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October Newsletter!

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February/March Newsletter!

February/March Newsletter!

February/March 2022

Welcome to the February/March 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.

Before we get into the topic for this month, I wanted to share that I had a great response to an article I wrote  for the Globe and Mail (Saturday edition) about the pitfalls of the ‘self-improvement’ industry, and had a chance to discuss it on the All Sorts Podcast with the very gracious Desiree Nielsen, RD (whose books you should read, and she has a brand new one as well). It was a wide-ranging interview/discussion, and Desiree’s questions were incredible. Hope you enjoy it. I also realized how much I use the filler words “you know” — will work on that! Consider it a fair warning!


Alright, the topic of this month’s newsletter,  is the idea of ‘value-based care’ in healthcare — one of the most crucial concepts in healthcare today, in both the US and Canada.

But how do we define it? Atul Gawande penned an excellent article in the New Yorker several years ago which hits the main points in a very compelling way. Further, several years ago, the American Board of Internal Medicine (ABIM) Foundation launched the “Choosing Wisely” initiative in part to support value-based care and reduce wasteful procedures/treatments (including that which has little to no evidence of effect).

Value as it relates to ‘value based care’ (VBC) is defined as “the measured improvement in a person’s health outcomes for the cost of achieving that improvement.” It’s crucial to note that while reducing costs/waste is related to VBC, it can’t be equated to VBC — they aren’t the same thing.

This brings us to a more philosophical argument: what does “value” mean generally, and how does this concept apply to both our health, and the systems that support it (the obvious ‘healthcare system,’ but also the places we work and play and live)?

First we can ponder what value means to ‘health.’ We can probably agree that our ‘health’ is inherently valuable, as it’s derivative: without it we’re limited in actualizing our other needs. As such, we place high value on our health, and are willing to invest in it, though oftentimes it falls by the wayside. Our health is valuable as it links to surviving but also thriving — without our health, our quality of life suffers (the ‘how’ we live), and at the most extreme, we cease to live (ie we die).

But what about value in healthCARE, i.e. the delivery of services for the purposes of optimizing health/well-being and offsetting/treating morbidities? How might we define that? I think we can conceptualize it in a few different ways.

For one: we can use the Costco example (for my international readers: Costco is described here). Most people would agree that Costco is a place where people seek value for household goods (food, appliances, etc). Why? Because per unit its on average cheaper: the consumer pays less per unit, so Costco remains in business primarily due to this perception of delivering ‘value’ by selling products that themselves deliver ‘value.’ Bulk stores are similar: what we save on packaging ends up in our pocket. A good example is shampoo: 20% more for the same price. That’s value.

Effectively, getting MORE for less money, even if we shell out a bit more money at the outset is ‘value.’ It feels like we got a deal. But it’s more than just monetary. Part of assessing value involves something intrinsic and somewhat intangible. It involves a ‘feeling’ of receiving more than we bargained for (in a good way, to be sure). Think about the last time you went to a cash register and realized a purchase was on sale. Or if your local barista threw in an item (I see you: extra shot of espresso!) for free. Or when searching for a hotel or airline ticket you realize you’ve stumbled upon a deal that’s too good to pass up. That feeling is akin to value. We feel ‘good.’

Can this idea apply to healthcare?

Currently, according to the Centers for Medicare & Medicaid Services (CMS), the US spends just over $12,000 on healthcare per person, per year. COVID has brought this into full focus: spending increased by close to 10% in 2020.  The US healthcare system is also one of the least cost-effective systems in the world (meaning more money spent with worse outcomes), especially compared with countries like Canada (where I’ve spent most of my life) and where I was born (United Kingdom). But why? Well a large fraction of spending goes to hospitals (31%) and doctors/primary care clinics (20%), and, as Gawande writes in his New Yorker piece, it’s very likely secondary to how physicians (and insurers, and hospital administrators) are incentivized. Wasteful procedures (and spending) become a byproduct of a mismatch between incentives and value.

Allow me to me share a few stories to illustrate this point.

First, upas a patient. In June 2020, a few months into the pandemic, I broke my left wrist — a classic FOOSH in my NYC apartment. I was lucky in that it involved my non-dominant hand/wrist. I was also lucky to have a friend who is an ER Doc in the city (hi Dan!) and whom I could call right away as I laid there watching the soft tissues of my wrist swell up (ouch!). Dan kindly organized for me to see his colleague at the emergency department (ED) at a big teaching hospital a few blocks away for an Xray and splint. That was done quickly, and Dan’s colleague kindly allowed me to take a photo of my scans. The orthopedic surgeon resident advised that I’d likely just need a cast, based on the scans alone. Then I was referred, as per protocol in the ED, for a one-week followup with a staff orthopedic surgeon. So, a week later, I dutifully went. The surgeon knew I had a medical background and am a physician myself. What he didn’t know was that I has sent the X-ray images to Dan, my brother (An ER doc in Canada) and a few other friends in ED and Ortho (in Canada and the US) — every single one said, based on the X-ray and my verbal history of what happened, that the bone alignment was good and a cast alone would suffice.

But what did the surgeon in clinic advise? Surgery. He explained that I would run the risk of arthritis if I didn’t take this option, as an an active woman in her thirties, this may not be ideal.

What’s the cost difference between a cast for a wrist FOOSH and surgery. ENORMOUS. The ED visit and split, as well as the followup clinic visit amounted to $3,600 USD. Surgery on top would have been at least $10,000 (and that’s being conservative).

And surgery includes risks (of anesthesia, post-surgical infection of the soft tissue/bone, etc).

I was able to explain to the surgeon that I was returning to Canada within days and would prefer to have surgery there if needed. He resigned himself to an ‘ok.’

Back in Canada I was seen quickly and casted, had a great physiotherapist and was about 75% in terms of range of motion and weigh-bearing within 8 weeks, and 100% within 7 months (that last 25% was tricky).

What’s the lesson here? This was a glaring example of the differences in approach between Canada — which has a universal healthcare system and a different setup of ‘incentives,’ and the US.  Not assuming ill intent, but was this surgeon aware that surgery would not in fact be better, especially considering the balance of risks and benefits, not to mention costs? Did he know that the risk of arthritis, according to the evidence, is equivocal between a cast and surgery? It’s unclear. But this was an experienced surgeon, so perhaps the incentive to recommend a relatively easy surgical procedure with a high payoff (to him and the hospital system) played a large role.

Now imagine doctors like him making similar recommendations — that is, ones that could be influenced by financial gain, not clinical evidence — to millions of Americans each year, Americans who do not have the privilege of having a medical background or someone they could turn to for an informal opinion before deciding.

This is how the US spends more on healthcare than most other industrialized nations.

Second story: as a doctor. A few years ago as a resident physician in the children’s hospital, I realized that the team was ordering daily ‘lytes’ (short for ‘electrolytes’) for every patient admitted on IV fluids.  Allow me a brief digression: our bodies very tightly regulate sodium (Na) and potassium (K), among other things (bicarbonate/HCO3 and chloride/Cl for instance). Intravenous (IV) fluids are a mainstay of supportive care for many patients admitted to the hospital, as hydration is often an issue in we’re sick, due to fluid shifts, insensible losses, etc. IV fluids themselves, as they contain electrolytes, can also lead to ‘too much’ or ‘too little’ electrolytes (specifically K or Na) which can lead to all kinds of issues for the brain and the heart.  For an illness like diabetic ketoacidosis (DKA), assessing electrolytes closely and comprehensively is very important for many reasons (more here, note that DKA is managed differently in children vs adults, but the general principle of close electrolyte monitoring remains the same).

But for other illnesses, namely ones that don’t involve massive shifts in electrolytes, and where the main concern is whether the patient could become hypernatremic (high Na) on an NaCl IV fluid, ordering a whole set of ‘lytes’ isn’t usually necessary: checking Na alone should suffice, and potentially, with good kidney function, checking every second day may also be reasonable. So why did the team order daily lytes on everyone on IV fluids? Again: it seemed to be an action that was incentivized, but not due to financial gain per se — it was likely an action incentivized secondary to ‘habit’ (i.e. ‘this is just what we do.’).

Why does this matter? Habits or shortcuts or heuristics save us from additional cognitive load. When we drive a car, we automatically know we need to stop at a red light, and go at the greenlight. We don’t stop to ask ourselves consciously whether we should stop or go (yellow lights on the other hand…). Stopping to think ‘does this patient need this action? Will ordering X change the course of management?’ are important questions, but they take time and effort. It’s often easier, especially in a busy hospital ward, to go into automatic mode and simply order more than what’s actually needed. The idea being: it’s better to be more comprehensive than not.
Except: that assumption is often wrong for patients who are clinically improving.
With this particular example of ‘daily lytes’, out of curiosity, I wondered about two things:

1. What was difference is in terms of volume of blood taken for a patient if we ordered ‘all lytes’  compared with just the one we needed (Na) in this case?

2. What was the cost difference between the two?

So, after a hasty lunch one day, I headed down to the lab second floor and asked a technician, who provided me with a list of costs. I also spoke with a phlebotomist to understand the blood volume issue.

Here’s what I found: blood volume wise, the difference was small, but there was still a difference — a few milliliters per tube of blood taken. Iatrogenic (hospital caused) anemia remains an issue in acute care medicine, secondary to taking too much blood from a patient.  For a patient in hospital for a week, a few milliliters a day can be significant enough to cause symptoms (fatigue for instance, on top of what may be normal secondary to an illness).

Cost-wise, the difference was about $5. I can’t recall the exact figures, but each electrolyte was roughly $1 dollar (for ease of explanation I’ll assume equivalence between the Canadian and US dollar). A full lytes panel of 6 electrolytes costs $6. What does this mean?  Let’s assume that each patient admitted to hospital requires a full lytes panel on admission, but then those that receive IV fluids only need their Na checked each day after. If the average stay is about 4 additional days on the inpatient unit, we’re dealing with a difference per patient of $5 a day — so $20 in total (with the total cost being $26 if we add that day 1 panel cost). Now imagine there are 500 patients admitted per month into the unit who require IV fluids. Thats 500 x $20 (=$10,000) compared with 500 x $4 (=$2000). Now multiply that by 12 to get the yearly figures, and then by the number of acute care wards in the country and….well you get the point. The financial difference that results from being more prudent with test-ordering is immense. The consequences of not stopping to think if there could be a better, less wasteful (and potentially less harmful, if we consider the volume of blood lost) way of delivering care results in the opposite of value-based care. Mind you: this is one example, of which there are thousands — as such the it’s not surprising that the waste we’re considering is into the millions if not billions. It’s the price we pay for physician/institutional inertia.

Last example — the everyday patient. In June 2021 I was visiting upstate New York, and had a really interesting chat with a taxi driver (as an aside: some of my most interesting chats about healthcare happen to be with ride-share and taxi drivers). I’ll call him Dale, and the moment I entered his car he launched into a discussion about the American healthcare system. In his 70s, Dale is a blue-collar worker with a grade 10 education. He also served in the military for several years, including in Vietnam. Dale has several chronic health issues, including Type 2 diabetes that’s poorly managed and requires insulin, high blood pressure, and high cholesterol. Recently his Medicare coverage stopped covering his insulin. This led to a very frank discussion with his primary care doctor, and Dale explained to me that he had all but “given up” and accepted that ‘death was around the corner’ (without insulin a patient with uncontrolled diabetes can go into organ failure and die).  It was a very tragic example and a story that has stuck with me. Here we  have an example of where, despite the high cost of care per patient in the US, we still have millions of people like Dale, who actually need the spending, who fall through the cracks, and adopt an almost resigned/pessimistic view of their longterm healthcare.
All three of these stories help us understand the puzzle pieces behind what we know as “value-based care.” But there is one more story that’s crucial, and particularly topical now: that of physician ‘burnout’ (aka anxiety, depression, etc) secondary to buckling under the pressures of performance, including the expectation to provide ‘value based care.’ When I mentioned cognitive load and institutional inertia/physician inertia earlier, it was because we must also understand that both of these concepts are in term impacted by the well-being of the physician. A stressed- out, unsupported, demoralized healthcare professional is unlikely to have either the time or the energy to stop to re-evaluate if they are ordering the appropriate test, or more broadly if they are providing the best possible care — one that maximizes outcomes for the patient and minimizes costs (not to mention makes the physician ‘feel’ like they’re making a difference).

Value-based care, in other words, must also, as it’s core assumption, place ‘value’ on physician health and well-being. It should be easier to provide value-based patient care, not more difficult, and there is value inherent in ensuring the physician feels good, remains healthy and thriving before/during/after delivering patient care.

Now that I’ve [hopefully] painted the problem clearly, we can agree that the *system* has to change. But for it to change in a sustainable way, the tweaks can’t just be topdown — from government or insurers for instance. We need to be thinking more creatively, like an entrepreneur. We need to ask how, to paraphrase Buckminster Fuller, of ways in which we can make the old system of how physicians are incentivized to deliver care, obsolete. The only way to do that is to create a better system, one that provides incentives that align with what doctors value.

Is there a way to provide value-based care while optimizing physician health/well-being and cutting down on unnecessary time wasted on administrative tasks? Yes.

Is there a way to improve patient outcomes while lowering costs, saving the most money on complex procedures that are actually needed.  Yes.

Could this also involve taking a more whole-person/patient approach to healthcare? Yes.

So what might this potentially ‘better system’ look like? That’s the topic of the next newsletter, and an exciting announcement I have about a pivot in my own professional focus.

 

Have a healthy, joyful, and safe month,


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

 

December/January Newsletter!

December/January Newsletter!

December 2021/January 2022

Welcome to the December/January 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.

This edition is a bit different from the previous one (and it’s a long one, so brace yourself!), because it’s focused on ONE big topic, which is: what do we ‘attend’ (pay attention) to? I’ve written briefly about this before, after reading a book I often recommend: Attending by Ronald Epstein.

This photo will make sense shortly.

 

so will this!

While I was in London for 6 weeks recently, for personal and professional reasons, I met a lot of fascinating people (maybe there was something in the air…besides the obvious SARS-CoV-2?), but one person, whom I’ll dub for dispositional reasons “Mr Darcy“, stood out for one reason: he paid attention to to the *right* things.

Mr Darcy is unique for many reasons: an academic surgeon but someone who grew up with a strong literary background, being diasporic but born in the UK, and having several unusual obsessions outside of work, all of which has allowed his mind to adapt and see connections between disparate things and experience the world differently. This same tendency has undoubtedly also led him to pursue the right questions in his research (think: senior authorship on several Nature papers, even though he’s technically an early career physician and researcher) and numerous professional opportunities.

Mr Darcy also happens to be an excellent cook, namely because he’s a bit of an obsessive. Once he made squid ink breadsticks (with a complicated dip recipe) for a party we attended, because at some point he realized regular breadsticks were not good enough. The extra few minutes to add squid ink paid off for the guests, mostly in ‘awe’ and joy, and even though the dish itself was tasty — that tiny tweak moved it from good to “extraordinary.”

But all of these things aside, Mr Darcy also left an impression on me personally because he paid attention to the *right* things. To be sure, it wasn’t an *excess* of attention — but an investment and calibration towards the things that matter.

It’s quite easy, when we think about it, to give anyone or anything a *lot* of generic attention: spend more money to impress someone, spend more time on one thing (this grit/slogging isn’t always ideal) or person to show ‘effort’ or ‘commitment.’ But the impact tends to be low, over time especially, if that’s the only dimension we focus on. Investing in the correct things, things that lead to the biggest payoff, is often a better, or at least complementary, strategy.

This idea led me to think about how often I pay a *lot* of attention, when I should really be spending the *right* type of specific attention. One big area is cooking.

I’m a relatively good cook: I’ve been cooking for many years. Overall, when I cook for loved ones, they enjoy the meal. But am I a great cook? Definitely not, if we define ‘great’ as ‘exceptional’ or ‘extraordinary’ — I can’t recall one time when a loved one brought up a meal I’ve made as specifically memorable, which is a good marker for ‘extraordinary.’ We know this because we often remember the moments that stand out as well above average — specific meals at restaurants are a big one.

So, for 2 weeks, mid November to December 1st, effectively just as I returned from London, I challenged myself to apply the principle of ‘paying the right attention,’ towards becoming closer to ‘extraordinary’ with cooking. My goal wasn’t to cosplay as a professional chef, in as much as a layperson can’t just put a white coat on and be a doctor, but I wanted to refine my thinking and approach enough to get closer to ‘extraordinary’ — to change up my ‘process’, and iterate to lead to a better outcome and experience.

I decided to experiment with a new dinner dish, or refine one I’d made before, daily, as this seemed the most efficient way to establish a habit, and enter into a learning curve where I could build upon skills each day (so total immersion!).

Instead of focusing solely on one sense (taste), I wanted to explore the other senses as well: aroma (the feeling that hits you just before you take a bite, or when a plate arrives), visual (how are things plated/the art element to the presentation), sound and texture (how do elements pair together and ‘sound’ e.g. a crunch). Flavor/taste was also important, but I wanted to dive into pairing things that we don’t typically see together, or explore ingredients I haven’t used before.

The way I cook is probably how I approach many things, including my writing: I begin with an idea, and build around it. With cooking, I’ve always followed the taste principle of balancing at least four of: sweet/sour/bitter/salt/fat in some way.  If I wanted to make one element the center — a cut of fish or meat, tofu, grain, or vegetable — I’d begin there, and then see how the other puzzle pieces fit together, according to the framework of flavor, visual, texture, etc. What worked best was creating a list of several potential dishes, and moving elements around over time.

The biggest gap was around technique: where I asked myself ‘if my goal is X, what cooking technique would be best?’ And in those instances, a quick google search or Youtube video sufficed to fill in that gap. This is all to say that I didn’t follow any preset recipes for most dishes (Dishoom’s black dal being one big exception!), and don’t tend to write out my recipes, because I simply don’t see cooking as prescriptive: and reversing my exact steps  seemed cumbersome.

Adventure was also key: having ‘beginners mind‘ conversations with people at niche grocery stores and asking for advice or ingredient recommendations, for instance.

Part of intentionally gaining any new skill is accepting that failure and risk are part of it. As such, I set an ‘error rate’ of 10%, meaning that if 10% of my dishes ended up inedible, I’d be ok with it. Setting this meant I was free to explore weird combinations, or plate things without the expectation of perfection.

I also wanted to ensure that, unlike when I typically cook, I wouldn’t multitask. This meant that music was fine, but no podcasts/audiobooks or phone calls — I wanted to cultivate a flow state and focus my attention to each step of the ‘cooking experiment.’ It thus became a form of ‘mindfulness’ in action, and allowed for ‘deep work.’

Last: I wanted to set a few boundaries — namely time (the daily experiments had an end date so I wouldn’t totally fall into a rabbit hole but could also spend the time cultivating this new skill; also that most dishes should take about an hour, even if prep involved a few minutes overnight) and ‘gadgets‘: often when we get excited about a new hobby we can be impulsive with getting all the gear, even before we know whether we actually need it. I did change my mind on a sous vide machine: I settled on a basic one that saved a lot of time and effort after I understood the manual investment (because I made the manual investment for one dish!), and because my perspective changed on Black Friday! But I didn’t purchase a blowtorch (which would have allowed me to cook pieces of fish directly on a plate).

Overall, the process was enjoyable, and a fun self-directed learning activity that allowed me to follow my curiosity, take risks, and improve in a tangible way. Now I’m inspired to offer this skill to loved ones as a way to change up the typical ‘ordering takeout’ or cooking something basic. Cooking for someone is, indeed, an under-appreciated love language and expression of care — why not make it extraordinary then?

It also made me realize that, when we often discuss ‘wellness’ strategies and approaches, we focus heavily on things like nutrition, sleep, connection, mindfulness (all things I’ve written about, are described on my website) but we pay less attention to the human need to explore and discover, and the unique benefit it poses to well-being that most other ‘self improvement’/wellness/self-help things don’t. For instance: when is the last time you took a ‘field trip’ to learn about something (eg an industry) that you’ve been curious about, without a professional payoff (eg as part of a job)? And why are adult field trips not more common?

So, as a small step up from Instagram, I’ve added a tab to my website as a nudge to inspire us all to do more curiosity-led experiments in the future, even if it isn’t daily (or even weekly), as part of our wellness.  Why ‘peaceful pescetarian’? That was a [now defunct] food blog I had several years ago to document seafood-y things I ate (and a few things I made). Needless to say it didn’t last, but I love the name (though if I could rename it, it would be ‘the peaceful pescetarian and the vegetarian hedonist’ 🙂 ).

We’re nearing the end of this rather long, hopefully not *too rambling*, letter but my hope is to inspire you to consider adding something to your wellness repertoire this holiday season, that perhaps you might carry forward into 2022, that goes beyond what we typically associated with ‘wellness;’ something that challenges you to learn something/get better at something you’ve perhaps been curious about for a long while; something that doesn’t necessarily need to be tied to your professional goals, but has the potential to expand your sense of joy and well-being. Part of this may involve exploring where you might have been paying *excess* attention, and where instead, you might get a better outcome from paying the *right* attention instead. Consider it an experiment that provides meaningful data to help you make better decisions, and re-evaluate how/where/when you spend your energy and time.

In other words, we can all benefit from Mr Darcy’s insight, especially as our well-being may be further challenged this winter due to the new variant: a reminder that we’re in a pandemic marathon, one that’s approaching almost two years, where it might be helpful to expand our toolbox of things that keep us calibrated towards more joy, peace, and wonder during these uncertain and troubling times.  And if you *do* try something new, shoot me an email or tweet it to me!
 

Have a healthy, joyful, and safe Holiday season, 


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

 

ps and on an unrelated note, I’m re-sharing the link to a very worthwhile fund to consider during this season of ‘giving’. I’ll have more to say in the next newsletter. 

 

An Opinion Pandemic

Contrarian viewpoints on Covid-19 policy in mainstream opinion journalism risk provoking dire consequences.

 

Credit: Rawpixel

 

Iogolevitch’s opinion was invaluable. For one, he argued that the term “Spanish flu” was incorrect, and that “pulmonary flu” was more appropriate. More importantly, he advocated for isolating infected cases, ventilation, and supportive care. He warned against transmission in children, and advised the appropriate use of medications. He also, humbly, lauded the efforts behind finding a vaccine while also emphasizing the need to educate the public about disease transmission:

“Thanks to the public health officials of this country, you appear to be on the eve of the practical application of a vaccine… I think your health authorities are on the right track… the public should be made acquainted with the disease through lectures, printed pamphlets, newspapers… in a short time the public may be taught the necessary fundamentals of the disease… such as not to cough or sneeze without a handkerchief.”

The Times appeared to heed his call to the key role newspapers play in impacting public understanding of the virus, increasing regular reporting of the pandemic such as the enforcement of fines to ensure public health guidelines were followed, and educating the public on the promise of vaccine research, all while warning them against ingesting “cures” that could “do more harm than good.” (La plus ca change!)

Portions of advertising space were also reallocated to public health messages that encouraged readers to wear masks and follow disinfection recommendations. That said, despite experts suggesting the pandemic had ended, and it was the time to reflect on learnings, transmission took a long time to curtail. After 50 million deaths, almost 700,000 of which were in the U.S., the last case was detected in April 1920.

Arguably, Iogolevitch’s views were influential in shaping how the Times and other newspapers reported on the pandemic, which then impacted public understanding and opinion, all of which collectively helped drive widespread behavior change. This illustrates that during a pandemic, it’s not just the reporting on the pandemic that matters; the opinions shared by experts also matter.

Over the last 18 months, with the influx of thousands of op-eds focused on the pandemic, we’ve seen the impact of airing contrarian opinions. In March 2020, a viral piece published by the Times, by David Katz, MD, a physician with expertise in nutrition, called for keeping businesses open.

A few days later, Trump used the same language from the piece to justify the administration’s inaction. As one journalist pointed out, this didn’t go unnoticed, suggesting that the op-ed may have, to some degree, either influenced Trump’s choices, or was used to justify his a priori plans.

One year later, an article in The Atlantic, by the economist Emily Oster, was similarly perplexing — another argument for a “laissez faire” approach to pandemic planning, this time applied to children. The blowback by infectious disease physicians and epidemiologists was huge, taking the form of an ad hoc scientific peer review over Twitter (as a disclosure, I consult for the Twitter health design team to support more productive disagreements on the platform), and while Oster issued a clarification on social media, the article itself still lacks a correction. It became weaponized by libertarians, and more recently, referenced in a testimony (and subsequent appeal) against mask mandates for children in Florida.

Then, earlier this month, another op-ed, by oncologist, Vinay Prasad, MD, MPH, called into question masks for children, only having been met by similar criticisms from epidemiologists and pediatricians. It appeared to be weaponized by anti-maskers and Governor DeSantis’ successful appeal may have benefited from this counterpoint narrative. While “children are not little adults” is an adage in pediatric medicine, which often applies to drug dosing, it doesn’t typically apply to standard practices like helmets, masks, seatbelts, and so forth — the potential trade-offs are usually worth it to prevent transmission at a time when pediatric cases, hospitalizations, and deaths are surging in this vulnerable unvaccinated group.

But the core issue here goes beyond any one self-described expert’s opinion. To make the criticisms solely personal is to fail to see the underlying problem. This dilemma has less to do with any specific individual, and more to do with the processes in place among newsrooms across the country to vet these opinions, including who deserves a platform (and who doesn’t), and whether the opinion offered is supported by sound data, all on top of the traditional challenges readers may face when discerning meaning from opinion journalism.

The idea to separate opinion from news was credited by the founder of the New York Tribune, Horace Greeley. Now there are codes of ethics for opinion journalism, and some newsrooms have their own. But this is complicated by the fact that most readers still have a hard time distinguishing between news and opinion, and efforts to label sections as “ideas” and “essays” may not always help with this distinction, particularly if they are written by an individual that “appears” to be an expert on pandemics.

At a time when editors may be burnt out, but when readers still expect quality data-informed advice, and where ad hoc scientific “peer review” on social media has limited impact (and fuels mob justice), we need a different approach, one that addresses two main problems. First, to what degree is expertise and credibility required when opining about an active pandemic, especially on policies by the CDC, and how best can editors determine this? Second, during an active pandemic, should the publication standards for pandemic-focused op-eds be higher, knowing that the consequences of readers integrating this information may be immense, potentially even impacting pandemic prediction models themselves?

The first issue involves expertise and credibility.

A common argument made by epidemiologists and infectious disease experts against the Oster, Prasad, and Katz op-eds are that they shouldn’t have been published because the writers lacked the specific expertise in the area they were commenting on. While this is an appropriate criticism
(we wouldn’t turn to an infectious disease expert to advise us on the economy of the country, the best chemotherapy protocol for a form of breast cancer, nor how national nutrition policy should be overhauled) it doesn’t heed the value of what “outsiders” — non-scientists and scientists alike — offer to the public conversation. Iogolevitch, despite being a physician, was an outsider by virtue of being a new immigrant who wielded no power compared to Surgeon General Blue or Lieutenant Colonel Doane. Moreover, we need only turn to Rachel Carson’s Silent Spring as self-evident. Carson was a citizen scientist, not an expert on environmental pollutants or human health, yet her outsider perspective helped shift public opinion, including that of countless scientists who resided in echo chambers, some who were unduly influenced by industry, and were altogether unable or unwilling to see their blind spots.

Echoing Thomas Kuhn, Carson spoke to the defining feature of science being that it evolves, including in her book an elegant quote from Johns Hopkins Professor Carl Swanson, that “others” are crucial to that evolution: “Science may be likened to a river… it gathers momentum with the work of many investigators and as it is fed by other streams of thought; it is deepened and broadened by the concepts and generalizations that are gradually evolved.”

As political science writer Philip Tetlock has written extensively about, experts are often blind to gaps in their understanding, which justifies why we need humble nonexperts in the room. As such, the downfall of many contrarian op-eds during this pandemic is at least in part due to a lack of intellectual humility; that is, the clear idea that their view is one of an outsider having appraised the evidence, but that the view is subject to change as understanding evolves. Indeed, if high quality traditional journalism is “balanced,” so too should opinion journalism be forceful yet flexible, especially so with opinions that run counter to established public health recommendations.

The second issue is whether an active pandemic necessarily raises the standards for pandemic-related opinion journalism.

This is specifically the case now where major news outlets are cosplaying as the main source of public health information, given the limitations on traditional authoritative bodies like the CDC. Compelling opinion journalism is supported by data and evidence. But who exactly is the judge of this evidence?

Unlike peer reviewed science, the judges, in this case editors, often do not have the deep expertise to scientifically appraise the quality of evidence used in an article; they can’t be expected to. Alas, that judgement rests primarily on the individual submitting their opinion, and their self-assessment of both expertise and ability to appropriately apply the data. The Katz op-ed was not buttressed by relevant scientific data, which was perhaps expected given that the pandemic was in its earliest weeks and such data was not available. As several infectious diseases experts pointed out, the Oster op-ed used sound economic modeling assumptions, but extrapolated these assumptions to epidemiological data (the crux of the concerns raised involved the conclusions perceived as erroneous). With the Prasad op-ed, as his critics pointed out, the overreliance on one small trial that wasn’t replicable and lacked external validity, rendered his main argument thorny. But what’s particularly puzzling with Prasad’s op-ed is that he co-wrote an excellent textbook that describes these very research limitations in compelling detail, and why they often lead to medical reversals.

To be clear, all three authors were likely well-intentioned in their efforts to provide a contrarian perspective; it’s the assessment of how these perspectives are weighed in mainstream media, during a time of immense uncertainty, that becomes a challenge.

A similar issue, around assessing expertise and the application of evidence, is present in the justice system with medical expert witnesses: Some states leave the judgement of medical expertise, and the application of scientific evidence, to a jury and judge who typically lack scientific training; others leave the determination to the expert’s professional peers who may be incentivized to support a colleague; both are imperfect.

During a pandemic, the stakes of misjudging expertise and the appropriate application of data, are high. One poorly supported opinion can be used to justify inaction or disobedience, which could then fuel higher transmission rates. Failing to have high standards effectively poses the same harm as the Tom Cotton op-ed controversy, but the consequences to flawed public understanding may be immediately dire and traceable, through the larger ripple effect on cases, hospitalizations, and deaths.

These two points — on expertise and standards — inevitably run up against arguments around free speech and censorship, which harkens back to another pressing issue in 1918, which was Wilson’s concern that contrarian opinions about the war, namely anti-war sentiment, could pose a risk to the populace. This led to the passing of the Sedition Act of 1918, which also covered which opinions would be voiced in the media (including newspaper editorial pages). The justification was that the common good of winning the war was held in higher esteem as compared to any individual’s right to protest against the war publicly. Seen as extreme, Associate Justice Oliver Wendell Holmes put forth a test the following year for assessing whether the Sedition Act could be applied, the “Clear and Present Danger Test” (bold emphasis mine):

“The question in every case is whether the words used are used in such circumstances and are of such a nature as to create a clear and present danger that they will bring about the substantive evils that Congress has a right to prevent. It is a question of proximity and degree. When a nation is at war many things that might be said in time of peace are such a hindrance to its effort that their utterance will not be endured so long as men fight, and that no court could regard them as protected by any constitutional right.”

Notably, the Covid-19 pandemic has been likened to war by the very nature that it requires collective action and cooperation in order to defeat the enemy named SARS-CoV-2. Holmes’ attempt was to create a more objective way of measuring when free speech should be curtailed for the sake of the war, and more broadly for the public good. (Of note, libertarian sentiment against pandemic regulations was uncommon in 1918, possibly because the broader libertarian value around winning a war, and the associated freedoms, was perceived more salient.)

So how might we reconcile these two broad issues?

First, ideally, newsroom opinion sections should have at least one editor with scientific training and experience in critical appraising research studies to provide insight around whether a submission, regardless of the author’s titles, is supported with valid data. As this may prove difficult, investing in training opinion editors to be better judges can help fill in the gaps (trainings are offered by the National Association of Science Writers).

Second, creating a standard rubric for opinion editors to help assess a given “expert” op-ed would help — as a scientific peer reviewer, I’ve often followed these, which could be adapted for pandemic-focused op-eds. Included in such a rubric would be a variation of a “clear and present danger test”— applicable to potentially hateful views as much as those that could pose a public health risk. Third, newsrooms should regularly publish and make available, explainer guides to help educate readers on scientific media literacy. Fourth, where clarifications or corrections (or even a revision of a prior opinion) are offered by the writer, as with the Oster example, editors could publish this as an update to the article itself, though in much of these instances resorting instead to a newsletter may be better.

Fifth, whether it’s opinion or traditional journalism, caution should be heeded on any article that offers a crystal ball — whether around herd immunity, planning for social events next season, or when/how the pandemic will end.

At a time when readers are looking to news outlets for certainty, the temptation by newsrooms to provide this is strong. We don’t know how this pandemic will end, and no “expert” or conscientious science journalist, albeit well-meaning, knows either. Certainty remains elusive, and the most accurate pandemic forecasts are made a bit like the weather: a week or two at a time, a diminishing return on this accuracy the further out we go. The news media must continue to normalize this, as well as normalize that the understanding of SARS-CoV-2, as with all science, will evolve, so the recommendations and messaging will too (which doesn’t equal flip-flopping). Reporting that helps place the pandemic’s trajectory in context, and guide readers’ thinking will continue to prove extremely useful.

For readers who are turning to these pages for hope, but also prudent expert guidance, a healthy acceptance of the uncertainty that all of us — expert or not — are grappling with, as well as the limits of forecasting, will help undo some of the pressure many editors face to meet that need in their outlets. And of course, subscribe and support these outlets.

The original title of this essay was “What Silence Springs” (not very SEO friendly!) which is a play on words of Carson’s book title. That was intentional, to underscore a crucial last point. I’d be remiss to omit the fact that oftentimes the most knowledgeable and experienced people lack the platform to lend their expertise, or are implicitly (or explicitly) silenced, which is fertile ground for overconfident voices to take the lead. As with other professions, the journalism world struggles with a bias towards a certain “kind” of journalist or expert; my volunteer work mentoring several academics through The OpEd Project only further cemented that meritocracy remains an ideal. When it comes to opinion journalism, it’s on editors to ensure that it isn’t just the loudest often self-proclaiming experts who are provided with a platform for their views and ideas, but those with demonstrated expertise, humility, and thoughtfulness, as they often add immeasurable value to the public conversation — perhaps, especially, those voices that remain underrepresented primarily because they are excluded.

An outsider, but one who held herself to the same standards of scientific evidence as her more decorated academic contemporaries, Carson demonstrated that the evidence-based opinions of a nonexpert can indeed shift the public’s perception of the most pressing issues of our time.

She once proclaimed: “Wonder and humility are wholesome emotions, and they do not exist side by side with a lust for destruction.” Though Carson was referring to how humans experience our natural world, the same might be applied to opinion journalism. A reader’s sense of wonder is rooted in noticing how differently another might understand crucial issues; we are often humbled if that perspective is novel enough to change our minds. We also value that which is rare, which is why we pay attention to contrarian views.

But this wonder and humility, in its truest sense, cannot be derived from arguments that are ultimately destructive by virtue of being unsupported by the evidence.

During a pandemic which has now surpassed the death count of 1918, and where millions of citizens and their leaders base (or justify) their actions on what they read in newspapers they trust, it’s simply a pattern we cannot afford to repeat.

**Originally published in Elemental, and subsequently (slightly different version) in Poynter**

October Newsletter!

October Newsletter!

October 2021

Welcome to the October 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. 

 

Wiltshire, UK, Oct 2021

Some things that had me wondering this month:

1. COVID and…
The kids are alright:  from The Washington Post, a story about a young boy not wanting to take his mask off for his school photo, and his sweet reason why!

A Canadian physician’s essay on caring for patients:  and reflections on managing those who remain unvaccinated.

A great way to frame the pandemic trajectory ahead (without forecasting): From The Atlantic, 6 rules to help provide context ahead of the Fall/Winter.

2. Podcasts (& shows/books) worth listening to/watching 
I loved this interview between psychiatrist Paul Conti and Tim Ferris on understanding trauma, the brain, and behavior.

And, in about 2 weeks in the US, Anil Seth’s book, Being You, will be released (it’s already out in the UK, a Sunday Times bestseller, and fascinating). I recently [and serendipitously] met Anil and had some of the most interesting chats in recent memory. His popular TedTalk is also worth a watch.

3.On…#Metoo, Consent, Desire, and so much more
By Philosophy Professor, Amia Srinivasan — her piece in the NYT was probably the most shared essay in my network last month. Her book of essays, The Right to Sex is also an excellent read.

4.Sound (and wise) reflections
And as part of the OpEd project, I coached Suparna Dutta and this is her first piece, on the butterfly effect impacting hospital transfers

5.Miscellany

The future of work is here.

If Canadian journalist, Sydney Page, who regularly writes for the “Inspired Life” column of the Washington Post, is not yet on your weekly reading list, she should be. This will make you cry (and hopefully smile too). 

6.Best tweets of the month goes to…
Sahil Bloom, on what the Chinese bamboo can teach us about growth
Tareq Hadhad on the Canadian election
Elaine Welteroth, quoting part of Michaela Coel’s Emmy speech

Adam Grant, on reframing ‘self-worth’

Ted Lasso (which I just started watching!), on grief

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

As mentioned last month, I’m trying something new. 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 this small device — the Zulay frother. I love it for matcha, chai, coffee lattes for ambrosia-like froth, even for milk alternatives like oat or soy. It just makes the colder mornings (and frantic Sunday afternoons) a little more enjoyable.

Here it helped me create a fluffy chai (a ‘chuffy’?)

         Chuffy!

In My Own Words…

For Elemental, I wrote about a topic I’ve been a bit obsessed with since February 2021: the sharing of opinions by ‘experts’ while a pandemic is underway. Poynter, which is a journalistic resource, ran a slightly different version as well.  Writing wise, I just submitted my second round of book edits, and got assigned a really interesting magazine story, which brings me to London for a few weeks. The last ‘truly’ longform story I worked on was this one, so I’m eager to dig in.

 

Fly-fishing in West Chisenbury

I also caught my first ever fish (wild trout!), during my first ever fishing trip (in Wiltshire), with a very patient teacher (thanks RC!). It’s not trout season, so we put it back. But…’teach a woman to fish and she’ll smile for a lifetime?’ might be a great quote adaptation for these times. As well: I didn’t realize how meditative and relaxing fly fishing is…though…

If you have time this month, please consider donating to St Michael’s hospital foundation. A dear mentor (and a much-loved teacher of medical students and residents) from medical school, Dr Robert Sargeant, was diagnosed with an incurable form of brain cancer just over a year ago. I know that I still remain hopeful. Arguably Dr Sargeant was among the first people who turned me onto writing about medicine, with an essay he suggested we (our clerkship rotation group in general internal medicine) read: Letting Go by Atul Gawande.
It takes on special significance at this time. 

Have a healthy, joyful, and safe October,


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

Can Prayer Heal?

Does spirituality play a role in health outcomes?

Credit: RawPixel

On the last day of January, my Twitter feed lit up with a curious and heartfelt call: “Please. Please. Please. Everyone PRAY for my daughter Molly. She has been in an accident and suffered a brain trauma. She’s unconscious in the ICU. Please RT and PRAY.”

The tweet came from a woman named Kaye, a lawyer and mother of three in Los Angeles. Her daughter Molly was in a pediatric intensive care unit after suffering a brain injury. I, along with thousands of others, heeded her call, sharing a private prayer that Molly would recover. Soon Kaye began tweeting live as to Molly’s status — she regressed with brain swelling, needing surgical intervention. She was then stable for another day before her blood pressure and the pressure in her brain (intracranial pressure) fluctuated, needing another brain scan and another surgery to reduce the intracranial pressure.

By sharing what was happening for Molly, Kaye brought thousands of us into that small ICU room over several days, highlighting the hard work and efforts by Molly’s doctors and requesting that followers (the number amassed to more than 60,000 within the span of just a few days) do one thing: pray.

The research on intercessory prayer—the formal name for praying to a higher being or force, for ourselves or for others—paints a conflicting picture. In 2020, a published case report caught my eye: A patient’s blindness “resolved” after the patient received intercessory prayer. But the case happened in 1972; surely the details may have become muddled in the retelling over several decades. The same researchers reported on other cases, like prayer for gastroparesis (when the stomach becomes unable to function) in a 16-year-old. Other research suggests prayer may be helpful as an adjunct for pain management among patients who might describe themselves as religious.

In 2006, researchers from the Mind-Body Medical Institute at Harvard Medical School reported on the Study of the Therapeutic Effects of Intercessory Prayer (STEP). This trial involved cardiac bypass patients across six hospitals in the United States. Each participant was in one of three groups: One-third received prayer from others after not being told if they would or not, another third didn’t receive prayer after being told they may or may not receive it, and the last third were told they would receive prayer. In the end there was no significant difference in death rates (mortality) between the groups.

Perhaps most prominently, a Cochrane review from 2009 that reviewed 10 studies and more than 7,500 participants compared intercessory prayer plus standard care with standard care alone and found that the results were equivocal — in other words, prayer didn’t make a difference to the patient’s outcome. That review was then criticized as failing to “live up to the high standards required of Cochrane reviews,” and other researchers have criticized the study more generally.

Yet, spirituality may effectively be a way to create meaning out of the experience. It can also help patients create meaning from their experiences.

Jonah Geffen, a 44-year-old rabbi in Manhattan, echoed some of these same sentiments. His path into spiritual work involved a stint at law school, after earning a master’s in conflict analysis and resolution. Now he works primarily in the community but on occasion gets called into hospitals or people’s homes specifically for healing purposes.

“[As a] rabbi… generally, no matter where you are, what you’re doing, there’s always an element of care involved in it… very often someone looking to heal something,” Geffen told me.

Over the years, Geffen has become prepared to run to someone’s side in the hospital or at home when crisis hits. He adds that the biggest challenge he sees, among those who are chaplains in hospitals, is that much of the time they might be asked to pray for someone outside their faith.

“It’s a challenge with some of the rabbis I know who might be asked to pray for someone. In our tradition, prayers are quite scripted, so the challenge is for them to step out of that and find another way to connect with that person and to God,” he says.

Christina Puchalski, MD, a physician based in Washington, D.C., became interested in spirituality at an early age. “There wasn’t one specific thing that got me interested in orienting myself towards the spiritual needs of my patients. I suppose it was years of knowing my connection to the sacred and that so much of the suffering we see in our patients is of the spiritual kind,” Puchalski told me.

In 1996, Puchalski developed the FICA (faith/belief/meaning; importance/influence; community; address/action of care) spiritual assessment tool for health professionals to help them integrate spiritual views into a patient’s clinical history. Puchalski has worked with everyone from the Vatican to the World Health Organization (WHO). With the WHO, she has advocated to include “spirit” within the definition of health, specifically in the realm of palliative care.

Currently, Puchalski leads the George Washington Institute for Spirituality and Health, dubbed GWish. Established in 2001, the institute has the primary role of raising awareness about the spiritual aspect of patient well-being. It’s the biggest center of its kind in the United States.

In her book Making Health Care Whole, Puchalski defines spirituality as “the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred.” She goes on to emphasize that spirituality helps us find meaning and purpose “even in the midst of failed jobs, relationships, accomplishments, and unattained successes, especially at the end of life… The inability to find meaning and purpose can lead to depression and anxiety.”

According to Puchalski, the triggers for potential spiritual growth can include serious illness, aging, loss of a loved one, stress, life change, social events, and tragedies.

So perhaps what Geffen and Puchalski are both alluding to is that asking whether prayer “works”—as in whether it hastens recovery—is not the right question, even if it’s important from a research and evidence-based point of view. Instead, perhaps it’s important to define the outcome more holistically: as a measure of healing for both the patient and their family, one that transcends merely “curing” or “recovery.” As well, perhaps the word “prayer” is unnecessarily constraining. We could instead reframe it as “compassionate and caring presence” for another person, where we genuinely hold their well-being in our thoughts.

On February 15, Kaye shared an update that Molly had passed away and that her family was grateful that the request for prayer, regardless of one’s faith, was heard and met many times over in the form of an outpouring of compassion from a community of friends and strangers. She said it brought comfort and a sense of being witnessed during the family’s time of immense need. Perhaps this same sort of compassionate presence has the potential to heal and assist those suffering with an unimaginable reality and subsequent uncertainty, even if, in the end, we’re met with the limits medicine itself places on the ability to cure.

**Originally published in Elemental, March 2021**

June/July Newsletter!

 

June/July 2021

Welcome to the June/July 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. 

A forest playground, near Chattahoochee Hills, Georgia, May 2021

Some things that had me wondering this month:

1. COVID and…
Pediatric Multinflammatory multisystem syndrome:  In the Lancet, some good news: the sequelae (long lasting effects) of the initial symptoms may not persist past 6 months.

On masks:  When and where to wear them, by a pubic health expert, in Slate and…could they be here to stay for cold/flu season (I think so), in the New York Times.

Vaccine Hesitancy: Among healthcare workers in the New York Times.

and….

How the pandemic ends, by the indomitable Helen Branswell, in STATNews.

2. Podcasts (and shows) worth listening to/watching 
The best series I’ve watched in a long time is “The Me you Can’t See,” a series on mental health and wellbeing, produced by Oprah and Prince Harry. I especially loved the last episode, which placed a solutions-lens on mental health as well where this issue intersects with other contemporary challenges, such as policing. Make the time to watch!

3.On…reconciling with Canada’s challenging past with residential schools
In the CBC, the discovery of the bodies of 215 Indigenous children, some as young as three, rippled throughout the country. It’s likely there are many similar mass graves across the nation. First comes ‘truth’ and understanding the true scope of this tragic legacy, and then reconciliation. I sense that we’re only beginning to get to the truth bit.

4.Sound (and wise) reflections
~In NiemanLab, why Darnella Frazier, now 18, should win a Pulitzer for her bravery in capturing the tragic death of George Floyd, which had a ripple effect on how we understand systemic racism in policing and more broadly in our society.
~Billy Porter, on sharing his truth as a man living with HIV, in the Hollywood Reporter
~On the Cicadas who are re-emerging after years, in the New York Times.

5.Miscellany 
~I developed a tree pollen allergy last year, and have been sneezing nonstop seemingly this month. Finally, I have my answer, from CTV.

~On brain implants that could translate thoughts into text, in Wired

~For subscribers to STAT+, the investment in healthcare teams, by tech companies.

~From Yahoo, the tragic death of Michael Lewis’ daughter, Dixie (along with her boyfriend, Ross Schultz), in a car accident last week reverberated throughout the literary community. Lewis is one of the most talented narrative nonfiction writers, and I just started his latest: The Premonition, about the pandemic. His podcast, with Pushkin Industries, Against the Rules, is one of my favorites, and last season he described being coached for singing, drawing parallels with Dixie’s experience with her softball coach. May Dixie and Ross rest in peace. 

6.Best tweets of the month goes to…

Adam Grant, on a mantra we need to finally do away with:

“We’ve always done it that way” is not a valid reason for anything. Don’t follow traditions because the status quo is comfortable and change makes you uncomfortable. Question whether past routines are serving you well in the present and guiding you toward a better future.

Rebecca Herbert, on attachment (or…”inosculation”, in the plant world) which continues to be a theme I think about often: 

The thinner tree was cut years ago and the big one has been holding and feeding it since then. They “wake up” together in the spring and “go to sleep” together in the autumn.

An excellent thread by Marie Beecham on cancel culture as a form of intellectualism.

This sums up a lot of the past 18 months with the pandemic: Mike DiCenzo: (a former writer for Jimmy Fallon, the Onion, etc):

Nobody really knows anything. Everyone’s just saying things. But some people say things more confidently than others.


NYC, enlivened, as the storm clouds (of COVID) appears to be clearing! May 2021 

 

In My Own Words…

For Elemental, I wrote about the “re-emergence” effect we may all be experiencing. And for Wired, I wrote about medical reversals, and what they mean in the broader context of our post-COVID world.

This was also a month with additional ‘in person’ reporting in and around New York with sources I couldn’t meet in person a year ago, given the lockdowns. We also cemented the title (On Healing will be the final!) and the subtitle (this was a toss up between two — so stay tuned!) and hopefully I’ll be able to share the cover in the next newsletter.

And a brand new book to be sure to get your hands on, by my friend Barrett Swanson (I’ve linked to his essays in previous newsletter): Lost in Summerland. This interview, in LitHub, is a great as well.

Have a healthy, joyful, and safe June and July!


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

We Must Rethink the Role of Medical Expert Witnesses

The Derek Chauvin trial highlighted a potential way physicians could better serve the criminal justice system

Credit: Getty Images

In the aftermath of the guilty verdict in the trial of Minnesota police officer Derek Chauvin for the murder of George Floyd, a consistent element of many criminal trials came into sharp focus: the role of medical expert witnesses, and the influence they wield in the courtroom, particularly as it relates to determining the cause of death. Within the span of the ensuing weeks, one juror said that the medical expert testimony was particularly influential, and a petition to investigate another medical expert witness’s track record of assessing cases for potential bias, garnered over 400 signatures from concerned physicians. Clearly, it’s worth asking this question: If the broader goal is to improve justice, can the system of using medical expert witnesses be re-imagined? This question can be examined by highlighting three main challenges.

First, the term “expert” is tricky in medicine, as medical science evolves rapidly (COVID is a prime example). Yesterday’s expert could be out of touch with their field of expertise today. Further, the prosecution and defense choose the expert most appropriate for supporting their respective legal strategies, which runs the risk of confirmation bias. At its best, medicine is a group sport; in hospitals, particularly for challenging cases, physicians share their knowledge; debate and discuss a case; and formulate plans in consultation with each other. And when it comes to the determination of death, the standard for group involvement is often higher. For brain death, for instance, two different physicians’ assessments may improve the likelihood of an accurate assessment.

The second issue is that the standard used by the courts to assess whether an expert witness’s scientific testimony can be included differs by state. Several states (including Minnesota) use the Frye Rule, established in 1923, which asks whether the expert’s assessment is generally accepted by the scientific community that specializes in this narrow field of expertise. Federally, and in several other states, the Daubert Standard of 1993 is used, which dictates the expert show their scientific reasoning (so the determination of validity is left to the courts), though acceptance within the scientific community is still a factor. Each standard has its drawbacks. For instance, in Frye, the expert’s community could be narrowly drawn by the legal team in a way that helps bolster the expert’s outdated or rare perspective, and the Daubert standard presumes that the judge and jury have an understanding of the science in order to independently assess scientific validity. Some states also strictly apply the standard, whereas others are more flexible. (The Canadian approach is derived from the case R v. Mohan, which states the expert be qualified and their testimony be relevant, but the test for “reliability” is left to the courts).

Third, when it comes to assessments of cause of death specifically, understanding the distinction between necessary and sufficient is important. Juries can have a hard time teasing out the difference. In the Chauvin trial, the medical expert witnesses testifying on behalf of the prosecution were aligned in their assessment of what killed Floyd: the sustained pressure of the officer’s knee on Floyd’s neck (note that asphyxia is a common cause of cardiac arrest). However, David Fowler, the medical expert witness for the defense, suggested the asphyxia was secondary to heart disease and drug intoxication as meaningful contributors to his death.

An example of a cause being sufficient on its own might be a person who is pushed out of a plane, at 10,000 feet without a parachute. In a case like that, having a preexisting condition is inconsequential to their certain death. An example of a cause being necessary but not sufficient might be an individual with a compromised immune system who is infected with the influenza virus; neither condition alone would typically be lethal, but the combination might well be. With the Chauvin case, the disagreement between the medical expert witnesses was effectively over whether the force used was sufficient to cause Floyd’s death, irrespective of preexisting conditions (akin to the example of being dropped out of a plane) or whether it was only deadly in combination with another condition such as trace amounts of drugs (i.e., more similar to a person with preexisting conditions dying from influenza).

If we had the opportunity to re-imagine how medical expert witnesses might be used more effectively, how would we approach it?

In a 2010 Canadian paper, two scholars made several recommendations, including that these experts share only opinions (based on facts and reasoning, ideally supported by the medical literature) from their area of expertise, make clear where elements may be controversial in the scientific community, avoid confusing jargon during their testimony, and be informed that their primary role is to assist the court by providing testimony that is impartial, as in free from bias.

Arguments to improve how medical expert witnesses serve the justice system have been made by prominent legal scholars such as David Faigman, the Chancellor and Dean and John F Digardi Distinguished Professor of Law at the University of California Hastings School of Law. However, Faigman shared that it remains a challenge to convince the courts to re-imagine this system.

One potential improvement involves vetting medical expert witnesses for potential biases, such as those based on gender or race before they take the stand (Fowler, the medical expert on Chauvin’s defense team, was involved in another similar case, involving the death of a young Black man, which raised concerns, which is leading to a review of his other cases after an open letter signed by over 400 physicians). According to Faigman, currently only good cross-examination may help elucidate these biases during a trial. As well, biases related to compensation could potentially be avoided by instituting a common pool of funding, with a standard rate, though in practice, this would be challenging to put in place.

Another improvement could involve ensuring that courts institute a more stringent application and selection process, in which medical expert witnesses would be required to demonstrate their clinical and research competence related to the specific issues in a case, and where their abilities are recognized by their professional group. For example, the American College of Cardiology could endorse a cardiologist as a leader in a relevant subspecialty—a similar approach has been suggested as a way to reform medical expert witness testimony by emergency physicians. One drawback, according to Faigman, is that courts would be unlikely to fully abdicate their role in evaluating expertise.

Last, instead of medical experts working for both sides, the courts could appoint a panel of medical experts who are required to explain their assessments (which would be part of the record) independently of each other and the opposing legal teams, but also have the panel work together and deliberate on a final assessment. Faigman shared that while this would offer an ideal solution, the courts would still need to decide how best to appoint and compensate this panel.

In any case, borrowing from how medicine works at its best in hospitals, to improve the current model in court may help us better reach our common goal of justice.

Since the time of Chiron, doctors have been viewed as godlike. More recently, and particularly during the pandemic, we realize that physicians have limits to their knowledge. Perhaps no other physician described the fallibility of doctors more profoundly than Roger I. Lee, who served as the president of the American Medical Association. In an essay aptly titled “Are Doctors People?” published in the New England Journal of Medicine in 1944, he wrote:

“We must accept the fact that the community, from the days of folklore and the

medicine man to the present, conceives the medicine man and the doctor as someone apart

from the rest of the tribe or the rest of the community…[but] Doctors are human beings.”

Lee was ahead of his time in his recognition that doctors also have a role to play in ameliorating social ills. Systemic racism is perhaps the most profound of these ills. The Chauvin trial has only furthered the salience and limits of physician expertise and judgement in the criminal justice system. While the verdict was ultimately aligned with the majority of medical expert witnesses, and those physicians who assessed Floyd at the time, it’s on us to make the system better.

**Originally published in Scientific American, May 2021**

April Newsletter!

 

April 2021

Welcome to the April 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. 

**to access all hyperlinks, please subscribe**

Some things that had me wondering this month:

1. COVID and…
~Vaccine hesitancy.  In December I wrote about a hypothesis on scarcity and social proof about potentially overcoming vaccine hesitancy. Recently the WSJ published data on vaccine hesitancy, which appears to be going down on several states — could it be secondary to scarcity and social proof? And what *might* it mean for vaccine hesitancy in general?

~The politics behind pandemics. This, from the New Yorker is an excellent review of Baylor Medicine’s Dr. Peter Hoetz latest book, Preventing the Next Pandemic, and a great reflection on a remarkable career in infectious diseases/global health.

~Design. COVID has impacted the design world in unique way, in the New York Times .

2. Podcasts to listen to:
The On Being podcast is a favorite. Recently host Krista Tippett interviewed psychologist Christine Ryntab about how our mental health has been affected by the pandemic.  

Part 1 (covers mastery vs success) and Part 2 (covers a beautiful term called “aesthetic force”) where Brene Brown, for her Daring Leadership podast, interviews Harvard’s Dr Sarah Lewis. It might be the best set of interviews I’ve listened to in years. It will nourish you and inspire you (and i’m currently listening to Lewis’ gorgeous book The Rise, on audiobook). 

I’ve been listening to poet and musician Morgan Harper Nichols daily for the last 2 weeks. Her 3-12 min episodes are beautiful reflections which leave you with a question. Nichols’ voice alone is incredible, and her instagram account covers her artwork as well. She’s a rising star to watch. 
Some of my recent favorites have been on trusting despite the uncertainty, on our purpose (with lovely) a river analogy, and 7 phrases to help with future worries. 

3.On…forecasting and expertise
This is from the archives of the Atlantic, by the incredible David Epstein (his book Range is a must-read). Here, citing Philip Tetlock’s work, he calls into question ‘expertise’ — indeed it must be a balance. We need experts to guide us, but non-experts help us identify blind-spots. This is a topic I’ve been thinking about a LOT with the pandemic. I’m now left thinking it’s more of an ‘amplification problem.’  Perhaps, with COVID, given the amount of uncertainty and the fast-moving nature of science, the media tends to rely on experts to self-identify. This then leads to many ‘non-experts’ (confident but incompetent, at least as it relates to medicine and public health), who *should* be part of the discussion, but shouldn’t be amplified, get amplified the media.

Recently an economist at Brown received immense criticism (here, here , here, and here, but really — there were lots of important points made) for an article about childhood COVID transmission.  It was inaccurate and simply unwise, as many physicians and epidemiologists identified, but it likely wasn’t intentionally so. The simplest explanation: economists and epidemiologists look at data and value various factors *differently.* As an economist, her views could add to the discussion — it may just be that they should not have been amplified in that fashion, as it drowned out the current recommendations and expert forecasts. It was quickly debunked but the harm cannot be underestimated. Reporters, and others without expertise but who write about a subject, are expected to incorporate expertise into their pieces, in order to report out an issue fairly and accurately. It’s possible that this economist may have avoided the controversy by interviewing epidemiologists in a “reported op-ed” (one that isn’t solely her opinion), as opposed to writing an op-ed from her point of view as, effectively, a non-expert in public health. Perhaps an article on the economic impacts of COVID or how an economist may *think* through the challenge of lockdowns would have been more appropriate.

We must amplify experts who are truly able to comment on the pandemic and make recommendations, and not simply allow the loudest voices (in the room or on Twitter) to prevail. This, ultimately, causes harm to public understanding, and influences behavior in a way that ultimately negatively impacts how the pandemic is handled. Editors and producers, therefore, must also be equally discerning when commissioning op-eds from academics, and ensure their expertise lines up with the subject matter.

4.Sound (and wise) reflections
~A former incarcerated man reflects on solitary confinement — which he suffered through for 18 years — in NYTOpinion 
~The challenge of bullying in healthcare, in the Financial Post 
~The role of trauma in gun violence, in the NYTOpinion
~There were many great pieces about anti-asian violence. This Q+A in the New Yorker and this op-ed by National Book Award winner, Charles Yu, in the LATimes are worth a read

5.Miscellany 
~From the LATimes, the things migrants carried and dropped on their trek across the border for a better life
~The incomparable Dr Eric Topol, for the WSJ, on how science accelerated over the last 13 months
~The plight of child caregivers, in the LATimes
~In the NYT, the incredible life of one of my favorite writers as a child — Beverley Cleary
~One of the best personal essays I’ve read in months, in the Washington Post, about medical error, second opinions, and the limits of medical ‘expertise’ 

6.Best tweet of the month goes to…
A Three-WAY tie:

This thread is inspiring (it’s worth reading in its entirety). 

@JouLee:
We think strength is self-sufficiency— achievement without reliance on others. We think that if someone else gains, we lose. But intertwined, we all go further. This is the secret of Silicon Valley. Help others, ask for help, and collective strength multiplies.

@gradydoctor:
Reflecting on these statements from 2 good friends in academic medicine this week: 1. “There HAS to be a consequence between nothing and professional death.” 2. “Healing HAS to include restorative justice–which begins with accountability.” Yeah. That part.

In My Own Words…

This was a month with lots of writing, and the next few weeks will be dedicated to my book revisions (due in 3 wks!). For Medium‘s Coronavirus vertical, I wrote a primer about the AstraZeneca vaccine, clots, and concerns about causality. For Elemental, I examined the role of prayer in healing, inspired by the story of Molly (that many of us were inspired by in February). Last, for Wired I tackled an issue that has been on my mind for many weeks: the puzzle of pandemic prognostication (and why some see things through an optimistic lens, whereas others are more concerned) — I make mention of epistemic trust and the issue I discuss above (point #3).

Also, a personal one from the archive (2017), about my grandfather, who has been on my mind late, in Hektoen International.

My time in Vancouver is soon coming to an end (as, sadly, variants are taking hold). It has been such an incredible place, with so much natural beauty, to spend time in over the last 8 months.

 
Have a healthy, joyful, month,


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

March newsletter!

March 2021
**To access all of the hyperlinks, please subscribe**

Welcome to the March 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

 

 

 

 

 

 

 

“Two days, Two seasons” (Kitsilano, Vancouver BC, February 14th vs February 13th, 2021)

 

 

 

 

Some things that had me wondering this month:

1. COVID and…
~A new vaccine. The Johnson & Johnson COVID vaccine is now available in the US (hopefully in Canada soon). How does it stack up against Moderna and Pfizer (and AstraZeneca)? This might be the wrong question when scarcity is at play: take what you get, as this NYT op-ed advises. Remember: the vaccine is intended to prevent severe disease, i.e. disease that would require a hospitalization/ICU visit or worse: death. It may not be perfectly effective at preventing infection. The flu vaccine is similar, though often has much lower effectiveness. But in general, those vaccinated with the flu vaccine are at a much lower risk of severe disease, even if they do have mild flu symptoms.

~Vaccine diplomacy. This will continue to be a topic to watch closely, and one I’ve been pondering since the Summer when I received a press release about an Indian manufacturer planning to ramp up production of a vaccine (which ended up being the Astra Zeneca vaccine). India specifically has played a major role over the last 15 years in terms of drug manufacturing: especially as it relates to anti-retroviral drugs, and facilitating a price drop which improved global access.  India has manufactured vaccines for global health (e.g. polio) as distributed by organizations like GAVI, WHO, UNICEF, etc. But this is the first time to my knowledge that India is playing a role in manufacturing vaccines for the ‘developed’ world.  So not only is Jamaica receiving shipments, but so is Canada.    The editors of the NYT Opinion section penned an excellent op-ed on the theme here. My question: will India then be able to leverage other interests (e.g. politically, trade/economic) with recipient countries? And what are the potential pitfalls and opportunities?   A handy comparison: the role China played in providing PPE to affected countries, and the potential downside regarding accountability as it relates to investigations into the virus origins in the country.

~On reopening schools. It remains a tricky debate. I like Dr Leana Wen’s take in the Washington Post.  Side note: I spent my 32nd birthday in Charleston, and Dr Wen happened to be there (story for another time, but she’s fabulous!)

Screening for health conditions. There’s no doubt that there are several externalities secondary to the pandemic. One big one that doesn’t get discussed enough: the negative impact on screening. This piece, in the NYT, tackles it head on.

~Children. A well presented and reported piece on the youngest victims of the pandemic in the Post — even if children rarely suffer from severe disease, they are impacted in other long-lasting ways.

~The best essay I’ve read (about COVID since the pandemic began), by none other than Dr. Siddhartha Mukherjee. This one is about the mystery behind the low death rate in India in the New Yorker (followup with my favourite New Yorker piece period, from 2017, Cancer’s Invasion Equation, also by Dr. Mukherjee)

2. Podcasts to listen to:
This episode of Brene Brown’s podcast features one of my favorite thinkers, Adam Grant.
Here they interview each other in a sense, and Grant gets into the topic of his latest book, “Think Again,” while also sharing a variety of anecdotes about his career and life decisions.

And because she’s utterly delightful, Fran Lebowitz interviewed by Kara Swisher on Sway is well worth the laughs and incredulity, if only for her line comparing herself to Helen Keller.

3.On…systemic racism in the 1950s and 2021
~Harry Jerome is a Canadian that I, and many others, never learned about in school. As a Black man attending a mostly all-white school in Vancouver in the 1950s, he had rocks hurled at him. His story of that time is captured here, in the CBC.  A track star that went on to set several world records, Jerome sadly died in 1982. Now Vancouver is finding a way to honor him.

~This is an important read from StatNews‘ Theresa Gaffey, about a big story that was trending on Twitter earlier in February. A program director, who happened to be a Black woman, was dismissed from her position after flagging issues of systemic racism. This topic in general is a sad and very real issue in academic medicine, affecting residents, but also, clearly, staff as well.  Of note, Gaffey is a multimedia producer but I hope she stays on this beat (medical education) as this article was so well reported, covering the nuances particularly well.

~And for GQ, the incomparable Wesley Lowery on how one police department, in Ithaca, New York is attempting reform. It may be a model for others.

4.Sound (and wise) reflections
~From NYTMag, this profile of Kazuo Ishiguro is simply sublime. What a brilliant mind

~The type of love that makes you happiest, in the Atlantic

~From ESPN, on injury and resilience, through the story of basketball player Azzi Fudd

~One of the most harmful questions you can ask children, by Adam Grant for CNBC

5.Miscellany 
~From NYTOpinion about nurses, and what the pandemic means for the future of nursing. We rarely hear from other frontline workers (other than physicians), so this was illuminating for me. That said, someone on Twitter, who happens to be a nurse, flagged to me that that article was not inclusive, and my sharing of it failed to amplify this issue. And, well, I agree (I have my own blindspots). That opinion piece did not include the fact that in many cities most hard hit, nurses of color (mostly women) have disproportionately been affected. So I also share this article, in CNN: about the toll on Filipino nurses in particular, though the same may be said of Caribbean-American nurses, Latin-American nurses, and so forth. It also reminded me of why I mentor with the Op-Ed project, to help ensure that under-represented voices get heard.

~The tragic story of Joe Ligon, which broke my heart and I *still* can’t wrap my head around: to be captive for THAT many years, and now released. Unimaginable.

~The death of groundbreaking cancer researcher, Dr. Emil Freireich hits hard for anyone in pediatric medicine. He was a trailblazer to say the least, and highly disagreeable in his approach as a pediatric oncologist and researcher. He didn’t care much for the status quo: his focus was on finding a treatment for childhood leukemia, which he did.  His obituary in the NYT is a must read.

6.Best tweet of the month goes to…
A compelling speech by Ryan Leaf, about the NFL’s failure to acknowledge mental health issues. As I write this another former player, Louis Nix, has died (though the cause has not been confirmed).

I don’t know who needs to hear this, or if I just needed to say it, but I will not continue to stand by and watch my brothers disappear because the multi billion $$$ corporation won’t do the right thing.
@nfl @NFLPA do something!! #igoturback #nflbrotherhood

And a thread by the incredible writer and musician Morgan Harper Nichols, about her recent diagnosis of autism, as a reminder of how women are often diagnosed late, or misdiagnosed:

Last Saturday, after a very long journey, I was officially diagnosed with autism and I just want to share my experiences here for anyone else out there whom it could help (a lengthy thread)

In My Own Words…

My lockdown obsession: colorful heritage hen eggs by Black Rooster Farms, Langley BC
January 2021  (these aren’t painted by the way– the colors are REAL!)

 

This month, I had the pleasure of being interviewed by influencer Camille Styles, on finding our purpose. I also participated in the “SoMeDocs writers conference” which was really fun (some great questions).

Other than that, I’m knee deep in book edits, with revisions due in April, and polishing off a textbook chapter I’m co-writing with a friend and colleague, Dr. Daniel Lakoff (emergency medicine physician with NYP Hospitals).  I will have a piece out next week, which I’ll include in next month’s newsletter.

To end I’d like to highlight Andre Picard’s book on elder care arrived this week, and is timely and important. For my American readers: Picard is a must follow, as arguably the most prominent health journalist in Canada, and longstanding columnist for the Globe and Mail. He shares his commentary thoughtfully and wisely.

Have a healthy, joyful, month,


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