Week of July 3, 2023
One afternoon last week, I called a large mail-order pharmacy to ensure a patient could obtain more than a 7-day supply of required long-term medication. I spoke with three people, answered the same prior-authorization questions four times, and spent 95 minutes on the phone. There were many silent, reflective moments while listening to prior auth specialists typing online forms and messaging their supervisors for "exceptions." Around the 45-minute mark, thoughts of "How is this kind of healthcare system sustainable?" morphed into ironic reflections on the sunk-cost fallacy. At 75 minutes, Ayn Rand's "Sanction of the Victim" concept from Atlas Shrugged roared in my head. And by minute 95, when I hung up, I fully understood how Winston could tearfully love Big Brother at the end of 1984 (and I needed oily Gin).
I am fortunate I do not have to do this frequently, unlike my colleagues who see patients full-time. And though I succeeded (in obtaining a 1-year approval for 30-day supplies), it took four years of liberal arts college classes to fully contextualize the experience.
https://thedecisionlab.com/biases/the-sunk-cost-fallacy
and
https://en.wikibooks.org/wiki/Atlas_Shrugged/Concepts
and
https://andrefrancois12.wordpress.com/2014/06/02/reflection-on-last-words-of-1984/
and
https://www.kff.org/policy-watch/examining-prior-authorization-in-health-insurance/
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The N.Y. Times COVID Tracker reflects only CDC-gathered hospital data as a surrogate (lagging) indicator.
https://www.nytimes.com/interactive/2023/us/covid-cases.html
Overall, trends are reassuring. However, check out hospitalization data in Deleware. The absolute value of COVID patients is relatively low, but the percentage increase is enormous. I wonder if hospitals are more diligently reporting cases or if beach-goers are gathering in poorly ventilated restaurants.
Wastewater monitoring is more of a LEADING indicator. There are some slight upward trends in some regions of the U.S. in the last week of July.
One follow-up on wastewater monitoring - "Wastewater sampling in Canada suggests COVID case rate 19 times higher than reported" https://www.cidrap.umn.edu/covid-19/wastewater-sampling-canada-suggests-covid-case-rate-19-times-higher-reported
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COVID articles
There were several interesting articles on the new interest in indoor air quality (both due to COVID and Canadian wildfire smoke)
Indoor air sensors
https://www.nytimes.com/2023/06/29/health/air-quality-pandemic-wildfires.html
The 100+ year historical public health-driven call for fresh air.
https://www.nytimes.com/2023/06/17/health/covid-ventilation-air-quality.html
Medical Trends and Technology
Meet Fanzor - another potential genome editing tool (think CRISPR/CaS-9 but possibly better). MIT biochemists used this protein to generate precise insertions and deletions at targeted genome sites within human cells. Fanzor is another DNA "cut and paste" tool to alter the genomes of plants, animals, and single-cell organisms. Gene editing and synthetic biology continue to be the next big thing.
https://www.popsci.com/science/crispr-gene-editing-fanzor/
and the scientific paper from
https://www.nature.com/articles/s41586-023-06356-2.epdf
I am greatly amused and curious (about the impetus for) this article: "The Feasibility and Impact of Practising Online Forest Bathing to Improve Anxiety, Rumination, Social Connection, and Long-COVID Symptoms: A Pilot Study." Read that title carefully.
Here is the gist: Psychologists recruited 22 patients (via social media) with self-reported long COVID symptoms and then, following symptom and quality of life surveys, had the patients engage in four weekly online "(virtual) forest visits." The goal was to determine if virtual forest bathing improved long COVID symptoms. Of the 22 participants, 27% did not participate in the follow-up survey. Of those who completed the study, "Online Forest bathing significantly improved well-being and symptom severity. [...] Where people have limited access to in-person nature, virtual nature may offer an alternative to improve health and well-being outcomes." This study has several issues - online recruiting, self-reported illness, high dropout rate, and no clear validation of virtual forest exposure, to list a few.
https://www.mdpi.com/1660-4601/19/22/14905
Twitter commentary: https://twitter.com/kacheston/status/1673670371889885196
Forest bathing is a thing that emerged in Japan. I like the woods but am unsure where the line is between a nice hike and "bathing." I am even less confident you can "virtualize" the experience.
https://www.nationalgeographic.com/travel/article/forest-bathing-nature-walk-health
Infographics
It is the 60th anniversary of implementing Zip Codes in the U.S.
Sending (paper) mail was forever different after 7/1/63. Luckily for those alive at that time, infographics had already been invented:
Things I learned this week
I have written extensively about how ideas travel and change through history. Our work and ideas often evolve from those that come before us.
In recognition of the 4th of July, I want to highlight John Witherspoon (1723-1794). Like the U.S., he has a complex history. Witherspoon was a Scottish Presbyterian minister who fought against the Jacobites in 1745. He moved to the colonies in 1768 to teach at and become president of Princeton University. His influence in the colonies was profound - not only was he a strongly pro-independence member of the Continental Congress, but he taught and influenced James Madison and Alexander Hamilton (amongst many others). "Government officers held by Witherspoon's Princeton students included one U.S. president (Madison), one vice-president (Aaron Burr), 10 cabinet officers, 6 members of the Continental Congress, 39 U.S. Representatives, 21 U.S. Senators, 12 state governors, 56 state legislators, 30 judges, and 3 Justices of the U.S. Supreme Court." He was a driving force in delivering the ideas of the Scottish Enlightenment (such as David Hume, Adam Smith, and Thomas Reid) to the minds of his fellow founding fathers of the United States. Recently, wider recognition of Witherspoon's two enslaved household servants has led to a debate on appropriately commemorating him.
https://enlightenment-revolution.org/index.php?title=Witherspoon,_John
and (noting that this is from the Journal of the Witherspoon Institute)
https://www.thepublicdiscourse.com/2023/02/87446/
Living with A.I.
Papers detailing the "reverse engineering" and then "running" (on a neural network) fruit fly (drosophila melanogaster) brains started getting some attention this week. We should begin queueing for our programmable, AI-driven robot fruit flies - holiday season 2026.
https://twitter.com/amasad/status/1675359568145137664
and
https://twitter.com/sdorkenw/status/1674859033076072448
Feeding the models: A.I.-driven fruit fly behavior interpretation-
I expect to see many more articles using trained algorithms to enhance physician judgment in complex, multivariate situations. From Machine learning for ECG diagnosis and risk stratification of occlusion myocardial infarction: "Using 7,313 consecutive patients from multiple clinical sites, we derived and externally validated and intelligent model that outperformed practicing clinicians [without a model] and other widely used interpretation systems, substantially boosting both precision and sensitivity [in identifying patients having heart attacks with only subtle EKG changes]."
https://www.nature.com/articles/s41591-023-02396-3
and commentary
A.I. art of the week
Fruit Flies at a Call Center (answering prior authorization calls?)
Clean hands and sharp minds, team
Adam
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