Daily Healthy: informed consent

The Bionic Medicine of Programmable People

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A couple of weeks ago I wrote <a href="http://onhealthtech.blogspot.com/2012/08/curb-your-enthusiasm.html" target="_blank">a post</a> about the clueless, but endearing, enthusiasm of technology people as applied to solving the health care problem. A few days ago Dr. Davis Liu published a post on <a href="http://thehealthcareblog.com/blog/2012/08/31/vinod-khosla-technology-will-replace-80-percent-of-docs/" target="_blank">The Health Care Blog</a> describing the vision of <a href="http://techcrunch.com/2012/01/10/doctors-or-algorithms/" target="_blank">Vinod Khosla</a>, the famed venture capital maven, of replacing doctors with machines. It turns out that Mr. Khosla wrote a series of <a href="http://techcrunch.com/2012/01/09/khosla-artificial-intelligence/" target="_blank">three</a> articles at the beginning of the year in a technology publication describing how his pioneering vision will replace people in industries where either he or his <a href="http://techcrunch.com/2012/01/15/teachers-or-algorithms/" target="_blank">wife</a> are investing capital. Venture capitalists (VCs), although I’m sure they wouldn’t agree with this assessment, are a combination of professional gamblers and loan sharks. The secret to success is pure luck and ruthlessness, and when the combination works and the ball lands on the exact number on the spinning roulette, venture capitalists make lots of money. This is very different than running a business ala Warren Buffet or even Mitt Romney, let alone inventing a business like Apple or Microsoft. In return for risking funds, venture capital gets its juiciest pound of flesh when the funded business sells itself to the public, hopefully for more than it is really worth, and hopefully for a lot more than the venture capitalist risked. For that to happen, you have to create demand for whatever your fund is investing in at the moment. This is why you find VCs shedding tears at the mere thought of global warming, or telling us that the future is all about “I Robot”, or miraculous genetic “I am Legend” drugs , or “gamification” or whatever happens to make up their current investment portfolio. The problem with letting venture capital dictate humanity’s agenda is that the globe is getting warmer; people are getting poorer, sicker and dumber while a few VCs are getting richer. 
 
So what is Mr. Khosla selling us now? It seems that his machines, outfitted with “bionic” software are set to replace the 80% of “middling” doctors and also 80% of equally “middling” teachers. Only physicians like Dr. House will remain standing (for a short time) so they can be “leveraged” to create even more “bionic” software, and may I suggest that Albus Dumbledore could be used to illustrate the surviving human teachers of the bionic era. If you are a little bit familiar with the startup world, then you probably know that a business based on services provided by people is not an appealing investment gamble, because it doesn’t scale well, i.e. revenues and EBIDTA cannot go simultaneously through the roof at the same incendiary rate, because people need to be paid for labor. The trick is to find a business model where no labor is required or to find laborers who don’t require payment. A couple of centuries ago we “imported” such laborers from Africa. Today we are “exporting” labor to where those laborers naturally reside. For tomorrow, we are proposing to make machines that work for free. And this in a nutshell is Mr. Khosla’s vision. 
 
Let’s pause for a moment and address the technorati among us. This is not about medical technology for Dr. Leonard McCoy and Dr. Beverly Crusher or about the holographic doctor in Star Trek Voyager, all very awesome and super cool. This is not about stardate 43632.8 or a galaxy far far away. This is about a time frame of “five or ten years” for “bionic” software and “a decade or two” for an army of “Dr. Algorithm” practicing independently. It should be obvious even to the most ardent believers that, in such a short period of time, neither the science of medicine nor technology will be anywhere near the creation of the medical droid that administered to Padme in childbirth. However, these time frames are short enough to appear on corporate financial projections and startup pro-forma budgets. This is about real money and about some flimsy machinery deployed to play doctor to the poor (China and India are mentioned by Mr. Khosla, but the Mississippi Delta can’t be far behind), and if folks are harmed in the process, oh well…. (See below). 
 
Now, how about this “bionic” software that Mr. Khosla envisions to be a temporary bridge between human cognitive endeavor and full machine control in “a decade or two”? Turns out that the term was introduced by a <a href="http://bryce.vc/post/12600078312/bionic-software-and-programable-people" target="_blank">serial entrepreneur</a> in the social media/marketing, hotter than molten lava, sector.  Later adopted by the <a href="http://oatv.com/are.html" target="_blank">O'Reilly AlphaTech Ventures</a> folks who invest in clicks and links and data as well, “bionic” software has something to do with “programmable people” and “it has the potential to unlock a massive amount of unrealized human potential”, presumably as programmed and networked by VC funded programmers. According to <a href="http://topics.wsj.com/person/B/dennis-k-berman/1589" target="_blank">Dennis K. Berman</a>, a WSJ journalist writing about technology and “corporate scandals”, also <a href="http://online.wsj.com/article/SB10001424052970203462304577138961342097348.html#ixzz1ioOP4QRs" target="_blank">cited</a> by Mr. Khosla, we should accept the “rise of the machines” just like we accept earthquakes and hurricanes because it is simply inevitable. And if we still have any doubts regarding the superior intelligence of Jeopardy winning machines, we are reminded that “systems are now of such scale that they can analyze the value of tens of thousands of mortgage-backed securities by picking apart the ongoing, dynamic creditworthiness of tens of millions of individual homeowners. Just such a system has already been built for Wall Street traders”. I am so totally convinced now, but if you need more real life examples, you should read about the $108 million in venture funds going to “bionic” software helping pharmaceutical companies track social media activity to identify doctors more likely to influence their peers, or the $84 million venture investment in “bionic” software to spy on customers and make them buy more fatty food stuff. 
 
According to Mr. Khosla, soon we will advance beyond simplistic “bionic assistance” to “lazy” doctors, and we will no longer be “free to be stupid or political” and “reject” the “cost optimization” served by “Doctor Algorithm” in its medical practice and none of us will need those multitudes of “average” doctors stuck in the “18th century tradition of “first do no harm””. Since VCs are only interested in engineering, as opposed to social engineering, their off the cuff suggestions for the “middling” 80% in any profession or occupation, where wages are proposed to be eliminated from the expenses column, is usually something vapid like “empathy, advice and caring”. Of course “empathy, advice and caring” doesn’t pay anything like actual doctoring, and it is precisely those large wages that need to be eliminated. Highly educated professional workers are also much harder to transform into “programmable people”, like say, the young girls working in one of those infernal laptop assembly lines in China. So once the new troves of captive cheaper-than-machine labor pools have been secured, all that is left in the quest for zero COGS, within the short cash horizons of venture capital, is to eliminate those expensive and volatile knowledge workers from the balance sheet. And since Mr. Khosla’s educated estimate is that “medical diagnosis or 90% of it is an easier task than Jeopardy”, and since he urges us “not to extrapolate the past and what has or has not worked”, it should be easy as pie to imagine a future almost completely free of professional physicians, classroom teachers and non-programmable people in general. 
 
Thus, in Mr. Khosla’s hospital of the future, medicine will be practiced by thinking machines, while floor scrubbing, sheets changing and bed-pan emptying will be left to humans. Eventually, the medical machines, or the few human lords remaining, will probably take on the last yard of efficiency and create menial machines for janitorial purposes, at which point the only human beings in a hospital will be the patients in the beds, and venture capital’s ROI will be inching towards infinity. Unfortunately for Mr. Khosla, or future generations thereof, the transactional volume will be trending to absolute zero, since the “middling” 80%, after advancing to the mindless 80%, are now mostly extinct or have reverted to gathering wild berries where vegetation still remains. I hope being the Supreme Ruler of nothing at all proves to be a very satisfying experience for Khosla Ventures.</div>

A couple of weeks ago I wrote a post about the clueless, but endearing, enthusiasm of technology people as applied to solving the health...

Healthy Hearts Grants for Community Projects

12:23 AM Meme Art Studio 0 Comment

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<a href="https://www.eventbrite.ca/e/chaos-comfort-the-arts-from-long-term-impact-to-social-change-tickets-15079642617"></a></div>
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What a line-up!</h4>
Short and sweet this week, as your blogger is out of the country. More on that soon. I’m thrilled to announce some of the line-up for our free one-day event here at Manchester School of Art on the 12th February. Alongside Dr Rebecca Gordon-Nesbitt, who will be publishing her new report on the long-term health benefits of participating in the arts, we will hear from/about: 
  WordPlay with Michelle Green and Harriet Morgan-Shami  
  42nd Street with Julie McCarthy  
  Red Balloon Pop with Sandra Bouguerch 
  I Care with Kate Bevan  
  The Art Room at The Christie Hospital with Patricia Mountford 
  Medical Waste with Coral Mallow  
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJodnvCHgNygxo7XniJrlFMlr4JE8a3y4sGKfOeMxeq2xGYwyb7j8j_rryXH0AKIVLJChWgVArR1MTgUictdwws6qmr628ieZhqAuAZ9MYDWKk0hGmRbUNaeIdftTWIbngsRbg3llX9K0/s1600/photo-53.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="Healthy Hearts Grants for Community" border="0" height="297" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJodnvCHgNygxo7XniJrlFMlr4JE8a3y4sGKfOeMxeq2xGYwyb7j8j_rryXH0AKIVLJChWgVArR1MTgUictdwws6qmr628ieZhqAuAZ9MYDWKk0hGmRbUNaeIdftTWIbngsRbg3llX9K0/s1600/photo-53.jpg" title="Healthy Hearts Grants for Community" width="400" /></a>  Gemma Climbs Her Mountain Gemma Christie and Chris Salt 
  Look200 with Lucy Burscough 
  Well into Words with Julie Walker  
  Outside In with Jennifer Gilbert  
  Pool Arts and St Lukes with Alison Kershaw 
  I AM - Art as an Agent for Change and a Recoverist Manifesto 
  Mark Prest and Clive Parkinson 
The event is fully booked, but you can join our waiting list by clicking on the winter scene above. 
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<a href="http://www.bbc.co.uk/programmes/articles/3XW7FvN20PD3xr2c1T62Xly/main-grants"><img alt="Healthy Hearts Grants for Community" border="0" height="309" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi3zAxydeKwA1wUVAGjK4CcnHpWdcTJwug_DV7sQpT_PzAThXL31O7IqJZowHzHvRdrg13SAqm9_VtkFnN4oTniCCYy7VfiT8QjybEYb2HunggaXWh0aVsJPAVycDK6UBR1HpmZgEWACGM/s1600/Beatrix-Potter-aged-25-with-rabbit-Benjamin-Bouncer-18911.jpg" title="Healthy Hearts Grants for Community" width="320" /></a></div>
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BBC Children in Need Main Grant Programme</h3>
BBC Children in Need has announced that the next applications deadline for its Main Grants Programme is the 15th May 2015. Funding is available to organisations that work with young people who are suffering from: 
 Illness   Distress  Abuse or neglect  Are disabled  Have behavioural or psychological difficulties  Or are living in poverty or situations of deprivation. 
The Main grants programme is open to applications for grants of over £10,000. find out more by clicking on the image of the bizarre Ms Beatrix Potter taking her poor rabbit for a walk<a href="https://www.youtube.com/watch?v=PaG4k13R3uc" style="font-family: Verdana, sans-serif; font-size: x-small; font-style: italic;">.</a> 
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 Healthy Hearts Grants for Community Projects</h2>
Heart Research UK has announced that its Health Hearts Grants Programme is now open for applications. Heart Research UK Healthy Heart Grants support innovative projects designed to promote heart health and to prevent or reduce the risks of heart disease in specific groups or communities. Grants of up to £5,000 and £10,000 are available to community groups, voluntary organisations and researchers who are spreading the healthy heart message. The closing date for applications is the 28th February 2015. Read more by clicking on the tickety-boom-boom below. 
 
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<a href="http://heartresearch.org.uk/grants/apply-hruk-healthy-heart-grants"><img alt="BBC Children in Need Main Grant Programme" border="0" height="198" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj4KGoZCJMwlGwtbYex81J4PLza-coq8Z_6vA_nlYsna73QwsiXx7vMKRDCK31zLI5UsBI8SfFvtnbae06dfyQFo69PeLMjkBReAm0WwXS_R6U-fWXgBwSSFr5DT9cCc5f65d0GPR8xHF4/s1600/Screen+Shot+2015-02-01+at+16.42.39.png" title="BBC Children in Need Main Grant Programme" width="200" /></a></div>
 That's it for this week. Short and Sweet.                                           
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health informed consent Minority Fellowship Program workplace Healthy Hearts Grants for Community Projects

What a line-up! Short and sweet this week, as your blogger is out of the country. More on that soon. I’m thrilled to announce some of ...

You want to do what?!?! The importance of informed consent in treatment

1:35 AM Meme Art Studio 0 Comment

<div align="center" class="MsoNormal" style="text-align: center;"> </div> <div class="MsoNormal"> By Gail  A. Edelsohn, MD, MSPH<o:p></o:p></div> <div class="MsoNormal"> </div> <div class="MsoNormal"> <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjHhuvRc7UIvhMRIcBvcdxgA_oN0zE5eApDkZO4EU8KMjylM-Q-jxF5-JvxOpBMJ9VMo4C2MLobcux0BV-KNOu2F9okxMfUOVd1n_gHqs1QqoK_FBO_h_Fmww2IgivNvLI1y7NcBkOWd9X/s1600/informed+consent.jpg" imageanchor="1" style="clear: right; display: inline !important; float: right; font-family: Arial, Helvetica, sans-serif; margin-bottom: 1em; margin-left: 1em; text-align: center;"><img border="0" height="132" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjHhuvRc7UIvhMRIcBvcdxgA_oN0zE5eApDkZO4EU8KMjylM-Q-jxF5-JvxOpBMJ9VMo4C2MLobcux0BV-KNOu2F9okxMfUOVd1n_gHqs1QqoK_FBO_h_Fmww2IgivNvLI1y7NcBkOWd9X/s1600/informed+consent.jpg" width="200" /></a>We come across ads in print, on television and on the Internet for medications and therapies that promise to make your child do his homework without a screaming match, behave better and generally restore harmony to home life. Not so easy, taking a medication raises a host of questions:  How long does the therapy take? Should I as the parent sign off on this? What about the possible serious side effects, such as significant weight gain, thoughts about suicide, risk of diabetes or a life-threatening condition?</div> <o:p></o:p> <div class="MsoNormal"> <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiv0DIfWlmYXutfyUNRrRoKyogzPi_GXrRhyphenhyphenGXtSpQcAHCz6gtYWPFfLKwIt-R-16dWXylPxUfUTWGb2CSIk6OtTdFqIll9TpVE79xg3mqcP29K18CI4h7dTfzVrVjkV_76NY_XSbcEiSWZ/s1600/African+American+family.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="" border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiv0DIfWlmYXutfyUNRrRoKyogzPi_GXrRhyphenhyphenGXtSpQcAHCz6gtYWPFfLKwIt-R-16dWXylPxUfUTWGb2CSIk6OtTdFqIll9TpVE79xg3mqcP29K18CI4h7dTfzVrVjkV_76NY_XSbcEiSWZ/s1600/African+American+family.jpg" title="" width="134" /></a>Parents and legal guardians make decisions about psychosocial therapy and medication treatment for children and adolescents every day. But who should give permission and sign informed consent?  What should parents, advocates, guardians be looking for or consider before signing informed consent? Is signing a form enough?  What about the child or teen - do they have a voice regarding their own treatment?<o:p></o:p></div> <div class="MsoNormal"> What is Informed Consent?</div> <div class="MsoNormal"> Psychiatric informed consent involves a parent or legal guardian giving permission for his/her child to undergo evaluation and treatment.  It is a process which partly involves receiving sufficient relevant information about the condition, prognosis, risks and benefits of treatment to be given and other types of treatment available. Informed consent is NOT simply a signed and dated form. Parents and guardian should expect informed consent to include<s>:<o:p></o:p></s></div> <div class="MsoListParagraphCxSpFirst" style="text-indent: -0.25in;"> <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-JeluYpVp8Eur1f6a04-6KMoPSPizt-vsp7J9lMlTgMUHkjEJlmcvIZi0BN7teGNdsuwY1RNe62ffnOcp9qwobl0l-H4l_n-hH4ih89dg68ofujVDgXqOUx4rca62amVGULAdzYDBg5op/s1600/father+&+boy.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="115" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-JeluYpVp8Eur1f6a04-6KMoPSPizt-vsp7J9lMlTgMUHkjEJlmcvIZi0BN7teGNdsuwY1RNe62ffnOcp9qwobl0l-H4l_n-hH4ih89dg68ofujVDgXqOUx4rca62amVGULAdzYDBg5op/s1600/father+&+boy.jpg" width="200" /></a> </div>   The purpose of the treatment <ul> <li>To address a specific condition or diagnosis?</li> </ul> <ul> <li>To lessen symptoms?</li> </ul> <ul> <li> To change behaviors?</li> </ul>   The effects of treatment <ul> <li>How will you know if it is working?</li> </ul> <ul> <li> How long till you see an effect?</li> </ul>   Risks of treatment <ul> <li>Side effects of medications</li> </ul> <ul> <li>Consequences of psychosocial treatment (e.g., therapy can be emotionally difficult)</li> </ul>   Risks of NO treatment <ul> <li>Will symptoms improve over time without treatment?</li> </ul> <ul> <li>Will things get worse or lead to other consequences? (e.g., Untreated individuals are more likely to use substances, get into legal trouble)</li> </ul>   What alternative treatments are available?    For medication <ul> <li>Is it FDA approved for this age and condition? (i.e., prescribed FDA on label)</li> </ul> <ul> <li>If it is prescribed off-label, why?</li> </ul> <ul> <li>Are there any FDA warnings about the medication and what do they mean?</li> </ul> <ul> <li>What is the plan for stopping or phasing out the medication?</li> </ul> <div class="MsoListParagraphCxSpMiddle" style="margin-left: 1in; text-indent: -0.25in;"> <o:p></o:p></div> <div class="MsoListParagraphCxSpMiddle" style="margin-left: 1in; text-indent: -0.25in;"> <o:p></o:p></div> <div class="MsoListParagraphCxSpMiddle" style="margin-left: 1in; text-indent: -0.25in;"> <o:p></o:p></div> <div class="MsoListParagraphCxSpMiddle" style="text-indent: -0.25in;">      Parents and legal guardians are asked to give legal permission or informed consent for treatment.  If a child is in foster care, it may be the parent or it may be child welfare service or court that can give consent.   Where a child is living (home, out of home placement) does not tell you who the legal guardian is.  In some states an adolescent may give informed consent for psychiatric treatment depending on the state’s legislation about mental health procedures. Ideally the parents/guardians and the child should be involved in treatment decision making.</div> <div class="MsoNormal"> Children also have a voice in this process.  Children and youth should be involved in giving assent.  Assent involves providing the child or teen with information about the therapy or medication in terms appropriate to their age and stage of development. The assent process should include opportunities for the child/adolescent to ask questions and have their concerns addressed.<o:p></o:p></div> <div class="MsoNormal"> Gail A. Edelsohn, MD, MSPH, is senior medical officer with Community Care Behavioral Health, clinical professor of psychiatry and human behavior,  Jefferson Medical College, and clinical professor of psychiatry and behavioral science, Temple University School of Medicine.</div>