Category: EBM and CQI

Reading two thoughtful articles attached re: physician cognitive health, well-being, and motivation brought to my mind three thoughts:

1. Wittgenstein wrote that all of ethics was outside the realm of language. For him, the whole point of ethics would be lost if it were but straightforward cognition of something objective that resides in the world, like a tree or gravity or a chair. This is a deceptively transcendent and marvelous insight that is lost on many physicians and bioethicists who write about healthcare morality, just my opinion. Fortunately, other influential writers share Wittgenstein’s viewpoint, and deserve study.

2. Chapter 46 from the Tao Te Ching:

When the world has the Way

horses till the fields.

When the world shuns the Way

war-horses are bred in the countryside.

No crime is greater than approving greed,

no calamity greater than discontent,

no curse exceeds possessiveness.

The satisfaction of contentment is always enough.

3. Daniel Callahan believes the plague of modern healthcare is “healthism”, the covert scourge of providers and populace alike. I think his insights should have been added to the attached NEJM essay as necessary dimension,……so, will briefly summarize in the next AoW.

Joe Kaempf, MD

Oregon Representative

Portland, OR

Volume 14, Number 1

‘Reason’ is what enables us to understand just how ‘unreasonable’ we are. And that is a thrilling feature of Homo sapiens’ consciousness.

“Churchill’s poodle” metaphor in our University of CQI: WC’s poodle knew many details of Master’s habits, moods, daily routines, as only a beloved pet could. But the poodle could not possibly grasp WWII, Hitler, Stalin, FDR, etc. Yet, we humans have some ability to ‘know we don’t know’,…..so why not with more consistency? It is do-able.

It is difficult to imagine a time more needful of understanding fallibilism – science (empirical knowledge based upon observation and experiment) produces knowledge that can only be accepted with some acknowledgment of doubt and uncertainty. In other words, we seldom can be confident of what is ‘true’,…….the scientific method is better suited at establishing what is ‘false’.

In fact, the stricter you view yourself as an empiricist (only the 5 senses and our brains produce objective knowledge), the more you understand how limited empiricism actually is,….meaning, authentic empiricists are the first to admit fallibility, uncertainty, and careful doubt (David Hume, Claude Bernard, Daniel Kahneman, Mary Warnock……).

Carlo Rovelli is a favorite physicist-writer of mine: “There are frontiers where we learn, our desire for knowledge burns. These are in the minute reaches of the fabric of space, at the origins of the cosmos, in the nature of time, in the phenomenon of black holes, and in the workings of our own thought. Here, in contact with the ocean of the unknown, shines the mystery and the beauty of the world. And it’s breathtaking.”

Lisa Rosenbaum’s attached essay is pre-COVID yet now more timely,…….pluralistic ignorance is a fascinating problematic phenomenon.

Joe Kaempf, MD

Portland, OR

Volume 13, Number 37

Continuing the thread of Nietzsche’s “anti-foundationalism” let’s consider “foundationalism”.

Plato is the model of foundationalism, his impact upon Western thought incalculable. Plato exposited ideals of reason and pure knowledge as Forms. These are ultimate conceptions of Wisdom, Courage, Temperance, Justice (his 4 primary virtues) as well as essences of matter and objects. These Forms exist apart from our earth-bound material world,……and understanding these ideals is the ultimate meaning of Mankind’s existence.

He wrote beautifully, mathematics clearly influenced his thought,……his attractive appeal to pure contemplation, and the seductiveness of an irreproachable world apart from our minds but available to imperfect humans played a large role in the subsequent growth of Christianity and other religions,……something not widely appreciated today.

Plato was never able to explain, much less prove, that these Forms actually existed,,……and materialists and empiricists of various persuasion over the last two millennia have quite disagreed with foundationalism’s assumptions and metaphysics. Thoughtful writers such as Baruch Spinoza, David Hume, Ralph Waldo Emerson, Friedrich Nietzsche, William James, and Bertrand Russell to name just a smattering, have argued that Plato’s Forms in regard to morality are wholly speculative and context-dependent. In reality, “What is ethical is what the majority decide”,……“Morality is what works for the powerful”,……”Virtue is entirely culture-specific”,……”The truth of any proposition is borne out by subsequent events, not theory.”

This makes for superlative reading and dialogue, if we wish. Foundationalism vs. Anti-foundationalism is 100% relevant to modern healthcare and our 4-dimensional complexities,………we get distracted by high technology, marketing, bias, short-term targets, and arbitrary hierarchies. The primary question might be – “Do we collectively, justly, reasonably improve healthcare and well-being based upon principles of foundationalism or anti-foundationalism?” Fundamentally, we can’t use both paradigms, despite wanting to appeal to both,……it’s ir-rational to try, unreasonable to defend.

The attached article is worth reading,.…..from an influential American physician who has contributed much good to healthcare, we respect that. But, reading it carefully reveals that he inadvertently mixes foundationalism and anti-foundationalism,………ironically, he being the progenitor of the vaunted Triple Aim, a benchmark no large organization has demonstrated successfully,..….because it’s a Platonic Form?

I added a few comment boxes to the article, feel free to correct me, point out what I missed,…….dialogics indeed.

Joe Kaempf, MD

Portland, OR

Volume 13, Number 36

I estimate there is no greater intellectual in History than Friedrich Nietzsche (defined as original, impactful, durable, influential, stylistic). Since his tragic death in 1900 his phenomenal breadth and depth of aphoristic writings have rung more prescient with each passing decade,……it’s exhilarating and rather spooky.

Sometimes when reading him late at night I think “He is writing about 21^st C healthcare, he is explicating our problems.” Very little of his books sold in a truncated lifetime, yet now he is unquestionably the most powerful philosopher of the past ~100 years,……perhaps ever.

One theme of his was anti-foundationalism which basically means that there is far, far more “untruth” than “truth” in our world,…….not necessarily lies or falsehoods, but “untruths”. Nietzsche persuasively argued that Mankind has wasted several millennia in the search for immutable “truths”. The cost of this unrequited desire for artificial stability and control has been oppression of 95% of the populace, violence, superstition, and arbitrary hierarchies. The tragedy of our grievous pursuit of non-existent foundations has been diversion from Mankind’s authentic meaning, journey, and fulfillment, i.e., self-mastery and self-creation.

We have not made progress toward the vaunted Triple Aim of healthcare (improved population health, better individual care, lower cost),……that is a data-driven, reasonable observation.

We cannot make progress toward the Triple Aim,……that is an “untruth”.

Obesity is the #1 healthcare problem in the USA that is organic and objective,……it exceeds just about every other upstream effector,……and it does have strategies that mitigate its devastating, long term consequences. Examples – first attachment is yet another study supporting the wisdom of preventing gestational diabetes. Whatever multi-prong strategy is proficient will pay for itself several times over. The second attachment demonstrates the skyrocketing incidence of obesity – 6% of “emerging adults” in 1976, to 33% in 2018.

RCTs could be designed with creative incentives of self-mastery and self-creation……

Joe Kaempf, MD

Oregon Representative

Portland, OR

Volume 13, Number 35

Associations of Maternal Diabetes During Pregnancy With Psychiatric Disorders in Offspring During the First 4 Decades of Life in a Population-Based Danish Birth Cohort – PubMed (nih.gov)

“We don’t have the time or money for CQI right now.”

Like Marie Antoinette, Rasputin, Lord Kelvin, Neville Chamberlain, Decca Records*, and notable others through history,…….let’s not be exactly wrong.

In these moments of Sturm and Drang, budget constraints, fatigue, overwork, much of it COVID-related,…….the inherent proficiency of CQI is more apparent than ever.

Wu Wei (Action by Non-action) – a seminal observation from the 2500 year-old Tao Te Ching, is exactly right for modern healthcare. The most effective CQI projects to create are de-implementation, i.e., Choosing Wisely initiatives that reduce or eliminate wasteful, ineffective diagnostic tests and therapies. Every department/unit/clinic should have a consensus-derived list of 5-10 items to reduce, if not eliminate, then track metrics and feed back to staff for input and adjustment.

Attached is a fine Choosing Wisely list from the Hospital for Sick Children in Toronto,……and a concise why and how explanation. De-implementation is both a process and an outcome, it saves your time and others’ money by eliminating non-EBM, anxiety-provoking, expensive procedures,……frees up precious energy for the “vital few”,……and allows you to focus your passion on what your patients and families actually need for well-being. Outpatient pediatrics, hospital pediatrics, obstetrics, perinatology, and most specialties have Choosing Wisely lists online for consideration…….

The second article debates the pro’s and con’s of universal newborn whole genome sequencing. Is WGS necessary on a population basis? Will it be truly valuable (health benefits gained divided by resources consumed) and fair? Should an OB/Newborn unit devote finite resources to universal WGS or universal breast-feeding support? Single family room NICU remodels or free prenatal and well-baby care?

If this, then that. If not this, then not that. The determinism of karma.

* British record company dismisses four lads from Liverpool in January 1962 remarking “Guitar groups are on their way out.”

Joe Kaempf, MD

Oregon Representative

Portland, OR

Volume 13, Number 34

Supposing for this moment our Hindu friends are correct and we do rebirth as part of Mother Nature’s cycle,…..if so, I might desire to be an anthropologic archeologist (recognizing ‘desire’ has no such role in karma).

The attached report from last week’s Science is exhilarating.  Humans roamed North America much earlier than previous estimates suggest,…..archeologists have now unearthed Homo sapiens’ footprints in White Sands New Mexico reliably dating to 23,000 years ago.  So,…..only about 1000 generations separate us from these ancients,.….just pause and let that go to every part of your psyche.  

Look at Figure 1, particularly panels B and E,……footprints of children roaming lakeside with young adults!  What were they doing?  Where were they going?  What happened in their lives?  I confess to tears in my eyes reading this manuscript.  This is a unifying, joyous contribution to discovery.

In our absurdly divisive age, we can focus on the much-wonderful that binds us – mutual challenges, common concerns, shared happiness, collective suffering,…..and children.  QI and EBM must never stray from the foundation of every civilized society that has endured in commune with Mother Nature – the well-being of pregnant women, young families, and children. 

Tangent alert – did you know that over 1,000 distinct tragedies were performed 5^th C BCE Greece?  Yet, only 32 are extant,……so let’s keep hoping that the Triple Aim of Smarts-Grit-Love inspires dedicated archeologists to unearth more treasures,……can you imagine what we will learn?  Regrettably, some notable philosophers have historically wielded far more influence than others not because of superior insight or scholarship,……but simply because their manuscripts survived the entropy that is time (e.g., Plato).  That is tragedy.

Joe Kaempf, MD

Oregon Representative

Portland, OR

Volume 13, Number 33

History doesn’t repeat itself,……but it does offer insights as to what might happen if we choose to do “X” rather than “Y”. Timothy Snyder writes with learned and earned power, his concise book of essays ‘Tyranny’ is a brief history book worth considering.

He’s awfully concerned with our collective disregard of thoughtful study of the past, be it three years or three millennia. He loathes social media and explains why, compellingly so.

Quality improvement is History in the sense we track what happened, discuss what and why, weigh options, and hope for reasoned consensus dealing with the present. Consensus isn’t science, and science isn’t consensus,…….witness our COVID-19 controversies.

We might use science trying to achieve consensus,……but be ever-vigilant,……as soon as the word ‘consensus’ is used, we are not dealing solely with science.

What has happened after wide adoption of the “39 Week Rule”?,……..Pilliod et al deliver a fine display of documented history (attached),…..very slightly more stillbirths, very slightly fewer neonatal deaths.

Can and should children consent themselves for vaccines? Well, as Morgan et al review briefly, this will largely be a matter of consensus, not science (attached).

Mr. Snyder agrees with Jacques Barzun – History can familiarize, it can warn,…….but pragmatists [the true meaning of pragmatic] have difficulty successfully competing with the passion of idealogues.

Truth can rarely be separated from power,……a central history lesson of the past 100 years.

Joe Kaempf, MD

Oregon Representative

Portland, OR

Volume 13, Number 32

We derive both pleasure and insight from travel writing, and few have composed such essays with better clarity and human sympathy than Ryszard Kapuscinski of Poland (1932-2007).

His observations are tonic for the disharmony and confusion of 2021. Travels with Herodotus is reading-rapture for me; I’ll never see nor understand Eastern Europe and post-colonial Africa, report ground level revolutions and coups, or be jailed 40 times (some with death sentences).

Kapuscinski was a modern day Herodotus (484-425 BCE), whose epic Histories is surely unmatched in curiosity and breadth of human observation, another delightful book. Kapuscinski modeled himself on the inquisitive sage from Halicarnassus (modern day Turkey), and was even accused of the same poetic license at times as Herodotus,……but history has proven kind to both.

What heroic principles these two role models display for us.  One RK essay is attached.

Joe Kaempf, MD
District VIII Oregon Representative
Portland, OR

Volume 13, Number 31

For everyone working so diligently with compassion during this C-19 pandemic, attached is the largest robust report yet published that concisely and comprehensively reviews the safety and side effect profile of the Pfizer mRNA vaccine. You can efficiently digest the manuscript just following the yellow highlightsand glancing at the beautifully powerful Figure 4. The Moderna vaccine is also mRNA as you know.

Nutshell

1. Vaccination is associated with increased risk of myocarditis, lymphadenopathy, appendicitis, and herpes zoster
2. Vaccination is associated with decreased risk of anemia, kidney injury, intracranial hemorrhage, and lymphopenia
3. SARS-CoV-2 infected persons have increased risk of myocarditis (4x higher than those vaccinated), kidney injury, pulmonary embolism, intracranial hemorrhage, pericarditis, myocardial infarction, deep-vein thrombosis, and arrhythmia.

These data from Barda et al (Israel) should be helpful for the vaccine-resistant and the vaccine-apathetic, two groups that warrant somewhat different conversations with healthcare providers.

Also attached is an informative report from Sabbatini and our Providence Health System colleagues regarding the increased rate of hospital deaths during unplanned admissions March to December 2020. Retrospective analysis revealed 5-6 excess deaths per 1000 hospitalizations at 51 Providence hospitals, suggesting the pandemic “spillover effect” noted by other hospital systems. Authors discuss the intricacies of determining the multiform reasons for these deaths – patient presentation factors vs. system access and quality factors.

Joe Kaempf, MD

Oregon Representative

Portland, OR

Volume 13, Number 30

Quite much to fret in August 2021, no call to rehash. Let’s take a break and celebrate science/math/technology at one zenith, just to bolster cosmic spirits.

The attached article is a gorgeous illustration of the phenomenal discoveries by astronomers over the past ~100 years re: our galaxy and the expanding universe. Lessons galore for us healthcare workers,…..the sovranty power of curiosity, re-imagination of perplexities, persistence, team work, and most of all humility/awe/perspective. Close your eyes and visualize: there are many billions of galaxies, each with many billions of stars, thus a bazillion exoplanets. We are not insignificant,…..to the contrary, we are likely not alone.

We cannot escape him you know. He’s even quoted in the attached article, because he suspected distant galaxies (nebulae) well before most others. Whether you have read him, or understand him, or agree with him, or not,……..we have to admit his light-year reach into disparate disciplines, and his paradigm-busting profundity second to no human I have read (just my opinion). On his tombstone in Konigsberg (now Kaliningrad) where he spent his entire modest 80 year life:

Two things fill the mind with ever new admiration and awe the more often we reflect upon them: the starry heavens above me and the moral law within me.

But, not included is his very next thought from the Critique of Practical Reason:

I do not seek either of them as veiled obscurities or extravagance beyond my vision; I see them before me and connect them with the consciousness of my existence.

Immanuel Kant 1724-1804

Joe Kaempf, MD
District VIII Oregon Representative
Portland, OR

Volume 13, Number 28