Category: EBM and CQI

Apothegms are concise insights addressing Nature’s mystery, and my favorite genre of aphorisms.  Meaningful apothegms avoid cliché, over-simplification, and speak to life-as-lived, in particular the sovereignty of complexity, the unknown, and uncertainty.

Prosaic apothegms and mystical apothegms are the two subtypes.  Apothegms are distinguished from maxim and dicta aphorisms by how uncertainty is accepted as the fundamental feature of our lives.  Dicta view life as a series of riddles to be solved, maxims are presented as proven imperatives.

But apothegms suggest that reason takes us only so far,……Nature does not exist to quench our desires, nor that should we understand her, nor necessarily be happy.  Our hubris and cravingsare far more problematic than our ignorance. 

Western culture (Enlightenment science/technology) tends to view the world as amenable to rationality, investigation, interventions, man-as-dominant,……while Eastern culture (Buddhism/Taoism) tends to view the world as flux, uncertainty, a mystery to be accepted, man-as-one-part.  So,…….maxim and dicta aphorisms are popular in the former, and mystical and prosaic apothegms reflect the latter.

Be aware that some Western philosophies blend these poles, e.g., Stoicism/Epicureanism/Skepticism/Pyrrhonism/Value Pluralism),..….and are pleasures to study.

There is a key distinction between mystical and prosaic apothegms that pertains to healthcare that I will discuss in the next Article of the Week. 

COVID-19 has made conference attending challenging,……so the attached manuscript by my colleague Mitchell Tsai and his associates, if read carefully, is as good as sitting through several lectures (excellent references too, note #7 and #18 from our visionary former VON colleague Paul Plsek).  Great endings are important too, note Dr. Tsai’s first two highlighted sentences in the Conclusions.

https://pubmed.ncbi.nlm.nih.gov/32371743/

Joe Kaempf, MD
District VIII Member Extraordinaire
Portland, OR 

Volume 12, Number 41

An abstruse first sentence truncates our yearn to learn. 

It dispirits us,……so many books and manuscripts, and so little time.  Worse, it fills turbid the moat around something essential. 

“Anyone who’s worth anything reads just what he likes, as the mood takes him (her).” Virginia Woolf reminds us.

The attached article exemplifies a regrettably incomprehensible first sentence that is not especially inviting,……but if you read on, Cuttini et al present a helpful qualitative study – what drives change in NICUs?  Authors inquire – Why do effective preventives/diagnostics/therapeutics take sooooo long to disseminate?

Look at their recommended fundamentals (all discussed in our University of CQI workshop):  a) involve all staff, b) listen to objections, c) pragmatic, non-judgmental audits, d) regular literature review (read!), e) participation in structured QI and research (yes!), f) incorporate EBM principles, g) early partnering with professional bodies for consensus and gravitas.  Figure 1 is instructive – the different priorities of RNs and MDs,…..it would be helpful to see other allied health providers’ sentiments.

Abdus Salam, Pakistani theoretical physicist and Nobel Prize Laureate – “From time immemorial, man has desired to comprehend the complexity of nature in terms of as few elementary concepts as possible.”  He knew well the danger of this royal road to over-simplification, scientism, technologic zeal, and unintended consequences.

Do you know who discussed uncertainty with as admirable honesty as any writer?  Inventor of the “essay” – Michel de Montaigne  (1533-1592).  

“Nothing is so firmly believed as that which we know least.”

Joe Kaempf, MD
District VIII Member Extraordinaire
Portland, OR 

Volume 12, Number 40

“Remembrance of things past is not the remembrance of things as they were” wrote Marcel Proust. Vladimir Nabokov observed  “The more you love a memory the stronger and stranger it becomes.”

30-some years ago during fellowship training a visiting physician from Ireland ordered phototherapy “on for 4 hours, off for 4 hours”…..which puzzled us.  During NICU rounds the big-boss (Dr. Fred Battaglia, a phototherapy skeptic who battled Jerry Lucey over its safety) blistered all who questioned the Eire guest.  Not because anyone was impolite,…..rather, it was impolitic.  Dr. Battaglia thought phototherapy was a reckless therapy, and perhaps safer given in circumscribed, cycled fashion.

Cody Arnold and colleagues (attached) have studied cycled phototherapy,……do their findings vindicate Dr. Battaglia?  BTW, a fine first sentence from Dr. Arnold.

About 10 years ago I listened to her plead with a PAS audience that “….being a mother of a sick premature infant prematurely ages women, it changes their chromosomes.”  Then we listened to 2 prominent neonatologists deride her position re: pregnancy, extreme prematurity and women’s rights,…..it was unsettling,……unforgettable.  Helen Harrison(1947-2015) was brave, compassionate, sharp, and witty in conversation.  Helen would have read with interest the second attachment re: telomere length and SES.

“Where does a thought go when its forgotten?” asked Sigmund Freud.

Joe Kaempf, MD
District VIII Member Extraordinaire
Portland, OR 

Volume 12, Number 39

I possess an unwarranted, requited love of first sentences.

No special virtue or wisdom, just an obsession.  Fiction,….non-fiction,….essays,….PowerPoints,….lectures,….text messages.  I try to keep forefront in my mind Lucas/Barzun/Thomas/Turner’s 5 pillars of prose – Clarity, Brevity, Truthful, Meaningful,…….and of course Style, the gorgeous nonpareil.  I fail a lot.

My all-time treasure (so far…..):  “The world is my idea.”  Arthur Schopenhauer’s spine-tingling inception to his magisterial The World as Will and Representation,…..published in 1818 when he was 30 years old.

#2 (a tie with 57 others….) – “When on board H.M.S. Beagle as naturalist, I was much struck with certain facts in the distribution of the inhabitants of South America, and in the geological relations of the present to the past inhabitants of that continent.”  A characteristic understated gem from Charles Darwin, On the Origin of Species.  His curiosity, persistence, humility unsurpassed,…..much like Abraham Lincoln, maybe America’s finest writer.

If you have not read Darwin’s autobiography, you are in for a treat,….especially so in these times of disruption/discord/dread.  CD restores optimism in Homo sapiens and our good nature,…..and good Nature.

Send me your personal favorites, if you wish.

So,….what is your impression of the first sentence in the attached manuscripts.  All 3 articles discuss items of great importance,…..does any first sentence seize your mind’s eye,…..and say to you “Read this.”

Joe Kaempf, MD
District VIII Member Extraordinaire
Portland, OR 

Volume 3, Number 38

Today we struggle with COVID-19, climate change, sectarianism, inequalities,…..yet compared to 75 years ago (specifically August 6, 1945), perhaps our desiderata could be better understood from the lessons of war .

John Hersey was an exemplary journalist with fine personal attributes.  He wrote – “….if civilization is to mean anything, people have to acknowledge the humanity of their enemies.”   His heroic description ‘Hiroshima’ stands as the 20th C model for ‘new journalism’, an unadorned, plain-speak style that displayed devastating facts in narrative form.

Our USA has problems to solve, healthcare and beyond.  Legacies of WWII now imbedded within medicine are briefly summarized by Barr and Podolsky (attached).  Largest single impact (p. 614 3rd column) was the Stabilization Act of 1942.   Wage freezes led employers (unable to provide higher salaries to attract employees) to offer health insurance as a fringe benefit, thereby launching employer-sponsored health insurance,….and generative of today’s population health failures (partly).

Operation Warp Speed (attached) is remarkable, something we can be proud of,……rapid, safe development of several SARS-CoV-2 vaccines driven by a commitment to cooperative science, funding, manufacturing, roll-out,……there will be glitches and controversy, but the magnitude of this 2020 ‘Manhattan Project’ is wondrous.

Back to John Hersey – if there is a more impeccable first sentence in the history of writing, you’ll have to show me:

At exactly fifteen minutes past eight in the morning on August 6, 1945, Japanese time, at the moment when the atomic bomb flashed above Hiroshima, Miss Toshiko Sasaki, a clerk in the personnel department of the East Asia Tin Works, had just sat down at her place in the plant office and was turning her head to speak to the girl at the next desk.

Joe Kaempf, MD
District VIII Member Extraordinaire
Portland, OR 

Volume 12, Number 7

At a QI conference last year a well-known speaker displayed a slide with a photograph of W. Edwards Deming (the ‘father of quality improvement’) with the caption – “If you can’t measure it, you can’t manage it.”

I can’t find that Dr. Deming ever said that,….what he did write was – “It is wrong to suppose that if you can’t measure it, you can’t manage it, a costly myth.”

Dr. Deming is 100% correct,….we ‘manage’ all sorts of things we don’t measure (and quite effectively at times).  All us parents out there know that for certain,…..chefs and great athletes live that,.…..above all, accomplished artists (esp. poets) thrive on the unmeasured!

Dr. Deming wrote – “Hard work will not ensure quality. Best efforts will not ensure quality, and neither will gadgets, computers or investments in machinery.  A necessary ingredient for improvement of quality is the application of profound knowledge. There is no substitute for knowledge. Knowledge we have in abundance. We must learn to use it.”

There is a whole lot in that statement from the pioneer who wrote the book on QI and walked the walk,….more on that in future AoWs.

 Pseudodoxia means false, erroneous beliefs,……a brief, prescient 1945 JAMA Revisited editorial that rings oh-so-true today.

https://pubmed.ncbi.nlm.nih.gov/32720995/

A concise summary of the National Academies of Sciences, Engineering, Medicine report re: home births (which perfectly loops back to the 75 year-old pseudodoxia editorial).

https://pubmed.ncbi.nlm.nih.gov/32826023/

Joe Kaempf, MD
District VIII Member Extraordinaire
Portland, OR 

Volume 12, Number 36

Liberty and Equality,……tenets of Western Civilization that actually compete?  Does predominance of one ‘right’ necessarily diminish the other, i.e., a zero-sum game? 

“Full liberty for wolves is death to lambs” he wrote.  Positive liberty (freedom to do ‘X or Y’), or negative liberty (freedom from ‘X or Y’)…..?  Enlightenment or Romanticism?  Georg Hegel or Karl Popper?  Immanuel Kant or Johann von Goethe? 

Do humans possess ‘natural rights’?  21^st Century healthcare ethics places an astonishingly high premium on autonomy,……is that the same as choice?  Do we then conflate choice with dignity?  Is it conceivable to agree upon basic, true value healthcare as a ‘right’, perhaps a feature of a civilized society that cherishes children, families, the misfortunate?

Our resource pie is unquestionably finite, to secure funding for whatever your healthcare ‘right’ happens to be will involve dispute.  Our glaring healthcare failure is lack of honest clarity and reasoned discussion of true value health services,….which investments produce desired health at reasonable cost? 

Baicker and Chandra (attached) effectively summarize Do We Spend Too Much on Healthcare?  They emphasize the importance of limiting low-value care (which per event can be expensive or inexpensive,….the point being it’s low-value).  Their graphic is powerful.  Do note p. 608 middle column, their exquisitely understated mathematic filet of the ‘quality-adjusted extra year of life’ concept – 2.5 days/365 x $150,000 = ~10% of what we spend per person per year in the USA. 

Healthcare Spending in Premies (attached) from Beam, Zupancic et al is a wonderful contribution to healthcare economics, Figures 1 and 2 are exquisite graphics.

Joe Kaempf, MD
District VIII Member Extraordinaire
Portland, OR 

Volume 3, Number 35

https://pubmed.ncbi.nlm.nih.gov/32786184/

https://pubmed.ncbi.nlm.nih.gov/32103158/

What is it about fluoridated water that incites such intense reactions from relatively small opponent-groups (pro-Fl vs. anti-Fl)?

The 2019 manuscript by Green et al (attached) is still a top citation in JAMA – maternal fluoride intake may adversely affect offspring IQ,….that is concerning.

Schluter et al’s recent manuscript from New Zealand (attached) captured my reading-eye because the word “neoliberal” is in their excellent Discussion.  The authors argue that community fluoridated water unequivocally improves oral health, yet is thwarted as an evidence-based public health measure by a relatively small minority.  Why?  How?

Worth mentioning – usage of the word liberal is quite different today compared to The Enlightenment (John Locke, Adam Smith, and others).  “Liberal” in the 17th and 18th C meant mankind has basic natural rights of freedom and individual choice (Latin liber – free), an inherent dignity that should not be violated by Church, Monarchy, or State.  Today, liberal has morphed to a more common-good conception, an expanded social contract role of government to monitor and regulate interactions among individual groups,……and conservative (in political terms at least) today more resembles classic liberalism of yore.

Schluter et al use the word neoliberal to point out the constant tension/irresolution of public health measures that appear to benefit the majority but can (should?) be legitimately opposed by an active minority.  Where do we draw the line of demarcation?  How do we negotiate complex and costly healthcare issues rationally and yet meet the growing demands of population health missives,……simplistically put –  “Here’s $11,000 per patient per year,….spend it on healthcare however you communally decide, but you’re not getting more.”

Do we have a grander, more fundamental challenge in 2020 than implementing compassionate, reasoned, consensus-based population health strategies?  Isaiah Berlin, the prescient philosopher of Ideas, astutely argued that history shows liberty and equality to be competing values,……a zero-sum game.

Joe Kaempf, MD
District VIII Member Extraordinaire
Portland, OR 

Volume 3, Number 34

What’s it like to be a bat?  I might be one of your few acquaintances who knows,..….sort of**.

Thomas Nagel inquired just that in an oft-cited essay (1974).  His point is consciousness is a phantasmagoric experience,…..the one and only thing you and I can be utterly certain of,…..yet a largely inexplicable phenomena despite efforts of scientists and artists.  This frustrates material reductionists and strict objectivists to great end (e.g., Daniel Dennett, Peter Hacker),……of course strict can never be an adjective of objectivist, at least in we humans.

Consciousness is the principal mystery of mankind (I would add quantum mechanics).  Why ‘something and not nothing?’ Gottfried Leibniz wrote long ago. Consciousness is defined by our qualia – those perceptions/sensations/concepts that are not and cannot be shared entirely and accurately with anyone, anytime, anywhere.  Why does one song make me melancholy and you happy?  What exactly is the color red to me and red to you?  How did you intuit that person was upset?  Why did you become an accountant?  What is interesting about your children?

Dr. Nagel wrote clearly – There are elements which if added to one’s experience, make life better.   There are other elements which if added to one’s experience, make life worse.  But what remains when these are set aside is not merely neutral, it is emphatically positive.  The additional positive weight is supplied by experience itself, rather than by any of its consequences.

What’s it like to be a premature infant in a NICU?  Well,…..a lot of interventions/manipulation/pain (see attached from Cong et al).  BTW, the subjects were 28-32 weeks GA,……can you imagine the torment tally in 23-26 week infants?  Bless the hearts of bedside RNs/RTs/therapists/MDs who strive to reduce noxious stimuli.  Less is More.

What’s it like to be SARS-CoV-2 virion in a child with COVID-19?  Well,…..you are present in the youngster’s nasopharynx, shedding yourself just as you do in adults, …..and likely not conscious of such.

** I hang upside down for several minutes a couple times a day. 

Joe Kaempf, MD
Medical Director CQI and Clinical Research
Women and Children's Services
Providence St. Joseph Health
Portland, OR   97225

https://pubmed.ncbi.nlm.nih.gov/28343092/

https://pubmed.ncbi.nlm.nih.gov/32745201/

Science is not about predicting,….it’s about explaining.  Not explaining what is always true, but rather clarifying what is false.

A discouraging feature of mass movements is leaders coaxing people into sacrificing the present for some hallowed, predicted future.  Whose blood, sweat, and tears (real or metaphorical) are shed?  Who suffers?  Be wary of those who preach historical inevitability, progress, destiny,……how many Georg Hegel (1770-1831) prophets must we endure?

Healthcare has “mass movements”.  Admixtures of fear,…pain,…profits,…hope,…urgency,…hierarchy, and bad mathematics ferment within a cauldron of eminence- and prominence-based medicine decocting authentic communal priorities to vapor.  Vapor is hard to measure and thus easy to disregard. 

All sorts of predictions surround the 21st Century Cures Act – the attached article is a concise summary of what might become as influential as the Stabilization Act of 1942.

Rucker opines – “Medical and cost information is far more helpful if patients can use it on their own terms, with tools of their choosing.”

“Imagine a new generation of smartphone tools informed by patients’ actual data, changing the nature of patient engagement.”

How exactly will that improve mental health, drug abuse, obesity, sedentary lifestyles, ACE, diabetes, Alzheimer’s, autism,……?  Smartphones certainly quicken our widget shopping and diversion-needs,……how does “more consumer choice” and “online economy” move us toward the Triple Aim?

Joe Kaempf, MD
Medical Director CQI and Clinical Research
Women and Children's Services
Providence St. Joseph Health
Portland, OR   97225

https://www.ncbi.nlm.nih.gov/pubmed/32160450