID19 narratives were from Wuhan, Iran, Lombardy and Spain, places where surges overwhelmed hospitals. In the US, COVID cases spiked in NYC.

Early COVID19 surges were over-running some big-city hospitals. This was bad because it caused excess or preventable death–people who could have been saved were not saved because of shortages of ICU beds, dialysis equipment, staff and ventilators.

Social distancing policies and postponement of elective medical care were necessary to stop the excess deaths. These policies allowed time for hospitals to prepare for COVID19 cases and for doctors to learn how best to treat these patients. Exhibit A: not intubating patients early. 

Social distancing worked. The number of cases slowed and the US got into the blue part of the curve. But now, months later, the narrative has changed.

Change in Flatten-the-Curve Narrative

What was once flatten the curve to prevent over-running hospitals has changed to flatten the curve to save lives. Some likened moderation of social distancing to human sacrifice.

That change in framing, I believe, is misleading. I will argue that the cumulative deaths from COVID19 will not be reduced significantly by flatten-the-curve policies. And that this virus will be as dangerous to vulnerable patients in 6 months to a year. We should be allowed to debate this.

My case has eight assertions.

First: the virus will not be contained. The chance for containment has long passed. The virus transmits before people know they have it and many patients never develop symptoms. It will be with us until an effective vaccine is both widely available and widely used. (See #6)

Second: Tests will under-perform. The high rate of asymptomatic disease, the low sensitivity of PCR tests (false negatives), imperfect specificity of antibody tests (false positives) and concerns over privacy mean that we should expect less from test and trace–even if proposed by a Nobel Laureate. Carl Bergstrom and others write persuasively on major barriers to contact tracing in the US. 

Third: US hospitals are now prepared and in little danger of being over-whelmed. In fact, many hospitals are so dormant they are nearing financial ruin. Healthcare workers have been furloughed due to postponement of elective work. I’ve talked to numerous colleagues in the US and the message is clear: hospitals are under-capacity and prepared for a “persistent” number of COVID19 cases during the coming months/years. Hospitals now have COVID response teams.

Fourth: Americans are not stupid. Before governors enacted lockdowns, economic activity and travel slowed, the NBA, MBL, NHL stopped their seasons and medical meetings were cancelled. People socially distance not because police are bearing down on them, but because it makes sense. The pictures of spring-breakers in Florida and crazies-with-guns in state capitals bring clicks to news organizations but belie the majority of sensible people in this country.

Fifth: Public-health surveillance has improved. Tests may underperform but they will not be useless. Tests will help signal coming hot spots and that will allow communities to act locally. Other technologies may emerge that help prevent surges. One cool example is the use of resting heart rate apps that might signal health officials early on.

Sixth: (I need a few paragraphs): Social distancing will not lower the infection fatality rate or IFR. Remember the red and blue curves? The y-axis of that graph is number of infections. Due to the contagion of this virus, the area under these curves is likely to be the same at the end of two years. Ok, then, if the number of cases is similar at two years, then the number of people who cumulatively die will not likely change either.

The only way fewer people die from COVID19 over time is if the IFR declines. Here is where American exceptionalism misleads people. Politicians have a strong bias to pump up optimism on any potential medical advance–no matter how dubious. (Exhibit B- hydroxychloroquine.)

That is not how Medicine works. History is replete with examples showing that drug development is super hard. But leaving aside the challenge of developing new drugs against a new virus, the basic math of COVID19 creates a huge barrier for success: already, more than 99% of people infected with this virus survive. A therapy that has a massive 50% reduction in death from a disease with 1% mortality (high estimate) delivers only a 0.5% absolute risk reduction.

What about Remdesivir? This antiviral may help a little. But even if you believe its ≈ 3% reduction of death was not due to chance (p = 0.06), the death rate in the remdesivir arm in that trial was 8%. Remdesivir is no game-changer.

COVID19 vaccine development is sobering. Most experts say a safe and effective vaccine is at least 18 months away. Again, the 99% survivability erects a huge safety barrier for vaccine makers. (I get that from Dr. Paul Offit.) Given society’s tension over vaccines, it would take only a tiny signal of harm to derail a coronavirus vaccine.

A slight hedge on the sixth assertion that IFR remains constant: some smart people say that getting the virus later may be better because doctors will be a little better at treating this disease. For instance, a year from now we may better understand how to use drugs that block clotting; we may have better vent protocols. These are big ifs. They may drive the IFR down a little but IFR is already low. Another benefit of infection in a year would be that most hospitals will likely allow family visitors.

Seventh: The more we test, the lower the IFR goes. Early estimates had it at 3%. Then it was revised downward to about 1%. Now most people put it at 0.1-0.5%. But that is still quite serious. You’ve probably read that 0.1% is similar to flu mortality. That is likely wrong. Dr. Jeremy Faust points out that flu mortality is grossly overestimated and is probably much lower than 0.1%.

Eighth: I wrote a piece on Medscape about the harms from COVID19 interventions. One of the points I made is that right now we count only deaths from COVID19. We stay riveted on day-to-day numbers. But the endpoint of this crisis is not next month but in 1-2 years. And when we get there, we have to count people who died from COVID19 and those who died from other causes.

This preprint from prominent researchers suggests a substantial proportion of excess deaths observed during the pandemic are not attributed to COVID19 and may represent an excess of deaths due to other causes.

In my column I cited an older study by Raj Chetty and co-workers that finds a strong association of lower income and lower survival. And that is the rub with COVID19 interventions: they make poor people even poorer. The rich just work from home. It is possible, therefore, that our social interventions will be especially hard on the disadvantaged.

I realize that no person overtly dismisses the harm from economic shutdowns. My friend Dr. Dan Morgan expresses my frustrations well in this thread. Why can one safely critique a drug for COVID19 but not massive public health interventions?

Conclusion:

I did not have a clear answer for my couple. But after thinking and writing about this question it seems that the most reasonable approach in this crisis is transparent information–no matter how stark. And, crucially, we must have space for public debate.

I hate this virus. I wish it never came. But we can make it worse by avoiding hard discussions on tradeoffs, the limits of modern medicine and risk.

JMM

P.S. At 173 comments, I cannot keep up the moderation. Thanks for your interaction. I have closed the comment thread.

2020 Mandrola Update

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Many things have changed in my life.

I still practice electrophysiology full-time in Louisville. I still write. And I still love endurance exercise.

You haven’t seen many blog updates because my writing has taken different forms.

One is academic writing. In 2019, I co-authored 21 academic papers. Here is a link to the papers on PubMed. This has been an exciting turn. I love being on the steep part of the learning curve for new stuff. Make no mistake: I am a beginner-academic.

Much of my academic work centers on the state of medical evidence. One of the studies I am most proud to have worked on is this evaluation of the prevalence of spin in the cardiovascular literature. Sadly, language designed to distract is damn common in medical science. Caveat emptor.

I am also grateful to Dr. Roderick Tung from the University of Chicago for inviting Baptist Health Louisville to participate in the first ever head-to-head randomized controlled trial of His-bundle pacing. This study garnered the big stage at the Heart Rhythm Society meeting and its findings were published in two leading cardiac journals–JACC and Heart Rhythm. (We kept the spin to a minimum!) Being part of an RCT was almost as nifty as pacing the his bundle.

  • That image is intoxicating.

A cool thing about the time we live in is the ability to have mentors all over the world. Here, Dr. Andrew Foy and his team at Penn State University in Hershey PA, deserve mention. Andrew is a true academic; he has helped me understand research methods. We have published many papers together, including my favorite: The Case for Being a Medical Conservative. Kudos and gratitude to the American Journal of Medicine for publishing our essay, and not putting it behind a paywall. Thanks also to the EconTalk podcast for devoting a show to the conservative approach to medical practice.

Another writing form that occupies a lot of my time is podcasting. Every week, I review the top 3-5 studies in cardiology. The podcast is called This Week in Cardiology. It’s produced and published by theHeart.org | Medscape Cardiology.

I was wrong about podcasts. Years ago, when my editor approached me about doing a weekly podcast, I was resistant. But now I hear from listeners all over the world. The strength of the podcast as a medical educational form has been stunning.

Malcolm Gladwell said (or wrote) that he started Revisionist History because he was afraid that if he didn’t, his writing would not reach younger people.

I think Gladwell was right. Most (but not all) the people who reach out to me to say they listen to TWIC are young. This makes me happy because I love teaching.

I still write for Theheart.org | Medscape Cardiology. You can find my columns at Musings From Mandrola. One thing you should know about Medscape is its professionalism. The news and editorial team have given me great faith in journalism. My columns may be called blogs, but the editorial oversight and fact-checking there far outpace most academic articles I have published.

The other major change in the way I create content is the lecture. In 2019, I was honored to speak in Park City, New Orleans, Phoenix, Vilamoura Portugal, San Fran, Chicago (at an oncology meeting), Paris, Venice, Rzeszów, Poland, Edinburgh, Scotland, Los Angeles, Salvador Brazil and Philadelphia. Meeting colleagues across the world is a thrilling life experience.

Three special notes: doing real cases in Poland with Piotr, Pasquale, and Jaro.

And meeting in real life, the Professor Darrel Francis:

And to you Dr. Andrew Flapan: thank you to the power of ten.

Finally, on the exercise front, I have retired from criterium and cross racing. These are for the young. I still ride my bike but no more in anger.

To fulfill my exercise addiction, I have gone back to running. This year, while in Poland, I ran the Rzeszów Maraton–an unforgettable memory. Thanks Arek, Magda and Piotr. This image is from the start. The image at the end is different. Hey Arek?

I know; the maraton is silly. But I will try another in 2020–to redeem myself for cracking in the last 10k in Poland.

Far smarter is a 5k run by the sea. Thank you, Dr. Luis Correia

If you don’t use Twitter, you should. It’s a brilliant medium for those interested in medical science. I am here @drjohnm

JMM

Missing an Obvious Cause of Medical Overuse

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This post introduces my latest column over at Medscape. I hope you go read the full piece. 

Medical overuse bothers me. Consuming medical care that does not improve outcomes makes you poorer, and puts you at risk for being harmed. 

I think a lot about why Americans consume more healthcare than our peers in other countries. This would be a no-brainer if excess spending led to better health. But it doesn’t. 

If you consider healthcare as a simple transaction for health, excess consumption without better outcomes forms a puzzle.

I have written before about the most obvious reasons American healthcare is so wasteful: profit motives of doctors and hospitals in a fee-for-service system, the human bias for action over watchful waiting, and ignorance of medical evidence. 

But maybe there is another more basic force at play. What if it comes down to the hidden motives embedded within human behavior? 

Over the holidays I read a terrific book called The Elephant in the Brain by Kevin Simler and Robin Hanson. It felt like a Eureka moment.

The writers’ core idea is that humans are social animals competing for power, status and mates. Due to evolutionary and social forces, humans are not only capable of acting on hidden motives, the authors write that we are designed to do it. “Our brains are built to act in our self-interest while at the same time trying hard not to appear selfish in front of other people.” 

In short, we signal. Three examples: In education, we say we are going to college to learn, but really, we go to get a certificate to show off our intelligence; in art, we say we appreciate beauty, but really, we use art to signal our cultivated elite status; in charity, we say we give to help people; instead, we use charitable giving to raise our social status and signal our value as an ally.

How does signaling apply to medical overuse? The authors use the example of the mother who kisses the scrape of her toddler. No healing takes place, but both parties appreciate the ritual. Key word: ritual. The ritual is conspicuous caring. 

Think about it: If healthcare was only about health, you would expect people to pay for, and clinicians to prescribe, only treatments in which benefits exceed costs. But conspicuous caring provides a (hidden) reason for demand that leads to consumption beyond the point of value.

The family who pushes the elderly parent to accept aggressive chemotherapy and the healthy executive who insists on silly heart imaging tests. These are signals of conspicuous caring. AF ablation has yet to be proven effective in a placebo-controlled trial. Yet, due its invasive nature, it puts out a big signal of conspicuous caring.

Such hidden motives explain a number of observations. 

Conspicuous caring explains why people shun simple remedies, such as stress reduction and better diet, but embrace fancy care with showy gadgets. (Think robotic surgery.)

Conspicuous caring explains the focus on public rather than private signs of medical quality. For instance, people still prefer doctors over advanced practice professionals for primary care—even though trials show similar outcomes.

Conspicuous caring motives also predict society’s reluctance to openly question medical quality. To the degree that medical care serves as a gift, it breaks a norm to question its quality. References: second opinions are uncommon and skeptical views of medicine carry a bit of a taboo.

The reason I wrote about Simler and Hanson’s idea is that for twenty years of practice I have missed the elephant in the room—or in this case, the elephant in the brain. Of course, John, human behaviors surely lie at the core of why we accept so much low-value care.

The other reason why this idea is important is that policies that ignore hidden motives may completely fail.

Take a look at my column. Read the book.

Let me know what you think. 

We get what we tolerate…

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Richard Fries, a cycling-safety advocate in Boston, uses the phrase we get what we tolerate to describe the dire situation of drivers killing cyclists and pedestrians. Many humans die from these collisions because we tolerate it. An inattentive driver kills a person on a bike; then nothing changes.

The phrase applies well to other dubious policies in the US. Before a gunman slaughtered 60 innocent people with a machine gun in Las Vegas Sunday night, I had planned to use the we get what we tolerate phrase in health care policy.

I was going to argue that US citizens pay too much for medication, navigate a morass of bureaucracy to get to their doctor, and succumb to capricious insurance companies for important medical decisions because we tolerate it. We get an unjust healthcare system because it’s what we tolerate.

Then came another gun massacre.

We also tolerate gun violence. Every damn time a mass slaughter occurs, the “thoughts and prayers” go out, and nothing changes. The comparative graphs of US gun violence to any other country boggle the mind.

During a fishing trip in Alaska this summer, the boat captain told me nearly every Alaskan has a gun. Guns, he said, are necessary if you live in the wilderness. I then asked if they have gun violence in Alaska. “Almost none,” he said.

The thing is: most of the US is not an Alaskan wilderness. Bears do not wander into most of our cities and suburbs. The lack of gun violence in Alaska, therefore, does not argue for arming teachers in suburban schools.

I don’t fancy guns, but I understand some people do. That is fine.

But, similar to the healthcare debate, it seems we could start a civil discourse with new set points. For instance, let’s agree on the notion that citizens need not own assault weapons, which are essentially war machines. Could we at least discuss how to register and regulate gun purchases?

I suspect a majority of citizens–even most gun owners–would favor a ban on assault weapons and some degree of gun registration.

Consider the we get what we tolerate phrase in relation to other public safety issues:

If plane crashes killed a fraction of those killed in gun massacres, there would be an outcry for aviation safety.

When infections threaten the population, people clamor for preventive therapies.

Society gets aviation safety and protection against microbes because we don’t tolerate unsafe planes and the spread of dangerous infections.

When we decide not to tolerate gun violence, dangerous drivers, and an unjust ineffective healthcare system, things might change.

JMM

Uplifting book — The Rosie Project

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Good book alert: This holiday weekend I read The Rosie Project by Graeme Simsion.

Simsion sets the story of a nutty genetics professor in Melbourne, Australia.

The book is sweet, funny and uplifting. It’s a perfect escape from the mean-spiritedness of today’s news cycle.

An Australian electrophysiologist who I had dinner with during the recent HRS meeting recommended the book to me. The sequel is called the Rosie Effect. I’ll read that one next weekend.

I hope the Rosie Project gets made into a movie. It’s that good.

JMM

Changing the mind of a doctor — Not an easy matter

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Changing one’s mind is hard. Changing the mind of doctors is even harder.

Doctors are supposed to be the medical experts. Often we are. But sometimes I wonder whether our attachments to old ideas gets in the way of seeing the obvious.

I am reading Michael Lewis’s book The Undoing Project. Learning how Kahneman and Tversky made their discoveries gets me thinking about how our minds trick us into missing important clues.

The information age levels the degree of expertise. Of course an internet connection and a smartphone does not transform people into skilled and experienced clinicians. What connectivity does do, however, is it allows anyone to look up the current evidence for or against a medical intervention.

In some cases, people without preconceived notions may be better judges of medical evidence.

Davide Epstein is a reporter for ProPublica and author of the Sports Gene. He’s written an important article on how tough if it is for doctors to incorporate new medical evidence into decision-making.

It’s called When Evidence Says No, but Doctors Say Yes.  It’s worth your time.

I am quoted in it. So are lots of other giants in the field of common-sense medicine.

JMM

Politics and Understanding the Human Condition

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This is not the first time I’ve been scolded for straying from medical topics. Last October, during the Lown Institute’s RightCare Action Week, I wrote about our ailing healthcare system. This prompted a different reader to send a similar message: Stick with topics about atrial fibrillation–went the gist of that terse note.

My first reaction to these rebukes was displeasure. Most people like to be liked, so getting negative reviews stung a bit.

But then I thought about the issue of doctors expressing political views. Maybe I should stick to medicine. I asked around.

A surgeon friend said he avoids politics and religion in all public discourse. He cited concern about mixing personal and professional voices in public. This surgeon is thoughtful and wise. His view gave me pause.

My virtual mentor and friend Dr. Bryan Vartabedian wrote a brief post on the issue. Doctor_V is an expert in navigating the public space.

He concluded with a question:

So the question of whether to weigh in on presidential politics as a public physician should be based on purpose of presence. Why are you public?

That helped me decide how to react to those who don’t like it when I stray from medicine.

I decided that my public voice is not merely as a specialist in a disease that affects millions of people. Patient education is part of my public voice. Sure, I know the heart rhythm; and it helps me, and perhaps others, to share a digital notebook of sorts.

But I am in the public to do more than provide medical facts.

As a doc, I am in the people business. Being a doctor requires understanding the human condition. This quest leads me to history, literature, behavioral psychology, statistics, writing, and yes, even politics.

Non-physicians have much to teach about the human condition. Would you be surprised, for instance, if Harry “Rabbit” Angstrom suffered from AF? I would not.

I spent much of my life learning how molecules and cells and organs work. These are important lessons.

But so are the human lessons one gathers from reading people like John Updike, Philip Roth, David Foster Wallace, Margaret Atwood, George Orwell, Noam Chomsky, Christopher Hitchens and perhaps the grumpiest of them all, Henry David Thoreau. I also love Sylvia Boorstein.

I stray from medicine because I am a public learner.

One way to get better at medicine is to think about how you think. Learn from mistakes. Consider biases. Avoid attachment to dogma. It’s the equivalent of reading The New Yorker and the Wall Street Journal.

The overused word amazing is defined by “casting great surprise and wonder.” Could there be a better word to describe the situation of humans in the United States?

To ignore what drove us to this political place in American history would be like treating AF with only an expensive catheter.

JMM