Mild and dire forecasting models serve different purposes, and can be tricky to interpret. But when they appear similar, it may signal the end of the pandemic.
CONSIDER THIS THOUGHT experiment: J is a 55 year-old patient who has smoked two packs of cigarettes a day since he was 22. He has just been diagnosed with stage III non-small-cell lung cancer. His doctor uses a series of methods, including a model, to decide his prognosis.
In Situation 1, his doctor uses the “precautionary principle” and presents the worst-case scenario based on a model of the worst case: J has about six months to live.
In Situation 2, the doctor bases her prognosis on future-projecting J’s present situation, by definition not the worst-case scenario and more “optimistic”: J has another two years to live.
Which scenario is better?
The answer isn’t so straightforward. In medicine, prognostication is fraught with its own challenges and depends largely on the data and model used, which may not perfectly apply to an individual patient. More importantly: The patient is part of the model. If the information used then shifts the patient’s behavior, the model itself changes–more precisely, the weights given to certain variables in the model change either toward a more negative or positive outcome. In the first scenario, J may decide to shift his behavior to make the most of his next six months, perhaps extending it to nine months or longer. Does that mean the model was inaccurate? No. It does mean that knowledge of the model helped nudge J toward a more optimistic outcome. In the second scenario the opposite may happen: J may continue his two-pack-a-day smoking habit, or only cut down to a pack a day, which may hasten a more negative outcome. It’s entirely possible that J in Situation 1 lives for two years, and in Situation 2 lives for six months.
This pattern exists everywhere, from prognosticating climate change to even polling (knowing poll results can affect voting behavior, potentially changing the outcome). We’ve seen a similar dilemma with Covid-19 pandemic modeling, which may help explain the divisiveness over everything from when the pandemic may end to whether lockdowns are appropriate. Last year, just as the World Health Organization declared Covid-19 a global pandemic, I wrote about uncertainty and risk perception. When faced with uncertainty we defer to experts, but a month later the National Institute of Health’s Anthony Fauci correctly noted that experts are fraught with predicting what was (and still is) a “moving target.”
Over the past few weeks we’ve seen more opinion pieces focused on optimism: that herd immunity will be reached by April, and summer will be more like 2019, wide open and carefree. We’ve also seen how this optimism, based on a “present-day accurate model” can sway behavior: from schools opening (but then locking back down) to Texas’ recent removal of its mask mandate potentially contributing to an uptick in cases. Others have taken a more pessimistic approach, saying it may be another two years until things “return to normal,” and the virus variants are a “whole other ballgame.” Today, in Michigan and in Canada, a potential variant-fueled third wave suggests a less optimistic outlook (for now). We’re all deeply familiar with how this pattern has repeated itself several times over the past year, and even experts disagree (and some have changed tack). It’s more than just bad news bias. But how do we reconcile this dichotomy between the “optimists” and the “pessimists”? It may come down to how we understand the purpose of epidemiological models in general, and the two types of pandemic forecasting models.
Justin Lessler is an associate professor of epidemiology at Johns Hopkins University and is part of a team that regularly contributes to the Covid-19 Forecast Hub. He specifies that there are four main types of models: theoretical, which help us understand how disease systems work; strategic, which help public officials make decisions, including to “do nothing”; inferential, which help estimate things like levels of herd immunity; and forecasting, which project what will happen in the future based on our best guess how the response and epidemic will actually unfold.
When it comes to forecasting models, there are those whose forecasts are not worst-case scenario by definition (thus more optimistic), which aim to describe present-day patterns in transmission and susceptibility and project out, assuming the current patterns stay the same. In these “dynamic causal models” a variety of different variables are added to also include, as University College London based biomathematician Karl Friston described, unknown factors that affect how the virus spreads, dubbed “dark matter.”
Then there are forecasting models guided by the “precautionary principle,” aka “scenario models,” where the assumptions are often the most conservative. These account for the worst-case scenario, to allow governments to best prepare with supplies, hospital beds, vaccines, and so forth. In the UK, the government’s Scientific Advisory Group for Emergencies focuses on these models and thus guides policy around lockdowns. In the US, President Biden’s Covid-19 task force is the closest equivalent, while the epidemiologists and actuaries that appear nonconformist may be the closest we get to a group like the Independent SAGE (which Friston works with).
“The type of modeling we do for the Independent SAGE is concerned with getting the granularity right, ensuring the greatest fit–with minimal complexity–to help us look under the hood, as it were, at what is really going on,” Friston told me. “So, the fundamental issue is namely, do we comply with the precautionary principle using worst-case scenario modeling of unmitigated responses, or do we commit to the most accurate models of mitigated response?”
This gets to the heart of the tension between various “experts.” For instance, epidemiologists like Stanford’s John Ioannidis have tended to be more concerned with modeling the pandemic to accurately explain current patterns (and extending this pattern into the future), which can come off as more optimistic and isn’t typically used to guide policy.
**Originally published in Wired, March 2021**
A series of interviews with pioneers bringing the world of wellness and technology to make meaningful change.
Parlaying a cancer diagnosis into an advocacy powerhouse, Ann Marie Giannino gives voice to people impacted by breast cancer, MS, and mental health issues. Since establishing the non-profit Stupid Dumb Breast Cancer organization in 2012, AnnMarie has worked tirelessly to engage the community through awareness programs and fundraising initiatives, and to ensure that everyone who suffers is heard. She currently serves as Director of Communities for Wisdo.com. Wisdo was created by Boaz Goan, in memory of his father, Benny Goan, who touched many with his wisdom. Goan wrote about the origin story and mission of Wisdo for Medium in 2016, writing: “Wisdom is practical knowledge. It’s what’s learned in hindsight. Kernels of “if only I had known then what I know now” information meant to pass along so that others can benefit.”
Amitha: What has the response been so far? And growth patterns (including by age but also geography — are some countries/regions more on board vs others)?
For me personally I have watched and nurture Wisdo from the start. We had ten guides when the platform started to over 100 now and over 3,000 helpers. We are global for sure USA and UK seem to be our strongest. The age range is amazing. 19 to 70!! I love the fact we can connect with so many ages to share a common story. There is truly something hopeful talking to someone older than you who has gotten through a really hard time. We have over 1.5million registered users now – the community is growing and thriving.
Amitha: What has the impact been, in terms of general comments and any measurable things (research if available — has it made a difference among people with diagnosis of depression or those with depressed mood that is self-described?)
Annmarie: Again I would like to speak about the community. Wisdo is this amazing safe space to talk about things that are hard to hear. Many regular users on other social platforms don’t get seen because of the algorithms, and the follower count. By creating an environment where our members feel safe to express their dark thoughts we have instantly helped. Not talking and hiding behind safeguards will only perpetuate the stigma and make those living with depression feel alone. Wisdo does the opposite. We show those living with many mental health crises that talking is just what they need and talking to those who have been there can show them they will get through. This also validates what they are going through, they can see in our community that they are not the only ones feeling this. What an amazing way to show people that talking is safe and that even though their depression may look different we all are going through something similar.
Awhile ago a girl – a 19 year old who just got out of rehab has posted in a ‘coping with addiction’ group. And her recovery was similar to them. I clicked “Been there” (a button on the app). And she replied and said “thank you for reacting to my post.” And I replied. So here’s this 19 year old looking near a 40-something year old and got so much hope. We need that so desperately. When you sign up for a support group, regardless of age or ethnicity, but you’re all connected based on a similar experience. We get a lot out of knowing someone’s story, so for the most part it’s a peer-to-peer support. It’s not about misery loving company…people with depression want to connect to people who know what they’re going through.
Amitha: What are your thoughts on the general trend, if you agree it’s a trend, of social media looking at ways to i)decrease its toxicity/addiction potential ii)improve mental health and well-being? What other apps/companies are thinking about the same problem and seem interesting to you? Social media has 100% made Mental Health “trending”.
Annmarie: The issue is while the general public sees this as a plus those who work in the mental health world see the problem. We are looking at pretty images of depression on IG, we see all the likes some get for posting, our world is at an all-time high for substance use disorder because it is “5 o’clock” somewhere, Eating Disorders have skyrocketed and domestic abuse is immeasurable right now. With the wave of COVID we will not know the true impact of how it has affected Mental Health for at least 2 years. We are living in an age where likes are giving many anxiety because they are not getting enough. Wisdo is not about social competition but connecting with those feeling like you do to help you see you are not alone.
Amitha: In 5 years where do you think social media in GENERAL (so the big names like Facebook, Instagram etc) will look like? And will they me more aligned with apps like
Wisdo, or will they be obsolete, i.e. replaced with platforms that connect people in healthier ways?
Annmarie: Personally I have seen a change in Instagram but more on the silence side. They are block certain # because they are scared of the conversations. If other apps would take in how Wisdo creates a space to have a real honest discussion about self-harm with healthy alternatives and understanding why this happens we would be ahead of the game. I think as we go into the next 2 years Instagram, Facebook TikTok will all have shifts. Mental Health workers and advocates are looking for Wisdo like platforms to send people to just to connect because crisis lines are overwhelmed. While Instagram and Facebook use moderation tools to watch their platforms TikTok is using algorithms which has proven to be problematic. Wisdo uses moderation with watchlist words that our team of volunteers keep an eye on. Our community supports each other and wants everyone to be heard. We have done an amazing job of letting people express themselves while keeping our community safe.
Amitha: What are you most excited about with Wisdo and what’s on the horizon that you can discuss now?
Annmarie: I remember a long time ago saying to Boaz “Wisdo has no personality” I think this bothered him a little bit, however what it did was show our team what was missing. Wisdo is alive with helpers, guides, coaches all wanting to engage the community. Watching Wisdo embark on some exciting new projects that will not just bring in members but a diverse group is really impactful. We all take a breath the same way and sometimes we forget that. Watching older adults come into the app and give their story to young adults is truly inspirational!
A series of interviews with pioneers bringing the world of wellness and technology to make meaningful change.
From her work on the initial Sephora team to her experiences in manufacturing, consulting, and brand strategy for companies like Gap Inc., Cisco, and Landor, Melody Mortazavi has been passionate about creating brands her entire career. Mortazavi is an entrepreneur who believes in the power of connection, and she founded UME in Menlo Park with that vision in mind. After UME was acquired, Mortazavi continued to pursue her love of brands and human connection by co-founding Longwalks with Trishla Jain.
Trishla Jain is an author, artist, and entrepreneur. Throughout her career, Trishla’s work has focused on helping people communicate and connect mindfully. She is an author of a mindful children’s book series and an accomplished artist with exhibitions exploring the intersection of joy, gratitude, and minimalism. Trishla sought to build a better way to spark meaningful conversations and deepen personal relationships online, co-founding Longwalks with Melody Mortazavi.
Amitha: So I downloaded Longwalks back in December, and I can’t remember where I had first heard about it – it might have been through Oprah magazine or a tweet she posted? It’s so well designed, and I love the concept. What got you motivated to create it? And what spurred the interest in well-being and self-care?
Melody: I think that we approached this in a very personal way to start with. We (Trishla and I) met quite serendipitously, and she had invited me to a conversation, sort of a Jeffersonian type dinner, at her home, where she had crafted a really beautiful conversation for the evening. The conversation was designed to bring 10 women together who had never met before in the most optimal way possible. And yes, that's very “Silicon Valley,” but like everywhere else in the world we're all quite pressed for time and so she wanted to create the perfect environment for us to really get to know each other. And that meant getting to know each other outside of what we do or what our significant others do or where our children go to school, which are the typical things you generally hear from each other when you first get to know someone. There was a question that was posed about a poem that grounded the conversation, and each person just shared, one at a time, as we went around the table, about a story that that poem reminded them of. It was a very new way to have a conversation because you actually got to sit there and really listen to what the other person was saying. And then when it was your turn, you could speak essentially your truth. And so, this form of uninterrupted one-direction type of sharing was really beautiful. It was really transformative for me, and I had never been in a conversation with someone else or a group of people where I didn't actually have to work very hard to keep the conversation going. And this was just a really beautiful way of connecting with other people at the table, and after the third or fourth time we had done this, I started thinking about the ways people are connecting with each other now digitally. So we started thinking about how to deliver this same sort of experience to others. I think, when social media was designed and developed, people didn't really think about the negative impact on mental health. They didn't think about the impact on people's relationships or attention spans, and all the things that you very well know. So we embarked on this very ambitious mission of creating a truly supportive and kind social platform where people can share their stories in a way that I was alluding to, to really tell the things about themselves that really matter to them and make up who they are: like the really the good juicy stuff of who you are. And so I think what we did really beautifully was really utilize psychology, Eastern philosophy and a lot of really mindful meditation practices to create a platform that not only provides the content that's that really helps people connect, but also create this really beautiful safe space which we hear about time and time again.
Trishla: I mean your question was really why we started Longwalks, and in essence I think the quality of our human relationships, the depth and intimacy of them is one of the primary indicators of lifelong long-lasting happiness and kind of what the Harvard Study of Adult Development says.
When you look back, a fulfilled life is one with beautiful deep relationships. So that's really kind of the vector where we wanted to focus. It all came together in this beautiful way. And the way Longwalks is really different is that in some sense it's not open-ended, unlike every other social platform where you can kind of share whatever it is you want to share, using various formats. We've really created a little bit of a cocoon around the user using our prompt. So, we provide one single piece of content, which is a fill-in-the blank question every day. And that's it. It's very simple. It's very equalizing pretty much being a human. I've had a lot families say that they do it with their kids. They do it on their phone with adults and then at night they use it at the dinner table, and they make all their little kids like six year old, seven year old, kids fill it out. So it’s kind of just like a moment where you get to share something and then we anchor we map out the whole year. In 365 days we kind of cover a large aspect of what the human experience. And it's beautiful because you don't really have to think about what you're sharing and get yet if you're doing this with people on the platform. You get to experience humanity and living together.
I think that I've been practicing this formula of sort of asking a question and then making everyone answer it in the fill-in-the-blank model for a very long time, since high school, so it's just kind of my modus operandi. This was the first time I had kind of done this in Silicon Valley and Melody happened to be there, and then with serendipity, one thing led to the other and in 2017 Melody started to think of this as like a full-fledged business rather than just a private kind of experience with friends, but by then we must have had over, 250 of such dinners like that. And the digital format kind of coincided with COVID, even though it started way before COVID it just, there's so there's a lot of serendipity in our journey.
Melody: What matters is that the question has to be supportive enough for people to want to access that as a nugget to share it with somebody else, so 2017 was a year of focus grouping, really, essentially, and then figuring out how we want to how we want to deliver this what it would look like, as a feeling to bottle up. I think one of the beautiful parts of the digital platform is that you can have that feeling with someone, all the way across the world, who has like a completely different socio economic background is of a different race and gender and every everything is different about them, but you can actually have that exchange of that feeling with that person. And that's what's happened to me a lot -- I've randomly met probably 20 or 30 people who are now my friends on Longwalks, that I share with, and I don't even know where they live!
Amitha: That's amazing. I was just talking to someone about on most apps or social media there aren’t really incentives to be civil. And I’ve likened it to a dinner party, where if you aren’t civil, even if you have opposing views, you won’t get invited again. But there’s this feeling where it's almost invigorating when you have a really interesting discussion or debate, or you know that feeling of being connected. So you're, totally right – it’s super hard to get that online with a lot of the apps that are out there right now that are being used.
Trishla: I read that you're also Yogi and you love yoga. And I think with Longwalks it’s that synchronicity that sometimes gets missed. Like when you're in a yoga class, the entire class is participating in a series of motions, everybody's on the same page and moving together. And that creates a very harmonious flow. It's not like everybody's doing their own thing. One of the most unique things about our platform is that everybody's doing the same ‘pose’ as in answering the same prompt. So you feel you're not alone, like you're just all different rays of the same sun.
Amitha: I love that analogy. So the actual digital element was that rolled out in 2020 then you're saying just around the pandemic?
Melody: The first version of the app was launched in August of 2018. We had been working towards a solution for a couple years before the pandemic hit.. What we've done really mindfully is that we are building this app for our users, and we have a big cohort of users who really love this app. And so we build and we iterate based on their needs, that you know of course are aligned with, with the mission. So we have taken quite a few updates and changes to the app in order to best align with our with our users, and when COVID happened and we all went into lockdown in March, had just launched our best MVP (minimum viable product) to date. And so we saw this really beautiful alignment of user with product. And that's when we had a significant uptake in users, and we have really great App Store reviews that are all organic and just people's real experiences. So, the alignment was really great, during a time where it was so uncertain for everybody. We were providing a tool that was helping people feel better. That was helping people feel connected to each other not as far apart, was giving them something to anchor their daily practices so that they could answer something with the people in their lives. And it was really helping them stay close to the people they couldn't be close to. And so that really gave us a whole big lift in order to kind of keep going and keep building and keep doing what we're doing
Amitha: Why the name Longwalks?
Trishla: Many reasons. Some of them are practical, you know, in the sense of wanting to have a name that's unique and all of that, but really Melody and I are just nature lovers who love to walk and we think of human relationships as kind of like walking hand in hand. And we think that sometimes the best conversations you can have is when you're on a long walk with a friend. Because the conversation just organically flows, and you're enjoying the earth, so there's many different kind of connotations. I don't know -- Melody what does the name mean exactly?
Melody: I will just embellish a little bit more in that I think that the experience we try to mimic on Longwalks, is really that kind of those special moments that you have during a long walk, you know those really those heartfelt conversations that you really get to know people that's essentially I think what we hope toreplicate.
Amitha: How do you feel like, like how is the uptake been so you obviously launched in 2018, you were saying, um, have you seen an uptake. I mean, as I mentioned, I've heard about it. I think through either Oprah Magazine or something, some something over related.
Melody: She gave us a shout out! Oprah’s a gifted conversationalist and gifted person at making anybody feel important and worth listening to. And I think we've always just reached out to her along the way when we've needed guidance or calibration or just talking to someone whose life's work has been about helping people connect meaningfully.The shout out was definitely a big surprise to us- we had no idea it was coming. And I think I was on a long walk at the time because I hike a lot on the weekends, and our biggest concern was ‘oh my God are the server's gonna crash?’ Luckily they didn't and our tech team, they're all just incredible. So, it was a great shout out from her that kind of validated the experience that all the users were having. They were really grateful for Longwalks during a time where there wasn't a lot to be grateful for.
Amitha: Definitely. So have you found during this pandemic that uptake has increased like? Because apps are tough in terms of getting people to stay on them. But I think that what you're offering is unique, so I would hope that there's more people are more incentivized to like stick to it.
Melody: I mean I think that's where we started the conversation is ‘How do you have social wellness’ and ‘what does that even look like’ as in having a healthy relationship with this phone and the things we do on it. And I think that one thing we try to do as we definitely don't hold ourselves accountable to the same vanity metrics that other social companies, hold themselves accountable to. So for us time spent on app is measured a little bit differently for us, because it's important to have a depth of relationship. We don't make it about Facebook likes or friend counts or friends lists and things like that because it's just, it's a different platform it's a more niche platform and I think our goal is to empower the depth of relationships and authentic connections, and helping people find like-minded people on Longwalks. When we are looking at acquiring users we unfortunately have to use the same mediums that other people use, and do your standard performance marketing things but the way I sleep at night is to think that I am leveraging these other social media platforms to bring people to Longwalks. It’s a healthier and better way to communicate with the people that they want to communicate with.We don't expect to take over. So the time that you spend on Instagram or Facebook we just hope to kind of counterbalance it with things that fill your bucket and make you feel really good about the people that you're talking to.
Amitha: I'm sure you both watch The Social Dilemma. I'm sure it's not a surprise, in terms of what they presented, but do you have any thoughts on sort of how Longwalks fits in? I guess you've sort of answered that question as it being a buffer or counterbalance?
Trishla: Tristan is one of the early attendees to dinners. And at the end of the dinner he shared a very profound experience about his mother and said ‘I challenge you to bring this to tech as I've never seen it.’ And at the end of The Social Dilemma they pose a question, you know, as in ‘what is the solution?’ They don't offer solutions. So we really feel like Longwalks is very sustainable, because it only takes a few minutes maybe 5-10 minutes a day. It's a very sustainable solution to create social wellness in your life, using your phone.
Melody: I think it's just a really actionable solution. So that's how we think of it as well, in relation to The Social Dilemma, and Longwalks is literally designed as an antithesis to all of the problems of social media. So, it's designed to not feel like a popularity contest -- we don't display any kind of counts. We don't publicly display how many people have liked your post. We don't let you know how many friends people have or any kind of numerical things like that. The way that our commenting works is that it's pre-scripted to be extremely supportive and kind. So it really eliminates that culture of bullying or negative commenting that occurs in other platforms. It's very unified like I said and has synchronicity because everybody's on the same page and answering the same questions. You don't get a lot of distortion or distraction there's no ads. There, nobody's trying to sell you anything. So a lot of the problems associated with social media just don't happen on our Longwalks: we've created a situation where they won't happen. But we always have our eyes open, just to see if things are creeping into that territory.
Amitha: Do you feel you're also sort of self-selecting as well for people that are not going to be that way maybe?
Trishla: We have the very committed and sticky users who use both regular social media and Longwalks, and then there are of course the people who doing a detox off other social media, so only doing Longwalks. So we find that it works really for anyone who wants to have a kind of new social wellness habit in their day.
Amitha: Got it. And then so you were mentioning I mean it sounds like when you, when you mentioned like Tristan Harris, for example, it sounds like you're pretty plugged into the Silicon Valley community so I'm curious to know like what your, what both of your backgrounds are in in tech, like a different form of tech before you could work for, you know, big tech before this like without a motivator. Tell me a little bit about that.
Melody: I actually come from a retail background and brand strategy background but during the latest part of my career I worked for Cisco and I did Internet Business Solutions consulting so I do come from a slight tech background but my specialty is really optimizing retail solutions for consumers. And then after I got pregnant with my first child I didn't want to consult anymore. I was not going to get on a plane every week, and so I decided I came up with this idea for a children's play space, and this was at the time where there were no other really placed bases around, so we raised a seed round and opened a 15,000 square foot children's indoor play space in Menlo Park called U-Me, so that I could work, and do something with my brain but also bring my kids to work. And so I did that for about seven or eight years and then that was acquired. Then I decided to go back into the corporate world.
Amitha: I'm just trying to imagine what it would look like in Silicon Valley like a big play space I imagine all of the, all of the activities are planned intentional and…
Trishla: Very. It was so beautiful I mean she has an unbelievable eye for design, they have this kind of minimal Scandinavian aesthetic where everything had a purpose, there wasn't any like random stuff and it was really the child was at the center of the experience and the child could direct it to play very well so, and she used a lot of that learning. I can see how she applies that user experience design in Longwalks.
Amitha: What about you Trishla?
Trishla: I grew up in India, and my family runs the Times of India group. So I kind of grew up
enmeshed in those walls. And then I went to an American school and then I came to the U.S. for college (Stanford) during college and fell in love with English literature, so I had a circuitous path where [I then attended Columbia University to do graduate work in education then] worked in brand marketing in New York. And after that, I went back to India and just worked at times in different capacities, learning about print. And then also learning a lot about how to embark into the digital world. I did that, and then I became a full-time artist, which is kind of my deeper love, where I had three solo exhibitions in India while having children.
Amitha: What sort of art?
Trishla: Painting. But during that time, I would say my main real job is being a full time Yogi. I did so many maybe 50 silent retreats like Vipassana. Yeah. Even a few 60-day ones where I left my husband with my parents. And I think that was just a time of profound growth intellectually, emotionally, physically and every way. And then we both moved here to America about four years ago. But we were thinking of it as coming back to Stanford, where me and my husband met. He runs the digital business of Times of India. Tristan is really more of a Stanford connection than a Silicon Valley connection.
Amitha: Got it. It sounds like you've had some really interesting experiences, both in India as well as in the US, and that blending of Eastern and Western practices in the sense?
Trishla: When you have profound meditation, it's almost like you just want to give back to the world in whatever way you can and then I found Melody.
Amitha: Yes, serendipitously! I'm such a fan of serendipity and have noticed that in my life as well. So obviously you both women of color – Melody you have Persian (Iranian) heritage, and Trishla you were born in India. How does that sort of affect or impact your experience in Silicon Valley as founders, anything that you want to share about that, like, in terms of opportunities or barriers?
Melody: So I think that if I had to talk for a moment about whenever I feel inadequate or when I feel that maybe I am not. I am not on par with the audience that I'm keeping has not necessarily been ever because I'm a woman, I think, for me it has always been a feeling that because I don't come from that so called White, tech, engineer, or a certain pedigree, I think that feels very heavy for women. I think that there's a certain level of...I think Trishla and I just don’t let it get to us, otherwise it becomes very demoralizing. So I think we do a very good job of tuning those things out and really making it about the product that we're building, and the solution where it could do with the solution we're giving to people. And because we are in a space of wellness, it makes it a little bit more comfortable, but for sure I would say it's very hard to maintain your confidence and not feel adequate being in the Valley and being women who are not from a pure tech background.
Trishla: I think one of the things my dad always taught me is that you have to turn your disadvantages into your greatest advantages. So in some ways, I like to think of it as this idea that we're fresh blood, like we never think of a solution on the product the way a veteran Facebook person or someone who spent 10 years at Google. And I think being mothers what matters is we care so much about building a future for our children. So we both have two young children, each and Melody's kids are older and she sees them already interacting with social media, and she wants to create a new alternative, kind of like a different way for her daughter to portray herself in the world. One option is for her to take a beautiful picture glowing skin and maybe comment on how sunny and beautiful it is in California on Instagram, and the other is to talk about maybe something totally different, something meaningful or something she's focusing on or, which is more Longwalks’ aim.
Melody: And people gravitate towards Longwalks generally are pretty open minded.
Amitha: One the things I’ve noticed when about individuals that are trying to make a difference in healthcare, almost all of them are described themselves as like outsiders. So people that early in life might have felt like they needed to fit in for one reason or another, because of their background or their way of thinking or whatever but over time they realize that those differences were actually an asset, and that was what sort of fueled them to think differently and make changes because as you can appreciate health care and the health system which is a very antiquated system. But the people that are actually making change are the ones that can actually see the solutions because they have an outsider sort of perspective. And I think, you know, it's our perspective and I also think it's a bit of grit as well like if you're someone that's used to adapting but you're also sort of like you're maybe a little bit grittier as well. I think that that's super interesting that you both seem to identify with that as well. Was there anything that I didn't ask you that you think is really important.
Ok my last question! Because I have an epidemiology I'm always interested in research. Have you thought about looking at the data in terms of assessing how people are feeling using the app? Could it be an intervention or studied in some way in terms of short and long-term impacts on mental and emotional health? Or do you have a sense of this already?
Trishla: I would say intuitively, qualitatively, the feedback indicates a resounding yes, that people see a kind of marked uplift in their emotional states, reduction in depression, reduction in anxiety, and loneliness. However, it would be a dream come true I think for Melody and I to have that documented in a way that's actually scientific with rigor.
Melody: We're looking at a way actually to incorporate these questions into the user journey to get a sense of how it has impacted them and the main reason we wanted to do that was just so we can make sure that we are staying true to their needs and really able to satisfy kind of those things so we are looking into it right now. I think given the pandemic and everything that's happening, I just feel a little uneasy asking users to fill in those questions. But definitely I think going down the line, it’s something we will be doing.
A series of interviews with pioneers bringing the world of wellness and technology to make meaningful change.
Miri Polachek is the CEO of Joy Ventures, the start-up studio building, funding and supporting companies developing consumer products for wellbeing. Miri joined Joy Ventures as CEO in 2018, bringing with her an extensive background in health and finance. Prior to Joy Ventures, Miri amassed a decade of experience in the pharmaceutical industry, working in financial management at Teva Pharmaceuticals and Pfizer and serving as VP Finance at healthcare services firm IntegraMed. She co-founded and served as the Executive Director of Israel Brain Technologies (IBT), a non-profit organization envisioned by former Israeli President Shimon Peres that accelerated brain-related innovation and positioned Israel as a leading global braintech hub. Miri holds a BA in Economics and Mathematics and an MA in Health Economics from Boston University, as well as an MBA from New York University Stern School of Business.
Amitha: I’m so interested in what brought you into this field, and what you think is on the horizon in terms of the intersection of well-being and tech. Can we reverse some of this damage that we've seen from technology? Is it about investing in companies that are focused on tackling this issue?
Miri:I've always been very passionate about health and health care. My mom is a neuroscientist, and my dad is an engineer and high-tech entrepreneur, so, science, technology and entrepreneurship were always conversations at the kitchen table. While I actually studied economics and finance, I found myself working in the healthcare industry because I was always very passionate about improving people's lives. I initially found myself in the pharmaceutical industry and then worked in various financial management roles in a few large global corporations. But over the years, mental health and brain health became a very strong passion of mine, in part because of having this strong neuroscience presence at home and having worked on product teams at both Teva and at Pfizer, but also because of having a brother living with a mental illness.
When I moved back to Israel 10 years ago, I jumped into the start-up ecosystem, and established and led a non-profit organization called Israel Brain Technologies, an initiative whose mission was to position Israel as a leading neuroscience innovation hub, specifically by commercializing Israel’s brain-related innovation. There, I helped run an accelerator focused on brain technology start-ups, and a very successful international conference that brought together the entire ecosystem of researchers clinicians, entrepreneurs, and investors. Working there was an amazing privilege, and several start-ups that went through the program have advanced in their development and some are already succeeding in the market.
Then about three years ago, Joy Ventures approached me to join them. I was already familiar with Joy, having been part of the same community interested in innovation in neuroscience and what Joy was calling “neuro wellness” at the time. Joy Ventures’ cared about understanding the healthy brain better in order to understand how we deal with stress and how we can improve our emotional wellbeing.
Amitha: I was really intrigued by Joy’s vision, because it takes an approach of looking at the science or innovating effective solutions that are not simply passing trends or gimmicks.
Miri: The word “wellbeing” is really something that we at Joy Ventures want to back up with technology that works, that makes a meaningful change in people’s lives, and that is enjoyable to use. Many wellbeing products create a nice experience, but the question is whether they actually create some kind of a change for the user. This could mean helping them relax or helping them sleep better, etc. This driving factor was what brought me to Joy in early 2018. I was first and foremost intrigued by the vision, which was to build a portfolio of companies that would help people feel good. At the time (several years ago) however, this sector was still very young, so the challenge was how to actually find companies that match our vision. At the time, we were looking primarily in Israel and there weren't that many companies back then, even worldwide, that fit our mission.
Some of the companies that are now unicorns were just starting out in 2018 and hadn't yet proven themselves in the market. There were a few companies that were starting to become household names. The Joy model is very much about incubating new companies, which means finding companies very early on and helping them develop their product concept, validate their ideas with users, and then gradually go to market. We also work to create awareness and community around innovation in this space.
Over these last three years, Joy Ventures has evolved as an organization; we've expanded our scope. While we are based in Israel, we invest globally. In fact, over the last year, we made our first investments both in the United States and in Europe. We just recently invested in a company based in Boston and founded by MIT researchers called Embr Labs, who created a thermal regulation wrist wearable that helps people adjust their body temperature sensation.
Amitha: It’s a form of biofeedback?
Miri: Yes. The wristband allows you to better regulate your temperature in terms of hotter or colder. In the future, Embr Labs also plans to enable a sensing or a closed loop capability. The wristband can help with sleep and is currently primarily being used to help “primetime women” in the menopausal stage, in which they are experiencing hot flashes. We also recently invested in a UK-based company called Empathic Technologies that created Doppel, another wrist wearable that helps to generate calm through haptic technology involving vibrations to your peripheral nerves. These vibrations, when at a high frequency, imitate your heartbeat, so it can cause the brain to either become more stimulated or calmer.
We're now also taking a much broader look at wellbeing, interpreting that word very broadly in order to pursue technologies or products that create some kind of meaningful change for the user through a delightful usage experience. This includes emotional wellbeing, physical wellbeing, and social wellbeing, which is one of our main focuses in 2021 due to the ongoing pandemic. We expect that social wellbeing will be one of the main issues this year compared to the past as loneliness and social isolation continue.
Amitha: That's an interesting topic because social media, to a degree, has been really helpful for some people during this pandemic to feel more connected, but we also know that there are issues with social media too and there's almost like an inverted U-curve or something: it’s dose dependent perhaps?
Miri: Definitely, and I think it's both dose and content dependent. We recently invested in a very exciting company that created a different kind of social network focused on rewarding those who are helpful rather than those who are popular.
Amitha: Do you think that these sort of apps that focus on well-being online can translate to offline social behavior? Specifically, in terms of creating connections offline. Yeah, so I guess what I'm thinking of is, for example, the recent riots in the US, on January 6th. There was a lot of talk about how it was planned online. So, it has me wondering if, since toxicity can build online, which translates offline, can the opposite be true? Can empathy and understanding those different from us, if built online, translate offline?
Miri: Yes, I would agree that if we create good online, it would reinforce positive behaviors offline. This is why, when we look for future investments, we also look for products that combine the physical and digital worlds, especially in terms of how they facilitate contact with another person. For example, the startup Noom is a weight loss program that includes both a digital aspect via an app as well as a personal interaction with a real group coach. This real-life interaction creates a more natural relationship and a higher level of accountability.
Amitha: So what do you think are the big trends as it relates to well-being and tech? You wrote an article in Fortune that came out in August about emotion-tracking apps. Was there anything you would add to that?
Miri: I think that a major trend in 2021 will be technology that creates connections – like products that help us stay in touch with our loved ones and our colleagues remotely, and anything that helps people create and maintain relationships on a more significant and deeper level. We recently announced which is you know helping grandchildren and grandparents, you know, connect and maintain their relationships, better. So I think that's the whole sort of connectivity from IQ, you know, maintaining these deeper relationships is going to be.
We're already seeing a lot of this technology take off. There has been a lot of traction around corporate wellbeing and solutions designed specifically for the workplace, that help maintain corporate culture and connections in a remote environment. If in the past employers’ premiums or health insurance grants were reduced because they’ve got an office gym, now this trend is expanding and offering a lot more through the corporate environment.
Amitha: Just at the start of the pandemic, around March or April 2020, I did a little interview series for Mind Body Green, interviewing different sort of public figures around what they were doing for their well-being. Almost everyone talked about routines, which I think is what you're getting at: these little moments in the day when you can sort of build in something to keep your routine that keeps you well and keeps anxiety at bay. I mean, again this was very early in the pandemic but it was interesting to hear that people were already understanding that the only way that we can sort of get through this is if we have a good sense of what our days are going to look like. This fits into well-being and all of that sort of thing. What do you think is one of the biggest challenges or barriers to this marriage between tech and well-being like?
Miri: I think the biggest challenge is the burden the tech developers and creators face in gaining the trust of their customers by proving that the products they created have a studied and tested impact. Some of these companies, especially those that are bringing in new approaches and new technologies, need to educate the market a bit before gain consumers’ trust.
Amitha: I wanted to end with a two-part question. First, how are you doing with all of this especially someone in the well-being space? Maybe you're doing better than most? And then the second part is: what are things that you build in personally in your day to keep you well during this time.
Miri: Thanks for asking. One thing that I always say about myself is that I was blessed with natural resilience. From a young age, I developed some strong coping mechanisms that have helped me handle stress and uncertainty, including during this challenging time, and I'm very grateful for that. There have of course been times during this past year that were really scary, and primarily I've been worried about my children. I think that depending on their age, not all children have those kinds of necessary tools to deal with all these changes yet. I have three kids who are extremely social, and it hasn't been easy to be separated from their friends so constantly. But thankfully, my whole family has been healthy. I think if we can teach our kids tools to cope with stress in different ways, they are much better off. Joy Ventures as an organization has luckily also been able to continue operating, though remotely. We feel blessed to be healthy and employed, and so I don't think we can ask for much more.
What I do for my own well being is highly conventional. I exercise, meditate, and try to spend a lot of time outdoors in nature. We live near the sea, so I like to spend a lot of time walking on the beach and sailing. We also have a lot of parks in Tel Aviv and I like to be around the greenery. I'm also lucky that I sleep well and I do make sure to get enough sleep.
Some of America’s biggest companies should consider leveraging their logistical capabilities—from using drive-thru windows for screening to turning megastores into diagnostic and treatment centers—as part of their corporate social responsibility, during these dire times.
Dear CEOs of McDonalds, Apple, Nike, and Marriott:
As you probably know, the success of both China and South Korea in decreasing the number of new cases of COVID-19 required both social distancing but also widespread testing and isolation of confirmed cases away from their homes. In other instances, testing even more aggressively made a big difference, and the World Health Organization now strongly recommends expanding COVID19 screening as well as isolation. Italy may have waited too long to implement crucial measures and North America has lagged behind for some time: estimates show that the US is now less than two weeks behind Italy and extremely behind in COVID-19 testing.
Testing is not widely available in the US and Canada, with the spread of misinformation leading symptomatic people to head to their local hospital or family doctor to try to get tested (with limited success while overburdening the system). It’s even more dire knowing that, in New York City for instance, an estimated 80% of ICU beds may already be occupied.
As powerful corporations, I hope you consider leveraging your own logistical capabilities, as part of your corporate social responsibility, during these very dire times—particularly in hotspots like Seattle, San Francisco, Toronto, Vancouver, and New York City. Here are some suggestions for what you can do during these perilous times.
Over the past week, McDonald’s announced they are closing seating. There are over 14,000 McDonald’s in the US alone, most of which have drive-thru windows.
So, my first idea involves pausing fast-food manufacturing for a few weeks in some of these outlets and using the existing drive-thru infrastructure for in-person fever screening (window 1) and COVID-9 throat swabs (window 2, if fever is present). These could be staffed with local nurses (wearing personal protective equipment, or PPE) who might typically work in community clinics that are currently closed. The brand recognition of McDonald’s means that most North Americans would easily be able to locate their nearest franchise. These would effectively serve as “Level 1” screening and diagnostic facilities for the next several weeks, with repeat testing weeks later to assess when an infection has cleared.
Second, over the past week, Apple (which has 272 stores in the US) and Nike (which has 350 stores) have closed their stores. Both of these stores, which maximize negative space and average several thousand square feet (so up to 4.5 million square feet of unused space), have design elements that may help reduce transmission during a pandemic. Some of these stores could be refashioned to serve as “Level 2” diagnostic and treatment centers, for more in-depth diagnoses and assessment of confirmed COVID-19–effectively “cohorting” positive cases together. Also, since both Nike and Apple have longstanding manufacturing relationships with China, with independent shipping and warehouse capabilities, they could help store any donated medical supplies from China and the country’s business leaders. Doctors who are not currently skilled to work in an emergency department or intensive care unit (for instance, most general practitioners) could administer the tests and basic treatment at these sites while wearing appropriate PPE, which offloads the burden on hospitals (which in turn serve as “Level 3” treatment sites for more advanced care). This could work better than military tents.
Third, China’s success in reducing transmission was in large part due to effectively quarantining cases away from their family (so as not to infect other family members). Yet building large quarantine centers, as China did, is not logistically feasible in North America. As such, now that there are fewer travelers, Marriott, which has wide reach across North America, could offer designated hotels in which to isolate the confirmed positives for 14 days to help induce “suppression.”
To be sure, North America should still follow the lead of both Britain and France by harnessing local manufacturing capabilities (which requires a Defense Protection Act), specifically for personal protective equipment like N95 masks, gloves, and gowns for first responders–this is even more crucial given the shortage. However, the bigger challenge will remain logistical. We may even end up having enough expensive equipment like ventilators (which may be used to serve multiple patients) if the milder cases are effectively identified and treated early.
I agree that “brands can’t save us” — but companies can leverage their strengths in collaboration with government. In fact, there have been countless examples from history of corporations pivoting to assist in public health challenges. The most prominent one that comes to mind is Coca-Cola. For decades, Coca-Cola offered its cold chain and other logistical capabilities to assist public health programs to deliver vaccines and antiretroviral medications, because donating money, simply put, just isn’t enough.
Through innovation, you’ve been able to place a thousand songs in our pockets, boast the largest market share of footwear, become the biggest hotel chain in the world, and serve as the most popular fast food company. Facilitating widespread screening, diagnostic testing, and facilitating the safe isolation and treatment of mild-moderate cases is not an impossible feat, especially if you work together with the healthcare system. Instead of allowing your brick-and-mortar businesses to sit idle please consider pivoting towards a solution in collaboration with government, as part of a coordinated and effective pandemic response.
Time is running out.
**Originally published in Fast Company on March 19 2020**
Canadian and international initiatives aim to apply AI to help solve global health conundrums
As we grapple with the coronavirus (COVID-19) pandemic, the pattern of viral spread may have been identified as early as Dec. 31, 2019, by Toronto-based BlueDot.
The group identified an association between a new form of pneumonia in China and a market in Wuhan, China, where animals were being sold and reported the pattern a full week ahead of the World Health Organization (which reported on Jan. 9) and the U.S. Centers for Disease Control and Prevention (which reported it on Jan. 6).
Dr. Kamran Khan, a professor of medicine and public health at the University of Toronto, founded the company in 2014, in large part after his experience as an infectious disease physician during the 2003 SARS epidemic.
The BlueDot team, which consists largely of doctors and programmers, numbering 40 employees, published their work in the Journal of Travel Medicine.
“Our message is that dangerous outbreaks are increasing in frequency, scale, and impact, and infectious diseases spread fast in our highly interconnected world,” Khan wrote via email. “If we want to get in front of these outbreaks, we are going to have to use the resources available to us — data, analytics, and digital technologies — to literally spread knowledge faster than the diseases spread themselves.”
In the past, BlueDot has been able to predict other patterns of disease spread, such as Zika outbreak in south Florida. Now its list of clients includes the Canadian government and health and security departments around the world. They combine AI with human expertise to monitor risk of disease spread for over 150 different diseases and syndromes globally.
BlueDot, as a company, speaks to the emerging trend of using AI for global health.
In India, for instance, Aindra Systems uses AI to assist in screening for cervical cancer. Globally, one woman dies every two minutes due to cervical cancer, and half a million women are newly diagnosed globally each year: 120,000 of these cases occur in India, where rates are increasing in rural areas.
Founded in 2012 by Adarsh Natarajan, the Aindra team recognized that, in India, mortality rates were high in part due to the six-week delay between collecting samples and reading pathology during cervical cancer screening programs. It was also a human resources issue: in India, one pathologist is expected to serve well over 134,000 Indians.
With the aim of reducing the workload burden and fatigue risk (misdiagnosis rates can increase if the reader is tired and overworked), Aindra built CervAstra. The automated program can stain up to 30 slides at a time and then identify, through an AI program called Clustr, the cells that most appear to be cancerous.
The pathologist then spends time on the flagged samples. Much like traditional global health programs, Aindra works closely with several hospitals and local NGOs in India, and hopes their technology may later be adopted by other developing countries.
“Point of care solutions like CervAstra are relevant to a lot of countries who suffer from forms of cancer but don’t have infrastructure or faculties to deal with it in population based screening programs,” Natarajan says.
Natarajan also points to other areas where AI is relevant in global health, such as drug discovery or assisting specific medical specialists in areas like radiology and pathology. Accenture was able to use AI to identify molecules of interest within 10 months as opposed to the typical timeline of up to 10 years.
The Vector Institute, based in Toronto, is also plugging into the potential of AI and global health. It works as an umbrella for several AI startups, some with a health focus and all aiming to have a global impact.
Melissa Judd, director of academic partnerships at Vector Institute, points to the United Nations’ sustainable development goals as a framework upon which to help orient AI towards improving global health. Lyme disease, for instance, is a global health issue that also comes up against the topic of climate change, and recently a Vector-supported AI initiative was able to identify ticks that spread of Lyme disease in Ontario.
Last December, the Vector Institute launched the Global Health and AI Challenge (GHAI) — a collaboration with the Dalla Lana School of Public Health to engage students from across the University of Toronto (from business to epidemiology to engineering) in critical dialogue and problem solving around a global health challenge.
The potential of AI for global health is immense. Major academic journals are also taking note. Last April the Lancet launched the Artificial Intelligence in Global Health report. By looking at 27 cases of how AI has been used in healthcare, editors proposed a framework to help accelerate the cost-effective use of AI in global health, primarily through collaboration between various stakeholders.
As well, a recent commentary in Science identified several key areas of potential for AI and global health, such as low-cost tools powered by AI (for instance an ultrasound powered through a smartphone) and improving data collection during epidemics.
Yet, the authors caution against seeing AI as a panacea and emphasize that empowering local, country-specific, technology talent will be key, as inequitable redistribution of access to AI technology could worsen the rich-poor divide in global health.
This warning aside, Khan with BlueDot is optimistic.
“We are just beginning to scratch the surface as there are many ways that AI can play a key role in global health. As access to data increases in volume, variety and velocity, we will need analytical tools to make sense of these data. AI can play a really important role in augmenting human intelligence,” Khan says.
**Originally published in CBC News**
Two recent US initiatives: the New York Times’ rare disease column and a TBS series called Chasing the Cure are pointing to an emerging trend in the media: the idea that medicine can crowdsource ideas to diagnose difficult cases. But, can it be used to help diagnose patients, and what are the potential pitfalls?
Reaching a correct diagnosis is the crucial aspect of any consultation, but misdiagnosis is common, with some studies suggesting that medical diagnoses can be wrong, up to 43% according to some studies. This concern was the focus of a recent report by the World Health Organization. Individual doctors may overlook something, draw the wrong conclusion, or have their own cognitive biases which means they make the wrong diagnosis. And while hospital rounds, team meetings, and sharing cases with colleagues are ways in which clinicians try to guard against this, medicine could learn from the tech world by applying the principles of “network analysis” to help solve diagnostic dilemmas.
A recent study in JAMA Network Open applied the principle of collective intelligence to see whether combining physician and medical students’ diagnoses improved accuracy. The research, led by Michael Barnett, of the Harvard Chan School of Public Health, in collaboration with the Human Diagnosis Project, used a large data set from the Human Diagnosis Project to determine the accuracy of diagnosis according to level of training: staff physicians, trainees (residents and fellows), and medical students. First, participants were provided with a structured clinical case and were required to submit their differential diagnosis independently. Then the researchers gathered participants into groups of between two and nine to solve cases collectively.
The researchers found that at an individual level, trainees and staff physicians were similar in their diagnostic accuracy. But even though individual accuracy averaged only about 62.5%, it leaped to as high as 85.6% when doctors solved a diagnostic dilemma as a group. The larger the group, which was capped at nine, the more accurate the diagnosis.
The Human Diagnosis Project now incorporates elements of artificial intelligence, which aims to strengthen the impact of crowdsourcing. Several studies have found that when used appropriately, AI has the potential to improve diagnostic accuracy, particularly in fields like radiology and pathology, and there is emerging evidence when it comes to opthamology.
However, an issue with crowdsourcing and sharing patient data is that it’s unclear how securely patient data are stored and whether patient privacy is protected. This is an issue that comes up time and time again, along with how commercial companies may profit from third parties selling these data, even if presented in aggregate.
As such, while crowdsourcing may help reduce medical diagnostic error, sharing patient information widely, even with a medical group, raises important questions around patient consent and confidentiality.
The second issue involves the patient-physician relationship. So far it doesn’t appear that crowdsourcing has a negative impact in this regard. For instance, in one study over half of patients reported benefit from crowdsourcing difficult conditions, however very few studies have explored this particular issue. It’s entirely possible that patients may want to crowdsource management options for instance, and obtain advice that runs counter to their physicians’ and theoretically this could be a source of tension.
The last issue involves consent. A survey, presented at the Society of General Internal Medicine Annual Meeting in 2015, reported that 80% of patients surveyed consented to crowdsourcing, with 43% preferring verbal consent, and 26% preferring written consent (31% said no consent was needed). Some medico-legal recommendations, however, do outline the potential impact on physicians who crowdsource without the appropriate consent, in addition to the possible liabilities around participating in a crowdsourcing platform when their opinion ends up being incorrect. Clearly these are issues that have no clear answer: and we may end up in a position where patients are eager to crowdsource difficult-to-diagnose (and treat) sets of symptoms, but physicians exercise sensible caution.
It’s often said that medical information doubles every few months, and that time is only shortening. Collectively, there’s an enormous amount of medical knowledge and experience both locally and globally that barely gets tapped into when a new patient reaches our doors in any given hospital or clinic. Applying network intelligence to solving the most challenging, as well as the illusory “easy,” diagnosis, may give patients the best of both worlds: the benefit of their doctor’s empathetic care with the experience and intelligence of a collective many, but the potential downsides deserve attention as well.
**Originally published in the British Medical Journal**
There’s more than meets the eye — here are some tips to help avoid confusion.
In August 2019, JAMA Pediatrics, a widely respected journal, published a study with a contentious result: Pregnant women in Canada who were exposed to increasing levels of fluoride (such as from drinking water) were more likely to have children with lower I.Q. Some media outlets ran overblown headlines, claiming that fluoride exposure actually lowers I.Q. And while academics and journalists quickly pointed out the study’s many flaws — that it didn’t prove cause and effect; and showed a drop in I.Q. only in boys, not girls — the damage was done. People took to social media, voicing their concerns about the potential harms of fluoride exposure.
We place immense trust in scientific studies, as well as in the journalists who report on them. But deciding whether a study warrants changing the way we live our lives is challenging. Is that extra hour of screen time really devastating? Does feeding processed meat to children increase their risk of cancer?
As a physician and a medical journalist with training in biostatistics and epidemiology, I sought advice from several experts about how parents can gauge the quality of research studies they read about. Here are eight tips to remember the next time you see a story about a scientific study.
1. Wet pavement doesn’t cause rain.
Put another way, correlation does not equal causation. This is one of the most common traps that health journalists fall into with studies that have found associations between two things — like that people who drink coffee live longer lives — but which haven’t definitively shown that one thing (coffee drinking) causes another (a longer life). These types of studies are typically referred to as observational studies.
When designing and analyzing studies, experts must have satisfactory answers to several questions before determining cause and effect, said Elizabeth Platz, Sc.D., a professor of epidemiology and deputy chair of the department of epidemiology at the Johns Hopkins Bloomberg School of Public Health. In smoking and lung cancer studies, for example, researchers needed to show that the chemicals in cigarettes affected lung tissue in ways that resulted in lung cancer, and that those changes came after the exposure. They also needed to show that those results were reproducible. In many studies, cause and effect isn’t proven after many years, or even decades, of study.
2. Mice aren’t men.
Large human clinical studies are expensive, cumbersome and potentially dangerous to humans. This is why researchers often turn to mice or other animals with human-like physiologies (like flies, worms, rats, dogs and monkeys) first.
If you spot a headline that seems way overblown, like that aspirin thwarts bowel cancer in mice, it’s potentially notable, but could take years or even decades (if ever) to test and see the same findings in humans.
3. Study quality matters.
When it comes to study design, not all are created equal. In medicine, randomized clinical trials and systematic reviews are kings. In a randomized clinical trial, researchers typically split people into at least two groups: one that receives or does the thing the study researchers are testing, like a new drug or daily exercise; and another that receives either the current standard of care (like a statin for high cholesterol) or a placebo. To decrease bias, the participant and researcher ideally won’t know which group each participant is in.
Systematic reviews are similarly useful, in that researchers gather anywhere from five to more than 100 randomized controlled trials on a given subject and comb through them, looking for patterns and consistency among their conclusions. These types of studies are important because they help to show potential consensus in a given body of evidence.
Other types of studies, which aren’t as rigorous as the above, include: cohort studies (which follow large groups of people over time to look for the development of disease), case-control studies (which first identify the disease, like cancer, and then trace back in time to figure out what might have caused it) and cross-sectional studies (which are usually surveys that try to identify how a disease and exposure might have been correlated with each other, but not which caused the other).
Next on the quality spectrum come case reports (which describe what happened to a single patient) and case series (a group of case reports), which are both lowest in quality, but which often inspire higher quality studies.
4. Statistics can be misinterpreted.
Statistical significance is one of the most common things that confuses the lay reader. When a study or a journalistic publication says that a study’s finding was “statistically significant,” it means that the results were unlikely to have happened by chance.
But a result that is statistically significant may not be clinically significant, meaning it likely won’t change your day-to-day. Imagine a randomized controlled trial that split 200 women with migraines into two groups of 100. One was given a pill to prevent migraines and another was given a placebo. After six months, 11 women from the pill group and 12 from the placebo group had at least one migraine per week, but the 11 women in the pill group experienced arm tingling as a potential side effect. If women in the pill group were found to be statistically less likely to have migraines than those in the placebo group, the difference may still be too small to recommend the pill for migraines, since just one woman out of 100 had fewer migraines. Also, researchers would have to take potential side effects into account.
The opposite is also true. If a study reports that regular exercise helped relieve chronic pain symptoms in 30 percent of its participants, that might sound like a lot. But if the study included just 10 people, that’s only three people helped. This finding may not be statistically significant, but could be clinically important, since there are limited treatment options for people with chronic pain, and might warrant a larger trial.
5. Bigger is often better.
Scientists arguably can never fully know the truth about a given topic, but they can get close. And one way of doing that is to design a study that has high power.
“Power is telling us what the chances are that a study will detect a signal, if that signal does exist,” John Ioannidis, M.D., a professor of medicine and health research and policy at Stanford Medical School said via email.
The easiest way for researchers to increase a study’s power is to increase its size. A trial of 1,000 people typically has higher power than a trial of 500, and so on. Simply put, larger studies are more likely to help us get closer to the truth than smaller ones.
6. Not all findings apply to you.
If a news article reports that a high-quality study had statistical and clinical significance, the next step might be to determine whether the findings apply to you.
If researchers are testing a hypothetical new drug to relieve arthritis symptoms, they may only include participants who have arthritis and no other conditions. They may eliminate those who take medications that might interfere with the drug they’re studying. Researchers may recruit participants by age, gender or ethnicity. Early studies on heart disease, for instance, were performed primarily on white men.
Each of us is unique, genetically and environmentally, and our lives aren’t highly controlled like a study. So take each study for what it is: information. Over time, it will become clearer whether one conclusion was important enough to change clinical recommendations. Which gets to a related idea …
7. One study is just one study.
If findings from one study were enough to change medical practices and public policies, doctors would be practicing yo-yo medicine, where recommendations would change from day to day. That doesn’t typically happen, so when you see a headline that begins or ends with, “a study found,” it’s best to remember that one study isn’t likely to shift an entire course of medical practice. If a study is done well and has been replicated, it’s certainly possible that it may change medical guidelines down the line. If the topic is relevant to you or your family, it’s worth asking your doctor whether the findings are strong enough to suggest that you make different health choices.
8. Not all journals are created equal.
Legitimate scientific journals tend to publish studies that have been rigorously and objectively peer reviewed, which is the gold standard for scientific research and publishing. A good way to spot a high quality journal is to look for one with a high impact factor — a number that primarily reflects how often the average article from a given journal has been cited by other articles in a given year. (Keep in mind, however, that lower impact journals can still publish quality findings.) Most studies published on PubMed, a database of published scientific research articles and book chapters, are peer-reviewed.
Then there are so-called ‘predatory’ journals, which aren’t produced by legitimate publishers and which will publish almost any study — whether it’s been peer-reviewed or not — in exchange for a fee. (Legitimate journals may also request fees, primarily to cover their costs or to publish a study in front of a paywall, but only if the paper is accepted.) Predatory journals are attractive to some researchers who may feel pressure to ‘publish or perish.’ It’s challenging, however, to distinguish them from legitimate ones, because they often sound or look similar. If an article has grammatical errors and distorted images, or if its journal lacks a clear editorial board and physical address, it might be a predatory journal. But it’s not always obvious and even experienced researchers are occasionally fooled.
Reading about a study can be enlightening and engaging, but very few studies are profound enough to base changes to your daily life. When you see the next dramatic headline, read the story — and if you can find it, read the study, too (PubMed or Google Scholar are good places to start). If you have time, discuss the study with your doctor and see if any reputable organizations like the Centers for Disease Control and Prevention, World Health Organization, American Academy of Pediatrics, American College of Cardiology or National Cancer Institute have commented on the matter.
Medicine is not an exact science, and things change every day. In a field of gray, where headlines sometimes try to force us to see things in black-and-white, start with these tips to guide your curiosity. And hopefully, they’ll help you decide when — and when not to — make certain health and lifestyle choices for yourself and for your family.
**Originally published in the New York Times**
Earlier this month, in a private imaging clinic in the Ginza district of downtown Tokyo, I lay patiently as the MRI machine buzzed and rattled. I wasn’t there at the request of a doctor, but to screen my brain using a machine learning tool called EIRL, which is named after the Nordic goddess Eir. It’s the latest technology, focused on detecting brain aneurysms, from Tokyo-based LPixel, one of Japan’s largest companies working on artificial intelligence for healthcare. Brain aneurysms occur when a blood vessel swells up like a balloon. If it bursts, it can be deadly.
After the MRI, the images get uploaded onto a secure cloud, and EIRL begins its analysis looking for abnormalities. Each scan is then checked by a radiologist followed by a neurosurgeon. The final report, with the images, is produced within 10 days and accessible through a secure portal.
While LPixel offers a number of other A.I. tools to assist with CAT scans, X-rays, real-time colonoscopy images, and research image analysis, the EIRL for brain aneurysm detection remains their most advanced offering. The EIRL algorithm was built upon data extracted from over 1,000 images with confirmed brain aneurysms, in partnership with four Japanese universities, including the University of Tokyo and Osaka City University. Data from a 2019 study by LPixel and their partner universities found EIRL for brain aneurysms had a high sensitivity of between 91 and 93% (sensitivity refers to the likelihood of detecting an aneurysm if one is indeed present).
Mariko Takahashi, project manager with LPixel, explains that EIRL differs from computer-assisted devices in that there is a learning component: “EIRL becomes more accurate the more it’s used,” she says. According to Takahashi, EIRL has detected cases of aneurysms that require immediate medical attention, even though the patients displayed no symptoms.
The EIRL for brain aneurysms algorithm was approved by the Japanese Pharmaceutical and Medical Devices Agency (PMDA) in the category of software as a medical device in Japan in September. The algorithm is based entirely on Japanese patients, but it could be generalized to other populations, says Takahashi, though she notes that their group is looking into studies showing that the Japanese anatomy of brain vessels may vary slightly from other ethnic groups and whether the algorithm would therefore need to be validated in other populations.
EIRL does have competitors. A Korean startup called Deepnoid is developing a brain aneurysm detection tool using MRI. Also, GE Healthcare is using brain CT to detect aneurysms. Lastly, Stanford is positioning itself to use deep learning in brain CTs to detect brain aneurysms, though it appears to be intended for diagnosis, not screening. Competitors in Belgium and China as well are using AI to detect brain tumors.
LPixel hopes to have FDA approval for EIRL in the U.S. in 2020 and is working to ensure it meets HIPPA compliance regulations and privacy and security.
But just because you might soon be able to get AI-assisted screening for your brain, should you?
It’s a complicated and very personal question. In the U.S. and Canada, there is a push to reduce unnecessary testing, which includes limiting screening tests to those that are inexpensive and have been shown to reduce the likelihood of disease, such as breast cancer and colon cancer. Currently in the U.S., Canada, and U.K., there is no recommended population-wide screening program for brain aneurysms, and the American College of Radiology recommends that head and neck MRIs be limited to situations where there are symptoms suggesting a pathology such as a tumor, or for cases where there may be brain metastasis of another cancer (such as breast cancer).
There are dangers to overscreening, particularly when it comes to the brain: for one, the possibility of unnecessary and invasive testing. In essence: when you go hunting for abnormalities in the brain, you might find things you didn’t expect to uncover—for example, an “incidentaloma,” which is a lesion that isn’t necessarily harmful or may just be a normal variation in human anatomy. These can occur in up to one-third of healthy patients. The harm involved in investigating these, such as the risk of infection when obtaining a sample, can outweigh the benefits.
However, those who are at high risk of aneurysms, such as those with a family history, may warrant screening. Notably, in Japan, brain aneurysms are more common compared to other populations, an issue that may also be muddied by the fact that more people choose to be screened for it. They may also be more likely to rupture. And MRI screening in Japan is less expensive: roughly $200-$300 for a head MRI, which is around 50-75% less than in North America.
Dr. Eric Topol, physician and author of the book Deep Medicine: Artificial Intelligence in Healthcare, shares these sentiments. “There’s no question AI will help accuracy of brain image interpretation (meaning the fusion of machine and neuroradiologist, complementary expertise) but there are drawbacks such as the lack of prospective studies in the real clinical world environment; potential for algorithmic malware and glitches, and many more, which I reviewed in the ‘Deep Liabilities’ chapter of my book,” Topol says. “Personally I do not see the benefit to using AI technology for ‘screening’ of brain aneurysms at this time, as there’s no data or evidence to support the benefit, at least in patients without relevant symptoms.”
That said, if the algorithm is validated for populations outside Japan, there could be potential in diagnostic situations, for instance in hospitals as opposed to private clinics, as well as for high-risk individuals who need screening. And that’s where the company seems to be headed.
“Right now we’re exploring how to best roll out technology in hospitals in Japan, in collaboration with our partners,” Takahashi says.
As for me, I received my results about 9 days later, and—assuming the translation from Japanese to English was accurate—according to EIRL, there were no abnormalities.
**Originally published in Fast Company**
“So, if we’re worried about viral myocarditis, would the patient have similar symptoms as someone with pericarditis?” The astute medical student slipped me his question as we hurriedly made our way across the ward to the next patient’s room.
He had wondered whether inflammation of the heart muscle (as in myocarditis) presents like inflammation of the protective layer around the heart (the pericardium). Classically we are taught that pericarditis-type chest pain is better when sitting up (because the protective layer is kept away from the nerves that transmit pain) compared with lying down or when taking deep breaths.
“Well there is some overlap in clinical signs,” I began. But we were already on to the next patient, and so my attention was redirected. The student had looked eager to hear my response, but that expression quickly slipped away.
These missed opportunities, to explore and address complex questions, are frequent in medical education, and the downstream consequences of not fostering this curiosity are significant.
Curiosity is the necessary fuel to rethink one’s own biases, and it can reap dividends for patient care. When doctors think about a set of symptoms separately, they may reach different conclusions; for example one study found that up to 21% of second opinions differ from the original diagnosis.
Allowing doctors to express their curiosity is crucial and it’s time we encourage all medical trainees to be curious.
The decline in curiosity could be caused, in part, by medical trainees assuming a traditionally passive role in hierarchically organized settings like hospitals, suggests a 2011 paper, coauthored by Ronald Epstein, MD, a professor of family medicine, psychiatry, oncology and medicine at the University of Rochester Medical Center.
“There’s a dynamic tension here. People pursue medicine because they are curious about the human experience and scientific discovery, but early in training they are taught to place things in categories and to pursue certainty,” Epstein told me.
A 2017 McGill University study led by pediatrician Robert Sternzus, MD, took this theme a step further. Sternzus and colleagues surveyed medical students across all four years about two types of curiosity: trait curiosity, which is an inherent tendency to be curious; and state curiosity, defined as the environment in which the trait curiosity can survive. Trait curiosity across all four years was significantly higher than state curiosity. The authors concluded that the medical students’ natural curiosity may not have been supported in their learning environment.
“I had always felt that curiosity was strongly linked to performance in the students I worked with,” Sternzus says. “I also felt, as a learner, that I was at my best when I was most curious. And I certainly could remember periods in my training where that curiosity was suppressed. In our study the trends that we found with regards to curiosity across the years confirmed what I had hypothesized.” Sternzus has since spearheaded a faculty development workshop on promoting curiosity in medical trainees.
So what might be the solution, especially as the move towards competency-based training programs may not reward curiosity, and at a time where companies in places like Silicon Valley — which invest in curious and talented minds — position themselves to be another gatekeeper of health care?
New work led by Jatin Vyas, MD, PhD, an infectious disease physician and researcher who directs the internal medicine residence at Massachusetts General Hospital, offers one idea. His team developed a two-week elective program, called Pathways, which allows an intern to investigate a case where the diagnosis is unknown or the science isn’t quite clear. They then present their findings to a group of up to 80 experienced physicians and trainees.
“What I have found is that many interns and residents have lots of important questions. If our attendings are not in tune with that — and it’s often due to a lack of time or expertise — the residents’ questions are oftentimes never discussed,” Vyas says. “When I was a resident, my mentors helped me articulate these important questions, and I believe this new generation of trainees deserve the same type of stimulation and the Pathways elective is one way to help address this.”
At the end of June, Pathways reached the end of its second year, and Vyas recounts that resident satisfaction, clinical-teacher satisfaction, and patient satisfaction were all high. “Patients have expressed gratitude for having trainees eager to take a fresh look at their case, even though they may not receive a breakthrough answer,” Vyas says.
The job of more experienced clinicians is to nurture curiosity of learners not just for the value it provides for the students, but for the benefits it poses for patients, Faith Fitzgerald, MD, an internist at the University of California Davis, has written. Physicians of the future, and the patients they care for, deserve this.
**Originally published in the Stanford Medicine Scope Blog**