Author: Joe Kaempf

Shakespeare’s genius created characters in literature, perhaps the first writer to portray humans as heroic and flawed, triumphal and defeated, insightful and blind,…..in short, what readers adore.  Prior to Shakespeare, characters in poetry and prose were largely symbolic of classic traits,…..representing Courage, Fidelity, Evil, Wisdom, Good, Fertility, Power, and so on. 

Greek myths fabulous yes, but typically humans are not portrayed in-the-flesh as the vulnerable, quixotic characters we are.  Who inspired Shakespeare to pursue this radical shift in literature?  Maybe the writer who invented the essay, the original virtuoso of introspection, humility, and conjecture.  Que scais-je?,…..his signature phrase.  Love it.

Michel de Montaigne (1533-1592) was a humanist nonpareil,…..described as “Having all the qualities a reader would desire in a friend.”  Consider enjoying his essai(etymology – trial, weigh) “On Presumption”.  2021 will be even more turbulent as young people unfortunately will witness poor behavior, suffer more ir-rational statements, divisive action, and unappreciated historical perspective,……mirroring the times Montaigne lived through in 16^th C France. 

Few physicians write as concisely on uncertainty and disputation than John Ioannidis – attached are his thoughts on our dysfunctional focus upon “minor health issues”, an ultimately wasteful and harmful habit he suggests. 

We appreciate systematic reviews to digest bulky literature,.….we adore clinical practice guidelines to improve value and safety,.….we know placental transfusion of the newborn is healthful,…..so also attached is a systematic review from Liyanage et al of 44 guidelines addressing deferred cord clamping and cord milking,…..not a minor health issue. 

Joe Kaempf, MD

District VIII Oregon Representative

Portland, OR

Volume 13, Number 3

Recent events are unsettling, in the tumult some disparaging descriptions:  “Person X is Machiavellian”,…..“Group Y is using Machiavellian strategies to push their agenda”.  Venal motives are implied.

Politics aside, this concerns me re: Niccolo Machiavelli (1469-1572), as he was hardly the “moral monster” routinely stereotyped by the unaware.  Machiavelli deserves kudos for being among the first Western writers to challenge monism – the oversimplified conception that in any given discipline or culture, it is one principle variable that explains everything.  You can scarcely overestimate the relevance of Machiavelli’s insight (and courage) brilliantly disputing this assumption.

He might be the first to postulate the veracity of value pluralism,…..human goods/beliefs/moral tenets vary between groups, are not necessarily resolvable, are often incommensurable, and not always irrational,……so we would be wise to adjudicate with sympathy, be reasonably tolerant, and co-exist peaceably with life’s uncertainty and suffering.  Society reliably devolves to hierarchy and chaos without such an ethos. 

Machiavelli’s insights juxtaposed two mutually exclusive constructs of morality – the ethics of Christianity (perfection of the individual life) in contrast to those of the Republic of Rome (power and glory of the body politic).  He believed there was no logical, rational criteria for choosing between these two value systems.  They were both valid, some favored one over the other, blood ought not be shed.  The past year’s conflicts suggest it might do well for us all to be “Machiavellian” in this regard.

Note BTW, Machiavelli was an impassioned admirer of women, championed their rights, wrote that women were every bit as fit to rule, and referred often to examples of female virtu (inherent qualities of merit).

In 2021 let’s nurture alternative insights, challenge dogma in a loving fashion, embrace uncertainty, and cultivate reasoned analysis.  Two engaging examples attached: a) pregnant women/fetuses should consistently have the option for safe breech deliveries,  b) just about anything we can do to safely reduce Cesarean section rates promotes long-term health.

Joe Kaempf, MD
District VIII Oregon Representative
Portland, OR

Volume 13, Number 2

https://pubmed.ncbi.nlm.nih.gov/32128861/

https://pubmed.ncbi.nlm.nih.gov/33211696/

I don’t favor the agonistic theory of literature or creative culture.  Art can rightfully and productively be emulative, even imitative.  Absorbing past masters and their works is nourishing, not stultifying, quite the opposite of alienation.  Shakespeare is a perfect exemplar, both his own self as a writer, and us reading him.  Just my opinion.

A distinct highlight of my neonatal-perinatal fellowship was meeting William Silverman.  This privilege in part inspired me to design and execute a modest RCT that was published in a reputable journal, a thrill for a young trainee (not possible without mentor Adam Rosenberg and OB colleague Richard Porreco).

A delightful activity might be all our hospital and clinic providers, and healthcare administrators be required to read Dr. Silverman’s classic Human Experimentation – A Guided Step Into the Unknown.  Last publication was 1985 which may strike Twitter/Facebook nation as old,…….but this vade mecum is as outdated as Aristotle’s Ethics, Shakespeare’s Hamlet, Nietzsche’s Genealogy of Morals, Virginia Woolf’s Mrs. Dalloway, Edith Hamilton’s The Greek Way……

As you formulate your 2021 reading list, consider Dr. Silverman’s primer,.…..I know we’re all busy, stress is high, demands many.  Reading is enlightening, comfortable absorption of others.  Human Experimentation is blessedly clear, concise, skeptically curmudgeon-ish,…..you don’t need to be a researcher or a doctor to profit from his incarnate data-knowledge-understanding-wisdom apotheosis.

So,…..three wonderful RCTs to start our year:  1) a multiplex RCT related to RBC transfusion practice in NICUs, 2)  a RCT from India testing highly affordable childhood development tools, and 3) the entrancing “The Gift of Chickens” from West Africa.

Which RCT is the best value guide of the three?

2021 resolution – Sapere aude!

Mediocribus esse poetis non di, non homines.

Horace (65-8 BCE).

Joe Kaempf, MD
District VIII Oregon Representative
Portland, OR

Volume 13, Number 1

https://pubmed.ncbi.nlm.nih.gov/33382931/

https://pubmed.ncbi.nlm.nih.gov/33148771/

https://pubmed.ncbi.nlm.nih.gov/33239474/

Arguably History’s most accomplished intellect, with accomplishments spanning science, philosophy, statesmanship, novels, and poetry. Read what Johann von Goethe perceptively said about poetry:

The key difference is whether the poet seeks the particular for the universal, or whether he beholds the universal in the particular. From the former originates allegory, where the particular is only considered an example of some universal. But, the latter is properly the nature of poetry, to express something particular without pointing to, or thinking of, some universal.

That is such an exquisite unity-thought, an insight that crosses many disciplines,…….who can match Goethe?

We have at least one accomplished poet and thought-full physician on our expanded listserv, Ryan McAdams at the University of Wisconsin,…..he generously gave me permission to share an attached poem of his creation with you, his colleagues,…..and it’s beautiful.

Ryan commented:  I love poetry.  I write, but shy away from honoring myself with the label of poet.  However, since Louise Gluck’s views resonate with me, I do feel a humble sense of collegiality because I can relate to what she so adroitly captures with brevity and clarity (poetry and CQI are not dissimilar).

In line with brevity and clarity, the second attachment capsulizes the ‘talking points’ you can rely upon when encountering resistance as to the wisdom of investing in the health and well-being of pregnant women and children.  Park et al adroitly summarize robust evidence that Medicaid support of the foundation of a civilized society (aka young families) should not be cut,…..further assistance supporting the telos of our vulnerable young people is compassionate genius,…….Goethean.

Joe Kaempf, MD

District VIII Oregon Representative

Portland, OR

Volume 12, Number 50

Think again of the beautiful Pensées – Blaise Pascal’s (1623-1662) masterpiece, born of quiet thought that has bridged time, culture, religion, and science:

Man is but a reed, the most feeble thing in Nature, but he is a thinking reed.  The entire universe need not arm itself to crush him.  A vapor, a drop of water, suffices to kill him.  But if the Universe were to crush him, Man would still be more noble than that which killed him, because he knows that he dies and the advantages the Universe has over him; the Universe knows nothing of this.

Maybe the lowest key of Nobel Prize notifications in recent history (Literature at least),….poet Louise Gluck?  Attached is her Wild Iris.  She adds dimension to Pascal – what is death and rebirth like for the other?  Using the metaphor of an iris, we can read her craft from several vantage points.

Ms. Gluck is described as a poet of “….austere intelligence, refined composition yet ordinary diction, a modern day Emily Dickinson, describes life-death-rebirth theme, focuses upon parents and siblings,….”   So, a lyricist for obstetrics, newborn medicine, and pediatrics?

Also attached is a Canadian view of “Value for Who?”  Zwicker laments the distance Canadian healthcare is from prioritizing value (health benefits gained/resources consumed).  Her neighbors to the south might say “Far worse here.”  The manuscript caught my attention because of the Avedis Donabedian references (the “Father of QI”) noting his plea for recognizing diminishing returns in healthcare,……maybe the principal challenge for us in 2021? 

Dr. Zwicker – “Value-based payment for services is the critical opportunity to consider the value of all services that impact childhood health, and requires special focus on quality and outcome measurement for all childhood health programs,.…[we must] move from theory to measurement and evaluation of value strategies.….”

Joe Kaempf, MD

District 8 Oregon Representative

Portland, OR

Volume 12, Number 49

You might enjoy the attached commentary:  a) provocative, b) combines insight and gross oversimplification, c) several accurate and inaccurate statements, d) the very definition of slippery slope, and e) reinforces (unintentionally) why we should consider two of the 20^th Century’s most exhilarating and prescient intellects – Isaiah Berlin and Eric Hoffer (just my opinion).

Part of me is surprised the JAMA editors published Dr. Miller’s piece,…..most of me pleased they did.  Dr. Miller will receive praise and criticism, sometimes the hallmark of insight,…..or “airing what needs to be aired”.

Keep forefront the distinction between scientific method versus scientism.  This dissimilitude, when not recognized, explains a fulsome share of history’s conflict, particularly since the Enlightenment.  History is chock-full of intellectuals and scientists making this mistake, an error not unique to John Q. Public.  Dr. Miller regrettably blurs the separation,…..but all of us in healthcare are guilty of such from time-to-time.

Some of my highest IQ friends and colleagues harbor the most moonstruck of beliefs,…..they assuredly would say “So do you Joe.”  The best we can do is gaze reflectively in the mirror  – “Am I being reasonable? Compassionate? Honest? Responsible?”

Isaiah Berlin’s contributions to intellectual integrity, perhaps our pre-eminent philosopher of ideas, cannot be summarized briefly,…..but a core contribution is IB’s thesis regarding Mankind’s principle miscalculation/delusion:  1) there exists an absolutely true and objective explanation to every entity in Nature and human activity,  2) we can reach that truth if we just keep persisting, and 3) all the truths for all the entities and activities will be consistent with each other.  #1-2-3 are “True, except in the real world.”

You might think “That’s obvious.”,..…but IB’s error-thesis has/is/will be denied, over and over and over,……and healthcare is a prime exemplar,…..suffering results.

Eric Hoffer’s True Believer addresses similar misconceptions and is a nominee for “Top Ten Under-appreciated Books” of the 20^th Century.  His personal story is inspiring, heroic.  There is a beautiful abstract sculpture honoring his legacy at Fisherman’s Wharf in San Francisco, Skygate,…..easy to walk right by without much notice, like his work.

Volume 12, Number 47

https://pubmed.ncbi.nlm.nih.gov/33136157/

How does a pregnant woman effectively and safely minimize or treat physical pain?  Are any medications safe for her developing fetus?

What are the downsides to untreated pregnancy pain?  What compensatory measures to reduce pain might be worse than a common medical treatment,. e.g., inactivity vs. OTC pain relivers….?

There are a dozen or so reports linking pregnancy acetaminophen use to a variety of childhood neurobehavioral disorders – ADHD, autism, ASD.  Correlation because of confounding-by-indication, or causation via acetaminophen metabolite neurotoxicity?

I thought of Goethe when I read the attached reports.

For everyone who does not know

How to control his inmost self would fain control

His neighbor’s will according to his own conceit.

Joe Kaempf, MD
District VIII Oregon Representative
Portland, OR

Volume 12, Number 45

Hypothesis – Therapy X prevents Disease Z and is safe.  So,….let’s randomize 30,000 people into two groups of 15,000 apiece (A and B).

Give Group A the experimental “Therapy X” and Group B a placebo….

Monitor for three months, and compare Group A and Group B….

Disease Z occurred in 5 of 15,000 people in Group A who received Therapy X,….90 of 15,000 people in the placebo Group B.  And, no safety concerns or serious side effects in Group A.  Because of the large ‘n’ many known and unknown confounders were equally distributed between the groups (grazi James Lind),….and the probability that these results would have been found if Therapy X were an ineffective therapy (null hypothesis) was well below 1 in 20 (the P value).

The Moderna SARS-CoV-2 mRNA vaccine coming soon!  If there has ever been a more impressive collaborative public health or science accomplishment ever you’ll have to share with us what that would be,…..Manhattan Project WWII?,.…NASA man-on-moon July 1969?,…. The previous fastest vaccine development ever was for the mumps – 4 years.

The world will now change again thanks to all those involved with vaccine science, study subjects, funding, and distribution.  Something to be in awe of.

Three brief COVID-19 pearls attached:  a) COVID-19 is likely not associated with less premature births, b) why you can be confident in vaccine safety, and c) why we should wear masks.  

“Gratitude is the parent of all virtues”,.……..Cicero.

Joe Kaempf, MD
District VIII Oregon Representative
Portland, OR

Volume 12, Number 44

https://pubmed.ncbi.nlm.nih.gov/33203528/

https://pubmed.ncbi.nlm.nih.gov/33064152/

https://pubmed.ncbi.nlm.nih.gov/33104157/

I love science,….but am forever wary of scientism.

Science is observation, measurement, hypothesis-testing, the constant re-adjustment of theories after bias is minimized and experience is analyzed.  Establish what is false, not necessarily what is true.

Scientism is the belief that the methods of science must be used for all of human experience, and given time, will settle every issue.

The blurring of these concepts has roots in the 16^th and 17^th centuries, e.g., Francis Bacon was influential advocating mankind’s “dominion over Nature”.  Quite the opposite of Buddhism and Taoism BTW.  In brief, science has led to less childhood deaths, better water and food, anesthesia, advanced medical Rx, better housing, instant communication, safe transportation, Facebook/Twitter, etc,……while scientism has led to technocratic hierarchy, accelerated conflict, waste, environmental degradation, consumerism, and WWI and WWII (oversimplifying a bit).  Bertrand Russell as a young man was an exemplar of strict empiricism, but in wise old age emphatically rejected scientism.

Help me determine where the blurring of science and scientism is more apparent in neonatology than NICU length-of-stay?  Well, we know one obvious area  – periviability conflicts and shared decision-making.

A few organizations have asked me to review and discuss NICU length of stay over the years – not because I’m an authority, but more because I worked in 2 separate NICUs with remarkably favorable length-of-stay, and did detailed visits to a couple of similar sites,….and maybe my interest in the science/scientism theme,……who knows?

I am certain there are accomplished folks with superior analyses and insights to offer re: NICU length-of-stay,……I have read and talked to many of them.

Not that you need more to read, but I attached a PowerPoint digest of my (biased) reading and experience re: NICU LOS,…..particularly thinking of our energetic younger providers and administrators trying to wade through this complex literature.  Science and natural philosophy, reason and compassion,…..the Chinese have a symbol for theunity of heart-mind,..…the English-translated word Xin.  It’s very-not-scientism.

Slides 23-30 are a reasonably accurate digest of hundreds of manuscripts I reviewed,….but please send your “Share Massively, Steal Shamelessly” pearls as Paul Plsek urges us.  Also attached is Braun et al’s fine and hopeful article from Kaiser Permanente re: unnecessary NICU utilization.

Joe Kaempf, MD
District VIII Oregon Representative
Portland, OR

Volume 12, Number 42

Studying the Vermont Oxford Network Annual Report every Autumn was a delight for me starting back in the 1990’s (the “phone book”).  The information provided by Dr. Horbar and his talented colleagues always coalesced into that desirable admixture of anticipation, surprise, and wonder.

Nothing then, and nothing now in the VON summary is more (one word cannot capture this) perplexing/enduring/worthwhile/astounding than the variance among participant NICUs in the total hospital length of stay for very low birth weight infants.  Just my opinion.  How can it be that similar gestational age NICU entrants later exit the NICU at time length differences of several weeks?  And differences would mysteriously persist year-after-year between NICUs……..

If there is any single item in the VON summary that deserves more reasoned (multidisciplinary) scrutiny, yet gets less, you’ll have to show me.  It’s analogous to the six categories of healthcare waste – failure to provide evidence based care,….overuse of unproven care,.…poor care coordination,….fraud,.…price irregularities,….administration costs.  The biggest “waste” category is the one which receives minimal rigorous study – administration costs.

Our AoW listserv colleague Dr. Billimoria and her colleagues led by Dr. Goldin have published a fascinating analysis of length of stay in 43 NICUs over six years.  Huge variation, not clear why,……authors conclude – “These data reveal the need to identify best practices in NICUs that consistently

discharge infants more efficiently.  Once these best practices are known, they can be disseminated to offer guidance in creating quality improvement projects…”   Understatement.

Also attached is the thoughtful commentary from John Zupancic and colleagues.

More on NICU length of stay coming,……it is an increasingly urgent population health management issue for healthcare payers and families.

https://pubmed.ncbi.nlm.nih.gov/32699067/

https://pubmed.ncbi.nlm.nih.gov/32699068/

Joe Kaempf, MD
District VIII Member Extraordinaire
Portland, OR

Volume 12, Number 42