Can be found here.

Can be found here. 😃

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November 2021

Welcome to the November issue of WonderWell, a newsletter intended to gather the most groundbreaking research and insightful commentaries in evidence-based medicine, wellness, healthcare leadership, writing, and innovation to help you live and work in alignment with your purpose and well-being. 

Some things that had me wondering last month:
 

1. COVID and…
Counterfeit:  from STATNews — the frightening burgeoning secondary industry of fake vaccines and COVID medicines. 

Children: in the NYT, preparing them for the trauma of COVID, and (an oped from the American Academy of Pediatrics) preparing ourselves for their vaccines  in the NYT

What it will take to end the pandemic: A smart, and pragmatic, take from Leana Wen, in the WashPo.

Rapid tests: First read this eye-opening tweet thread by David Leonhardt (of the NYT) about issues with accessing rapid tests in the US (also applies to Canada), then read this profile of Michael Mina, an early proponent of these tests, in Bloomberg. For what it’s worth, it does seem that access to free rapid tests is around the corner for North America (below, an example from London, where the NHS provides them for free).

2. Podcasts (& shows/books) worth listening to/watching 
Not a podcast or show or book (Sadly I have started nothing new this month…) but I did really love Ryan Holiday’s newsletter (a yearly one he puts out for his birthday).  

This is from the archive but it made me think and re-think.

Lastly, I was very late to this viral piece, “The Bad Art Friend,” but finally listened to it on The Daily, and it was immensely horrifying and sad. In my view, there’s no question who the person in the wrong was: Dawn Dorland was gaslit and tormented for years — make no mistake: this was not an impulsive petty comment or bit of gossip. It was an orchestrated campaign over years to take her story, and associated themes around it (including perhaps the question of altruism vs validation — a great film about this theme is underway), her own words, with the goal of profiting off of it and dehumanizing her. Brene Brown discusses the idea of “common enemy intimacy” — this was certainly at play here: a group of very insecure writers, or perhaps a group of neutral writers, who were swayed (groupthink/social psychology stuff) by an individual with sociopathic and/or Machiavellian tendencies to partake in this abuse and gaslighting. It’s all made worse by two things: that Dawn had openly disclosed her trauma and mistrust (and they did it anyway, to re-traumatize her) and that the perpetrator used the excuse of being a woman of color as a way to paint Dawn as a person abusing her ‘white privilege’ (which only does harm to legitimate claims of bias and systemic racism in writing and beyond). 

I’m hopeful Dawn will find justice, and more importantly, healing. I also hope this experience might plant the seed for her own memoir — could this just be a turning point in a fascinating story about altruism, kidney donation, and healing from trauma? I hope so.

3.On…when to quit (not grit)
In the NYT Opinion section, an incredible ‘video oped’ from Lindsay Crouse, on  video when to quit (over grit).

4.Sound (and wise) reflections
This is very old (if May 2021 is old), and sadly I just found it a few weeks ago, but it’s one of the best ‘think pieces’ about the pandemic, in the Tyee (which is Canadian!). 

5.Miscellany
Dr Eric Warm’s paper on game theory and the Match is well worth the time and introspection. The only thing that might have made it a bit better: incorporating the “Secretary Problem,” which someone told me about a month ago, and I can’t get enough out of my head (it’s brilliant…and applicable to many things).

Somewhat unrelated to this, is the “Avocado Problem” (which I believe I just made up…but I’m anxious to google it, in case it isn’t exactly original). It began with this….(M & S is a fine food shop, part of Marks & Spencers)…..read on and tell me if there’s anything to this…(by the way — it’s great that they specify that the ‘eat now’ avocado and the ‘eat later’ one are from two different places…)

It begins with a question: is there an optimum number of avocados that one (a buyer) can purchase in order to maximize satisfaction (having a ripe avocado to eat relatively soon) and minimize distress (buying an overripe one accidentally, buying an underripe one that needs time…i.e. cannot be eaten when the buyer wants)? I believe M+S has solved this. The optimum number is exactly 2, but one must be ‘ready to eat’ and the other slightly unripe. Why?  Let us assume that most people who buy avocados imagine themselves eating it later that day (guac, snack) or the following morning (avocado toast, huevos rancheros). That leaves a window of 8-12 hours for pleasant consumption.  Let’s also assume that most people who buy avocados dont like to go shopping for them daily. We rarely buy apples one at a time, right? But apples are not avocados (forget oranges)…more on that later. 

Ok so now we have a person who wants to buy an avocado for imminent consumption but *also* has planned to eat another one within the next few days. Placing household size aside for a moment (but we would multiply the stable answer by the number in a household), the stable answer is 2: one ripe, one unripe (preferably not in the wasteful/plastic package as above, but individually).  So why do grocery stories sell them as 5-7 in that green netting? Everytime I’ve given in to ‘buy more to save more’ idea, with avocados only (not apples!) I’ve regretted it. Why? Because avocados ripen more or less at the same time when they are sold like that — it’s the ethylene gas they give off to one another. So while we *think* buying more is better, the net outcome is roughly 3 edible avocados, with 3-4 going to waste. (again: not the same for apples, oranges, etc…avocados are among the most temperamental and unforgiving of fruits!).

Now you might be wondering…what does this have to do with a newsletter about well-being and health? Everything! Because so much of our well-being deals with *how* we make decisions. Not the *what* (outcome isn’t relevant here) but the process. Good decisions heighten our well-being (regardless of the outcome) because we minimize regret around the counterfactual. Bad decisions: the opposite. We weigh a variety of factors differently when we make decisions, and there’s also an element of chance (read anything by Annie Duke, like this or this, to get more insight into this — her work has shifted my perspective immensely over the last 18 months).  Apples, you’ll recall, are not avocados. Apples are one of the most forgiving and stable of fruits — the time window to consume them is relatively long (a week or more) as opposed to short (avocados: hours !). That’s why buying apples in bulk makes sense: you can trust there’s one available for immediate consumption, and one (or many) for later. It doesn’t become a frantic exercise in planning and calculating….as it does for avocados. When we make decisions: about picking the right professional opportunity, business/romantic partner, etc, we weigh some of these same factors. And a big one, beyond compatibility around values etc is *timing*. The problem is that we often presume that these opportunities are like apples: ready when we are, and if we aren’t ready they will still be around when we are; as humans we tend to over-emphasize our own sense of timing and time more generally. This is, obviously, wrong.

Most things (opportunities, people we may want to partner with) are like avocados: If we’re ready (timing wise), we ‘match’ to the right opportunity that might be ready (ripe) as well, except that there’s also the element of uncertainty and chance: that ripe opportunity may not be all it that it seems (the ripe opportunity may end up being overripe/rotten when we finally dig in…which we perhaps didn’t judge well beforehand) OR, since we dont function in isolation but with other people, others may jump at that ripe opportunity before us. As such, the most stable solution is to pursue the ‘ripe’ one, but have a somewhat ‘unripe’ one in the wings. Note: this isn’t the same as having a backup plan: a backup plan is effectively like lining up two ripe things one after another — having something in the wings that isn’t totally ‘ripe’ (either the opportunity is still in flux, or you are still somewhat unsure), but could be sorted out over a period of time is better (this means that we also avoid the competition element). 

Thanks M&S Simply Food for sponsoring this not-so-simple digression (kidding). And yes, I know avocados are not the most sustainable fruit…but let’s park that for now, for the sake of this thought experiment. 

6.Best tweets of the month goes to…
Adam Grant on prestige and jobs
Sahil Bloom on following your curiosity 
Maria Popova on living just the one life
Amy Edmondson on…cookies 🙂

7.Products/Services that have made a meaningful difference during the pandemic:
This newsletter is not sponsored, but I love sharing products that have made a meaningful difference in my day to day (increased productivity, more joy, etc).  This month I’m sharing my absolute favorite tea: Marco Polo by Mariage Freres.

I discovered it at a friend’s house in 2016, in Cabbagetown Toronto — the teabags are just sublime and a bit over the top (think: linen). I managed to find the loose tea version at Pottery Barn of all places, but paid a visit to the Covent Garden location recently and picked up some more teabags, and have made a few cups for friends here. It’s a black tea with a fruity essence, and is simply delicious with or without honey/milk — perfect post dinner, pre conversation tincture 😍 

In My Own Words…

I just completed my reporting for a longform piece I’m working on for Wired (now the writing begins), and gave keynote talk for the National Partnership for Hospital and Hospice Innovation (their Summit is underway), on the topic of burnout and healthcare revolutions (I’ll share the video next month). Funny enough, my mother sent me a photo from London (where I am for another 10 days) from the late 1980s — my first ever keynote! Thankfully my audience was slightly larger this time around, and I found a nicer bookshelf.

I also had a chance to visit my old house (where I lived from about 2 to 6 years old), a duplex in Welling, Kent: 24 Clifton Road. It was really fun to chat with one of the neighbours and get all caught up on the neighbourhood happenings over the last couple of decades! I also retraced my walk to primary school — I’m a bit dumbfounded at how long it was (about 20 min for an adult, so 35 min for a 6 year old?)  

Have a healthy, joyful, and safe November,

Amitha Kalaichandran, M.D., M.H.S.

Credit: Rawpixel

Her husband collapsed just before reaching the top of the stairs in their small one-bedroom house in São Paulo, Brazil. Frantic, Thais Andrade grabbed the portable pulse oximeter she had purchased after hearing that a low oxygen reading could be the first sign of the novel coronavirus. Erik’s reading was hovering eight points lower than it had that morning. He also looked feverish.

“When he hit 90% [on the oximeter], I said we can’t wait anymore,” Andrade recalled. “I called an ambulance.”

At the hospital that day in June 2020, a CT scan showed multiple lesions in her husband’s lungs — an indication of severe Covid-19 infection – which was later confirmed via a blood test. Erik, 44, had likely contracted the virus up to a week earlier, from a friend who had visited their home.

He spent the next several weeks on oxygen in the ICU, a stay that was complicated by blood clots before he was discharged. But it wasn’t his sudden decline and subsequent recovery that is notable: It’s that Andrade had been sharing the same close quarters with her husband while he was infected and able to transmit the virus. She never wore a mask in the home with him. They shared the same bed. They were physically intimate. Yet when tested for an active or past infection — twice — her bloodwork came up negative.

And that wasn’t the only time she was potentially exposed. As part of her research work as a veterinary neurologist, she went to a meeting at the University of São Paulo where an infected attendee set off a chain reaction of positivity – but Andrade dodged it. Her tests were again negative.

Both experiences suggest that Andrade may have won a sort of biological lottery — that she’s one of a lucky few “resistant” to the virus that has killed more than 4 million people. But how? That’s the mystery researchers around the world have set out to unravel.

The question of viral resistance has perplexed Mayana Zatz, a University of São Paulo genetics professor, for years, beginning with exploring the clinical variability of genetic diseases in patients who carried the same pathogenic mutation. She began with neuromuscular disorders like Duchenne muscular dystrophy, and then expanded to exploring why the Zika virus caused severe brain damage in some newborns while others were healthy.

In 2018, she published a study of nine sets of twins — seven fraternal and two identical — born to Zika-infected mothers; in each pair, one twin was born with microcephaly and developmental delay while the other was spared. Zatz suspected the answer to Zika resistance lay in their genes. To test this hypothesis, she collected blood from three of the pairs and reprogrammed their cells in the lab to generate induced pluripotent stem (iPS) cells and immature brain cells called neuroprogenitor cells (NPCs) that had genomes identical to those of the resistant and non-resistant infants. Then, her team infected the NPCs with Zika and found that the virus destroyed the NPCs of only those who were not resistant — supporting the idea that resistance is genetic.

It was a serendipitous moment in early February 2020, on her daily walk, that caused Zatz to turn her interest to exploring resistance to the Covid-19 virus.

September 2021

Welcome to the September issue of WonderWell, a newsletter intended to gather the most groundbreaking research and insightful commentaries in evidence-based medicine, wellness, healthcare leadership, writing, and innovation to help you live and work in alignment with your purpose and well-being. 

1. COVID and…
The impact on Pediatric Hospitals in the US:  In Time, veteran health reporter takes us into a busy New Orleans children’s hospital, and the reality that has emerged: Delta is different. Children are not spared. Cases are rising, as are deaths. With vaccine approval pending, stronger mandates may be all we have left.

Vaccine incentives:  Since consulting for Twitter’s health design team, and now serving on their incentives advisory board, I’ve gained a new appreciation for how to incentivize for healthier behavior both online, and offline. Offline, I specifically mean public health behavior. As reported by the CBC, it’s clear that mandating vaccines for social activities like eating at restaurants, is effective in incentivizing those who have held out from being vaccinated. It provides people with a choice: if socializing in private institutions is of value and can supercede any residual mistrust in public health, vaccine rates can increase.

Vaccines — they aren’t a panacea:  In STATNews, an excellent explainer on the COVID19 vaccines, how they work, and the limits.

The brain and mind: From NatGeo, an incredible deep dive into how SARSCoV9 may impact the brain, even or especially in those who had mild respiratory symptoms.

Learning to live with COVID19: echoing the Atlantic, it’s here to stay (and a nice buffer for this poorly titled piece in the same outlet — can we do away with these sorts of forecasts once and for all? Have we not learned to take things one week at a time? 😔). 

2. Podcasts (and shows) worth listening to/watching 
It’s no surprise that most of us are facing trying times mentally and emotionally; this is a time of collective trauma as we face what appears to be a never-ending pandemic. A great podcast with Ezra Klein, interviewing The Body Keeps the Score author Bessel van der Kolk about trauma and the body. Follow this up with Gabby Bernstein’s discussion with the founder of Internal Family Systems Therapy founder, Richard Schwartz. An excellent PDF handout on IFS, as it could apply to *you*, by Canadian psychotherapist, Derek Cook is excellent and found here.

I also had a chance to watch the Susan Sontag documentary, Regarding Susan Sontag, on HBO — what an incredible life! She was a writer who spent time between NYC (West Village) and Paris, bucked the status quo (especially for women) and was insatiably curious. Definitely worth a watch.

3.On…Afghanistan through a renowned author and an inspiring athlete
The situation in Afghanistan is troubling to say the least. This is why both this article, featuring author (and doctor!) Khaled Hosseini in the NYT and another article, also in the NYT, about a ParaOlympian from Afghanistan named Abbas Karimi is timely and inspiring.  

4.Sound (and wise) reflections
~What public health communication can learn from advertising and marketing, in Business Insider. (twitter thread here).
~A powerful essay, in the NYT, about being a full-time caregiver for a loved one during a pandemic

5.Miscellany 
A frightening tragedy in the Bay area, which hit close to home after having recently spent time in SF/Oakland, which included hiking. Thankfully, Pulitzer-prize winning journalist Matthias Gafni, of the SF Chronicle is on the case, hoping the mystery gets solved soon.

I learned a new term in August: “Japandi” — thanks to Better Homes and Gardens. Those who know me know my interest in all things design and design-thinking. For a long time I wondered if Japanese industrial design was more similar to Bauhaus (German) or Scandinavian. Perhaps this answers it, or simply suggests that there’s a different approach that melds it all together. 

Shine Theory came up during a recent Op-Ed Project call. Worth reading (and ideally, integrating!). 

6.Best tweets of the month goes to…

@White_Owly, referencing Oscar Wilde  😜. 

“It is absurd to divide people into good or bad. People are either charming or tedious.”

@Saahil_Desai on diversity in newsrooms — not just reporters but the editors as well (though a quick look at the Atlantic’s masthead suggests it’s not much better  — potentially actually less diverse editorially — than the WaPo) 🙃

“I know we’re all over the Indian Food Discourse, but fundamentally, this is a diversity in journalism problem. If for no other reason, hire nonwhite editors so they help ensure that your publication doesn’t clown itself”

And this clip from Jimmy Fallon/Kit Harrington, because it made me laugh extra hard.

7.Products/Services that have made a meaningful difference during the pandemic:

I’m trying something new this month — this newsletter is not sponsored, but I love sharing products/services (including books, workshops) that have made a meaningful difference in my day-to-day, i.e. things I’d share with my friends. So I thought I’d share one with you each month. This month, I’m sharing the Harmoni standing desk converter. The standing desk craze is a few years old now, and became more popular since work-from-home/WFH began 18 months ago. It’s a good craze overall: sitting for hours on end *isn’t* healthy for us!

That said, I’m a stickler for design, and I try not to buy things that seem too trendy (i.e. what we could get bored of, and what might end up collecting dust), tough to assemble, or bulky and not pleasant design-wise (think lots of metal, plastic etc). So when I heard about the Harmoni desk I knew I found something that would work. It even has a “Japandi” design! A quick search online (amazon, etsy) has a few others that are similar but either require more assembly, are more expensive, or the reviews suggest the wood might be a bit flimsy.

The Harmoni comes in 4 pieces that slot together, which follows the Japanese tradition of “kanawa tsugi,” which means wood joinery via slats. In other words: no tools, nails etc. It takes 15 sec to assemble and disassemble, and stores flat or vertically when you want to use your desk the ‘regular’ way. Best part is that it’s affordable: from approx $250 Cad ($200USD) and up, depending on the finish. Displayed below is the cork mat which I added on to ensure it doesn’t slip. Combine with an anti-fatigue mat to stand on (which you can purchase anywhere), and you have a great WFH setup! 

Again, this isn’t sponsored, so I don’t have a discount code to share, but let me know if you’re using a standing desk or a converter or just improvising (for awhile I just used a lapdesk on top of books). 

In My Own Words…

For STATNews, I wrote about a topic I’ve been a bit obsessed with since December 2020, after an offhand comment a friend made (about being ‘resistant’ to COVID19) caused me to wonder if there were, indeed, people out there that may have true genetic resistance to the virus that has killed millions, crippled economies, and has left the vast majority of us anxious/unwell/uncertain. Indeed, there are — but researchers are only beginning to understand it, and what role this knowledge might play in terms of therapeutics for this pandemic, and others in the future. The response to the article has been great — I continue to receive emails and letters from readers believing they could be resistant (classically: having been exposed to multiple family members, sharing a home, etc but never having a positive antibody or PCR test) and wanting to participate in a North American trial, if the Brazilian trial is replicated. The one question I have left is: now that vaccine rates are high, does this pose issues for discerning who may be resistant?    

I also recently got invited to give a keynote talk at a major conference in November, and now my mind is busy imagining *what* I could talk about and *how* to make the topic compelling. Thankfully, I have time, and will likely build on a recent article I wrote!

A few weeks ago I read the late Susan Sontag’s beautiful New Yorker short story about the time of AIDS, “The Way We Live Now,” published in November 1986. It’s well worth a read as the themes certainly resonate today as well. And, September is National Yoga Month (more information about the evidence here) — try to get out, stretch and move if you can. Earning my yoga teacher training certification in 2016, was one of the best decisions I’ve made, for my body, mind, and spirit.

Have a healthy, joyful, and safe September (and upcoming labor day weekend),

Amitha Kalaichandran, M.D., M.H.S.

By backing away from major sports tournaments, three high profile athletes have prioritized their healing above all else

Credit: Rawpixel

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August 2021

Welcome to the August issue of WonderWell, a newsletter intended to gather the most groundbreaking research and insightful commentaries in evidence-based medicine, wellness, healthcare leadership, writing, and innovation to help you live and work in alignment with your purpose and well-being. 

Some things that had me wondering this month:
 

1. COVID and…
Delta and Children :  What to be aware of when planning for late summer and Fall.
The CDC reversal “flip flopping” on masks:  And what it means for trust in public health  [and this relates to a piece I wrote for Wired several weeks ago].
On the WHO booster shot moratorium, and imminent pandemic ‘booster shot’ inequality
The role of the media in COVID coverage and public health communication

2. Podcasts (and shows) worth listening to/watching 
A great podcast with Tim Ferris and Michael Pollan on his latest book about plants/plant medicine, and ties to the drug war (including an interesting origin story that harkens back to a never published essay in Harpers).  And one with Ezra Klein in conversation with two giants in understanding the history of race in America, reflecting on the debates around the 1619 Project.

3.On…headaches
A reported Op-ed by Thomas Zellar, on headaches, delves into the realities and research. Complement with the wonderful Joan Didion, whose essay, “In Bed,” is an ode to migraines, and just an excellent model for a science essay.

4.Sound (and wise) reflections
By BF Skinner, on ‘how to discover what to say‘

5.Miscellany 
~An incredible UCSF study which translated a paralyzed/nonverbal man’s ‘brainwaves’ into words.

6.Best tweets of the month goes to…

Simone Biles, on being more than her occupation. 

“the outpouring [sic] love & support I’ve received has made me realize I’m more than my accomplishments and gymnastics which I never truly believed before.”

Rebecca Carroll, on Issa Rae’s OOO response 🙂

“Issa Rae’s out of office email message says “I am unavailable, unreachable and uninterested for the next two weeks” and I love it.”

and James Clear (who has an excellent Newsletter)

1. Do great work. 2. Share it publicly. 3. Cold email people 2 steps ahead of you. 4. Talk about your work and trade ideas. 5. Host events and meet in-person. 6. Become friends. 7. Rise together.

In My Own Words…

For Elemental, I wrote about recovery and rest, which is more timely now, after the Olympics, as Simone Biles also notoriously stepped away from several gymnastics events (and went on to medal).                     

This has been a trying few weeks, with the emergence of Delta and new lockdowns/restrictions. We’re in a marathon, clearly, which is easier together.

Have a healthy, joyful, and safe August,

Amitha Kalaichandran, M.D., M.H.S.

After Covid, being open with patients about uncertainty may be the surest way to build trust in medicine.

IN 2001, when the pediatric allergist Gideon Lack asked a group of some 80 parents in Tel Aviv if their kids were allergic to peanuts, only two or three hands went up. Lack was puzzled. Back home in the UK, peanut allergy had fast become one of the most common allergies among children. When he compared the peanut allergy rates among Israeli children with the rate among Jewish children in the UK, the UK rate was 10 times higher. Was there something in the Israeli environment—a healthier diet, more time in the sun—preventing peanut allergies from developing?

He later realized that many Israeli kids started eating Bamba, a peanut-based snack cookie, as soon as they could handle solid foods. Could early peanut exposure explain it? The idea had never occurred to anyone because it seemed so obviously wrong. For years, pediatricians in the UK, Canada, Australia, and the United States had been telling parents to avoid giving children peanuts until after they’d turned 1, because they thought early exposure could increase the risk of developing an allergy. The American Academy of Pediatrics even included this advice in its infant feeding guidelines.

Lack and his colleagues began planning a randomized clinical trial that would take until 2015 to complete. In the study, published in The New England Journal of Medicine, some children were given peanut protein early in infancy while others waited until after the first year. Children in the first group had an 81 percent lower risk of peanut allergy by age 5. All the past guidelines, developed by expert committees, may have inadvertently contributed to a slow increase in peanut allergies.

As a doctor, I found the results unsettling. Before the findings were released, I had counseled a new parent that her baby girl should avoid allergenic foods such as peanut protein. Looking back, I couldn’t help but feel a twinge of guilt. What if she now had a peanut allergy?

The fact that medical knowledge is always shifting is a challenge for doctors and patients. It can seem as though medical knowledge comes with a disclaimer: “True … for now.”

MEDICAL SCHOOL PROFESSORS sometimes joke that half of what students learn will be outdated by the time they graduate. That half often applies to clinical practice guidelines (CPGs), and it has real-life consequences.

A CPG, usually drawn up by expert committees from specialized organizations, exists for almost any ailment with which a patient can be diagnosed. While the guidelines aren’t rules, they are widely referred to and can be cited in medical malpractice cases.

When medical knowledge shifts, guidelines shift. Hormone replacement therapy, for example, used to be the gold-standard treatment for menopausal women struggling with symptoms such as hot flashes and mood changes. Then, in 2013, a trial by the Women’s Health Initiative demonstrated that the therapy may have been riskier than previously thought, and many guidelines were revised.

Also, for many years, women over 40 were urged to get annual mammograms—until new data in 2009 showed that early, routine screenings were resulting in unnecessary biopsies without reducing breast cancer mortality. Regular mammograms are now suggested mainly for women over 50, every other year.

Medical reversals usually happen slowly, after multiple studies shift old recommendations. Covid-19 has accelerated them, and made them both more visible and more unsettling. Early on, even some medical professionals presented the coronavirus as no more severe than the flu, before its true severity was widely described. For a time, people were told not to bother with masks, but then they were advised to try double-masking. Some countries are extending the intervals between the first and second vaccine doses. Of course the state of the pandemic, and of our knowledge about it, has been shifting constantly. Still, throughout the past year and a half, we’ve all experienced medical whiplash.

It’s too early to say how these reversals will affect the way patients perceive the medical profession. On the one hand, seeing debate among medical experts conducted openly could give people a heightened understanding of how medical knowledge evolves. It could also inculcate a lasting skepticism. In 2018, researchers analyzed 50 years’ worth of polling data on trust in medicine. In 1966, 73 percent of Americans reported having confidence in “the leaders of the medical profession.” By 2012 that number had dropped to 34 percent—in part, the authors surmised, because of the continued lack of a universal health care system.

*

THE ANCIENT GREEK sea god Proteus was able to see the future, but he was forbidden from sharing his prophecies unless he was captured. This was challenging, because he was a shape-shifter: He could become a young man, a tree, a bull, a flame. No one has explored the protean nature of science more prominently than the Viennese scientist and philosopher Thomas Kuhn. In The Structure of Scientific Revolutions, published in the early 1960s, he proposed that science shape-shifts, or advances, through five sequential phases.

The first involves accepting “normal science,” the prevailing theory or “paradigm,” and conducting experiments that merely verify and reinforce the paradigm. During this phase, skepticism is often suppressed. Phase 2 involves finding an “anomaly” that doesn’t fit with the paradigm, but treating it as an outlier. In phase 3, a critical mass of threatening “anomalies” lead to a “crisis”—which prompts phase 4: “revolution,” by way of a series of new experiments to test alternative theories. Finally, a new worldview emerges, a “mature science.” The phases then repeat.

Remarkably, Kuhn didn’t argue that science is in search of “truth,” but rather that it “moves away from” an outdated, problematic, and “primitive” worldview. Also key is that what scientists and non-scientists understand in the new paradigm is reflective of what they see, as well as what they have been taught to see from experience. A switch in gestalt may be “I used to see a planet, but now I see a satellite”—referring to points in time and assuming that the initial observation may have been true. A paradigm shift, on the other hand, may word it as “I used to see a planet, but I was wrong, as it’s actually a satellite.”

Kuhn based his phases primarily on physics. What happens when we apply them to medicine and health care? When we deal with human lives and preventing illness, “advancement” can look a lot like “flip-flopping.” Is a changed recommendation an admission of harm? And where does that leave us with large public health efforts? Medical reversals place doctors in a bind. Improved medical knowledge represents progress, but honestly admitting to a past error may lead patients to see them as incompetent, breeding mistrust.

*

What if we got rid of reversals? That’s what University of Chicago Medical School professor Adam Cifu and oncologist Vinayak Prasad propose in Ending Medical Reversal: Improving Outcomes, Saving Lives. In many cases, they conclude, recommendations are simply issued too soon and are based on low-quality trials. Guideline committees may succumb to groupthink or feel pressured to reach a consensus where none exists. “If we look at something like peanut restriction,” Cifu told me, “the initial recommendations were mostly based on theory—good immunology theory, but theory nonetheless.” If doctors “stick with what’s evidence-based, our advice will be less likely to be overturned.”

Yet diseases don’t wait for evidence. Doctors must sometimes make medical decisions even if good data is rare or unavailable. Cifu and Prasad draw a sharp distinction between evidence- and theory-based recommendations, but in practice, doctors often adopt a looser framework. They may use lower-quality (often theory-based) recommendations until they can be replaced with higher-quality ones. Doctors combine this knowledge with their own personal experience in making clinical decisions.

Medical guidelines are similarly a composite thing, often seeking to balance new evidence with deference to established authority. And decisionmakers may also consider how a revision will affect trust in the system as a whole. In the 1990s, for example, the rotavirus gastroenteritis infection killed more than 130,000 children globally each year. In 1998 the pharmaceutical company Wyeth released a vaccine, called RotaShield, that dramatically reduced the mortality rate. Within a year, however, doctors and patients poured in with complaints. Among the inoculated, there seemed to be a small increase in a bowel condition called intussusception, which in rare cases can be deadly. In 1999, after 15 reported cases of vaccine-related intussusception, both the Vaccine Adverse Event Reporting System (VAERS) and the Centers for Disease Control ordered that RotaShield be withdrawn from the American market. It’s worth noting that VAERS is limited by the honor code: Adverse events are not confirmed.

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It will take time and patience to reemerge from the collective crisis of the pandemic with our mental and physical health intact.