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Month: June 2020

Whimsical Software

One of my past projects was developing a more effective solution to live patient updates in the labor and delivery ward. During that process, we observed the flow of patient information from one provider to the next, all in two places: pieces of paper scrunched up in the pockets and labcoats of providers, or on Epic’s software.

What does the company behind it look like? Kate Kelly compares it to Willy Wonka’s chocolate factory:

In the farm country of southern Wisconsin, 12 miles from Madison, is one of the nation’s biggest tech companies — and almost certainly the quirkiest. The woman who controls it is a septuagenarian coding savant, its campus contains a human-size rabbit hole and an elevator to hell, and in all probability your personal medical records are on servers running its software.

[. . .]

Epic’s software is ubiquitous in doctors’ offices and operating rooms, and companies like Amazon, Microsoft and Alphabet regularly hoover up its young engineers. Yet most people outside of the Madison environs, I’d be confident to say, have never heard of the company.

I certainly hadn’t. I cover Wall Street, not health care or technology, and when I came across the privately held Epic this year I was consumed with questions. Who was this publicity-shy yet spectacle-loving C.E.O., and how did her theme-park sensibility coexist with the mundanity of health care billing protocols? Was Epic’s odd culture a magnet for talent and clients, or was it an indulgence that kept the company from growing even bigger? In August, I traveled to Wisconsin to see what this 1,100-acre Midwestern behemoth might be hiding.

Kate Kelly

Dossier

“Willy Wonka and the Medical Software Factory,” by Kate Kelly, December 20, 2018. https://www.nytimes.com/2018/12/20/business/epic-systems-campus-verona-wisconsin.html

Is it Time for FaceTime?

On the heels of the tenth anniversary of the introduction of FaceTime by Steve Jobs, most people rarely video call, argues Ali Drucker. Despite a recent surge due to the pandemic, “Zoom fatigue” often sets in after only a half hour of continuous video calls. It’s surprisingly exhausting. Why?

Perhaps it takes much more mental effort, creating a space and a neat background, touching up appearances to make sure we’re presentable, adjusting lighting, and constantly paying attention. But now during the pandemic, there is renewed interest in video calling, connecting with others digitally when we can’t do so physically.

Somehow, even though I rarely saw my New York friends in the Before Times, I’ve been missing their faces more. Their wisecracks and constant, clever one-upmanship. All the while, I could have just asked for this — a modest video call to catch up — whenever I wanted to. But I didn’t. And if you’re a bit like me, you probably didn’t either.

[. . .]

So why, actually, are so many of us only just now making video calling a habit? Did I really not see my parents’ faces for months on end, even over a screen, simply because I had the option of socializing with my partner and nearby friends instead? Was I actually “just super busy” or did I want to avoid confronting how much I missed them? How I was quietly nursing the loneliness of feeling like I might not truly know the people I can’t see in person anymore.

Amid the continuing carnage in this country, I can’t bring myself to make a rhetorical turn toward a silver lining. The pleasant paradox of families and friends like mine getting in more quality time in the age of social distancing feels moot when there’s a national reckoning on racism and the scourge of police violence against black people; when every day thousands of people are still contracting a disease that could kill them — that has already killed more Americans than several wars did. There is no public plea here to boldly carry this newfound sense of connectedness with us into the new normal, whatever that is.

For me, that kind of optimism would be a sleek betrayal, albeit a convenient one: Focusing on the good in all of this would be much easier than admitting the truth — that I could have reached out to my loved ones at any moment, but didn’t until this pandemic made me feel as though I was hanging on by a bare thread.

Ali Drucker

Dossier

“Why Weren’t We Video Calling All Along?” by Ali Drucker, June 15, 2020. https://www.nytimes.com/2020/06/15/opinion/covid-video-calls-zoom-facetime.html

“Why Zoom Meetings Can Exhaust Us,” by Jeremy Bailenson, April 3, 2020. https://www.wsj.com/articles/why-zoom-meetings-can-exhaust-us-11585953336

“Why Does Zoom Exhaust You? Science Has an Answer,” by Betsy Morris, May 27, 2020. https://www.wsj.com/articles/why-does-zoom-exhaust-you-science-has-an-answer-11590600269

From the Helicopter to the Hospital

One of my aviation friends discussed with me the incredible advances in night vision technology in recent years. Only a few days later, we visited the LifeFlight program at UMass and were treated to an amazing demo of the helicopter and a conversation with the pilots, mechanics, nurses, and paramedics that make the whole program run.

The pilot explained that, without night vision technology, they would not be able to land in adverse conditions, pointing out that they don’t have runway approach lights in the fields and roads that they land on to bring patients in.

I imagined one of my own flights. The setting sun peeking behind the wispy clouds; the turn onto final as the approach lights flit towards the runway; slowly gliding down towards the ground; winding down with friends after a fun evening flight.

Then I pictured the harrowing image of rain beating down while the rhythmic thump of helicopter blades overshadow the blaring siren of an ambulance; three paramedics stand soaking wet protecting the stretcher from the downdraft as the patient is loaded in. (See the Prologue of Jurassic Park, the book) The stark contrast between the two images reminded me of the stakes.

Image: Sam Aldon, New York Times

The same scene unfolds half an hour later at the entrance of the hospital:

My office overlooked the street in front of the hospital. After half an hour, I looked down to see the surface of coffee in my mug rippling like in the scene in “Jurassic Park” where the approaching T. rex’s footsteps are detected in puddles of water. Within seconds, there were rhythmic pulsations all around, then a strong thump-thump-thump-thump as the air beat against my window. Outside in the midst of the downpour, trash cans tumbled down the street and pickup trucks were forced down on their shocks. I gazed up to see an Army Blackhawk helicopter, giant in comparison to our standard medical helicopters, hovering steadily over the children’s hospital helipad, rain and fog swirling in all directions. Every part of the office thumped, the heartbeat in my own chest now overpowered.

[. . .]

The operating room team was ready for the girl, the sterile instruments laid out on the back tables, blue drapes applied after a quick clipping of her hair and lightning-fast wash of her head with sterilizing prep solution. Knife. Retractor. Drill. Scissors to open the dura, the thin leathery covering of the brain, bulging and tight from the underlying blood. Once the brain is exposed it does the work for us, extruding most of the coagulated clot in a matter of seconds. We clean out what is left at the edges and I see the offending vein, torn away from the brain during the accident. We coagulate it and begin to make our way out, step by step, gently repairing all that we had to take apart to get there.

[. . .]

A decade and a half after her injury I received one such letter. No longer the hand-drawn cards of childhood or newspaper clippings from her proud parents, this was a handwritten note on elegant stationery inviting me to her wedding. Her wedding. I could still see her in the bed of the pediatric I.C.U. after surgery, a 9-year-old child with abrasions on the side of her face from the accident and a clean white head wrap around her head. The nurses methodically connecting her to the monitors, line by line, tube by tube. Me urging her to squeeze my hand, for a sign, any sign, that she was better. Now, years later, I was reading how thankful she was to have been given this chance. Grateful for those soldiers in that helicopter, the two hospital teams, and for me. She promised to always have us in mind as she began her new married life and hopefully one day raise her own family.

As I read the letter sitting in a different office in a different city, thinking back over those events, I found myself realizing how deeply grateful I was to her, for her evolving story over the years — all the cards, each barrier broken, every milestone — and for what that experience taught me. So many other critically ill children in the subsequent years benefited from this early experience, when I was learning how hard to push, where to draw the line and how much to expect of others.

My father’s lessons in the air, that industrious emergency room doctor, those brave soldiers soaked to the bone standing there as we rolled away — so many people and events came together for this one child to grow into her life, to find happiness, to find love. All of us need a living, breathing reminder to just keep pushing on. There may be a life there to be beautifully and fully lived, a person who just needs someone, anyone, to work the problem, to make the hard call, and to fly in a storm.

Jay Wellons

From this, I am reminded of the incredible cooperation that we are lucky to have here.

Dossier

“From Blackhawk to Brain Surgery to Bride,” by Jay Wellons, February 29, 2020. https://www.nytimes.com/2020/02/29/opinion/sunday/doctors-medicine-military-emergency.html

The Humble Mask

Moving Away from Nosology

Medicine is a privileged field. Every day, patients place their trust and lives in the hands of physicians. As a result, physicians have a responsibility to society, and that includes being aware of their own biases and mitigating their effects.

Nosology: the branch of medicine that deals with the classification of diseases

Despite this, disparities exist. For example, black women are much more likely to suffer from complications during childbirth. Even more troubling, is that they are also less likely to be listened to by doctors.

On Sept. 2, the day after giving birth to her daughter via cesarean section, Ms. Williams was having trouble breathing and “immediately assumed she was having another pulmonary embolism,” the article says.

She alerted a nurse to what she felt was happening in her body and asked for a CT scan and a blood thinner, but the nurse suggested that pain medication had perhaps left Ms. Williams confused, according to Vogue. Ms. Williams insisted, but a doctor instead performed an ultrasound of her legs.

“I was like, a Doppler? I told you, I need a CT scan and a heparin drip,” Ms. Williams, 36, said she told the medical team.

When the ultrasound revealed nothing, she underwent a CT scan, which showed several small blood clots in her lungs. She was immediately put on the heparin drip. “I was like, listen to Dr. Williams!” she told the doctors.

Maya Salam

Athletes like Serena Williams are particularly tuned in and aware of their bodies. Of anyone, they would be most likely to understand when things feel wrong or abnormal.

There is a movement to move medicine and the role of the physician away from the age-old idea of the nosologist. Medicine in the past was about the heroic physician-scientist; the idea that doctors are there to solve puzzles, make diagnoses, classify diseases, rather than treat patients. That job is supposedly for nurses and other healthcare professionals. That philosophy of medicine is slowly going away, as medicine as a whole is becoming more humanistic and empathetic.

There is still a long way to go. However, I think we are on the right path and are continuing to move forward. Ultimately, it is important to recognize that it is our human experience that brings us together. While physicians are certainly not immune from bias, they take pride in being able to recognize that patients come in with complex and nuanced issues, including the social determinants of health.

Hospitals are one of the very few places left where you encounter the whole span of society. Walking the halls, you begin to understand that the average American is someone who has a high-school education and thirty thousand dollars a year in per-capita earnings, out of which thirty per cent goes to taxes and another thirty per cent to housing and health-care costs. [. . .]

Most people don’t have this broad vantage. We all occupy our own bubbles. Trust in others, even our neighbors, is at an historic low. Much of society has become like an airplane boarding line, with different rights and privileges for zones one to ninety-seven, depending on your wealth, frequent-flier miles, credit rating, and S.A.T. scores; and many of those in line think—though no one likes to admit it—that they deserve what they have more than the others behind them. Then the boarding agent catches some people from zone eighty-four jumping ahead of the people in zone fifty-seven, and all hell breaks loose.

Insisting that people are equally worthy of respect is an especially challenging idea today. In medicine, you see people who are troublesome in every way: the complainer, the person with the unfriendly tone, the unwitting bigot, the guy who, as they say, makes “poor life choices.” People can be untrustworthy, even scary. When they’re an actual threat—as the inmate was for my chief resident—you have to walk away. But you will also see lots of people whom you might have written off prove generous, caring, resourceful, brilliant. You don’t have to like or trust everyone to believe their lives are worth preserving.

[. . .]

I didn’t understand him or like him. But all it took to see his humanity—to be able to treat him—was to supply that tiny bit of openness and curiosity.

Atul Gawande

Dossier

“Curiosity and What Equality Really Means,” by Atul Gawande, June 2, 2018. https://www.newyorker.com/news/news-desk/curiosity-and-the-prisoner

“For Serena Williams, Childbirth Was a Harrowing Ordeal. She’s Not Alone,” by Maya Salam, January 11, 2018. https://www.nytimes.com/2018/01/11/sports/tennis/serena-williams-baby-vogue.html

The Story of Pain in Munich

The U.S. healthcare system is a bit strange compared to the rest of the world. In almost every aspect, our focus is on direct treatment. While one can argue that this is a result of economic or legal incentives and the free market innovation, ultimately, I think it is about cultural attitude. Americans value choice, above all—the freedom to make their own decisions about what happens to them.

What this results in is the lack of preventive medicine, to the detriment of the population at large. Fewer and fewer physicians are going into primary care, instead choosing to pursue more lucrative specialties—and who can blame them? That’s what society seems to want.

A story I read in the New York Times illustrates the differences in perception:

I recently had a hysterectomy here in Munich, where we moved from California four years ago for my husband’s job. [. . .]

I brought up the subject of painkillers with my gynecologist weeks before my surgery. She said that I would be given ibuprofen. “Is that it?” I asked. “That’s what I take if I have a headache. The removal of an organ certainly deserves more.”

“That’s all you will need,” she said, with the body confidence that comes from a lifetime of skiing in crisp, Alpine air.

I decided to pursue the topic with the surgeon.

He said the same thing. He was sure that the removal of my uterus would not require narcotics afterward. I didn’t want him to think I was a drug addict, but I wanted a prescription for something that would knock me out for the first few nights, and maybe half the day.

[. . .]

“. . . but I am concerned about pain management. I won’t be able to sleep. I know I can have ibuprofen, but can I have two or three pills with codeine for the first few nights? Let me remind you that I am getting an entire organ removed.”

The anesthesiologist explained that during surgery and recovery I would be given strong painkillers, but once I got home the pain would not require narcotics. To paraphrase him, he said: “Pain is a part of life. We cannot eliminate it nor do we want to. The pain will guide you. You will know when to rest more; you will know when you are healing. If I give you Vicodin, you will no longer feel the pain, yes, but you will no longer know what your body is telling you. You might overexert yourself because you are no longer feeling the pain signals. All you need is rest. And please be careful with ibuprofen. It’s not good for your kidneys. Only take it if you must. Your body will heal itself with rest.”

I didn’t mention that I use ibuprofen like candy. Why else do they come in such jumbo sizes at American warehouse stores? Instead, I thought about his poetic explanation of pain as my guide, although his mention of “just resting” was disturbing. What exactly is resting?

I know how to sleep but resting is an in-between space I do not inhabit. It’s like an ambiguous place that can be reached only by walking into a magic closet and emerging on the other side to find a dense forest and a talking lion, a lion who can guide me toward the owl who supplies the forest with pain pills.

[. . .]

Come to think of it, I bring a lot of medicine with me from the United States, all over the counter, all intended to take away discomfort. The German doctors were telling me that being uncomfortable is O.K.

[. . .]

After a week, I took the tram to the doctor’s office to have my stitches removed. My doctor, with her usual cup of chamomile tea in hand, remarked on my progress. “I rested,” I told her. Normally, I would have said, “I did nothing,” but I didn’t say that. I had been healing, and that’s something.

Firoozeh Dumas

Dossier

“After Surgery in Germany, I Wanted Vicodin, Not Herbal Tea,” by Firoozeh Dumas, January 27, 2018. https://www.nytimes.com/2018/01/27/opinion/sunday/surgery-germany-vicodin.html

How Language Connects People

Cognitive Heuristics in Medicine

Heuristics are incredibly useful to help us make decisions quickly and effectively. But, by definition, heuristics do not take into account the nuances and complexities of the real world.

This is especially frightening, however, in medicine, where we expect our physicians and caretakers to treat us without regard to anything else (including cost in America, though a separate issue).

In this article in the New York Times, Jena and Olsenki describe a few cases in which cognitive heuristics can have adverse effects on patients. For example, they show: (1)”that when patients experienced an unlikely adverse side effect of a drug, their doctor was less likely to order that same drug for the next patient whose condition might call for it, even though the efficacy and appropriateness of the drug had not changed” and (2) “that when mothers giving birth experienced an adverse event, their obstetrician was more likely to switch delivery modes for the next patient (C-section vs. vaginal delivery), regardless of the appropriateness for that next patient.”

In their own study, Jena and Olsenki report the impact of left-digit bias:

This is the bias that explains why many goods are priced at $4.99 instead of $5, as consumers’ minds round down to the left-most digit of $4.

We hypothesized that doctors may be overly sensitive to the left-most digit of a patient’s age when recommending treatment, and indeed, in cardiac surgery they appear to be. When comparing patients who had a heart attack in the weeks leading up to their 80th birthdays with those who’d recently had an 80th birthday, we found that physicians were significantly less likely to perform a coronary artery bypass surgery for the “older” patients. The doctors might have perceived them to be “in their 80s” rather than “in their 70s.” This behavior seems to have translated into meaningful differences for patients. The slightly younger patients, more likely to undergo surgery, were less likely to die within 30 days.

Anupam Jena and Andrew Olsenki

These issues might not be that surprising in retrospect, given that physicians are humans too, just like anyone else.

Dossier

“How Common Mental Shortcuts Can Cause Major Physician Errors,” by Anupam Jena and Andrew Olsenki, February 20, 2020. https://www.nytimes.com/2020/02/20/upshot/mental-shortcuts-medical-errors.html

“Do Language Heuristics Reduce Creativity?” by Sahil Nawab, May 15, 2019. http://www.sahilnawab.com/blog/do-language-heuristics-reduce-creativity/

Civil Liberties and the Constitution

The civil liberties that have been granted by the Constitution are neither unlimited nor universal. This is clearly visible in the differing reactions of police, between the armed protests in Michigan against the COVID-19 lockdowns and the ironic, forceful police response to protests against police violence in the Black community.

Constitutional law scholars have shown time and time again that the individual rights of citizens must be balanced with the interests of society as a whole. This may mean infringing on the rights of individuals, or at least the appearance of doing so from certain perspectives. The specific virtues of doing so have been debated endlessly throughout the history of the nation. Likely, this debate will continue, especially in light of the underlying social issues that the COVID-19 pandemic and the killing of George Floyd have surfaced. Regardless, we are lucky to be in a society where despite such infringements, we can expect that these rights are quickly returned as a situation diffuses.

It interesting to look at the different responses to protests in order to glean a more comprehensive understanding of the rhetorical warrants that underscore the arguments presented by citizens, the current Administration, and scholars.

In response to the lockdowns from the COVID-19 pandemic, armed protesters with semi-automatic rifles assembled at the Michigan Capitol building. These protesters frame their methods as a way to uphold their rights to bear arms. While not inherently inimical, looking at the impact of their tactics can help elucidate their true intentions. As a result of the armed protests, the Legislature was adjourned. Weiner reframes their tactics, stating that “Those who [use] weapons to inhibit the business of government are better understood as armed rebels.”

Even so, the armed rebels expect that their rights are not infringed upon. They expect Constitutional protection despite actions that are directly opposed to the very purpose of the Constitution to “enable the peaceful resolution of disputes” and “prevent a resort to violence in politics” (Weiner, 2020).

“There is no reasonable claim that their weapons were necessary for self-defense — unless, that is, they planned to use them against law officers. The only reason to stand over a session of the State Senate wielding military-grade weapons is to intimidate its members, a goal in which the rebels succeeded” (Weiner, 2020). It is clear that their intentions were against the country and the Constitution.

If the armed rebels were truly concerned about an abusive government policy, there are Constitutional methods in which to remedy such abuse. The tactics used by armed rebels “inherently entails exiting the constitutional order, not claiming its protections” (Weiner, 2020).

Locke argues that “the majority have a right to act and conclude the rest.” This means that when the majority agrees, the government has the authority to make, and implement, decisions that all must follow. It is important to note, however, that these decisions may not always be “right.” When this happens, Weiner points out that, “in the end, the choices were to accept the constituted authority or to rebel against it.”

The question in Michigan and other scenes of armed protests against coronavirus restrictions is not whether states have struck the proper balance between public health and other considerations. Nor is it even whether governments have exceeded their legitimate authority. The question the would-be rebels must answer is whether social-distancing measures are so tyrannical that they are willing to take the extraconstitutional step of rebellion. They can either claim or relinquish the Constitution’s protections. They cannot have both.

Greg Weiner

In this respect, they differ in both motive and objective from the protesters raging against police violence in Minneapolis and elsewhere. The tactics of both groups have unraveled. But the complaint against police violence is against officers of the state breaking the law, not lawfully making policy in the first place.

Greg Weiner

Dossier

“Anti-Lockdown Rebels Don’t Get to Choose Their Own Constitution,” by Greg Weiner, May 31, 2020. https://www.nytimes.com/2020/05/31/opinion/protesters-lockdown-constitution-covid.html

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