Tuesday, December 01, 2015

What enviromental radical said this?

As the world leaders meet to dicuss climate issues, it is illustrative to remember these quotes:

For generations, we have assumed that the efforts of mankind would leave the fundamental equilibrium of the world's systems and atmosphere stable.  But it is possible that with all these enormous changes (population, agricultural, use of fossil fuels) concentrated into such a short period of time, we have unwittingly begun a massive experiment with the system of this planet itself.


We must have continued economic growth in order to generate the wealth required to pay for the protection of the environment.  But it must be growth that does not plunder the planet today and leave our children to deal with the consequences tomorrow.

We should always remember that free markets are a means to an end. They would defeat their object if by their output they did more damage to the quality of life through pollution than the well-being they achieve by the production of goods and services. 

Answer:  Margaret Thatcher, address to the Royal Society in September 1988, and another speech to the United Nations General Assembly in November 1989.

Saturday, November 28, 2015

Don't get angry . . . and don't get even.

Watching the recent angry back-and-forth between Russian President Putin and Turkish President Erdogan has caused many of my friends in the medical world to wonder: Why do high ranking national officials stoop to apparently immature approaches in their disputes, approaches that might lead to an expansion of a conflict to something that neither party wants?

And then I remind them of behavior they have witnessed between senior doctors in their hospitals' operating rooms, intensive care units, and treatment floors. Sheepish looks quickly follow.

There is a school of thought that suggests that your effectiveness as a negotiator is enhanced when you display anger. Professor Alison Wood Brooks at Harvard Business School presents the alternative view in a recent HBR article:

[T]here’s a body of research . . . that documents the consequences of feeling angry while negotiating. This research shows that anger often harms the process by escalating conflict, biasing perceptions, and making impasses more likely. It also reduces joint gains, decreases cooperation, intensifies competitive behavior, and increases the rate at which offers are rejected. Angry negotiators are less accurate than neutral negotiators both in recalling their own interests and in judging other parties’ interests. And angry negotiators may seek to harm or retaliate against their counterparts, even though a more cooperative approach might increase the value that both sides can claim from the negotiation.

Or, as Lucius Annaeus Seneca put it:

Anger: an acid that can do more harm to the vessel in which it is stored than to anything on which it is poured.

In her article, Brooks offers some strategies that can be employed to help people tamp down unproductive anger, both in themselves and in their negotiation counterparties.  Most of her advice relies on a party's emotional intelligence.

Coincidentally, Dr. Gene Lindsey devotes a portion of his most recent weekly newsletter to this issue of emotional intelligence in the health professions. His focus is on the importance of this attribute in enhancing the value proposition for health care delivery, but the topic is also relevant in simple face-to-face clinical relationships.

Many of the points seem self-evident.  For example:

Emotional intelligence — plays a significant role in determining how effectively physicians communicate and establish relationships with patients, as well as with their colleagues.

Effectively leveraging emotional intelligence requires an understanding of how emotional intelligence manifests itself, as well as tools to help understand an individual's emotional intelligence in a healthcare context.

Emotional intelligence has four components: self-awareness, social awareness, self-management and relationship management. EQ is the ability to perceive, evaluate, understand, respond to and influence emotions. 

Having spent many hours in offering negotiation training to residents and medical students over the past four years, I have seen first hand how often these latter four components are missing. Even in classroom simulation exercises, I've seen anger and its close ego-driven relatives--stubbornness, aggressiveness, and passive aggressiveness--employed as negotiation strategies.

More sadly, while working in the medical field, I found myself mediating and moderating such behavior among highly experienced attending physicians.

Linda Pololi, in Changing the Culture of Academic Medicine, explores the environment in medical schools and finds precursor behavior among the faculty that likely influences medical students, to wit, "feelings of dehumanization [and] erosion of trust . . . within an environment where competitive individualism was rewarded and collaboration undervalued."  If their teachers present such an example, is there any wonder why young doctors carry it along through residency and beyond?

But there is hope. As educators we can create a safe learning environment to help young professionals develop aspects of self-awareness, social awareness, self-management and relationship management.

Here's a story from two students who learned some key lessons during a simple negotiation game in one of my classes at Telluride. Derek summarizes what he learned: "The frantic pace of a situation [can] overwhelm you into making irrational decisions.  Once we’ve jumped to a diagnosis, and confidently shared it with others, we are too prone to cling to it beyond rationality. Our ego gets in the way of us re-evaluating, asking what we may have missed, and being open to different opinions."

Note, too, Sam's comment: "I’m not going to lie – my ego still stings a little bit, but what a great lesson, and what a good way to learn it. I hope that stings stays with me so that I don’t make the same mistake again when it matters, when it can affect a patient."

A home for orphan wearables

How many people do you know who've bought a Fitbit or similar device to track their exercise patterns--who have then let the whole venture lapse? The Fitbit now resides comfortably and peacefully in their drawer!

Well, there's a useful way to recycle them, offered by Tufts University professor Lisa Gulatieri. As noted in this article:

Gualtieri started RecycleHealth in April with the goal of giving unused activity trackers — mostly Fitbits so far, but RecycleHealth accepts all devices — a second life. The company has collected about 20 devices so far and has plans to donate them to the Montachusett YMCA in Fitchburg, Massachusetts, where they will be used to help older and lower income individuals have access to devices, as well as to learn about how those populations interact with activity trackers.

Check out the Facebook page for stories on how the idea is spreading, plus more information, including how to get free mailing labels.

Monday, November 23, 2015

Ancient grains are not just old plants!

Just in time for Thanksgiving preparation, I ran into Maria Speck the other day, and we started talking about ancient grains.  She published her second cookbook on the topic a few months ago, and I've now had a chance to look through it.

Beyond some really beautiful pictures by Erin Kunkel, there's lots to view in this compendium.  Of course there's background information from amaranth to wild rice, with stops along the way for freekeh, millet, sorghum, and more.  We learn, too about the absorption method of cooking, contrasted with the pasta method and others.  Should we rinse?  Soak? Toast?  How do we know when it's done?  There are handy charts with cooking times, so we can be more secure about planning ahead.

And then, of course, the recipes. By the dozen, in all kinds of categories.

This encyclopedia is a joy to read.  I'm looking forward to sampling its contents.

"They really need to know"

In her day job, Susan Hackley is chief administrative and financial officer for the Harvard Program on Negotiation, but her prior experience in a variety of public policy and other positions offers her a crisp view on many issues facing the country and the world.  She decided to devote her observational skills to a new project, "A Child's Guide to War," when she realized that for American children aged 13 and younger, we have been at war their entire lives.

As noted:

A Child’s Guide to War is a documentary film project that is helping to bridge the civilian–military divide in the United States.

A wide gulf exists in America between those who have served in the military and their families and those who haven’t. While respect for the military is high, real knowledge is not.

Through the film, a public television program, teaching materials and public meetings we are hosting, we will help Americans better understand the role of the military in our democracy and the role of civilians in understanding, respecting and appreciating the service of those who solemnly swear to protect our country.

This is a work in progress, but you can see some tidbits in this short video produced in Indiana, where Susan and crew interviewed children whose mom or dad has been to war and asked: "What is it like?"  "What do you worry about?"  "What makes you proud?"

There's something compelling about the straightforward answers given by these children.

"My dad's not a killer."

"I just put my thoughts aside."

"They really need to know."

 Take a look and, if you feel moved, please support this effort.

Sunday, November 22, 2015

Serendipity is allowed

How's this for a lesson plan?

Serendipity is allowed . . . and even encouraged.

It is a philosophy set forth by Ed Moriarty, an instructor at MIT's Edgerton Center.  Opening the doors of the strobe lab for "that Saturday thing," as it is called by the students, Ed provides mentorship and asks challenging questions of children and adults of all ages who drop by to play and experiment.

Here is learning at its most creative, combining physical manipulation of electrical components with thoughtful observation.  There is no syllabus, just the joy of learning.

We were giving some friends a tour of MIT and we had explained that the philosophy of play is an important component of life at MIT.  We walked by the strobe lab at an opportune moment and were immediately hijacked by Ed. He said, "Hey, come in here. I want to show you some stuff."

He borrowed a circuit that eight-year-old Amelia had constructed and asked us, "What kind of shadow is created when you have three small diodes shining red, blue, and green and put a finger in front of one of them?"

"What if you hold up several fingers and the shadow falls on someone's face?"

Or as above, "What happens when water comes out of a sixty cycle-per-second pump and is illuminated by a sixty flash-per-second strobe?"  This little boy learned that the stream of water is actually composed of droplets, not a continuous stream.

As noted on the Edgerton Center website:

Always willing to follow students’ lead and to let them discover their own voice, Moriarty offers the intellectual and emotional support that enables students of all ages to learn to engineer by doing.

What do we do in classrooms?  Well, for the most part, we throw away spontaneity and and shoehorn students into tightly constrained curricula.  They learn the facts, but they often lose the creativity and joy of learning that comes from impulse and experimentation.  They soon forget the surprises that serendipity can bring.

Saturday, November 21, 2015

A leadership lesson learned?

As turmoil continues around the world, back here in Massachusetts there's been a kerfuffle surrounding Governor Charlie Baker's remarks about limiting Syrian refugees' access to the state. Several of us, including me, we appalled by what he said. Among those was US Representative Seth Moulton.  Moulton's criticism was, in turn, deemed partisan by the Governor, an accusation Moulton roundly denied. The Governor, too, said that his remarks had been taken out of context, and he appeared upset that he had been accused of a lack of compassion. Indeed, he declined to sign a letter from other Republican governors asking President Barack Obama to suspend efforts to resettle Syrian refugees in the U.S.

A friend on Facebook noted, with regard to this last item:

At least our governor is intelligent enough to listen to his constituency. And it shows we can push him on things, which is a good thing. Bravo Baker for listening and learning from your people.

The question that I ask today is what lesson was learned and how might other leaders also learn from this episode.  If the only lesson Charlie learned from the events was that he had gotten out too far in front of an issue relative to public sentiment and that therefore he had to backtrack, that's just a lesson in politics.

If, however, he learned another leadership lesson, then there is a better result for him personally and for the state.  You see, what Charlie did in his initial comments was to fan a spark of fear, resentment, and xenophobia among at least some people in the state. It does not matter whether Charlie's words were taken out of context. He grabbed the moment and became a lightning rod.

For example, here's one comment from Michele that I received on my blog post:

So if I don't like what this government is doing or the people that are running this country, I should pack up a couple tiny things, my very small children and move to another country? I joined the Navy. I was honored to work beside the Marine Corps. So instead of trying to fix my country I should move and expect everyone else to take care of me? My Grandfather remembers the government coming to his father's house to offer aid to farmers hit by the depression. He proudly refused. Where is the working through adversity attitude? Why is everything "give me help"?

I replied:

Michele, please take a look at some of the pictures and read the stories from these folks. This is not about working through adversity. This is about having your community destroyed, losing your housing and possessions, with threats of bombs every day.

She answered:

I know. I sobbed when their stories started coming through. My concern is my children, Paul. As is their concern I am sure. I am not willing to sacrifice my children's safety as they are not either. We are making decisions based on the same priorities. 

We should in no way discount people's fears when bad things happen in the world. But acknowledging that fear is not the same as fanning it.

Charlie doth protest too much when he claims his words were taken out of context.  The overall context was that a slew of mainly Republican governors were saying approximately the same thing at the same time.  The Governor needs to understand that the moral stature of an elected official is such that his job during times of stress is to bring people together, to appeal to their better instincts and values, and not to their fears.

When he says that "my job is protect the people of Massachusetts," he is both saying too much and too little.  Too much because no one person can protect six million.  Too much because, on this issue, he has no jurisdiction in any event.  Too little because his job is to help maintain a sense of community during a period of unrest.  Too little because his job is to remind us of our underlying values and shared history.

The question for Governor Baker is whether he learned that leadership lesson, not just a passing lesson in politics.

Thursday, November 19, 2015

How to secure more block time

While I hate to promulgate stereotypes about any particular group of medical specialists, this short video is too good to leave without broader dissemination.

Blog roll revisions

I've just finished editing the blog roll on the right hand side of my blog's home page.  I've deleted sites that have been inactive for six months or more.  If yours is no longer listed and you think it should be, please let me know.  Likewise, if you have a new (or old) blog to which I've not linked, please let me know.

Wednesday, November 18, 2015

Blind science

Thanks to Brian Klepper for alerting me to this:

Here's a poignant personal story about modern medicine from my friend Michael Millenson. Michael is a journalist who has played a significant role in ushering in the quality and safety movements in American health care.

The lede:

When I was a newborn — a preemie struggling to survive in a hospital nursery’s incubator — an article deep inside The Washington Post saved me from becoming blind.

The article — on Page A22 — discussed research showing that too much oxygen in an incubator could cause babies to lose their sight. When my worried parents phoned the hospital, they were told doctors had also seen the piece and promptly adjusted the incubator’s air mixture. What none of them knew was that the sight in my right eye had already been destroyed by what is now called retinopathy of prematurity, or ROP. Fortunately, the vision in my left eye remained intact, saving me from a lifetime in the dark.

That was way back in 1953. Yet just a few months ago, a federal judge dismissed a lawsuit involving premature babies enrolled in a study of what incubator oxygen level was best. The infants’ parents said they hadn’t been fully informed of all the risks to their infants. I was stunned. In 2015, how can the oxygen level in incubators still be endangering babies?

Tuesday, November 17, 2015

A gift from Monique

As we approach the Thanksgiving holiday here in the US, I'm reminded that it is almost the anniversary of Monique Doyle Spencer's death.   Here's a repeat of a post from 2013.  I just found a few more copies of the book.  If you'd like one, free, just leave a comment with your full name and snail mail address.

When Monique Doyle Spencer wrote The Courage Muscle, A Chicken's Guide to Living with Breast Cancer, she couldn't find a publisher willing to take the book on.  It was funny, you see, and all the publishers thought it was inappropriate to have a funny book about cancer.  She showed me a draft, and I said that our hospital would publish the book, and we did.  Since then, it has brought good-humored hope and advice to patients and families around the world.  As one reviewer said:  "It should become a textbook for the medical professions and a guidebook for all who must confront, or support those who do, breast cancer. It is a beautiful book, beautifully written, that sweetly balances gravitas, zaniness and one person's truth. The author's humanity is in full, accessible display for all to see, share and learn from."

Monique died on Thanksgiving weekend in 2011, and along with our fond memories of her, the book remains.  I happen to have several dozen copies, as does her husband Michael.  We have decided to offer them at no cost to the readers of this blog.  First come, first served, until we run out.  Just submit a comment with your name and snail mail address, and we will send one off to you in a few days.

To whet your appetite, here is a story about Monique's humor.  It occurred a few months before in 2011.  Michael tells it:

Bobby McFerrin gave a marvelous concert, showing his voice as an instrument, to a packed house at Symphony Hall.  Afterwards he came to the front of the stage and sat, legs dangling, to answer questions. After a bit, Monique plunged in, without being acknowledged, and asked about whether he was asked to do "Don't Worry Be Happy."  I could feel the audience cringe.  McFerrin gracefully answered the question and said he does not perform the song and was sorry to disappoint.  Monique shot back, "I did not say I liked it."  The audience broke out laughing and McFerrin fell to the floor and lay down on the stage, doing the same.

Monday, November 16, 2015

Why, Governor Baker?

I've worked for a lot of governors and have known a lot of governors, and I have always appreciated their need to balance what they might want to say about an issue with the political realities of their job.  But the best of our leaders are the ones who rise above the exigencies of local politics and manage to display a sense of commitment to human needs and values during periods of political stress--and in so doing remind us that compassion is often the best antidote for fear and unrest.

So it was with a tremendous sense of loss that I heard of Governor Charlie Baker's comments about Syrian refugees. Loss as in a lost opportunity to bring people together rather than being divisive. And lost admiration on my part as the Governor stooped to a level that I could never have imagined coming from his mouth.

According to the Boston Globe, here's what he said:

In the wake of the deadly terrorist attacks in Paris, Massachusetts Governor Charlie Baker has joined a group of nearly two dozen American governors who announced Monday they would not allow any Syrian refugees to move to their states.

“I would say no as of right now,” Baker told reporters at the State House Monday. “No, I’m not interested in accepting refugees from Syria.”

“My view on this is the safety and security of the people of the Commonwealth of Mass. is my highest priority,” he added. “So I would set the bar very high on this.”

“I think at this point in time we’d have to be very cautious about accepting folks without knowing a lot more about what the federal government’s plan looks like and how it’s going to be actually implemented and executed,” he said.

"As a general rule, I don’t like, completely without any knowledge at all, to just say yes or no to anything. I mean, I’m a data guy I always have been and always will be,” he said.

He also said, “I’m always going to be willing to at least hear what the federal government has to say.” But he added, “Hearing what they have to say does not mean saying yes.”

Mr. Baker is smart enough to know that, as Governor, he has no jurisdiction on such matters. Immigration policy is solely in the hands of the US government.

So, is he making his remarks to try to influence federal policy or simply to grandstand on the issue?

But what would it mean to stop the flow of refugees from a country that is literally being destroyed before our eyes?  I recently met one such refugee.  She and her husband and baby boy lived in Damascus.  Their home was taken over by the rebels.  It was then bombed by the Government.  They were homeless and were left with no possessions.  They managed to escape through Lebanon and thence to the US, where she is now enrolled in a graduate program at one of the state's great universities. Their local religious community has welcomed them with open arms and has helped them adjust to their new lives. The family is eternally grateful to the US and people here for giving them a chance to live a normal and productive and peaceful life.

Taking the Governor at his word, this family would have been stopped at the border.

Is he really so insensitive and uncaring about people in distress that he means what he says?  Or, does he not really mean what he says but just feels it expedient to say it? I'm not sure which is worse.

I forget right now, but it was either historian Theodore H. White or Arthur M. Schlesinger who, in summarizing his years of studying American history, said, "Never underestimate the tendency of the US public to become xenophobic." True leaders recognize that danger and work against irrational fear of foreigners: They do not stimulate it by dipping into the mire of anger and fear.

Sunday, November 15, 2015

I told you so

There are a lot of terrible lessons that come from the sad case of Amy Reed and other women who have developed more widespread cancer as a result of morcellation of uterine growths.

Here's a comment from a pathologist friend:

I remember, when these morcellators first came out, saying to the gyn's that if a woman had an unexpected endometrial cancer, I would not be able to stage it because you can't tell how deep it went into the uterine wall when the uterus is in pieces. And yes, we were puzzled about the leiomyomas, too. We used to have a rule that you took so many microscopic sections per centimeter of leiomyoma (i.e. larger ones are more likely to be sarcoma) to look for sarcoma. But how could you tell how big it was or which one was which from pieces?

We were ignored of course. It all goes back to how new things are introduced - there is no vetting process at all.

Let's consider this deeply. Pathologists are highly trained MDs who specialize in the identification of anatomical and cellular abnormalities. They are the doctors upon whom other doctors rely for diagnosis of and phasing of cancer. In this case, they made it clear to the doctors who take care of women with potentially cancerous conditions that a piece of equipment and a technique employed by those gynecologists could eliminate diagnostic clarity. And yet, the technology was adopted.

This story represents an institutional failure of the highest order. Underlying that failure, I would assert, is the ongoing medical arms race. Manufacturers design a product that makes life easier for one segment of the medical world.  FDA approval with regard to safety is limited in scope. Because data emanating from usage of the device is inherently inaccurate or incomplete (i.e., a needle in a haystack level of precision), it remains in use notwithstanding harm that has been caused.

But doctors also need to consider the story and reflect on how their own behavior can be destructive.

The pattern. Stories start:

About ten years ago, reports started surfacing in the medical literature of women with severe pelvic pain or unexplained bleeding who all had something in common: they had undergone morcellation years prior. Doctors reported finding growths in the abdominal cavities that could be traced back to the fibroids and uteruses that had been removed. This was troubling enough in itself—it had been assumed that missed particles, without a blood supply, would simply be reabsorbed—but it also raised the possibility that cancer could be spread too.

Serious concerns emerge:

Between 2008 and 2010, case reports of disseminated leiomyosarcoma by researchers in New Delhi, Montreal, Boston and Osaka were published. In at least one instance, the new tumour growth was definitively linked to the original specimen. Other papers compared outcomes for women whose undetected LMS had been morcellated versus not morcellated, and they found that morcellating an LMS tumour made it more likely the cancer would spread, and, according to at least one paper, more likely that the woman would be dead within five years.

By 2011—two years before Reed’s surgery—morcellation had become a full-on conversation among cancer doctors. Jeong-Yeol Park, a gynecological oncologist at the Asan Medical Center in Seoul, Korea and the lead author on one of the morcellation comparison papers, presented his findings at the Annual Meeting on Women’s Cancer. In an Oncology Times article about the talk, Bobbie Gostout, chair of gynecology at the Mayo Clinic in Minnesota, commented: “I don’t think there’s an acceptable, safe morcellator out there ... We are exposing our patients to a risk that to me seems out of bounds.”

Nonetheless, inertia rules, as per what happened after a review of Amy's case and an impassioned plea from her surgeon husband Hooman Noorchashm:

By the end of the meeting, little had been achieved. The Brigham would not lead the world in banning morcellators or even curtail their use in its own operating rooms. A few days earlier, the hospital had circulated an internal memo acknowledging that the risk of accidentally morcellating a sarcoma might be much higher than previously thought. It suggested that all surgeons get informed consent from patients before using the device. With that, the hospital felt that the matter had been dealt with.

Likewise, across town:

Isaac Schiff, head of obstetrics and gynecology at Massachusetts General Hospital (MGH), another Harvard affiliate . . . recalled being alarmed by the case of a morcellated fibroid turning out to be a sarcoma and he brought it up at a faculty meeting on December 12, 2013. There, he and his colleagues changed the hospital’s informed consent procedures.

Meanwhile, the person trying to be the agent of change is himself attacked, as incumbents in the system started to eat their young:

Now, though, the Brigham moved to isolate Noorchashm. The day after the December meeting with CMO Ashley, senior hospital staff circulated an internal email instructing Noorchashm’s colleagues to not communicate with him directly but instead to go through official channels. His job also became a sticking point. 

His descent was steep and lonely. In a matter of weeks, Noorchashm had gone from being a Harvard-affiliated surgeon, a golden boy with a shining future, whose life and identity revolved around the operating room, who got up at 4:30 every morning and seldom made it home in time to kiss the kids goodnight, to someone whose major scheduled activities involved dropping his children off at school in the morning and listening for their buses in the afternoon.

Tragedy upon tragedy upon tragedy. And totally avoidable, if from the start, the thoughtful voices from the pathology profession had been taken into account. Rosemary Gibson (in The Wall of Silence) has written elegantly about the underlying problem, a problem the profession steadfastly refuses to address:

The people who provide health care to patients are organized in different tribes. . . . Virtually no training exists to help them learn how to work together, so instead of learning to understand and respect one another's role, there are chasms among the tribes.

Measuring . . . nothing

At his talk at Harvard last week, the Aga Khan reflected on the state of things in the world and spent a moment on the role of technology.  He noted one adverse result:

The more we communicate, the harder it can sometimes be to evaluate what we are saying. More information often means less context and more confusion. 

We were treated to a prime example of this during Saturday night's debate among the Democratic candidates for president.  As we watched the debate, we were presented with a visual hodgepodge.  The candidates were in the middle of the screen.  To the right was a semblance of a Twitter feed, showing real-time reactions to the debate from . . . .  Wait, from whom?  Who knows.  The chosen tweets were the ones some CBS functionary had decided were noteworthy enough to share with the millions of people viewing the debate.  Who were these chosen gods and goddesses of political observation, the ones whose 140-character notes were deemed thoughtful, entertaining, or controversial enough to warrant national exposure? Why were their opinions relevant, helpful, or important in any way?  How did their comments help us as citizens reach our own conclusions about the effectiveness of the candidates?

As if that weren't enough, CBS presented the following chart directly underneath the debating candidates:

When we consider all of the possible metrics about the political world, could we come up with something less meaningful that the "relative number of tweets per minute about three candidates during a debate?" What possible probative value about anything does such a metric offer? Simple answer: Not a damn thing.

A superb reporter, Carey Beth Goldberg, in a note to me, said:  "This is one more example of how the ability to measure something online doesn't mean you should."

She then said:

"There was a really good piece on On The Media about how just measuring clicks is misguided too  -- based on a story about spooning (?!?)"

That article is worth a click!