Uncertainty and regret in medicine

The Power of Regret

While reading NEJM I find an article on regret:

As physicians, we are acutely aware of the element of uncertainty in medicine, but we less often recognize its close companion, regret. Regret in all its forms can be a powerful undercurrent, moving patients to act in ways that may baffle us.

Kahneman and Tversky said  that bad outcomes from recent action are more regretted than similar outcomes from inertia. There two types of bias that affect regret. Omission bias is the tendency toward inaction or inertia — reflects anticipated regret. Commission bias is the tendency to believe that action is better than inaction, and can result in regret arriving later when a bad outcome occurs.

When we’re in pain or acutely anxious, we are “hot” and apt to make choices that we imagine will rapidly remedy our condition, which predisposes us to commission bias. In a hot state, patients may discount too deeply the risks posed by a treatment and overestimate its likelihood for success, paving the way for later regret if the outcome is poor. Patients who choose elective procedures while in a hot
state and end up with a bad outcome may be at particular risk for regret due to commission bias.

Georges Seurat. Two Sailboats at Grandcamp (Deux voiliers à Grandcamp), c. 1885.
Oil on panel, BF1153. Public Domain. Barnes Foundation

The apocalypse and our true fate, who knows?

THE FIVE HORSEMEN OF THE MODERN WORLD: Climate, Food, Water, Disease, and Obesity

In the book of Revelation or Apocalypse of John, you'll find the seven bowls. Seven angels are thus given seven bowls of God's wrath, each consisting of judgements full of the wrath of God poured onto Earth:

First Bowl: A "foul and malignant sore" afflicts the followers of the Beast. (16:1–2)
Second Bowl: The Sea turns to blood and everything within it dies. (16:3)
Third Bowl: All fresh water turns to blood. (16:4–7)
Fourth Bowl: The Sun scorches the Earth with intense heat and even burns some people with fire. (16:8–9)
Fifth Bowl: There is total darkness and great pain in the Beast's kingdom. (16:10–11)
Sixth Bowl: The Great River Euphrates is dried up and preparations are made for the kings of the East and the final battle at Armageddon between the forces of good and evil. (16:12–16)
Seventh Bowl: A great earthquake and heavy hailstorm: "every island fled away and the mountains were not found." (16:17–21)

As you may notice Apocalypse is just that, a book. Daniel Callahan set a title of five horsemen of the modern world as a metaphor of current evils. Global warming, food shortages, water shortages and quality, chronic illness, and obesity could be the key ingredients of our fate?.
At the end, Daniel Callahan calls for a diplomatic model:

to persuade the research, academic, and policy communities to accept what I will call the diplomatic model of relationships, typically now seen between and among nations, and to open a serious dialogue with the business community

Agree.

Obesity: a multifaceted approach

The Current State of Obesity Solutions in the United States

We all agree that we need to face the obesity epidemic. But, when talking about solutions, difficulties and uncertainties  arise. US National Academies held a worksop on 2014 that described interventions designed to prevent and treat obesity in seven settings:
• early care and education,
• schools,
• worksites,
• health care institutions,
• communities and states,
• the federal government, and
• businesses and industry
The book is only a first approach to these experiences, though more evidence is needed in my opinion. They say in the book:

"Much of what needs to be done is clear, he said. The challenge now is to figure out how to do what needs to be done."

 DocField 2017

Now in Barcelona

How to change individual letters of your DNA?

Gene editing has made another step forward. And maybe a complementary to the former one, the CRISPR-Cas9,  that was proved viable by Jennifer Doudna and I explained some months ago in this post. No it is indeed more interesting. Two different approaches, base editing and CRISPR-Cas13, have been described in Science and Nature. Adenine base editing allows to correct mutations, it doesn't cut the gene to insert a new one. It is a sharp pencil rather than scisors. With CRISP-Cas13 it is possible to edit RNA, which converts genetic information into proteins. An exciting approach, you correct a book with temporary ink that disappears, rather than making a permanent mark (like in CRISPR-Cas9).
These are exciting times for genetic research, though we'll have to wait for specific clinical applications

Modigliani, now at Tate Gallery

Voluntary health insurance: fulfilling expectations

Memòria entitats d'assegurança lliure 2015
Regulació de l'assegurança voluntària de salut

Let's take one country that has a mandatory social security system for the whole population, though its funding comes from taxes (?). If 25% of the population in this country voluntarily buy  duplicate coverage for the roughly the same benefits, what would you say?. The potential answer is that the public system is not fulfilling people expectations and has a big problem. Unfortunately, politicians don't recognise the situation. Imagine that in the capital more than one third of the population hold private insurance, you would say indeed that the problem is larger. This is the case of Barcelona.
Somebody should review the situation. Both public and private systems have their drawbacks. If public mandatory funding is not providing an efficient system, than a prescription is needed. If voluntary health insurance solves the unfulfilled expectations, then a close relationship should be established, and this is not an option by now.
I wrote a paper some time ago on the required new regulation for voluntary health insurance. My impression is that nobody read it. Maybe now it's the time.

PS. Right now 735.997 patients are waiting for a surgery, a visit or a diagnostic procedure.

 

 

Richard Estes. Galeria Marlborough

The end of marginal revolution

Richard Thaler was awarded with the Nobel Prize some days ago. If you follow this blog you'll know his works on behavioral economics and nudging. Since many years I've been interested in this perspective, though it has still more to deliver.
Today I would suggest you to read JM Colomer blog. He has written an excellent post on him and its impact on economic science. Selected statements:

Marginalist microeconomics held that we could understand collective outcomes by assuming that they derive from free interactions among homines economici.
A first big counter-revolution was the reintroduction of institutions in the basic analysis, especially since the 1980 and 1990s (including by Nobel laureates related to the social choice and public choice schools such as Kenneth Arrow, James Buchanan, Ronald Coase, Douglass North, Amartya Sen, Thomas Schelling, Leonid Hurwicz, Roger Myerson, political scientist Elinor Ostrom, Oliver Williamson, and others).

The second is the reintroduction of realistic observations about people’s motivations and behavior, including emotions. This has been based on psychology, on the background of huge progress in neuroscience (while pioneers include political scientist Herbert Simon and psychologist Daniel Kahneman). That Richard Thaler professes at the University of Chicago, once the temple of the neoclassical school, shows the depth of the change.

Now we know again that the three pillars of social analysis are, together with people’s calculated self-interested choices, emotions and institutions, as Hume and Smith masterfully had already established.

And this is the return to the roots of economics with a new toolkit.

Parov Stelar

Understanding Generic Drug Markets

Comparing Generic Drug Markets in Europe and the United States: Prices, Volumes, and Spending

The development of generic drug markets depends widely on an active regulator. This is the main reason of differences in consumption among countries. A new article highlights these differences and allows to understand better such market.

Substituting generic medicines for more expensive brand-name versions is likely among the most cost-effective interventions in health care systems.

There remain large differences in the usage and prices of generics in Europe and the United States. The barriers to market entry for generic companies vary between countries, as do pricing and reimbursement policies. Beyond such features of the market,
there are differences in whether, and to what extent, patients and health care professionals perceive generic and branded medicines to be bioequivalent.

Healthcare Quality Lessons

Caring for Quality in Health

An OECD report provides the lessons on caring for quality, quite general but of interest to dive into each one:

Lesson 1. High-performing health care systems offer primary care as a specialist service
that provides comprehensive care to patients with complex needs
Lesson 2. Patient-centred care requires more effective primary and secondary prevention
in primary care
Lesson 3. High-quality mental health care systems require strong health information systems
and mental health training in primary care
Lesson 4. New models of shared care are required to promote co-ordination across health
and social care systems
Lesson 5. A strong patient voice is a priority to keep health care systems focussed
on quality when financial pressures are acute
Lesson 6. Measuring what matters to people delivers the outcomes that patients expect
Lesson 7. Health literacy helps drive high-value care
Lesson 8. Continuous professional development and evolving practice maximise
the contribution of health professionals
Lesson 9. High-performing health care systems have strong information infrastructures
that are linked to quality-improvement tools
Lesson 10. Linking patient data is a pre-requisite for improving quality across pathways
of care
Lesson 11. External evaluation of health care organisation needs to be fed into continuous
quality-improvement cycles
Lesson 12. Improving patient safety requires greater effort to collect, analyse and learn
from adverse events 

It is like a check list, have you done your homework?

Searching for a book to read

Manel Castro

Precision medicine initivatives around the world

Human genomics projects and precision medicine

Governments and research funders in developed world have decided to support precision medicine with different initiatives. Its scope and strenght it is quite diverse. It is good to know what's going on, and this is explained in an article in Nature. A data driven medicine is raising with next generation sequencing (NGS) tools:

The tremendous amount of data that NGS technologies are producing and the difficulties to manage and analyze such quantity of data require the implementation of powerful data centers for storage and analysis. Nevertheless, recent improvements in cloud computing allow managing and analyzing these huge data amounts remotely. With this goal in mind, the main internet companies have taken positions to compete in this area of NGS (data storage and analysis).
As three main examples, Google Genomics, Microsoft Genomics and Amazon Web Services (AWS) Genomics In The Cloud allow researchers to store, process, explore, and share large and complex data sets. The idea behind is to provide userfriendly tools to the researchers.

But finally it is no only for researchers, there will be one day that will be applied by clinicians. The whole article worths to be read.

Lita Cabellut. Barcelona exhibition

Beyond precision medicine: high definition medicine

High-Definition Medicine

Some months ago I was posting on medicine as a data science. Now:

The foundation for a new era of data-driven medicine has been set by recent  technological advances that enable the assessment and management of human health at an unprecedented level of resolution—what we refer to as high-definition medicine. Our ability to assess human health in high definition is enabled, in part, by advances in DNA sequencing, physiological and environmental monitoring, advanced imaging, and behavioral tracking. Our ability to understand and act upon these observations at equally high precision is driven by advances in genome editing, celular reprogramming, tissue engineering, and information technologies, especially artificial intelligence.

This is what high definition medicine is about:

the dynamic assessment, management, and understanding of an individual’s health measured at (or near) its most basic units. It is the data-driven practice of medicine through the utilization of these highly detailed, longitudinal, and multi-parametric measures of the determinants of health to modify disease risk factors, detect disease processes early, drive precise and dynamically adjusted interventions, and determine preventative and therapeutic intervention efficacy from real-world outcomes

In this framework, precision medicine is only a small piece of the engine.

The article published in Cell by scholars from Scripps Translational Science Institute sheds light on the new perspectives of the practice of medicine, a milestone on the current knowledge of life sciences and its application.

***

Catalunya, 1 d'octubre de 2017 · .

Bloody Sunday

Bloody Sunday, Oct 1st, 2017

BBC
Le Monde

Rafael Subirachs 41 years ago - Els segadors - Anthem (1640)

One of the biggest financial scandals of all-time (and remains unsolved)

The LIBOR scandal involved the illegal fixing of this rate. Banks would over or under-report the rate so as to benefit them – making tons of cash in the process. Raise the rate a few basis points, and suddenly you’ve made an extra $200 million dollars in two minutes.
The size of fines for banks up to now is  €9 billion, and the most surprising thing is that it is still working as before. VoxEU explains

You might think that after this costly scandal, and knowing challenges of maintaining LIBOR, market participants and regulators would have quickly replaced LIBOR with a sustainable short-term interest rate benchmark that had little risk of manipulation. You’d be wrong. The current administrator (ICE Benchmark Administration), which replaced the BBA in 2014, estimates that this guide (now called ICE LIBOR) continues to serve as the reference interest rate for “an estimated $350 trillion of outstanding contracts in maturities ranging from overnight to more than 30 years"
In short, LIBOR is still the world’s leading benchmark for short-term interest rates

Sounds incredible but it is true. I'm reading the book: The spider network and it reports the worst professional financial practices that you can imagine. Where is the regulator? The european one is on vacation, for sure.

Public Health and behaviour change

Behavioral Epidemiology. Principles and Applications

It is quite surprising that a new book on Behavioral Epidemiology forgets Tversky and Kahneman, or Thaler. I couldn't find any reference to their works. After all these decades it seems that their works should be taken into account. Epidemiology and Public Health need to review its foundations, basically its rational decision making paradigm that has been their foundations.
I thought that this book could help, but finally I saw that only the first chapters are partially of interest. We'll have to wait.

Health in all policies narrative

Engagement of Sectors Other than Health in Integrated Health Governance, Policy, and Action

A good review on the topic is welcome. You'll find this article in Annual Reviews of Public Health. If health is created largely outside the health sector, engagement in health governance, policy, and intervention development and implementation by sectors other than health, is therefore important. I have reviewed this topic earlier, but I suggest a close look at it and its assumptions:

(a) Health is created largely outside the health care (or disease) sector; (b) the health care (or disease) sector, however, often carries social ownership of all health issues, even when they are beyond its control; (c) the health sector itself is a reproduction of (power) divisions in the public and private sectors and, while calling for integration, is itself fragmented; and (d) calls for broad social engagement with integrated research, policy, action, and governance for health may not align well with assumptions a–c.

The purpose of the article is to provide an evidence-based overview of how broad social engagement in health policy, action, and governance can be initiated, developed, and sustained.

 In Barcelona Caixaforum, right now.