Change is So Hard

August 20, 2007 at 10:57 am · Filed under Health IT, Business of Health, Research

As a young man it seemed probable to me that life would become better for everyone. After all, our combined annual budgets in the United States and Europe were enough to make the entire world a better place for everyone.  If we had decided to make it happen, there was enough money for every person to have a home, a car and a job.

Vietnam would be our last war ever.  We would find a substitute for sugar so that we would no longer be overweight.  A replacement for butter, trans fat enhanced margarine, would ease the population away from the epidemic of heart disease, and the cure for cancer as declared by President Nixon, was only a few years away.  Finally, we would have a four day work week and spend quality time with our families.

Thirty years later.  One must wonder just exactly what went wrong?

Daniel E. Koshland Jr in his article the Cha-Cha-Cha Theory of Scientific Discovery describes scientific discoveries as “the steps—some small, some big—on the staircase called progress, which has led to a better life for citizens of the world.”

In its purest sense, Mr. Koshland is absolutely correct in his description.  The problem is that we, as a population, as a species, as a herd, tend to fight change at every level at all times.

In the book “Change or Die” the author, Alan Deutschman, discusses the reality that when cardiologists tell patients with heart disease that they have to “change or die,” nine out of ten fail to switch to healthier lifestyles, 90% of us would knowingly select death rather than change.

Truthfully, when you consider how long we have held onto the outdated, inappropriate practices of the Industrial Revolution, it is fascinating to me that science has evolved at all under the current system, a broken system about which I have written numerous times.

So, we go to the question list:  What can be done to change science?  What can be done to change health care?  What can be done to change man’s inhumanity to man?

Short of a national tragedy, like a pandemic of the avian flu, we continue to embrace old realities that are no longer appropriate.

Collectively, however, we are approaching a major paradigm shift internationally that has been fashioned by the enormous technological advances that our world has been experiencing during the previous decade. Predicated upon the fact that we are now totally and completely tied to each other world wide for the first time in history, this transformation could potentially result in the broadest societal change that the Earth has ever faced.

We are hooked up on multiple levels. From the mountains of Afghanistan to the deserts of Saudi Arabia, from the Arctic to Siberia, our fellow human beings have wireless communication devices that provide contact capacity where it had never existed before.

We now have the ability to commune through the Internet, through cell phones, through Treos and Blackberries with almost anyone anywhere in the world. When teenage kids join each other in chat rooms across continents, nothing goes unchallenged. Regardless if it is the misstatement from leaders, from clergy or from a shock jock, they now have the ability to confirm, verify and validate immediately and completely by tapping some keys or simply calling each other.

This quantity of massive change has resulted in anger, fear and a certain amount of chaos as we struggle to define new pathways in our culture.  All of this is because this connectedness has begun to create new truths and new accountability.

What we have experienced over the past several years has been a reaction to this new world order, a very conservative movement that results from that fact that when life becomes more challenging, we tend to go as far back into our conservative past as we can to find whatever we can attach ourselves to so as to protect our future from change to help us cope with the fear of change.

Let’s hold on for dear life and hope that this potential revolution allows us to change the pursuit of truth through science and to allow our health delivery system to evolve into a useful system more appropriately directed toward chronic illness and prevention.

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What Exactly Does “Risk” Mean?

August 14, 2007 at 11:03 am · Filed under Policy Makers, Population health management, Research

I have noticed a disturbing inconsistency in the use of the word “risk” when describing the occurrence of certain “risk factors” and the nasty things for which they are reported to be a risk.  One meaning of the term, and one that seems to be the most popular meaning in the popular press, involves reports that when a given risk factor is found, it is often accompanied by the nasty thing.  So when it is found that both obesity and diabetes have grown at alarming levels in recent years, for example, and that people who are obese are more likely to have diabetes, it is reported that obesity is a “risk factor” for diabetes.

The trouble with any such conclusion reached through “cross-sectional” analysis, i.e. a simultaneous look at two factors in a given population at one time, it is literally impossible to tell whether one tends to cause the other, or vice versa, or if there is no causal connection at all.  For example, if it is found that people who drink a lot of sodas, whether sugary or diet, tend to be more likely to be overweight and obese than those who refrain from sodas, relatively speaking, what does that show?

The answer is – absolutely nothing, except that they seem to occur together.  It could be that some people who drink lots of sugary sodas are obese because their intake greatly increases their daily calorie intake, and they naturally gain weight.  At the same time, other people who are already obese may have shifted to diet sodas in a vain hope to lose weight, while continuing to eat high-calorie foods and engage in little exercise, both of which tend to preserve rather than correct obesity.  Or it could be that both are signs of a “sweet tooth” preference for foods that naturally tend to be high in calories, and this general preference, rather than the ingestion of diet sodas is what causes obesity.  Or there might be no causal connection, whatsoever.

The point is that the only way to arrive at a logical guess as to whether there is any causal relationship between two factors, and which causes the other, is to perform a “longitudinal” analysis, which follows populations to see if introduction of that factor into one segment of that population, where no other significant differences exist between the two segments, is then followed by a difference in the occurrence of some nasty thing.  All other definitions and applications of risk identification can mislead as often as they help focus health improvement attention.

The fact that the illogical and limited definition and application of “risk” in the purely statistical artifact sense is by far the most common choice in popular media is simply another reason for people to treat media stories with some skepticism.  It is unfortunate that mass media, which could be a major and meaningful ally in efforts to protect and improve the health of populations, is instead a major source of doubtful or misleading information.  And the fact that third-party payors do not even compensate healthcare providers for countering such misleading information is another indictment of the insurance industry.

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Is anyone really focused on fighting cancer in this country?

August 8, 2007 at 2:34 pm · Filed under Drug Development, Research

As a young, Baby Boomer, I remember President Nixon’s declaration of war on cancer.  Billions of dollars and thirty years later, I became part of the Medical Industrial Complex, and now marvel at the disconnect called cancer research that exists in this country.

In a recent New York Times op-ed by Shannon Brownlee, she posed the following question, “Has the profit motive gotten in the way of finding a cure for cancer or better treatment?”  She goes on to question, “Could it be that at least some of the $100 B we spend each year on detecting and treating this disease is . . . to prop up hospital finances?”

Obviously, with my hospital administrator hat on, that question felt very uncomfortable, but I’m carefully avoiding the obvious answer and will point you in the direction of our already seriously strained health care system, a system that is attempting to preserve the status quo in a time of significant demographic change that, in my opinion, is not sustainable.

It always reminds me of the chilling question posed by one of my professors in Graduate School, “If the town has three brain surgeons and it only needs two, which one doesn’t drive a Mercedes?”  The answer then was, “They all do.”

Concurrently, the issue of funding cancer research continues to raise it’s ugly head, and, reading the opinions of people like Dr. Susan Love, Nancy G. Brinker from the Komen Foundation and David Perlin, director of the Public Health Research Institute regarding this issue, it has become painfully clear to me that the research system in this country is broken as well.

The problem is that it is a system of small science, a system that currently dominates our NIH/NCI, academic medical center approach.  Organizations that have embraced the concept of sharing information, working collaboratively on all levels, and not rewarding individuals for keeping secret their theories and discoveries can easily become causalities in the fiscal environment that dominates our federal research funding mechanism.

We are spending 30% of our health care dollars on the last thirty days of life with little or no possibility that we will cure or improve the status of the dying individuals.  We are continuously, financially stroking those individual divas that discover their secret sauce and then have no incentive to share their findings because it may interfere with their personal grant streams.

We are rewarding unendingly the finances of our oncologists through profit sharing relationships with pharma, but do not see that as a conflict in any way.  We will radiate, administer chemo, and treat unnecessarily or unproductively until death actually arrives.  All of these decisions represent huge health care expenditures.  The majority of our medical schools have still not embraced hospice and palliative care, and the result is also a financial train wreck.

The United States has no science policy and no health care policy except to feed the current system.  If you doubt that, visit the $1B hospital constructed on the campus of NIH that has an average daily census of well under 100 patients as just one example of a broken system.

Someone has to stand up and be counted or this system will crash and burn with no significant steps taken to fight the war or find the cure.

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Science…

July 17, 2007 at 11:29 am · Filed under Business of Health, Research

One or our lead scientists from the research institute forwarded a piece to me written by Janet D. Stemwedel regarding Clarity and Obfuscation in Scientific Papers on her blog Adventures in Ethics and Science. She humorously explores the spin that is placed on scientific papers with catch phrases like “It has long been known,” “I don’t know the original reference” and “Typical results are shown.”

Numerous scientists commented on this post. One stated, “While people may have become scientists because they wanted to learn more about the natural world, that is only a side effect of the enterprise they are actually engaged in, and the enterprise on which they are judged and for which they are rewarded. What they are really engaged in is a race to prestige . . . There is a pattern that we have to oversell our results in an attempt to make ourselves each look more important than perhaps we really are . .. Unfortunately, we each have our own livelihood to look out for, which, given the way the system is put together, often pushes us in the wrong direction.”

Finally, PhysioProf wrote, “It seems to me that the reason we have to attend to these details in the first place turns largely on the set-up of a scientist vs. scientist competition instead of scientists against the world, i.e., working together to work out the truth.

With that revelation, if any of you are still reading, let me reveal my personal intellectual property as to how we have put together our research center and how, at least I believe, science should operate. All of our scientists are given the opportunity to explore the same pristine samples that are collected meticulously by physicians and techs from a 40 page protocol that we developed.

Our data flows collectively into one large data repository to which all of our scientists have access. They are discouraged from keeping their data on their hard drive.

Scientists of all disciplines are encouraged to work on the same projects so as to bring a complete diversity of knowledge to the table.

All the grant monies come from combined applications so that jobs are not lost from lack of funding, lack of performance, yes, but not lack of funding.

Physicians represent a large part of our work as we actually dedicate our efforts toward helping them solve medical problems that can save lives. This is translational medicine.

Simple to see through the eyes of a non scientist, but difficult to change in a world built on getting there first as opposed to getting there together at whatever cost.

For background on our research center, see WRI: Preventive, Personalized Medicine, a short video profile available on YouTube.

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