Author: Joe Kaempf

Words – Part 3

With words, who can link the Buddha to Shakespeare to Keats?  Our Nobel Laureate poet Louise Gluck, that’s who.

A tenet of Buddhism is non-self (anatta) – this regrettably is misunderstood as no-self which, of course, is exactly wrong.  Self is the one thing we can be certain of,…..our supreme difficulty is exploring outside-our-self with an sense of curiosity and sympathy.

Ms. Gluck writes of Keats’ genius, “…..he refused to value what he did not believe, and he did not believe what he could not feel.”  Further, “…..he advocated the opposite of egotistical self-awareness and self-cultivation,…..rather, the negative capability he felt in Shakespeare,….of suspending judgment in order to report faithfully, a capability of submission, a willingness to annul the self.”

I think that is what the Buddha intended – a collective consciousness borne of dialogue and kindness, rather than no-self.  A challenge.

Two inspiring attachments, low-tech and high-tech, yet the same puissance:  a) the simplest, deepest human connection saves the newly born, b) everything we do to newborns (in the hospital/clinic/home) is registered in the phantasmagoric, exhilarant tour de force we call the developing brain.  And, wouldn’t it be terrific if every manuscript had a ‘Graphical Abstract’ as Ellis et al provide?,……our hippocampi would activate.

Joe Kaempf, MD

Oregon Representative, District 8

Portland, OR

Volume 13, Number 17

Words – Part 2

Philosophy is a battle against the bewitchment of our intelligence by means of language.  It is not humanly possible to gather immediately from our words what the logic of our language is. Language disguises thought.  If we spoke a different language, we would perceive a somewhat different world.  If a lion could speak we would not understand him.

The limits of language is best exemplified in ethics.  The issues that matter most to us and have the greatest significance lie outside the scope of language.  Ethics, morals, values, the meaning of life, the existence of the universe as a whole, these are all questions that can be settled neither by observation nor logic.

Ultimately, our solutions to logical problems with language must be neat because they set the standard of neatness.  And, at the limit of reasons comes our persuasion.  I act with complete certainty, but this certainty is my own.

Words to live by?,…….thoughts belonging to Ludwig Wittgenstein, a philospoher like few others in the history of ideas.  Recall his friendship with Elizabeth Anscombe, an anti-determinist, anti-consequentialist of prodigious insight, a devoutly religious intellectual who despite some profound disagreements with Wittgenstein, befriended him, and expertly translated his works for the Western world.

Wittgenstein’s conclusion from the epic Tractatus – “Whereof one cannot speak, thereof one must remain silent.”  To which Ms. Anscombe adroitly commented – “But who is allowed to speak, and who must be silent?”

Think of that re: the composition of “expert panels” at healthcare meetings.  Why were they chosen?,……Who is being excluded?,……Who actually represents the interests of dissent, and concerns of variant cultures?

The two largest expenses of early childhood are NICU hospitalizations and downstream expenses, and well-child care.  Extremely premature infants (who survive the NICU experience) have extensive health needs even when not neurodevelopmentally impaired (attached Rysavy et al),…….and group well-child care may offer valuable efficiencies (attached Gaskin et al).

Joe Kaempf, MD
District VIII Oregon Representative
Portland, OR

Volume 13, Number 16

https://pubmed.ncbi.nlm.nih.gov/33758389/

https://pubmed.ncbi.nlm.nih.gov/33961210/

Words – Part 1

Etymologists note the word pragmatic has a checkered past, and a multiform present.  The Greek root pragma means ‘a thing to be done, a fact, rightly done.’

But pragmatic has veered far and wide over the centuries to mean meddlesome, opiniated, according to common practice,…..and nowadays a fusion of compromise, abandonment of stated goals, opportunistic.  Jacques Barzun reminds us this is not what Charles Peirce, William James, and John Dewey (pioneers of pragmatism) meant as they developed their incandescent, oddly under-appreciated branch of philosophy and science.

William James was a magnanimous, obsessively curious intellect whose contributions to psychology and consciousness understanding, the scientific method, and religious studies are so pervasive it is now taken for granted as everyday knowledge (similar to Spinoza, Hume, Kant, Nietzsche, Freud).  By pragmatism, James an authentic radical empiricist, meant “Truth is what will be steadily borne out by subsequent experience.”  Something is true (like a hypothesis or opinion) if the consequences and hard facts of acting on that ‘truth’ are supported by subsequent objective experience.  So, we are constantly modifying what is thought to be ‘true’,……..the scientific method only securely reveals what is false.

A belief, in contrast, is an idea or sentiment that has yet to be, or cannot be, verified by a shared, objective experience.  James never implied ‘belief’ was wrong or undesirable (quite the opposite actually),…..he just made a clear distinction between pragmatism as a discipline of truth-seeking, versus the vagaries of human consciousness, our flux of streaming perceptions/emotions/memories.

Nobody ever has precisely the same thought or experience twice, because we simply cannot, he believed.  Our brain is a material thing,…..consciousness is an event, zillions of interactions, a process.

So, I am cautious when someone labels a QI project or randomized clinical trial as pragmatic.  If simpatico with William James, that is high praise of empiricism and the scientific method.  If they are inferring it’s practical, or real-world, or compromise-filled, or short-of-expectations,……well, I am confused what they are implying.  

Attached is a pragmatic QI experience (and commentary) founded upon solid principles of evidence-review, education, feedback loops, and the ethos of collaboration – how can we meaningfully reduce unnecessary cesarean sections in nulliparous, term,  singleton, primiparous pregnancies?

Joe Kaempf, MD

Oregon Representative

Portland, OR

Volume 13, Number 15

Know – Part 3

Can a process/event/statement be true and not true?

I had a college dormitory roommate who resembled the lead singer of the Rolling Stones.  It was remarkable.  Naturally, he employed his good fortune to amusing effects.

For example, if anyone at university would scoff he would casually comment “That’s me helping Carly with ‘You’re So Vain’.”  Rather brilliant piece of subterfuge, him blending feigned familiarity with another rock star and her monster hit, with casual “insight” into the then-mysterious urban legend (Is that Mick singing back-up?).  No Google fact-checking in the 70’s.

In essence, he unwittingly played on one of Eric Hoffer’s many unsurpassed observations re: mass movements and ideologues,…..Just remain vague enough to not be completely understood, because people tend to be certain only about things they don’t fully comprehend.   

If you have not read his classic – True Believer – well, you’re in for brain-delight.  His noble, heroic personal journey makes his writings indelible and authentic.  “When people are bored, it’s usually with themselves,…….The greatest weariness comes from work not done,…….You can never get enough of what you don’t need to make you happy,……..Propaganda serves more to justify ourselves than to convince others,……….The beginning of thought is disagreement, not only with others but also with ourselves”,……among hundreds of other musings about the nature of truth and knowing related to idealogues.

Variation in care processes and outcomes is the defining characteristic of the Vermont Oxford Network, nowhere more evident than NICU length of stay – the principle driver of resource utilization in neonatology.  LOS has been increasing for years,….how and why?.  It’s beyond noteworthy, and it largely resists current explanations.  Drs. Edwards, Horbar, et al have written a clear expository, and Drs. Arnold and Davis have added an insightful commentary (attached).  

Consider Ludwig Wittgenstein’s engaging “family resemblance” theory of knowledge and language games (he drew inspiration from Plutarch) – Things [NICUs] thought to be linked by a given feature [increasing LOS] do not share one principle similarity, rather, they overlap with several in variant fashion.  Just look at a large family of siblings and the two parents – you can see the overall resemblance, but no single shared feature for all.

Joe Kaempf, MD

District 8 Oregon Representative

Portland, OR

Volume 13, Number 13

Know – Part 1

No word surpasses know for instigating predicament.  In general, what we think we know is: a) a matter of fact, b) a matter of policy, or c) plans of action.  For ‘a’ we use the verb “is”,…for ‘b’ the verb “should”,…for ‘c’ the verb “will”.  Examples: a) Mexico is south of Canada, b) freedom of speech should always be a basic right, c) our CQI efforts in healthcare will improve markers of population health.

George Boas (a historian of ideas) points out that ‘b’ and ‘c’ require the essential truth test of:  1) there is a problem in the present system, 2) the policy or plan does or will reduce the problem, and 3) the policy or plan will not introduce new problems.  Note ‘a’ is not always incontrovertible either as best exemplified in quantum physics,…..e.g., light must be a particle or a wave,……in reality it is both. 

Maybe we should heed the British empiricists – every word we use should correspond to an idea, and every idea should correspond to an actual experience.  That is,  we will be clear in healthcare that we do not know much at all, rather we have plenty of ideas.  And Goethe observed “We are never more opposed to an idea than after it is rejected as one’s own.” So, it doesn’t take long to see how meager our knowledge of diagnostics and therapeutics is (esp. the latter).  But, we do know unfavorably low socio-economic status harms pregnant women, the fetus, and the child (see Lu et al attached),……and we know heroic noble pioneers inspire us (see Dr. Crumpler bio attached). 

Joe Kaempf, MD
District VIII Oregon Representative
Portland, OR

Volume 13, Number 11

https://pubmed.ncbi.nlm.nih.gov/33779746/

Doubt – Part 4

And all our yesterdays have lighted fools the way to dusty death.

Shakespeare (Hamlet)

The great experimental principle is doubt, philosophic doubt which leaves to the mind its freedom and initiative, and from which the virtues most valuable to investigators in medicine are derived.  True science teaches us to doubt, and in ignorance, to refrain.

Claude Bernard

The scientific method rarely confirms what is true.  The proper function of science is to demonstrate what is false.

Karl Popper

The most common element by weight on Planet Earth is iron.  Consistent with the ubiquity of irony, the most common nutrient deficiency in infants and children is iron.  Say we told a pregnant woman “If we make sure your newborn/infant/toddler receives sufficient “X” her/his brain function will be significantly healthier.”  Might she and her partner make certain “X” was supplied properly?Placental transfusion/breast feeding/iron rich foods and Fe drops starting at 6-9 months (see attachment).  We can immediately imagine dozens of QI quality bedrocks of equal value, do-able, awaiting us.

When Roger Goodell (Commissioner of the NFL) said ~5 years ago “There are more concussions in youth soccer and basketball than football.”,…….oh my goodness the uproar and criticism that was heaped upon him.  He was right (see attachment).  Are we going to outlaw soccer, basketball, and lacrosse?

My colleague Mitchell Tsai sent me the entertaining third attachment re: useless therapies,…….lest we providers forget our humble past and its lessons.    

One way to enjoy life is to read.  Reading is pure unadulterated exhilarant listening.  You can only interrupt yourself, not the writer.

Joe Kaempf, MD
District VIII Oregon Representative
Portland, OR

Volume 13, Number 10

https://pubmed.ncbi.nlm.nih.gov/33144115/

https://pubmed.ncbi.nlm.nih.gov/33738313/

Doubt – Part Three

20 May 1747 – I took twelve scurvey patients aboard the HMS Salisbury at sea, cases similar as I could have them,….gave two a quart of cider,….two 25 gutts of elixir vitriol,….two vinegar,….two sea water,….two orange and lemon,….two nutmeg,……and given each day.  Consequence was the most sudden good perceived from the use of orange and lemon.

Captain James Lind

What a person calls moral judgment is merely their desire to generalize, and so make available for others those values he or she has come to choose.

C Wright Mills

Philosophy, tho’ it cannot produce a different world to wander, makes us act as if we were different beings from others,….at least makes us frame to ourselves, tho’ we cannot execute, rules of conduct different from those set to us by Nature.

David Hume

Perak et al provide yet more evidence that there is nothing in healthcare that exceeds the paramountcy of ensuring the health of the pregnant woman.  Pregnant woman well-being = fetus well-being = child well-being = family well-being = civilized society.  Maybe epitomizing C Wright Mills above, but we’ll stick with it.

The nocebo effect  – unpleasant side effects from a placebo or sham Rx – is real.  Yet more evidence of the public’s general skepticism of science and healthcare.  What do we call it when we see this in parents of hospitalized infants or children?  Nocebo-by-proxy?

Despite James Lind’s careful observations above (and subsequently duplicated by others), it took the British Navy over 50 years to make citrus juices compulsory for seafaring.  Take home lesson for us all:  well-executed QI projects, scoping reports, RCTs, systematic reviews, and meta-analyses sit on our desks awaiting our careful reading,…..or easily available online.

Joe Kaempf, MD
District VIII Oregon Representative
Portland, OR

Volume 13, Number 9

https://pubmed.ncbi.nlm.nih.gov/33591345/

https://pubmed.ncbi.nlm.nih.gov/33533926/

Doubt – Part Two

Immersion in water makes the straight seem bent.  Reason confused by false appearances is restored by measurement.  This drives out vague notions of greater or less,….surely the better part of thought relies on measurement.

Socrates

We travel like Ulysses to learn of the particolored world and its motley ways, but what we see is mostly patterns formed in our minds long before we took the first step.

RM Adams

A wise man proportions his belief to the evidence.

David Hume

First take of the attached Pizzo et al editorial is likely “Of course, we all agree.”  But do we?  I imagine a good number of physicians and providers might be disturbed by Pizzo et al.  There is some irony and inconsistency within.  For example, the second author is the medical director of the Stanford Center for Integrative Medicine.  Visit their website and count the number of “therapies” offered that lack a robust evidence base.

All CQI begins with a look in the mirror – a University of CQI axiom.  Schopenhauer – “A person can do as he wills, but cannot will as he wills.”  I find inspiration in this aphorism, though not precisely certain why. Humean John Ioannidis gets right to the crux of a related matter (attached) – be respectfully wary of physicians and scientistswho sign petitions.  At best a perilous pitch of ordained authority and expertise (Daniel Callahan),…..worse, self-delusion (Friedrich Nietzsche),…..worst, hierarchy and coercion (Simone Weil).  Ask yourself where you experience this in your own life.

Joe Kaempf, MD
District VIII Oregon Representative
Portland, OR

Volume 13, Number 8

https://pubmed.ncbi.nlm.nih.gov/33538765/

https://pubmed.ncbi.nlm.nih.gov/33106240/

209 years ago today two inspiring heroes were born, February 12, 1809.  Just a moment of gratitude.

Spectacular contributions, incalculable positive influence, both bedazzle exponentially the more studied,…..Abraham Lincoln and Charles Darwin.  

Request:  A) recent social media review useful for providers, B) poem, C) happy article.

1. Lu et al want to bring order to social media’s dominance so we can use it successfully with patients and families,….promote healthy dialogue, education, feedback.  Sovereign force it is, peculiar admixture of diversion/speed/facts/fiction/seduction, yet social media is not without historical precedent.  Don’t be misled that 2020-21 dynamics are unlike anything post-Gutenberg. 

One example – 18^th C Scotland, more on that later.

Lu et al write “…..harness social media”…..?  Not likely.  Develop innovative communication tools for inclusion, discussion, passion, diffusion of reason-ing with providers, pregnant women and children?  Perhaps maybe.

2. Did I find this poem with a few clicks on social media?,……it’s relevant to Lu et al’s manuscript, it’s insightful, and rife with unconventional punctuation. 

              Did not.

I’m Nobody!  Who are you?

Are you – Nobody – Too?

Then there’s a pair of us!

Don’t tell!  they’d advertise – you know!

How dreary – to be – Somebody!

How public – like a Frog –

To tell one’s name – the livelong June –

To be an admiring Bog!

Emily Dickinson, 1861

3. Last – no nutriment is more scrutinized than coffee.  Happily, java always comes through for us.  Stevens et al brew up more support for trimethylxanthine addiction,……less heart failure.

Joe Kaempf, MD

District 8 SONPM Oregon Representative

Portland, OR

Volume 13, Number 5

Two requests from friends:  a) a useful shared decision-making review, b) a poem.

Shared decision-making is akin to Bayesian-thinking,……we do it every day naturally in healthcare, unaware at times, often skillfully, sometimes not.  Stiggelbout et al expertly summarize a confusing literature for us (attached).  I especially appreciate their 1-2-3-4 summation,……bless their avoidance of overwrought constructs. 

#1 (a decision must be made) is the snafu/rate-limiting enzyme of SDM in emergency and intensive care, more so than acknowledged,……and manipulated by participants in various fashion.  That would be my opinion.

I agree with Arthur Schopenhauer, music should not be categorized with the other arts, it is a separate realm entirely.  Music is ante-language, pura-emotion, primal impulse,..……sorry, can’t find one word.

So, is poetry the purest art?

I have read “13 Ways of Looking at a Blackbird” many times and still cannot fathom its grip on me,…….a different stanza vaults out each time (attached).  If someone told me an enlightened Japanese Zen master wrote this poem I would say “of course she did.”

Wallace Stevens was an insurance agent who lived a fairly quiet life (by today’s measure) in suburban Connecticut.  A consummate craftsman of language precision, obscure allusions and history-particulars,……..an exemplar of why some believe “Poetry is the purest art.”

Joe Kaempf, MD
District VIII Oregon Representative
Portland, OR

Volume 13, Number 5

https://pubmed.ncbi.nlm.nih.gov/26215573/

https://www.poetryfoundation.org/poems/45236/thirteen-ways-of-looking-at-a-blackbird