January 31, 2009
Life Outside the Bell Curve, a.k.a. The Limitations of the Evidence Base
The strength and weakness of what we consider traditional American medicine (more accurately referred to as allopathic medicine) is that it focuses on the aggregate rather than the individual, on macro-level patterns rather than micro. The reverse is largely true for homeopathy.
If one stops to really consider the methodology of the analysis that underlies allopathic medicine the significance of this becomes more clear. The researcher first identifies a question that is relevant to a substantial community. It has to be a substantial community because it isn't possible to gather enough data to show statistical significance (if it exists) from a small data set. Therefore one is limited to asking questions that at least provide the potential for collecting statistically significant data.
Supporting this focus on large-scale scientific inquiry is funding, which goes primarily to support finding solutions to conditions that effect large numbers of people, even mildly, rather than those that effect small communities severely. For example, in the USA, you'd have to be sleeping under a rock to not be aware of the tremendous push in the last decade for research in breast cancer. The push has paid off, and breast cancer has shifted from being something terrifying and deadly to one of those where, if you have to get cancer, better to get one you have a fair chance of surviving -- it is considered more of a chronic illness than a deadly disease.
That is now, ten or twenty years ago it was a completely different story. Meanwhile, ovarian cancer has always been one of the really bad diagnoses to get, but because it is comparatively rare (affecting fewer people) it is not as well funded, not as well researched, not as well diagnosed, and has stayed pretty much the same for prevalence and mortality for the past 20 years. (NOTE: This is a drastic oversimplification, and I am aware of that.) If you look at the stats comparing breast cancer to ovarian, even with the dramatic improvements in treatment of breast cancer and little improvement in treating ovarian, breast cancer still kills over twice as many women in the US as ovarian.
How devastating an illness is doesn't drive funding (which drives both quantity and quality of research) -- it is how many lives it touches. As long as it is still a significant problem, even if we've made huge strides in treatment, it will still drive funding. At some point, this can become a self-perpetuating cycle, the funding drives itself and we keep funding the same things because we have for so long.
Another aspect of what drives research questions is being able to clearly define the question. This is why conditions such as fibromyalgia, that are defined by nonspecific symptoms -- symptoms shared with many other conditions -- tend to be under-researched. The nature of the condition means it is ill-defined and difficult to research.
Bottomline, you don't want to get either a rare disease or one that is vague or ill-defined. God forbid that you be an outlier. You know the whole standard distribution curve analysis, right? Bell curve? 95% of all people fall within 2 standard distributions from the mean. What about those 5% of people who don't fall in the main part of the curve - the outliers? Well, we don't really know what to do with them -- that is not what the research looks at.
Does this mean that rare conditions don't exist? Of course not. Does the presence of a non-specific symptom for which there is no clearcut or inexpensive differential diagnostic process mean that the symptom doesn't exist or that it is purely hypochondriacal or psychosomatic? Of course not. But it does mean that it is sometimes it is, sometimes it isn't, and as a healthcare provider it is often expensive and difficult to tell the difference. Does that mean nothing is wrong? That is isn't REAL? Or that there is no solution? No way to make life even a little easier? Heck no to all of the above. It does mean that the burden of figuring out the problem, solutions, what helps, what doesn't, all tends to lie largely on the person with the problem and their loved ones.
Another complicating situation is when the patient has multiple symptoms. They might be related, or they might not; it might be a syndrome, or it might be a series of otherwise unrelated problems that just happen to be present in the same person. Almost a coincidence. As a general rule, the medical literature and research process don't do well with complicated situations. That makes it hard for the doctors, and it isn't something that it easy to address in training. It is hard to understand the various bits and pieces as part of an overall pattern. It is not unusual to break it down into bits and pieces and look at them one at a time. This to manage the pain, that to control the inflammation, this lifestyle change to build strength and combat fatigue, this dietary change to help manage fatigue at certain times of day.
Often the only difference between being told a problem is in your head and not is the trust between you and your clinician. By this I mean you have a pre-existing relationship with your clinician which has generated trust on both sides. Even then, there is a fair chance they will say, "How much stress have you been under lately?" or "Why don't you just make sure you're eating well, exercising, drink lots of water, and make sure you are sleeping well - none of those late nights, ok? Come back if that doesn't work." Luckily, vague symptoms sometimes respond to vague solutions.
My personal perspective on this dynamic is a little off-center. I am trained in evidence-based healthcare research methodologies and consult in this area. I have a fair understanding of how the evidence stacks up, or doesn't, the significance of insufficient evidence to support an important question, the importance of being able to assess the levels of evidence available and make decisions based on the best available evidence (even if it isn't perfect). At the same time, I have the eccentric joy of being a member of a family just stuffed chock full of outliers. I know quite well what happens when what is wrong with you or your loved one doesn't fit under the curve.
Alright, well, so our healthcare and research systems are not designed to deal with all situations. The evidence is incomplete, and that is part of our process - it is always incomplete, and always will be until we stop learning and asking questions. That means the decisions, services and accommodations based on that research share the same flaws. As long as we understand that, we can adapt the decisions, services, and accommodations; we can include the outliers, those who don't fit under the curve. The danger, the very real danger comes in trusting the research completely without questioning, without acknowledging the inherent flaws and limitations of the evidence base.
January 28, 2009
"Seeing White in Black"--a Fungible Concept
Dr. Kafi Kumasi, of the Library and Information Science Department at Indiana University, recently spoke to a UM SI/MIX audience in an expansion of her dissertation "Seeing White in Black," a narrative of 10 African-American participants (14-16 years old) in the Circle of Voices Book Club at the Monroe, Indiana, Public Library. The major points of the discussion involved Whiteness Theory and Double Consciousness Theory. Tension and challenges were employed as integral, constructive components of these racially-centered book discussions to tease out social and cultural emotions and impressions.
Dr. Kumasi quoted Audre Lord (librarian/poet/activist) who believed that librarianship should be part of social and cultural perspectives.
Using Dr. Kumasi’s thoughts and presentation as a jumping off point, it occurs to me that the Whiteness Theory can be used as an allegory for other ethnic marginalized groups. This theory encompasses the concept that whites hold privileges automatically that they don’t even realize they have and that whites are not considered a race but are defined by their not being one of the marginalized races that are subordinate to them. This theory, by another name, can, I think, readily be applied to other groups as well. For example, we might propose: “Seeing Christianity through Judaism”. This would work perfectly well on several levels: sociologically, psychologically, and biblically. The theory of double-consciousness is similarly fungible. As an example, the Germans and Italians of Jewish ancestry often did not think of themselves primarily as Jews until they were so defined dictatorially by Hitler and Mussolini, respectively. In similar fashion, when the “Racial Laws” took hold, there was the sense of being both a citizen of one’s native country and a member of a subordinate special group, in effect fitting the theory of a double consciousness. I think that these two theories might also be applicable to various other populations with which I am less familiar—the Hutus and the Tutsis, perhaps, as well as most other marginalized and therefore disadvantaged ethnic groups?
January 25, 2009
Publicity is Hard to Do
I heard yesterday from some neighbors, a group of UM Dental students, that on a previous occasion when the Dental School had offered free dental checkups and fillings for the public, there were only about three patients who showed up to take advantage of it. With so much demand for health care and so many people who cannot afford it, I see this situation as a sad mismatch between excellent intentions and the failure to reach the appropriate audience to let them know about the opportunity to take advantage of the offer. I know that when I personally was trying to raise interest in our "Opening Doors" event, I visited churches, wrote to schools, asked numerous friends and acquaintances, generally racked my brain for possible ways to tap into the appropriate interested individuals, and worked for hours and hours trying to publicize the upcoming project. At the occasion itself, we had an adequate crowd, but, frankly, I was expecting more people, considering the amount of time and effort that had been expended in trying to spread the word about an excellent presentation that could possibly impact students' future in the health professions. In conclusion, with the UM Dental School's "Give Kids a Smile" Day offering free dental care for children aged 5 to 12, coming up soon, and since I know from experience how hard it is to publicize similar events, I am trying to help out by jumping into the attempt to spread the word.
January 23, 2009
HEALTH: CARE: COST
I was having a little conversation with someone at lunch today about health care costs, and after a while our talk meandered over to a very specific local site--the University of Michigan. I happen to be familiar with the fact, from being on various internal committees, that health insurance costs here are on an upward trend of 10%/year, which, although all costs are going up everywhere nationwide, is higher than it should be. The UM is self-insured. As a result, the keepers of the funds at UM are worried; however, I am happy to say, they are very reluctant to have to cut benefits for their employees; therefore, they are trying mightily to reduce costs. We see their attempts in the various MHealthy preventive programs--the exercise promotion with fun and financial incentives; the health assessment with $2,000,000 worth of incentives; and the Wellness Champions for various units, who are supposed to provide psychological incentives. From both a personal and an institutional point of view, I wish that more people in the UM community understood this and would willingly and enthusiastically take responsibility for their own health. It is not such a difficult thing to do, and it might have positive results both individually and with respect to the common good.
January 20, 2009
MLK Event--Health Sciences
Kenneth May, UM Dental School Chair, performed a gracious introduction and welcomed the audience. Afterwards, a liturgical dance was performed by some 8 women in colorful garb. Then Frank Ascione, Chair of the School of Pharmacy, welcomed everyone in the Dow Auditorium of the UMHS. I also spotted Douglas Strong, UMHS CEO in the audience. Raymond Gist, Chair of the MLK Program, introduced Dr. Joanne Dawley, the first female president of the Michigan Dental Association, who happens to also be an African Amercian woman, an individual who earned her undergrad degree at UM and her DDS at UM School of Dentistry. The keynote address was about "the perfect storm," meaning what is happening in Michigan economically as well as socially with particular concern about the lack of regular dental care for children who are African American, especially in the inner city. That was essentially it. She quoted statistics to reveal how dismal the situation is and gave a few examples of how lack of dental care can cause systemic disease and even death in one case (fulminating infection in a young man whose mother could not afford to have his tooth extracted in time). Then Q&A with a little discussion about the free dental day at UM but the fact that this is insufficient care. A couple of other questions were followed by a reception in the hall; there was another short segment of dance by the liturgical dancers, and then some of us (those with tickets) went to lunch downstairs in the lunchroom, which was set up nicely with lots of tables-room was just about filled. After lunch, more Q&A and then flowers were presented to Dr. May by a woman with a lot of charisma, possibly Valener Perry, I believe, who said that he was her actual dentist and that she retains her actual teeth (Dr. May had given Dr. Dawley a bouquet on stage right after her presentation).
January 18, 2009
More on Communication
I have continued to ponder the blog-o-sphere. Last night on BBC World Service, there was an interview with a journalist who protested that blogging is not journalism. Just because a person has something to say and posts it, does not entitle that individual to be considered a reporter, this interviewee stated. That may be the case; however, in an op/ed piece in today's (1/18/09) NYT "Horatio Alger Relocates to a Mumbai Slum," Anan Giridharadas points out thst the social is back in politics, that whereas a decade or so ago, Americans were said to be "bowling alone," now there has been "a neo-Tocquevillean flowering online, of Wikipedia editors, Twitterers, and bloggers, an unpaid army stirred by that ancient impulse to blow in larger currents." My feeling about the burgeoning blog trend is that this is a wonderful new era and I love it. I have always enjoyed reading "Letters to the Editor" and have considered them to often be the most interesting section of the daily newspaper. Now, I can wallow in blogs as if they were lengthy "letters", thus keeping current with events and other people's perspectives on them and skip "the straight news" entirely if I want to.