Category: EBM and CQI

Complementarity caught my reading-eye in the attached article from David Hunter, for two distinct reasons.

Epidemiology-driven advances in public health (clean water, vaccines, rural electrification, better housing,….) are principally responsible for the sizable 20^th C increase in life expectancy,…..not medical care and high-technology interventions.  Maldistribution of evidence-based public health and basic medical care, not the need for ever-more sophisticated “therapies”, is responsible for health disparities.  Dr. Hunter’s steady plea for deeper understanding of epidemiology and population health is timely,…..and his Geoffrey Rose quote is essential.  

Examples – preventing gestational diabetes is wiser (best one-word I can think of) than advanced therapies for related neonatal anomalies and childhood obesity,…….HPV vaccination is wiser than developing ever-more expensive treatments for infections and cancer,……you are likely thinking of 37 more examples.

Complementarity also refers to the fundamental paradox of quantum physics – it seems incoherent to describe basic matter (electrons, photons, electromagnetic radiation) two completely distinct ways, i.e., as both particle and wave.  Yet, both descriptions are true (hence Niels Bohr coined “complementarity”).  Albert Einstein could never accept this “sidestep magic”,…..he could not agree that anything in Nature can be described by two mutually exclusive, rigorous methods.  That is worth meditation.

Einstein and Bohr famously debated this for 30+ years until AE was found slumped over in his office working on an elusive unifying theory, dead from an aortic aneurysm.  And NB at the time of his death had AE’s objections sketched on his office chalkboard.   I love it, inspiring, steadfast.

If you are intrigued, just Google ‘single-slit experiment’ – the paradigm-blowing experiment of beaming photons through two slits to a detector panel.  Particle and wave,..….yes.

The implications of this are greater than any single scientific finding in History,……just my opinion, could be wrong.

Joe Kaempf, MD
District VIII Oregon Representative
Portland, OR

Volume 13, Number 27

Part 2 – If friend or family happen to ask “Who do you think is the 20^th C’s greatest philosopher?”

Let’s remain with the eccentric, empathetic, hyper-intelligent Simone Weil,…..just for learning if nothing else.  She wasn’t perfect, had flaws and mis-understandings just like you and me. 

As Robert Zaretsky writes, her conception of learning, and particularly attention, aremarvelously insightful:  Weil did not view ‘attention’ as a concentrating, performative task of working hard to concentrate, filling your brain with facts, i.e, work.  She thought true ‘attention’ was reflective, a mindset of standing still as a receptacle, canceling our desires, turning away from self to the other, waiting not seeking, and not ‘filling your brain’ but ‘sculpting the self’.  Her vita contemplativafueled a disciplined life of action and problem-solving, not self-absorption.

“Attention is the purest form of generosity”, Weil wrote in her journal.  In our Twitter/FB/IG world, aptly called the “attention economy” era,…..we have finite “X’ units of attention to give, but now in this Internet age we can receive unlimited attention.  And therein lies our problem.

You could go to a QI conference and work hard to pay diligent attention for several days through variant lectures and presentations, all fine and good,…..or you could absorb with Weil-like attention the attached quality improvement article from Villosis et al.  I met her at a poster session 4-5 years ago and we talked about her BPD prevention project,…….the manuscript is a terrific read, lots of details to discuss relevant to QI science.  Their project exemplifies both the strengths and limitations of methodology, EBM therapeutics, and results-reporting. Amidst all the wonderful learnings,……there is one particular detail that requires receptive attention to spot,…….email me if you think what I’m thinking, if you wish.

Joe Kaempf, MD
District VIII Oregon Representative
Portland, OR

Volume 13, Number 26

https://pubmed.ncbi.nlm.nih.gov/34181013/

If friend or family happens to ask me “Who do you think is the 20^th C’s greatest philosopher?” my first response is “It depends upon what you mean by great.”

If by ‘great’ they mean 100% commitment to philosophy-as-life, integrity, personal sacrifice, all combined with a breathtaking intellect,…….well, my opinion is Simone Weil.  Just Wiki her and spend a few focused minutes attending to her brief, accomplished life.  Better – read her biography and books.  Whether you be Hindu, Christian, Jew, Muslim, Taoist, non-theist, or whatever,……her accomplishments and insights are both unimaginable and inspiring.

She wrote “How much time do you devote each day to thinking?”,…….”The philosopher’s mandate is action and practice.”,……”The great human error is to reason in place of finding out.”,……and she frequently cited Aeschylus’ “to pathei mathos”  (knowledge comes through suffering).  Most of what she wrote was unpublished in her unprecedented, and tragic lifetime.

She lived and died lonely.  Thanks to Albert Camus we can know her, and be a posthumous companion.

Jean Twenge and Jonathan Haidt have added yet another sobering contribution to our understanding of the harms of digital media/cell phones and adolescent loneliness and well-being (attached).  How much more data do we need before we realistically search for a better way to help children live?

Mother Nature – my parents took me and my siblings camping every summer,…..all nine of are indebted,…..the smell/sound/feel/taste/sights are rooted in our brains to this day (second attachment). 

Most “solutions” to our many healthcare crises are beautifully simple, primal, authentic,…..not technocratic nor expensive.    

Joe Kaempf, MD

Oregon Representative

Portland, OR

Volume 13, Number 25

It’s not consciousness that distinguishes humans from animals, it’s language.  By language we mean sophisticated vocals, symbolic marks (writing), and art (especially music).  Can we measure a society or sub-segment by its language content/usage/focus?  In other words, what are we listening to and reading and looking at? 

Example #1 – the attached ‘children-with-masks-rebreathe-CO2’ has caused a stir,……I quickly received calls from family and friends “Are COVID masks harming our kids?”

Note the fairly quick retraction from JAMA attached,…….BTW, the # of views of the retraction at the JAMA website within 72 hours was 39,385with an Altmetric score of 3,666.  Translation – many providers saw this right quick.

In contrast, an expert JAMA meta-analysis re: foreign body aspiration protocols received 619 views and Altmetric score of just 6.  I would guess we spend millions of dollars each year evaluating children in clinics and ERs trying to figure out how to best accomplish this safely.

Example #2 – do you wonder what percentage of children who become SARS-CoV-2 antibody positive develop ‘long haul symptoms’?  Answer – not many.  The # of JAMA views in a similar time period as above was 27,851 with an Altmetric score of 823,……..a lot of folks noticed this report (attached). 

We are what we read and click and discuss,…..not what we eat.

History is on every occasion the record of that which one age finds worthy of note in another.  To each eye, the outlines of a great civilization present a different picture.  In the wide ocean upon which we venture, the possible ways and directions are many; and the same studies which have served for my work might easily, in other hands, not only receive a wholly different treatment and application, but lead to essentially different conclusions.

Jacob Burckhardt, 1818-1897

Joe Kaempf, MD

District Oregon Representative

Portland, OR

Volume 13, Number 24

Amidst the flurry of electronics that discomposes our lives, I find content reading forgotten heroines and heroes (well, forgotten to my many limitations).  

There are almost no ‘new’ ideas, I mean radically, authentically novel.  Yes, there are modern interpretations of recent data and derivative techno-gizmos to breed consumption……but imaginative insight?  Sparse.  But that’s not discouraging, it’s exhilarating.  A reason to study and think and collaborate.

Example:  Who uncannily predicted the rise of nationalism, tyranny, and 20^th C despotism abysmally tied to science and technology?  Who was marginalized by the entrenched academics of his era (few of whom are seriously studied today BTW)?  Who wrote perhaps the definitive study of the Italian Renaissance? 

Who penned this perfect truth in the latter 19^th C – “Our intellect, no matter how independent of the past it may feel in matters of science and technology, is ever-renewed and consecrated by the consciousness of its connection with the mind of the remotest times and civilizations.”  

Jacob Burckhardt, 1818-1897, Swiss-German historian of culture and art.  Worth knowing him, just my opinion.  Him, and hundreds of past others.

Two attachments from our excellent colleagues re: neuroprotection and neuropromotion of the newly born living in NICUs.  Not unproven invasive technology and medications, but rather humane, organic, historic habits.  Smarts/Grit/Love, the real  CQI ‘Triple Aim”.  

Joe Kaempf, MD

District Oregon Representative

Portland, OR

Volume 13, Number 23

Prospero in Shakespeare’s last play The Tempest.  I can read that 107 different times and appreciate its wisdom with slight variance at each.  Healthcare in 2021 is challenging, 2022 likely more so,.….relying on genius writers past is a must, and a treasure, and our duty. Several of the smartest, kindest women I have ever known tell me George Eliot’sMiddlemarch is one of the finest books written.  Attached is a short essay addressing part of her genius and character,……it strikes me as relevant and learn-full as ever.  

Joe Kaempf, MD
District VIII Oregon Representative
Portland, OR

Volume 13, Number 22

From Marvin Weisbord’s Productive Workplaces, he of Six Box Theory,…..reflecting upon his career and theory of creating meaningful organizational change:

I would do this work again because I believe that:

Finally, I would do this work again for the sake of future generations.  Everyone improving the whole is a legacy from the ancestors honored [in my writings],….our descendants richly deserve this legacy.”

BTW, his ‘Six Box Theory’:  1) Purposes, 2) Structure, 3) Relationships, 4) Rewards, 5) Helpful Mechanisms, 6) Leadership.  Our inability to make consistent progress in quality, safety, value, and satisfaction, Weisbord argues, reside in one or more of these six boxes.

I would modify his meaning of “relationships’ to something more fundamental than just human interactions/emotions/communication,…..and argue that the very nature of life, the entire universe, all matter/energy/things, are in fact interaction-relationships.  Not just humans and sentient creatures, but a table, a mountain, an apple, an atom, a quark.

Anything that is not interacting with some other thing does not exist to us.  We don’t comprehend anything as thing-in-itself,.…….we only sense a tree, a shirt, a best friend, a book, a neutrino by its interaction with another “thing”.  And that is why (my opinion) authentic quality improvement science is not pyramids, hierarchies, rules, and static protocols.  Successful QI is 3-D networks of node-interactions (which includes Weisbord’s “relationships”).

More on that metaphysical bedrock coming,…….meanwhile, why do we charge families for childbirth?  Average $3000 out-of-pocket, with private insurance.  Even more if the NICU is used.  My nominee for the perfect droll understatement of 2021 thus far –  page 3, bottom, middle column.

Joe Kaempf, MD
District VIII Oregon Representative
Portland, OR

Volume 13, Number 21

https://pubmed.ncbi.nlm.nih.gov/34140392/

Heroes and Heroines – Part 1

Recall from school-days the “Great Man Theory of History”, credited to Thomas Carlyle from the 19^th C.  History, he wrote, was nothing but a continuous stream of geniuses and hyper-achievers (both male and female) leading, imprinting, forcing, and inspiring their will upon others.  Although typical to critique the “Great Man Theory” as conservative, Western, and hierarchical, in truth it’s actually radical,…..I think anarchists and intellectual extremists of various stripes concur.

Maybe only genius understands genius, the  greatest minds are more often than not ignored by contemporaries.  Example – his first book The Birth of Tragedy barely caused a ripple, and only in a small circle of philologists, yet was his biggest seller despite being followed by what are now considered classic contributions to the Western canon. 

Few are aware of what sustained Friedrich Nietzsche in the darkest days of being ignored, his somatic illnesses, and loneliness,………a simple trans-Atlantic letter in 1881 from 3 unknown admirers in Baltimore, MD encouraging him to continue his “depth of thought and sublime diction”.   That “epistolary lifeline” was a butterfly’s wings leading to a sublime hurricane.  Think every day who might need encouragement in our midst?,…..who wants to be a local champion, a catalyst, a teammate?

Last thought – it’s odd how Nietzsche is cursorily brushed aside as fanatic, a crazed fringe-element,.……but do you know who was a pivotal influence upon his thought nonpareil?  Ralph Waldo Emerson,……a widely recognized “Great Man of History”.  Only genius understands genius……?

We don’t need geniuses to help us all understand that effective healthcare is at our beckoning:  a) attachment 1 – marijuana is unequivocally harmful to the developing brain, and b) attachment 2 –  the domino effects of excessive maternal weight gain and gestational diabetes on future maternal and childhood health is gargantuan, but effective preventive measures exist.

Joe Kaempf, MD

District 8 Oregon Representative

Portland, OR

Volume 13, Number 20

The world is my idea.  This proposition is a truth for every living and thinking being, though only Mankind can bring it to the state of abstract and reflective knowledge.  When he really does so, one can say that the philosophical spirit has been born in him.  He is then absolutely certain that he is acquainted with neither a sun nor an earth, but only with an eye that sees a sun, a hand that touches an earth.

If that isn’t the most entrancing opening lines of any non-fiction tome , I don’t know what surpasses it.  Arthur Schopenhauer’s The World as Will and Representation is a masterpiece first released in 1818.  His foundational metaphysical concept of ‘will’, the blind driving force intrinsic to all matter, not just living things, is the extension of Aristotle’s telos, and heavily influenced Nietzsche’s ‘will-to-power’, Bergson’s ‘elan vital’, and Freud’s ‘libido’.

Although Schopenhauer is oft-conceived as a dour misanthrope, that is mostly unfair.  He was not a philosopher of death, but rather a lifelong habitue of the search for truth, with the keenest sense of the uncertainty of consciousness,  the vicissitudes of subject vs. object,….and above all how we struggle with the ‘conditions of knowledge’, as Houellebecq notes.

It was Schopenhauer who developed Immanuel Kant’s thesis that there is no such thing as time or space (the first quantum theorist?).  Time and space are just constructs built into our brain’s perception structure (the waffle iron molding what is batter into a shape).  Example – we can think of events without time, but not time without events,……we can think of objects without space, but not space without objects.  That’s because time and space don’t exist as distinct ‘things’. Consciousness and cognition, our deserved idee fixe, so:  a) first attachment from our colleagues McAdams and Berube, an excellent summary of neonatal encephalopathy, and b) cognitive decline in Baby Boomers endangering retirement assets,..….quick – count backward from 100 by 7 as fast as you can.

Joe Kaempf, MD
District VIII Oregon Representative
Portland, OR

Volume 13, Number 19

https://pubmed.ncbi.nlm.nih.gov/33712717/

Words – Part 4

Just where no ideas are,

the proper word is never far.

Men usually believe if only they hear words,

that there must be some sort of meaning.

         Mephistopheles (Goethe’s Faust)

When the first terms seemed to come right [Bohr’s existing rules] I became excited, making one error after another.  By three o’clock in the morning all my calculations lay before me.  It was correct in all terms.  Suddenly I no longer had any doubts about the consistency of the new quantum mechanics that my calculations described.  I was deeply alarmed,…I had gone beyond the surface of things and was beginning to see a strangely beautiful interior,…and felt dizzy,…this wealth of mathematical structures Nature had so generously spread before me.

        Werner Heisenberg (describing his matrix theory of quantum mechanics)

From Mephistopheles taunting our gullibility, to the far reaches of genius seen within Heisenberg’s stupendous “Uncertainty Principle”, every livelong day is a reminder we make decisions based upon partial data, bias, chance, undisclosed motives, and misunderstanding.  And that’s just deciding what to have for dinner.

Can we actually have informative shared decision making with families about the particulars of intensive care or hospital services or emergency treatments?

One example (from a bazillion)  – probiotics to reduce death, necrotizing enterocolitis, and infection in premature infants – two excellent discussions attached.

Joe Kaempf, MD
District VIII Oregon Representative
Portland, OR

Volume 13, Number 18

https://pubmed.ncbi.nlm.nih.gov/34031231/

https://pubmed.ncbi.nlm.nih.gov/34047767/