The turtle menace – the peril of ICD-10 code W5922XD

Have you heard of the menace represented by ICD-10 code W5922XD?

If you don’t know what the hell I am on about, check it out here.

There’s also the menace of other species.

There’s fires in perhaps unexpected places.

Injuries can happen anywhere – such as here or here or here,

For those who may be offended by my tone, having survived multiple turtle and macaw attacks while being burnt while watersking in the prison pool en route to the library while singing arias, apologies.

At least you don’t have to face this. Repeatedly.

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Theranos, hype, fraud, solutionism, and eHealth

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Anyone who has had to either give or take a blood sample has surely thought “there must be a better way.” The promise of replacing the pain of the needle and the seeming waste of multiple blood vials has an immediate appeal. If there was a technology that could

Theranos were one of the hottest health teach startups of the last decade. Indeed, their USP – that existing blood testing could be replaced by a pin prick – would have been a genuinely disruptive one.

Theranos was founded in 2003 by Elizabeth Holmes, then 19 years old, who dropped out of studying engineering in Stanford in order to start the company. In 2015 she was named by Forbes magazine as the youngest self-made female billionaire in history, with an estimated worth of $4.5 billion. In June 2016, Forbes revised their estimate to zero. What happened?

At times of writing, Holmes has been charged with “massive fraud” by the US Securities and Exchange Commission, and has agreed to pay a $500,000 fine and accept a ban from serving as a company director or officer for ten years. It is unclear if a criminal investigation is also proceeding.
At its height, Theranos had a seemingly stellar team of advisors. The board of directors has included such figures as Henry Kissinger, current US Secretary of Defence James “Mad Dog” Mattis, various former US Senators and business figure. In early 2016, in response to criticism that, whatever their other qualities, the clinical expertise of Mad Dog Mattis et al was perhaps light, it announced a medical advisory board including four medical doctors and six professors.

 

Elizabeth Holmes’ fall began in October 2015, when the Wall Street Journal’s John Carreyrou published an article detailing discrepancies between Theranos’ claims and the actual performance of their technology. This was in response to a Fortune cover story by Roger Parloff, who subsequently wrote a thoughtful piece on how he had been misled, but also how he missed a hint that all was not what it was.

 

Theranos’ claims to be able to perform over 200 different investigations on a pinprick of blood were not borne out; and it turned out that other companies’ products were used for the analysis of many samples.

 

The fall of Theranos has led to some soul-searching among the health tech stat up community. Bill Rader, an entrepreneur and columnist at Forbes, wrote on What Entrepreneurs Can Learn From Theranos:

 

     I have been watching first in awe of perceived accomplishments, and then feeling burned, then later vindicated, when the actual facts were disclosed. Don’t get me wrong, I really wanted their efforts to have been both real and successful – they would have changed healthcare for the better. Now, that seems unlikely to be the case.

 

By now, almost everyone has heard of Holmes and her company, and how she built Theranos on hype and secrecy, and pushed investors into a huge, $9 billion valuation. Now everyone in the industry is talking about this and lawsuits are flying.

Just a couple months ago, a Silicon Valley venture capitalist appeared on CNBC’s “Closing Bell” and instead of talking about the elephant in the room, he diverted to a defense strategy for the Theranos CEO.

 

He claimed Elizabeth Holmes had been “totally attacked,”and that she is “a great example of maybe why the women are so frustrated.”

He also went on to say, “This is a great entrepreneur who wants to change health care as we know it.”

 

The last statement was the strangest thing he said. Wouldn’t we all like to change things for the better? But “wanting” and “doing” are two different things.

 

 

 

Rader’s piece is worth reading for clinicians and IT professionals involved in health technology. The major lesson he draws is the need for transparency. He describes being put under pressure by his own board; why wasn’t he able to raise as much money as Theranos? It transpires that Theranos’ methods may make life more difficult for start-ups in the future, and Rader fears that legitimate health tech may suffer:

 

Nothing good has come of the mess created by Theronos secrecy, or as some have characterized, deception. The investor has been burned, the patient has been left with unfilled promises (yet again) and life science industry start-ups, like my company, have been left with even more challenges in raising much needed investment. And worse of all, diagnostic start-ups in general are carrying an unearned stigma.

 

In this interesting piece, Christine Farr notes that the biggest biotech and health care venture capital firms did not invest in Theranos, nor did Silicon Valley firms with actual clinical practices attached. As Farr writes, the Theranos story reflects systemic issues in funding of innovation, and the nature of hype. And one unfortunate consequence may be an excessive focus on Elizabeth Holmes; a charismatic figure lauded unrealistically at one point is ripe to become a scapegoat for all the ills of an industry the next.

 

The “stealth mode” in which Theranos operated in for the first ten years of its existence is incompatible with the values of healthcare and of the science on which it is based. Farr points out how unlikely it would be that a biotech firm vetting Theranos would let their lack of peer reviewed studies pass. The process of peer review and building evidence is key to the modern practice of medicine.

Another lesson is simply to beware of what one wants to be true. As written above, the idea of Theranos’ technology is highly appealing. The company, and Holmes, sailed on an ocean of hype and admiring magazine covers. The rhetoric of disruptive and revolutionizing healthcare featured prominently, as the 2014 Fortune magazine cover story reveals:

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Perhaps a healthy scepticism of claims to “revolutionise” health care will be one consequence of the Theranos affair, and a more robustly questioning attitude to the solutionism that plagues technology discourse in general.

Clinicians and health IT professionals should be open to innovation and new ideas, but also hold on to their professional duty to be confident new technologies will actually benefit the patient.

“They should teach that in school….”

One of the academic studies I haven’t had time to pursue (so only blog about) is a thematic analysis of editorials in medical journals – with a focus on the many many “musts”, “need to s”, “shoulds” and “have to s” imposed on doctors, “policymakers”, and so on.

Education is more prone to this, and from a wider group of people. Everyone has their idea of what “they” should teach, ascribing to schools magical powers to end social ills by simply putting something on the curriculum.

Much of this is very worthy and well-intentioned. People want their children to be prepared for life. That the things suggested may not lend themselves to “being on the curriculum” with any degree of effectiveness is rarely considered.
That curricula are pretty overloaded anyway is rarely considered.

Anyway, the UK Organisation “Parents and Teachers for Excellence” has been keeping track of these “X should be taught in schools calls” in 2018 so far.:

How often do you hear the phrase “Schools should teach…” in the media?
We’ve noticed that barely a week goes by without a well-meaning person or organisation insisting that something else is added to the curriculum, often without any consideration as to how it could be fitted into an already-squeezed school day. Obviously the curriculum needs to be updated and improved upon over time, and some of the topics proposed are incredibly important. However, there are only so many hours in the school week, and we believe that teachers and schools are the ones best placed to decide what their students need to know, and not have loads of additional things forced on them by government because of lobbying by others.

So far, as of today, this is the list:

So far this year we count 22 suggestions for what schools should do with pupils:
Why We Should Teach School Aged Children About Baby Loss
Make schools colder to improve learning
Schools ‘should help children with social media risk’
Pupils should stand or squat at their desks, celebrity GP says
MP’s call for national anthem teaching in schools to unite country
It’s up to us: heads and teachers must model principled, appropriate and ethical online behaviour
Primary school children need to learn about intellectual property, Government agency says
Call for more sarcasm at school is no joke
Schools should teach more ‘nuanced’ view of feminism, Girls’ School Association president says
Schools ‘should teach children about the dangers of online sexual content’
Schools should teach children resilience to help them in the workplace, new Education Secretary says
Government launches pack to teach pupils ‘importance of the Commonwealth’
Schools must not become like prisons in fight against knife crime, headteacher warns
Schools should teach all pupils first aid, MPs say
Call for agriculture GCSE to be introduced as UK prepares to leave the EU
Councils call for compulsory mental health counselling in all secondary schools
Set aside 15 minutes of dedicated reading time, secondary schools told
Pupils must be taught about architecture, says Gokay Deveci
A serious education on the consequences of obesity is needed for our most overweight generation

Teach girls how to get pregnant, say doctors
Start teaching children the real facts of life

I am confident there are a lot more out there PTE haven’t been linked with. From sarcasm to “how to get pregnant” to first aid to intellectual property to resilience.

I do wish someone would do my study on medical journals’ imperatives for me!

Critical thinking about critical thinking

At Aeon, an interesting piece on “critical thinking”, by Carl Hendrick:

Essentially, “critical thinking” as a skill detached from context is meaningless and illusory:

Of course, critical thinking is an essential part of a student’s mental equipment. However, it cannot be detached from context. Teaching students generic ‘thinking skills’ separate from the rest of their curriculum is meaningless and ineffective. As the American educationalist Daniel Willingham puts it:

[I]f you remind a student to ‘look at an issue from multiple perspectives’ often enough, he will learn that he ought to do so, but if he doesn’t know much about an issue, he can’t think about it from multiple perspectives … critical thinking (as well as scientific thinking and other domain-based thinking) is not a skill. There is not a set of critical thinking skills that can be acquired and deployed regardless of context.

This detachment of cognitive ideals from contextual knowledge is not confined to the learning of critical thinking. Some schools laud themselves for placing ‘21st-century learning skills’ at the heart of their mission. It’s even been suggested that some of these nebulous skills are now as important as literacy and should be afforded the same status. An example of this is brain-training games that claim to help kids become smarter, more alert and able to learn faster. However, recent research has shown that brain-training games are really only good for one thing – getting good at brain-training games.

Hendrick concludes:

Instead of teaching generic critical-thinking skills, we ought to focus on subject-specific critical-thinking skills that seek to broaden a student’s individual subject knowledge and unlock the unique, intricate mysteries of each subject. For example, if a student of literature knows that Mary Shelley’s mother died shortly after Mary was born and that Shelley herself lost a number of children in infancy, that student’s appreciation of Victor Frankenstein’s obsession with creating life from death, and the language used to describe it, is more enhanced than approaching the text without this knowledge. A physics student investigating why two planes behave differently in flight might know how to ‘think critically’ through the scientific method but, without solid knowledge of contingent factors such as outside air temperature and a bank of previous case studies to draw upon, the student will struggle to know which hypothesis to focus on and which variables to discount.

As Willingham writes: ‘Thought processes are intertwined with what is being thought about.’ Students need to be given real and significant things from the world to think with and about, if teachers want to influence how they do that thinking.

Medicine of course has had a vogue for “problem-based” learning for over half a century now. The premise of this is similar to that of critical thinking skills, and both have a laudable root of increasing learner engagement and showing the relevance of what they learn to “the real world.” Yet there are all sorts of assumptions, and wishful thinking involved.

“Mental health apps offer a head start on recovery” – Irish Times, 18/01/18

Here is a piece by Sylvia Thompson on a recent First Fortnight panel discussion I took part in on apps in mental health.

Dr Séamus Mac Suibhne, psychiatrist and member of the Health Service Executive research technology team says that while the task of vetting all apps for their clinical usefulness is virtually impossible, it would be helpful if the Cochrane Collaboration [a global independent network of researchers] had a specific e-health element so it could partner with internet companies to give a meaningful rubber stamp to specific mental health apps.

“There is potential for the use of mental health apps to engage people with diagnosed conditions – particularly younger patients who might stop going to their outpatients appointments,” says Dr Mac Suibhne. However, he cautions their use as a replacement to therapy. “A lot of apps claim to use a psychotherapeutic approach but psychotherapy is about a human encounter and an app can’t replace that,” he says.

Here are some other posts from this blog on these issues:

Here is a post on mental health apps and the military.

Here is a general piece on evidence, clinical credibilty and mental health apps.

Here is my rather sceptical take on a Financial Times piece on smartphones and healthcare.

Here is a piece on the dangers (and dynamics) of hype in health care tech

Here is a post on a paper on the quality of smartphone apps for panic disorder.