I apologize in advance for the somewhat scattered nature of this post. I'm trying to work through some ideas.
What I'm trying to figure out is whether certain cost problems in the US health care system can be solved using free market approaches or whether solutions require government intervention. The nature of the problems I'm looking at arise as a consequence of conflicting interests between insurance companies, hospitals, doctors, and patients. Any solution has to find a way to harmonize the respective interests of each. Recent evidence suggests government action works, although the case is far from certain. Also, supposing there are equally effective free-market solutions we still must ask why we'd chose one type of solution of the other. Let's get some statistics on the table first to get a general overview of the US health care situation.
Give or take a few, total US expenditures on health care in 2013 was 2.9 trillion. When we average that cost over the population the average per person's cost is $9, 225.00 (2013). To give those figures some context, OEDC average per person health care spending is $3, 448. The next highest spender is Switzerland at $6, 080.00 per person. Despite the familiar mantra of "but we have the best healthcare in the world", the US performs comparatively poorly in terms of many health outcomes. (To be fair, there are also a few areas where it doesn't, such as wait times for specialists and surgeries, and for cancer treatment outcomes.) Currently, health care costs represent about 17% of US GDP and is expected to rise to 22%, whereas the OECD average is 9.5% of GDP, the next highest being the Netherlands at 12%.
If you're like me, your thinking, "wait a minute, I didn't consume even close to $9 000.00 in health care this year. Where is this number coming from?" In other words, we can't just look at averages, we need to know how those costs are distributed across the population. That information will allow us to target cost saving policy at the costliest populations and/or health issues. Are you ready for your head to 'asplode'?
In a single year, what percentage of total health care dollars spent do you think went to the top 5% of health care users? (I.e., the sickest people). Ready? About 49%. That's right. Just 5% of the population consumed almost half of all health care dollars spent in a year. Now, what percent of the total health care dollars spent do you think went to the top 1% of health care consumers? Ready? The top 1% of health care consumers consumed about 30% of the total health care dollars spent in a single year.
Ok, let's look at the other end of the spectrum. What percentage of total health care spending did the bottom 50% consume? (I.e., the healthiest people or those with the cheapest conditions to treat). Ready? It's 3%. Yup, 50% of the population only consumes about 3% of the total health care dollars spent in a year.
(For more fun facts about the distribution of health care spending, here's a--wicka wicka--breakdown)
So, why--beyond shock value--should we care about these statistics? Because if we're going to set policy to decrease health care costs we're going to get way more bang for our buck if policy is directed at the top 5% of users rather than everyone all at once. There's very little to be gain by reducing the health care costs of the healthiest 50% whereas there are very likely cost savings available from the top 5%.
We might ask why treating this population is so expensive. To figure this out we need to know if their treatment is expensive because of the nature of the conditions for which they need treatment or the way the conditions are treated/billed/managed or they're always in and out of hospitals or it's some combination of all of the above.
It turns out that the 5 most expensive conditions to treat are heart disease, cancer, trauma, mental disorders, pulmonary conditions. But if only a small percentage of the population has these conditions, they won't account for the high costs. What we need to know is both what conditions are the most prevalent in the population and of those, which are the most expensive to treat.
A quarter of the population has at least one of these five chronic conditions: diabetes, heart disease, asthma, mood disorders, or hypertension. Unfortunately, each of thes conditions is associated with other conditions and illnesses. Treating the primary conditions in conjunction with the associated illnesses accounts for 50% of all health care spending.
How do we put all this information together? If we want to figure out a way to reduce costs, clearly we want to go after the most costly people and conditions to treat. And if those two variables overlap, that's probably a good target. So, how should we do it? Does government need to implement some sort of policy or are there free market solutions? To answer this question I want to use as a case study of one hospital's method of reducing treatment costs. There are other successful models for cost reduction as well which I'll also look at briefly. The point I want to establish is that it is possible. Not only is it possible, but these successful models reduced costs, increased quality of care and health outcomes.
What I really want to know is whether these models were a consequence of government policy (i.e., the ACA) or whether they could have come about without a government mandate. If the reply is the latter, we must ask the obvious question: Then why didn't it happen pre-ACA? The pro-market person can correctly point out that it did in a very small handful of cases. Just look at the Mayo clinic and an HMO in Colorado. But there's a further question lurking. If these models were so successful, why weren't they copied? Presumably, when someone finds a superior business model, other businesses must copy it or lose out.
The pro-market person might reply that the regulatory environment pre-ACA interfered with market forces such that efficiencies weren't realizable. But their own example--the Mayo clinic seems to undermine this argument. I'll have to investigate this claim. On the other hand, the ACA (government action) brought in (Medical) Accountable Care Organizations (ACOs). ACOs are voluntary programs that reward Medicare and Medicaid providers (e.g., hospitals, clinics, doctors, etc...) for cost savings through innovation. Health care economists and pretty much anyone else that works in health care policy have known for decades that preventative medicine and coordinated/managed care (this is when groups of specialists are paid as a team to manage patient outcomes) is the best way to bring costs down and improve patient outcomes. So, why wasn't anyone doing these things pre ACA? Why didn't market forces converge on this more efficient model?
My answer is that there were two prisoner's dilemma-like situations. The first is between health insurance companies, the second is between doctors and hospitals. Let's take a look at the first. The health insurance business is an odd one. You're trying to sell a product that you hope your customer will never use. And so, the best customers from the insurance companies' point of view are the healthiest ones. Every one wants the healthy customers. No one wants the sick ones. Here's the deal with preventative care and managed care programs: Setting up these programs requires up-front investment that won't see returns for up to 5 years.
Here's the problem. If you're the only insurance company that invests in a preventative and managed health system you're going to have lots of healthy customers. This might seem good until you realize that you're the only one that invested in the program. What are the other companies going to do? They're going to try to poach your customers! You invested all that money and created healthy customers and now all the other insurance companies are going to swoop in and steal all the healthy customers you created. Seeing how this might happen, no insurance company wants to be the sucker--even though they want to have healthy customers! And so no insurance company makes the up front investment and we end up with no cost saving measures.
It looks like the only way you can get the health insurance companies to make the up front investment in these cost saving measures is if somehow "someone" gives each company assurances that all the others will do the same. This way, no one will end up a sucker by being the only one to make up front investments only to have the new healthy customers poached. It looks like the government is that "someone" who can offer the assurance by mandating preventative care be part of health care insurance policies. Doing so allows the insurance companies to exit the prisoner's dilemma.
The second prisoners' dilemma occurs between doctors/care providers and insurance companies (I'm less sure if this is technically a prisoner's dilemma, it might just be a more general case of conflicting interests). Doctors and care providers (e.g., hospitals) want to get paid more money rather than less. Insurance companies want to pay less rather than more. This leads to high costs. For example, if a doctor is charging for every test he orders and every minor consultation, he's likely to order more tests than is necessary. In fact, there's good evidence that this happens. Consider this data from 2012. For some types of tests, US doctors order significantly more than their OEDC counterparts. So, how do we get doctors and hospitals to move to a managed care model? I.e., where they aren't necessarily under a fee-for-service model or at least where they're under a model that doesn't incentive ordering unnecessary tests and procedures?
Again, it looks like at least one answer is through government mandate. ACO programs under the ACA are voluntary for hospitals to enter. Hospitals get to share whatever cost savings the hospitals generate through managed care initiatives. Interestingly, the hospitals are free to experiment with whatever managed care models they want. So, if the hospitals save medicare and medicaid 2 million compared the previous year, the hospital gets to keep just over half of the savings. The program has been a huge success. Here are a couple highlights:
In the first year of the program 58 Shared Savings Program ACOs held spending $705 million below their targets and earned performance payments of more than $315 million as their share of program savings. Total net savings to Medicare is about $383 million in shared savings, including repayment of losses for one Track 2 ACO.
In the second year Pioneer ACOs generated estimated total model savings of over $96 million and at the same time qualified for shared savings payments of $68 million. They saved the Medicare Trust Funds approximately $41 million.
Where We At?
So far it looks like there's a strong case to be made that government action can solve many of the cost problems with the US health care system. Of course just because the government can solve these problems it doesn't follow necessarily that a market-based solution couldn't solve these problems. Some might even argue that the problems arose in the first place as a consequence of government intervention in the market. I'll look at these arguments in the next post. For now, amaze your friends with your new-found knowledge of healthcare statistics.
Wednesday, May 20, 2015
Friday, May 15, 2015
Day 3: Psychological Jade and The Arrogance of Ignorance
Introduction
Before reading this, I suggest reading my post from yesterday since most of what I talk about here relates to it (and I end up retracting most of what I said).
'The arrogance of ignorance' is one of my favorite phrases. I'm not sure of its origins but I heard it first from Dr. Steven Novella. I think the phrase is the best way to capture a cluster of common cognitive errors. In no particular order: a) Assuming that because you are knowledgable in one domain that you know a lot about another (or are able to correctly evaluate another). b) Moving from small data sets/anecdotal experiences to broad conclusions. 'The arrogance of ignorance' is a close cousin to the Dunning-Kruger effect: You have so little knowledge of a particular domain that you are unable to assess how little you actually know and grossly overestimate how much you do know, in turn leading you to wildly wrong conclusions.
Anyhow, yesterday I was guilty of all of the above crimes. You'd think a guest pass to a hospital and a few hours of observation would give me enough authority and knowledge to correctly evaluate an entire subfield of medicine. Strangely, it didn't.
Today I went back to inpatient psych, and boy am I glad I did (from a pedagogical point of view). Let me try to both convey my experience and undo some of the misconceptions I had.
Sample bias
Most of the patients I met yesterday had been in the hospital for over a week. I was meeting them after they'd undergone treatment and had been stabilized. Of course they seemed normal to me! As I learned (and hopefully you will too once you read this post), what I did was the equivalent of walking into a surgery unit and looking only at the patients about to be discharged, then asking"why did they need surgery? They look fine to me!"
So, what are patients like on admission and early in treatment?
Obviously there are a variety of disorders but all of them are severe. Here's the thing, unless you work in a hospital or have someone in your family with a severe mental illness you've probably never actually seen severe mental illness. To most of us, this is an invisible population because most of their lives are lived in care homes or in institutions and, unfortunately, in the streets.
The patients range from very well-spoken with linear thought to having only elementary vocabulary with disjointed unintelligible thought, and any combination of the above. Regardless of where they fall on the spectrum, most of them suffer from severe delusions. Some examples: (1) Being part of an intergalactic group of assassins being pursued by the (intergalactic) mafia, (2) believing that a family member is dead who isn't and all the evidence they have should lead them to conclude the opposite, (3) being pursued by terrorists and (actually) destroying windows and cars to avoid/prevent the terrorist plot, (4) having voices in their head telling them to kill others or kill themselves. There were more but this should suffice.
Interestingly, the ones that had grand conspiracy delusions, e.g., (1) and (2), were extremely pleasant to talk to. If you were to have a conversation with them and the content of the delusion never came up, you wouldn't suspect a thing. It was as though they simultaneously inhabit two realities. When you ask them, they know where they are and why they're there. They'll say "I just want to get better" but at the same time they'll discuss their delusions as though they're just as real as the chair they're sitting on.
Unlike what I hypothesized yesterday, these people don't "just need a little more social and material support." That's the equivalent of saying someone with cancer can be healed with a back rub.
I think my reaction yesterday is probably analogous to what happens with many deniers of modern medicine. They've been in the hospital to visit a friend or they read some article online--maybe even spoken to a disgruntled doctor. But they've only seen 1 billionth of the data set, and only from the patient side of the bed. Things look very different from the doctor's side of the bed and as you get a larger data set...
Tip of the Iceberg
Another factor that led me to my (wayward) conclusions yesterday was I didn't ask enough questions about case histories. Once you read the case histories, your perspective will change very quickly. Every patient in there has a lifetime history of psychosis that is well documented. Almost all have been suffering the same symptoms since adolescence. Some have their condition for unknown or unknown biological reasons (usually genetic, as it runs in their families), others (there were 2 there) had suffered major brain injuries at some point earlier in their lives and haven't been the same since, others have their condition as a consequence of a life-time of substance abuse. For many it was a combination.
Someone who thinks that a little positive thinking or mere talk-therapy is going to solve these people's problems is extremely naive--like I was yesterday. Someone who thinks along these lines is mistaking people who have one-off breakdowns or depression with this other population. Like I said, unless you work in a hospital or have a family member (or work in law enforcement, probably) it's unlikely you've ever met anyone from this unfortunate population. Until you do, you can't fathom just how serious it is.
Philosophy of Science Lesson: Depression and Jade (Bear with me, You'll See How this Relates in a Moment)
What is jade? Up until the 19th century it was believed to be a kind of mineral. However, a French mineralogist (Alexis Damour) discovered that it was in fact two distinct minerals: Jadeite and nephrite, each with distinct chemical and structural properties. Nephrite is a microcrystalline interlocking fibrous matrix of the calcium, magnesium-iron rich amphibole mineral series tremolite (calcium-magnesium)-ferroactinolite (calcium-magnesium-iron). Jadeite is a sodium- and aluminium-rich pyroxene. The gem form of the mineral is a microcrystalline interlocking crystal matrix.
This isn't Rocks for Jocks 101, so why should we care? I'm getting there. Notice that both structurally and chemically, nephrite and jadeite are different. What does this mean? Well, we know that different chemical compositions will react differently and different microstructures will also also behave differently. Jadeite and nephrite have different fundament properties. From the point of view of science, if we think that science divides and studies the world in terms of its fundamental rather than superficial properties there's no such thing as jade. There's no one structure or chemical structure that is jade.
Here's another way to illustrate what I'm getting at. Why isn't there a science of green things? Why aren't there green-ologists? The reason is that green is a superficial property. Knowing that something is green gives us no predictive power in terms of how other green things will behave. It also provides no explanatory power for why it behaves the way it does.
For example, green algae has very different fundamentals chemical properties from a green glass. Suppose I put a HCL on the green algae. Based on the chemical reaction, would I be able to predict what will happen if I put HCL on green glass? Does the algae's greenness explain why it reacts the way it does to HCL? Of course not. In science, I want to lump things into categories that are going to allow me to make generalizations and predictions about other things in that category.
Learning about green algae doesn't help me learn anything important about green glass except what I already knew--they're both green. We don't lump the two into a scientific category because science is only concerned with "lumping" things in terms of shared fundamental properties rather than superficial properties. We ought to "split" superficial categories that contain objects that have different fundamental properties.
Ok, so what does all this have to do with psychiatry and psychiatric diagnoses? Consider that a common diagnosis we hear about is depression. Most cases we (by we, I mean non-medical professionals) have encountered are probably infrequent non-pathological affairs, perhaps set off by a traumatic event. We know that, with support, most people eventually work through the depression and end up fine. The problem is, 'depression' is psychological jade.
Different types of depression can manifest the same superficial symptoms but the underlying causal structures are different. (No, alt-meders, this isn't the same "root cause" you're thinking of but it's the one you ignore). So, the mistake is to think, "ah, depression...we just need to treat it with x, that's what we did with the last case". But this is to treat depression like jade--i.e., as a homogenous category based only on superficial resemblance.
For example, I learned (the very surprising fact) that for many types of deep depression the most effective treatment is ECT (electroconvulsive therapy)--yes, you read that right! I had to ask the doctor twice because I couldn't believe my ears. Apparently, it's well studied. Of course, the current procedure is quite different from how it was in the early days but still...who'da thunk?
"Jadists" about depression might think all cases of depression can be treated with ECT. This would be a mistake. There are different kinds of depression with different etiologies (underlying causal structures). It turns out that depression in manic depressives doesn't respond to ECT. Depression has its own jadite and nephrite (and more). The "root cause" of depression in manic depression is fundamentally different than it is in other kinds of depression.
Beside this overview of a famous philosophical argument, why am I talking about this? Because if you're a human being you're probably going to commit the same cognitive error that I made when it comes to psychological diagnoses. You hear that a patient (or someone you know) is depressed or has some other general psychological problem and you think about how you or someone you know dealt with it. You think, well, all they have to do is x (whatever worked for you or your friend). It's so simple!
But you're treating the diagnosis like psychological jade. The diagnosis might have the same symptoms but it doesn't mean it has the same underlying fundamental structure and thus, there is no reason to suppose it will respond to the same intervention. It's a different kind.
Worse yet, someone could dogmatically claim the all disease and/or psychological diagnoses share the the same "root cause". Such dogmatism precludes any chance of recovery since the same ineffective treatment will only be applied more and more vigorously. What's more, this way of thinking is the opposite of scientific thinking. Saying everything has the same "root cause" is just like being a green-ologist. You're confusing superficial similarity for fundamental similarity. To use the lingo of metaphysics, you're lumping when you should be splitting.
We see green-ology all over the place in alt-med. For chiropractors, the "root cause" of all disease is some sort of spinal misalignment, for Ayurvedic medicine the "root cause" is chakra alignment (or some shit), for reflexologists the "root cause" is something to do with your feet (WTF? How are these people even a thing?), etc... (While I'm pointing the finger I should make clear that I have my own "root cause" default. I have a tendency to lump various problems as being caused a general lack of meaningful social relationships, belonging to a community, and sense of purpose.) And then there's alt-med's favorite: stress. The "root cause" of all disease--physical and mental is stress. More green-ology.
To be charitable we can say that stress can trigger or make people more susceptible to disease but this is to confuse notions of causation. Let me illustrate. Suppose someone is in the hospital with a broken leg because they got hit by a car. What "caused" the broken leg? Being hit by a car, right? Now, just because the car was the trigger for the broken leg no one in their right mind would believe that removing the car will heal the leg.
I can just imagine the doctors at an all-alt-med hospital: "We've cured your leg by getting rid of the 'root cause'--the car has been destroyed! You can walk now!"
So, while it's true that stress can trigger certain reactions, it doesn't follow that the solution to the problem is merely to remove the trigger. Yes, doing so may decrease the likelihood of the same event from occurring again, just like not getting hit by a car will prevent you from breaking your leg again (that way); however, this insight is often of trivial value. No one with more than two brain cells to rub together thinks chronic stress is good for them. What's the next great insight? A poor diet isn't good for your health? Revolutionary! Please collect your Nobel Prize.
The Lesson
The causes of many diseases, physical and mental, have to do with their fundamental underlying structural properties. This is why people respond differently to different treatments. Superficial similarities can cause us to lump when we really should be splitting. Overzealous lumping leads to failed treatment and frustrated patients. Overzealous lumpers are green-ologists. Don't be a green-ologist.
Anyhow, this is just one more cautionary tale for me to heed. Hopefully, it gives you pause too the next time you diagnose someone (including yourself) and assume that superficial similarity implies fundamental similarity...
Also, hopefully this little digression shows the value of philosophy to science. You can't do one without the other.
In a Nutshell
The conclusions I drew in my last post were wrong. But I'm leaving that post up as a cautionary tale to both myself and to anyone reading this. My hope is that it reminds us how easily we can get things wrong when we only have a little bit of information, particularly about areas where we are not experts. People think it's "being a sheeple" to defer to experts. It's not. It's smart and good epistemic practice. Only arrogance fueled by ignorance would lead a person to think that they know more than an expert in that expert's domain.
Before reading this, I suggest reading my post from yesterday since most of what I talk about here relates to it (and I end up retracting most of what I said).
'The arrogance of ignorance' is one of my favorite phrases. I'm not sure of its origins but I heard it first from Dr. Steven Novella. I think the phrase is the best way to capture a cluster of common cognitive errors. In no particular order: a) Assuming that because you are knowledgable in one domain that you know a lot about another (or are able to correctly evaluate another). b) Moving from small data sets/anecdotal experiences to broad conclusions. 'The arrogance of ignorance' is a close cousin to the Dunning-Kruger effect: You have so little knowledge of a particular domain that you are unable to assess how little you actually know and grossly overestimate how much you do know, in turn leading you to wildly wrong conclusions.
Anyhow, yesterday I was guilty of all of the above crimes. You'd think a guest pass to a hospital and a few hours of observation would give me enough authority and knowledge to correctly evaluate an entire subfield of medicine. Strangely, it didn't.
Today I went back to inpatient psych, and boy am I glad I did (from a pedagogical point of view). Let me try to both convey my experience and undo some of the misconceptions I had.
Sample bias
Most of the patients I met yesterday had been in the hospital for over a week. I was meeting them after they'd undergone treatment and had been stabilized. Of course they seemed normal to me! As I learned (and hopefully you will too once you read this post), what I did was the equivalent of walking into a surgery unit and looking only at the patients about to be discharged, then asking"why did they need surgery? They look fine to me!"
So, what are patients like on admission and early in treatment?
Obviously there are a variety of disorders but all of them are severe. Here's the thing, unless you work in a hospital or have someone in your family with a severe mental illness you've probably never actually seen severe mental illness. To most of us, this is an invisible population because most of their lives are lived in care homes or in institutions and, unfortunately, in the streets.
The patients range from very well-spoken with linear thought to having only elementary vocabulary with disjointed unintelligible thought, and any combination of the above. Regardless of where they fall on the spectrum, most of them suffer from severe delusions. Some examples: (1) Being part of an intergalactic group of assassins being pursued by the (intergalactic) mafia, (2) believing that a family member is dead who isn't and all the evidence they have should lead them to conclude the opposite, (3) being pursued by terrorists and (actually) destroying windows and cars to avoid/prevent the terrorist plot, (4) having voices in their head telling them to kill others or kill themselves. There were more but this should suffice.
Interestingly, the ones that had grand conspiracy delusions, e.g., (1) and (2), were extremely pleasant to talk to. If you were to have a conversation with them and the content of the delusion never came up, you wouldn't suspect a thing. It was as though they simultaneously inhabit two realities. When you ask them, they know where they are and why they're there. They'll say "I just want to get better" but at the same time they'll discuss their delusions as though they're just as real as the chair they're sitting on.
Unlike what I hypothesized yesterday, these people don't "just need a little more social and material support." That's the equivalent of saying someone with cancer can be healed with a back rub.
I think my reaction yesterday is probably analogous to what happens with many deniers of modern medicine. They've been in the hospital to visit a friend or they read some article online--maybe even spoken to a disgruntled doctor. But they've only seen 1 billionth of the data set, and only from the patient side of the bed. Things look very different from the doctor's side of the bed and as you get a larger data set...
Tip of the Iceberg
Another factor that led me to my (wayward) conclusions yesterday was I didn't ask enough questions about case histories. Once you read the case histories, your perspective will change very quickly. Every patient in there has a lifetime history of psychosis that is well documented. Almost all have been suffering the same symptoms since adolescence. Some have their condition for unknown or unknown biological reasons (usually genetic, as it runs in their families), others (there were 2 there) had suffered major brain injuries at some point earlier in their lives and haven't been the same since, others have their condition as a consequence of a life-time of substance abuse. For many it was a combination.
Someone who thinks that a little positive thinking or mere talk-therapy is going to solve these people's problems is extremely naive--like I was yesterday. Someone who thinks along these lines is mistaking people who have one-off breakdowns or depression with this other population. Like I said, unless you work in a hospital or have a family member (or work in law enforcement, probably) it's unlikely you've ever met anyone from this unfortunate population. Until you do, you can't fathom just how serious it is.
Philosophy of Science Lesson: Depression and Jade (Bear with me, You'll See How this Relates in a Moment)
What is jade? Up until the 19th century it was believed to be a kind of mineral. However, a French mineralogist (Alexis Damour) discovered that it was in fact two distinct minerals: Jadeite and nephrite, each with distinct chemical and structural properties. Nephrite is a microcrystalline interlocking fibrous matrix of the calcium, magnesium-iron rich amphibole mineral series tremolite (calcium-magnesium)-ferroactinolite (calcium-magnesium-iron). Jadeite is a sodium- and aluminium-rich pyroxene. The gem form of the mineral is a microcrystalline interlocking crystal matrix.
This isn't Rocks for Jocks 101, so why should we care? I'm getting there. Notice that both structurally and chemically, nephrite and jadeite are different. What does this mean? Well, we know that different chemical compositions will react differently and different microstructures will also also behave differently. Jadeite and nephrite have different fundament properties. From the point of view of science, if we think that science divides and studies the world in terms of its fundamental rather than superficial properties there's no such thing as jade. There's no one structure or chemical structure that is jade.
Here's another way to illustrate what I'm getting at. Why isn't there a science of green things? Why aren't there green-ologists? The reason is that green is a superficial property. Knowing that something is green gives us no predictive power in terms of how other green things will behave. It also provides no explanatory power for why it behaves the way it does.
For example, green algae has very different fundamentals chemical properties from a green glass. Suppose I put a HCL on the green algae. Based on the chemical reaction, would I be able to predict what will happen if I put HCL on green glass? Does the algae's greenness explain why it reacts the way it does to HCL? Of course not. In science, I want to lump things into categories that are going to allow me to make generalizations and predictions about other things in that category.
Learning about green algae doesn't help me learn anything important about green glass except what I already knew--they're both green. We don't lump the two into a scientific category because science is only concerned with "lumping" things in terms of shared fundamental properties rather than superficial properties. We ought to "split" superficial categories that contain objects that have different fundamental properties.
Ok, so what does all this have to do with psychiatry and psychiatric diagnoses? Consider that a common diagnosis we hear about is depression. Most cases we (by we, I mean non-medical professionals) have encountered are probably infrequent non-pathological affairs, perhaps set off by a traumatic event. We know that, with support, most people eventually work through the depression and end up fine. The problem is, 'depression' is psychological jade.
Different types of depression can manifest the same superficial symptoms but the underlying causal structures are different. (No, alt-meders, this isn't the same "root cause" you're thinking of but it's the one you ignore). So, the mistake is to think, "ah, depression...we just need to treat it with x, that's what we did with the last case". But this is to treat depression like jade--i.e., as a homogenous category based only on superficial resemblance.
For example, I learned (the very surprising fact) that for many types of deep depression the most effective treatment is ECT (electroconvulsive therapy)--yes, you read that right! I had to ask the doctor twice because I couldn't believe my ears. Apparently, it's well studied. Of course, the current procedure is quite different from how it was in the early days but still...who'da thunk?
"Jadists" about depression might think all cases of depression can be treated with ECT. This would be a mistake. There are different kinds of depression with different etiologies (underlying causal structures). It turns out that depression in manic depressives doesn't respond to ECT. Depression has its own jadite and nephrite (and more). The "root cause" of depression in manic depression is fundamentally different than it is in other kinds of depression.
Beside this overview of a famous philosophical argument, why am I talking about this? Because if you're a human being you're probably going to commit the same cognitive error that I made when it comes to psychological diagnoses. You hear that a patient (or someone you know) is depressed or has some other general psychological problem and you think about how you or someone you know dealt with it. You think, well, all they have to do is x (whatever worked for you or your friend). It's so simple!
But you're treating the diagnosis like psychological jade. The diagnosis might have the same symptoms but it doesn't mean it has the same underlying fundamental structure and thus, there is no reason to suppose it will respond to the same intervention. It's a different kind.
Worse yet, someone could dogmatically claim the all disease and/or psychological diagnoses share the the same "root cause". Such dogmatism precludes any chance of recovery since the same ineffective treatment will only be applied more and more vigorously. What's more, this way of thinking is the opposite of scientific thinking. Saying everything has the same "root cause" is just like being a green-ologist. You're confusing superficial similarity for fundamental similarity. To use the lingo of metaphysics, you're lumping when you should be splitting.
We see green-ology all over the place in alt-med. For chiropractors, the "root cause" of all disease is some sort of spinal misalignment, for Ayurvedic medicine the "root cause" is chakra alignment (or some shit), for reflexologists the "root cause" is something to do with your feet (WTF? How are these people even a thing?), etc... (While I'm pointing the finger I should make clear that I have my own "root cause" default. I have a tendency to lump various problems as being caused a general lack of meaningful social relationships, belonging to a community, and sense of purpose.) And then there's alt-med's favorite: stress. The "root cause" of all disease--physical and mental is stress. More green-ology.
To be charitable we can say that stress can trigger or make people more susceptible to disease but this is to confuse notions of causation. Let me illustrate. Suppose someone is in the hospital with a broken leg because they got hit by a car. What "caused" the broken leg? Being hit by a car, right? Now, just because the car was the trigger for the broken leg no one in their right mind would believe that removing the car will heal the leg.
I can just imagine the doctors at an all-alt-med hospital: "We've cured your leg by getting rid of the 'root cause'--the car has been destroyed! You can walk now!"
So, while it's true that stress can trigger certain reactions, it doesn't follow that the solution to the problem is merely to remove the trigger. Yes, doing so may decrease the likelihood of the same event from occurring again, just like not getting hit by a car will prevent you from breaking your leg again (that way); however, this insight is often of trivial value. No one with more than two brain cells to rub together thinks chronic stress is good for them. What's the next great insight? A poor diet isn't good for your health? Revolutionary! Please collect your Nobel Prize.
The Lesson
The causes of many diseases, physical and mental, have to do with their fundamental underlying structural properties. This is why people respond differently to different treatments. Superficial similarities can cause us to lump when we really should be splitting. Overzealous lumping leads to failed treatment and frustrated patients. Overzealous lumpers are green-ologists. Don't be a green-ologist.
Anyhow, this is just one more cautionary tale for me to heed. Hopefully, it gives you pause too the next time you diagnose someone (including yourself) and assume that superficial similarity implies fundamental similarity...
Also, hopefully this little digression shows the value of philosophy to science. You can't do one without the other.
In a Nutshell
The conclusions I drew in my last post were wrong. But I'm leaving that post up as a cautionary tale to both myself and to anyone reading this. My hope is that it reminds us how easily we can get things wrong when we only have a little bit of information, particularly about areas where we are not experts. People think it's "being a sheeple" to defer to experts. It's not. It's smart and good epistemic practice. Only arrogance fueled by ignorance would lead a person to think that they know more than an expert in that expert's domain.
Thursday, May 14, 2015
Day 2: Naiveté, Falsificationism, and the Counterfactual
Psychiatric Inpatient
Many years ago in my early 20s I read a short story that stuck with me for its nightmarish realism. I can't remember the title or the author, although I think it was G.G. Marquez. I do know it was a Latin American author (if you know the story I'm talking about let me know so I can put a link--it's a great short story). The general plot goes something like this:
A young woman is touring the countryside and goes into a tourist stop to get some food and use the bathroom. There's also a tour bus full of people at the stop. She happens to exit the store at the same time the tour bus is loading its passengers. One of the "tour guides" asks her where she's going. She says that she's going to her car to drive to the next town. She's on vacation. The tour guide smiles and nods and directs her to get on the bus. She's confused by this and tries to explain again. Again the tour guide gives a similar response, but this time calls over the other "tour guides". Once again the woman tries to explain that she's not with the tour. They smile and nod.
Anyhow, to make a long story short, the people on the bus were patients from the local psychiatric hospital and the "tour guides" were the doctors. The upshot of the story is that there's nothing she could say to convince them that she didn't belong on the bus (and eventually institutionalized). When she got agitated, they interpreted this as a need for sedatives. When she explained her story, they interpreted this as delusion.
My naive impression of the psych ward (and psych consult), in some cases, was very much like this. There was no way for the patients to answer any questions without their answers being interpreted as evidence for some pathology. In short, a psychiatric diagnosis was unfalsifiable.
There were, of course, also cases were the patients did have obvious serious psychiatric problems--such as attempted suicide (and usually a history of the behavior)--but some of the patients' behaviors, to my naive eyes, seemed like totally rational responses to their difficult situations. Many were in there after a particularly traumatic and stressful event.
Since I now have an official visitors' badge I think this entitles me to give a diagnosis. Basically, my visitors' badge plus two days of observations put me at just one level below an expert. Anyway, my evaluation was that there was very little that was abnormal about their response. The major difference between me (and many of my peers) with many of the patients is that we have access to the social and financial resources to weather a storm. Most of the patients didn't. Think about a crisis in your own life. Can you imagine having to go through that without the people that got you through it and, on top of that, having to worry about where you were going to sleep the next day? Very few individuals can bear trauma alone and under additional stressful conditions.
One gentleman's wife was dying. He was functionally illiterate and she had handled all their affairs. He had admitted himself and was very anxious. The staff kept asking questions to try to give a psychiatric diagnosis--i.e., they needed a label for his general anxiety and confusion. He keeps repeating "My wife is dying and I need to take care of her and I don't know what to do." Meanwhile the physicians are asking him to answer math questions and spell words backwards. I literally wanted to scream "Why are you asking him these questions? He's already told you 3 times what the problem is. His wife is dying and he doesn't know how to handle it. How is this pathological? This is the response we'd expect from any normal person."
Here's the thing. What I don't know (and the doctors do know) is the patient's case history. He has a history of various serious psychological problems. While this particular response is normal it could trigger more dangerous responses. And so they adjust his medication.
I don't mean to be an apologist here. Unlike food babe, I don't want to be quick to judge things that I know very little about--despite what my gut tells me (which, incidentally is never wrong--that's a scientific fact). Based on the little I observed, more than anything the guy needs social support. He needs someone to help him manage his wife's care. He isn't literate. How's he supposed to administer the medicines properly? Pay the bills? Manage everything that she had done previously for the both of them? He needs to know/feel that he isn't alone and that there are people that care about him. Of course, this doesn't necessarily preclude medical treatment to stabilize his behaviors. But it seems to me the emphasis should be on social and emotional support.
. . . .
The psych ward is a strange place. The rooms are barren. No TVs, no radios, no paintings, no cellphones. the patients do, however, have access to books. Think of a running track. The inside of the track is where the staff are. Most of the desks face outward so the patients can be observed while the staff work. The patients, with nothing to do, walk aimlessly around the island, again, again, and again. They're like zombies.
This set up strikes me as odd. Why the intentional sensory deprivation? How would you act if you were in a room all day with no art, no TV, no cellphone to text or call your friends, and nowhere to go and nothing to do? I can tell you right now, whatever sanity I had going in would be long gone after a few days.
Well, that was my first impression. It turns out, they do also get group and individual therapy. There's a stretching class. And there is a TV room--just not one in each room. Not as bad as my initial impression.
I met a woman who seemed quite normal. I can't remember how many days she'd been in the unit. Less than a week. Anyhow, the first time we talked to her, at the end she asked when she could go home. She wants to go home today. She was very polite about it but you could sense the pleading in her voice. The medical student said "I'll talk to the doctor and we'll let you know in an hour".
We went back with the attending doctor about an hour later. We repeated that previous conversation. "How are you feeling? Are you hearing any voices? To you have any desire to harm yourself?" All these questions were answered just as you or I would answer. Again, she asked if she could go home today. The doctor replied, probably tomorrow.
I'm thinking: this woman sees totally normal. If I'd asked to go home and someone said no, I'd get agitated (which she didn't). Of course, she probably knows that if she acts agitated it will be further reason to keep her (i.e., problem non-falsifiability). Anyhow, later I asked the Dr. why she didn't let her go home.
Here's where case history and having more than a visitors' badge are important. When the patient was admitted she was having suicidal thoughts and hearing voices. Of course, I didn't know that part, but given the conditions of the admission, the doctor's caution isn't as odd as it appeared.
And there's more. Every day these doctors must deal with the counterfactual. If a patient comes in (most seemed to be self-admitted) and doctor releases them and something happens--a suicide or homicide--guess who has that on their conscience for the rest of their lives? If you knew that someone in your direct care was a suicide or homicide risk, would you release them the first day they said they felt better? From this point of view, keeping someone an extra day or two doesn't seem so strange.
Many years ago in my early 20s I read a short story that stuck with me for its nightmarish realism. I can't remember the title or the author, although I think it was G.G. Marquez. I do know it was a Latin American author (if you know the story I'm talking about let me know so I can put a link--it's a great short story). The general plot goes something like this:
A young woman is touring the countryside and goes into a tourist stop to get some food and use the bathroom. There's also a tour bus full of people at the stop. She happens to exit the store at the same time the tour bus is loading its passengers. One of the "tour guides" asks her where she's going. She says that she's going to her car to drive to the next town. She's on vacation. The tour guide smiles and nods and directs her to get on the bus. She's confused by this and tries to explain again. Again the tour guide gives a similar response, but this time calls over the other "tour guides". Once again the woman tries to explain that she's not with the tour. They smile and nod.
Anyhow, to make a long story short, the people on the bus were patients from the local psychiatric hospital and the "tour guides" were the doctors. The upshot of the story is that there's nothing she could say to convince them that she didn't belong on the bus (and eventually institutionalized). When she got agitated, they interpreted this as a need for sedatives. When she explained her story, they interpreted this as delusion.
My naive impression of the psych ward (and psych consult), in some cases, was very much like this. There was no way for the patients to answer any questions without their answers being interpreted as evidence for some pathology. In short, a psychiatric diagnosis was unfalsifiable.
There were, of course, also cases were the patients did have obvious serious psychiatric problems--such as attempted suicide (and usually a history of the behavior)--but some of the patients' behaviors, to my naive eyes, seemed like totally rational responses to their difficult situations. Many were in there after a particularly traumatic and stressful event.
Since I now have an official visitors' badge I think this entitles me to give a diagnosis. Basically, my visitors' badge plus two days of observations put me at just one level below an expert. Anyway, my evaluation was that there was very little that was abnormal about their response. The major difference between me (and many of my peers) with many of the patients is that we have access to the social and financial resources to weather a storm. Most of the patients didn't. Think about a crisis in your own life. Can you imagine having to go through that without the people that got you through it and, on top of that, having to worry about where you were going to sleep the next day? Very few individuals can bear trauma alone and under additional stressful conditions.
One gentleman's wife was dying. He was functionally illiterate and she had handled all their affairs. He had admitted himself and was very anxious. The staff kept asking questions to try to give a psychiatric diagnosis--i.e., they needed a label for his general anxiety and confusion. He keeps repeating "My wife is dying and I need to take care of her and I don't know what to do." Meanwhile the physicians are asking him to answer math questions and spell words backwards. I literally wanted to scream "Why are you asking him these questions? He's already told you 3 times what the problem is. His wife is dying and he doesn't know how to handle it. How is this pathological? This is the response we'd expect from any normal person."
Here's the thing. What I don't know (and the doctors do know) is the patient's case history. He has a history of various serious psychological problems. While this particular response is normal it could trigger more dangerous responses. And so they adjust his medication.
I don't mean to be an apologist here. Unlike food babe, I don't want to be quick to judge things that I know very little about--despite what my gut tells me (which, incidentally is never wrong--that's a scientific fact). Based on the little I observed, more than anything the guy needs social support. He needs someone to help him manage his wife's care. He isn't literate. How's he supposed to administer the medicines properly? Pay the bills? Manage everything that she had done previously for the both of them? He needs to know/feel that he isn't alone and that there are people that care about him. Of course, this doesn't necessarily preclude medical treatment to stabilize his behaviors. But it seems to me the emphasis should be on social and emotional support.
. . . .
The psych ward is a strange place. The rooms are barren. No TVs, no radios, no paintings, no cellphones. the patients do, however, have access to books. Think of a running track. The inside of the track is where the staff are. Most of the desks face outward so the patients can be observed while the staff work. The patients, with nothing to do, walk aimlessly around the island, again, again, and again. They're like zombies.
This set up strikes me as odd. Why the intentional sensory deprivation? How would you act if you were in a room all day with no art, no TV, no cellphone to text or call your friends, and nowhere to go and nothing to do? I can tell you right now, whatever sanity I had going in would be long gone after a few days.
Well, that was my first impression. It turns out, they do also get group and individual therapy. There's a stretching class. And there is a TV room--just not one in each room. Not as bad as my initial impression.
I met a woman who seemed quite normal. I can't remember how many days she'd been in the unit. Less than a week. Anyhow, the first time we talked to her, at the end she asked when she could go home. She wants to go home today. She was very polite about it but you could sense the pleading in her voice. The medical student said "I'll talk to the doctor and we'll let you know in an hour".
We went back with the attending doctor about an hour later. We repeated that previous conversation. "How are you feeling? Are you hearing any voices? To you have any desire to harm yourself?" All these questions were answered just as you or I would answer. Again, she asked if she could go home today. The doctor replied, probably tomorrow.
I'm thinking: this woman sees totally normal. If I'd asked to go home and someone said no, I'd get agitated (which she didn't). Of course, she probably knows that if she acts agitated it will be further reason to keep her (i.e., problem non-falsifiability). Anyhow, later I asked the Dr. why she didn't let her go home.
Here's where case history and having more than a visitors' badge are important. When the patient was admitted she was having suicidal thoughts and hearing voices. Of course, I didn't know that part, but given the conditions of the admission, the doctor's caution isn't as odd as it appeared.
And there's more. Every day these doctors must deal with the counterfactual. If a patient comes in (most seemed to be self-admitted) and doctor releases them and something happens--a suicide or homicide--guess who has that on their conscience for the rest of their lives? If you knew that someone in your direct care was a suicide or homicide risk, would you release them the first day they said they felt better? From this point of view, keeping someone an extra day or two doesn't seem so strange.
Wednesday, May 13, 2015
Day 1: First Impressions
For the next month-ish I'm observing rounds in a Cleveland-area hospital. More on how I got here later, for now here are some of my first impressions
Waiting
From my notebook while I was waiting for the MICU (Medical Intensive Care Unit) rounds to start.
7:30am
People look tired but are friendly with each other. A janitor sees me sitting by myself in the atrium. "They didn't forget about you did they?" The visitors badge combined with my nervous fidgeting must be more obvious than I'd hoped.
8:15-noon MICU Rounds
I've always had a lot of respect for doctors but observing the MICU doctors took my respect to another level. As a patient you might think your doctors barely know your name. In fact, they know every minute medical fact about you. They know your medical history. In many cases they know your family's medical history. For every chemical, endogenous or foreign, they know the concentration in your body. If you've been in the hospital for a while they know the whole history of every chemical's concentration in your body. They know what each chemical concentration might indicate about your health. They know a bunch of stuff about you that was too fancy for me to follow or remember. The amount of health-relevant data they have on you is staggering. And like I said, it's not just that they have so much data it's that they interpret and analyze all of it.
Of note: Most of the patients in MICU were alcoholics and/or smokers whose bodies eventually couldn't keep up. Most end up with partial organ failure and chronic infections all at once. If you're a hard drinker or smoker, please stop. The future isn't bright.
1:20pm-5pm Psychiatry Consult Liaison
When patients get admitted into emergency and there are obvious or probable reasons for psychiatric evaluations, these doctors are called in to do just that. For example, if someone suffered an injury that looks like a suicide attempt or someone is delusional or even extremely depressed the psychiatry evaluation team is called in.
To me this was by far the most interesting part from the point of view of medical ethics. Based on the psych evaluation, the patient can be forced to stay in the hospital. For example, if they're perceived as a suicide risk.
I filled half a notebook on my thoughts and experiences doing this round but I'm going to limit this entry to just one anecdote.
As an official observer--unless asked for my opinion--I'm expected to do just and only that: observe. But this isn't always easy.
One person I saw was extremely depressed. They (I'm intentionally using an ambiguous pronoun) were in their later years but still living independently---even working. They had recently beaten what is for many a terminal illness. They had mustered the strength to get through the treatment. Quite a feat for anyone. They got their life back. They fought for their life back. They were exercising again and even working. Life was looking up.
During the post-treatment there was a complication and their organs failed. Now there is nothing that can be done. All that fighting for nothing. They explained to the doctor what had happened. "Do you want to live?" asked the doctor. "Not like this...not like this. I'm independent and I took care of others and now I can't even take care of myself". The patient began to cry. I wanted to comfort the patient and hold their hand but all I could do was observe.
Waiting
From my notebook while I was waiting for the MICU (Medical Intensive Care Unit) rounds to start.
7:30am
People look tired but are friendly with each other. A janitor sees me sitting by myself in the atrium. "They didn't forget about you did they?" The visitors badge combined with my nervous fidgeting must be more obvious than I'd hoped.
8:15-noon MICU Rounds
I've always had a lot of respect for doctors but observing the MICU doctors took my respect to another level. As a patient you might think your doctors barely know your name. In fact, they know every minute medical fact about you. They know your medical history. In many cases they know your family's medical history. For every chemical, endogenous or foreign, they know the concentration in your body. If you've been in the hospital for a while they know the whole history of every chemical's concentration in your body. They know what each chemical concentration might indicate about your health. They know a bunch of stuff about you that was too fancy for me to follow or remember. The amount of health-relevant data they have on you is staggering. And like I said, it's not just that they have so much data it's that they interpret and analyze all of it.
Of note: Most of the patients in MICU were alcoholics and/or smokers whose bodies eventually couldn't keep up. Most end up with partial organ failure and chronic infections all at once. If you're a hard drinker or smoker, please stop. The future isn't bright.
1:20pm-5pm Psychiatry Consult Liaison
When patients get admitted into emergency and there are obvious or probable reasons for psychiatric evaluations, these doctors are called in to do just that. For example, if someone suffered an injury that looks like a suicide attempt or someone is delusional or even extremely depressed the psychiatry evaluation team is called in.
To me this was by far the most interesting part from the point of view of medical ethics. Based on the psych evaluation, the patient can be forced to stay in the hospital. For example, if they're perceived as a suicide risk.
I filled half a notebook on my thoughts and experiences doing this round but I'm going to limit this entry to just one anecdote.
As an official observer--unless asked for my opinion--I'm expected to do just and only that: observe. But this isn't always easy.
One person I saw was extremely depressed. They (I'm intentionally using an ambiguous pronoun) were in their later years but still living independently---even working. They had recently beaten what is for many a terminal illness. They had mustered the strength to get through the treatment. Quite a feat for anyone. They got their life back. They fought for their life back. They were exercising again and even working. Life was looking up.
During the post-treatment there was a complication and their organs failed. Now there is nothing that can be done. All that fighting for nothing. They explained to the doctor what had happened. "Do you want to live?" asked the doctor. "Not like this...not like this. I'm independent and I took care of others and now I can't even take care of myself". The patient began to cry. I wanted to comfort the patient and hold their hand but all I could do was observe.
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