War Elephants of Healthcare

The war elephant was the heavy artillery tank of antiquity. Some of history’s greatest empires, from the Carthaginians of North Africa to the Mauryans of India, utilized the war elephant to devastating effects.

But for all their strengths, the war elephant had one fatal flaw – it was unable to confront uncertainty. Daring soldiers would approach with torches most elephants have never seen or produce unfamiliar, raspy sounds to frighten the animal – with surprising effectiveness.

In the end the uncertainty overcame the strength of the war elephant. And what appeared as an insurmountable weapon of war deteriorated into an unwieldy beast, as capable of exacting self-inflicted wounds as casualties to the enemy.

This is the nature of uncertainty, capable of transforming perceived strengths into actual weaknesses when approached by something new or unfamiliar.

Something many of us experienced during the COVID-19 pandemic. Uncertainty crippled massive healthcare systems into debt ridden organizations living and dying through government aid. It destroyed the belief that patients will always seek care, whether in good times or bad. And it eroded trust in federal healthcare institutions that long served as the voice for healthcare public policy.

Uncertainty is an inescapable reality of healthcare that we have largely ignored, until we could no longer afford to. The impact of the pandemic became too much to bear. And if we are to truly implement the lessons learned from the pandemic towards the future of healthcare, then we need to integrate frameworks of uncertainty into healthcare.

But healthcare is already rife with frameworks. You could even say the field has too many frameworks already. Whether it is creating protocols for patient care, or designing algorithms to streamline clinical decision-making for routine patient care, healthcare – more often than not – has a framework for most situations.

But it is a framework for the unfamiliar, unknown situation that can add the greatest value. Whether it is a protocol to handle uncertainty, or a database for reporting unknown presenting symptoms, we need to systematize the reporting and management of uncertainty.

This requires a shift in culture. Not unlike the shift towards acknowledging and reporting errors. For decades, healthcare had created a culture of Darwinian, intellectual competitiveness. In which an error was seen as a sign of weakness, or of a weak mind that, conceivably, a smarter physician or nurse would not have made. Yet instead of eliminating errors, this culture simply swept errors under the table, denying their presence altogether.

But once committing an error became culturally acceptable, we began to find errors more easily, and address them more effectively.

Uncertainty is not much different from errors. It is simply a matter of semantics. Uncertainty produces errors, as errors come from situations in which what is unknown exceeds what is known, and the uncertainty overwhelms the decision-making – leading to a wrong decision.

In this manner, uncertainty can be seen as a cause for many errors. And if we are acknowledging errors to be inherent in healthcare, then we should acknowledge uncertainty to be inherent in many decisions that lead to healthcare error.

Study uncertainty as a discipline within healthcare much like it is studied in engineering. Most engineering fields acknowledge error and have developed sophisticated risk and error minimization frameworks which acknowledge uncertainty. And by acknowledging uncertainty, engineers optimize it.

In healthcare we do not even acknowledge uncertainty. As a result, we have no means to optimize it. If we encounter a patient with fatigue, pale composure, and dizziness, then we may reflexively consider anemia as a possible diagnosis and initiate a work up that involves drawing lab values such as serum hemoglobin. Depending on the acuity and severity of the symptoms, we may consider a cardiovascular or neurovascular work up for a heart attack (myocardial infarction) or a stroke, respectively.

We use the uncertainty of the symptoms, balancing the acuity, severity, alongside the constellation of symptoms to determine what course of action to take. This line of thinking predisposes to action, meaning we address uncertainty incrementally, trying to eliminate it by ordering test after test, imaging after imaging.

Some is good, more is better. But whatever we do, we tend to overdo.

The problem is that we never actually address the uncertainty. We merely wish it away by ordering and testing, hoping we understand the presenting symptoms well enough to know what the treatment should be.

Most of the time, this approach actually works. But in those rare moments when it does not work, we will find ourselves confronting a war elephant of healthcare. A situation in which the uncertainty overwhelms what we think we know.

The rare moment when the blood work and imaging work up produces something other than anemia or some cardiovascular or neurovascular disease. The rare moment when what we assume to be true or certain is anything but that.

Those are the moments when we need to rely on frameworks of uncertainty to standardize our approach to what we do not know. Every aspect of healthcare has established standards of care through which we think through an issue – a presenting set of symptoms, a public policy issue, or a hospital guideline.

These standards structure clinical thinking to eliminate uncertainty overtime decision over decision, which mostly has worked quite effectively. Until they do not. Until we meet a war elephant.

We need to add provisions in these standards and protocols to account for uncertainty. Make uncertainty an acceptable aspect of real-time decision-making in healthcare, and not a last resort default when all other viable options have been exhausted.

Many forward thinking medical schools train students to think about the cost-effectiveness of ordering a test or an imaging study, balancing the value of a test or study relative to its cost – as an opportunity cost. We can easily incorporate uncertainty into a comparable opportunity cost framework. Openly discuss the perceived value of ordering something or taking some action relative to the uncertainty addressed through that order or action.

From that shift in perspective, we can create new frameworks or modify existing frameworks that encourage us to think in terms of uncertainty. And embrace it as an integral part of healthcare.

So we will be ready for the war elephants of healthcare.

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Vaccine Passports: what we need to know

The COVID-19 pandemic has killed more than half a million people in the US and has seriously impacted our daily lives. The granting of Emergency Use Authorizations for COVID-19 vaccines has been a game changer in helping to reverse the pandemic onslaught. Demand for the vaccines currently far exceeds supply nationwide. They have become the golden ticket that can transport us back to a time when routine activities, such as attending school or taking vacations, didn’t seem fraught with danger. What’s the best way to go about re-establishing these activities? One idea that’s getting discussed seriously is giving those who have been immunized a vaccination passport (VP).

What is a vaccination passport?

Let’s start by clarifying some terminology. VPs are documents that show that someone has been given a vaccine(s) and is therefore presumed to be immune from getting and sharing that disease. These are distinct from diagnostic tests to determine if a person is or is not infected with a particular virus (PCR and viral antigen tests) or has been exposed to a virus (antibody tests). VPs are the modern day equivalents of the “letters of transit” that played a key role in the film Casablanca. They’ll enable you to travel freely.

Why give vaccine passports?

Vaccinated people are unlikely to transmit the virus that causes COVID-19 with others, though this has yet to be definitely proven. So, what’s the primary rationale for giving vaccination passports? It seems the goal is to incentivize people to get vaccinated. Folks might be more likely to seek out the vaccine if it bestows upon them certain privileges, such as being able to travel freely. While the idea might sound appealing at one level, the road to vaccine passports is pockmarked with political potholes and littered with logistical land mines.

Administrative issues

There are a lot of important questions that need to be answered before VPs can become widespread; it’s unlikely there will be a “one size fits all” solution. What might VPs look like? Pieces of paper (that could easily be lost or counterfeited), or a digital key or document you store on your smartphone (that many older folks still don’t have)? If you lost one, how would you get it replaced? Would your vaccination records be tied to your other medical records, and if so, what kind of privacy and security protections would be needed to safeguard your data? How would the passport administrator verify that you got vaccinated in the first place? Who is responsible for correcting any errors that crop up? Given how much we’ve struggled as a nation to simply solve the scheduling of vaccinations, VPs might be significantly more difficult to manage.

Who’s going to run the program?

A coalition of health tech leaders (including Epic, the Mayo Clinic, Microsoft and Salesforce) has started the Vaccination Credential Initiative to create an internationally accepted digital health card. Its vision – as stated on its website – is “to empower individuals to obtain an encrypted digital copy of their immunization credentials to store in a digital wallet of their choice. Those without smartphones could receive paper printed with QR codes containing World Wide Web Consortium (W3C) verifiable credentials.” Some European countries (e.g. Denmark) are working on developing their own immunization passports, and the President of the European Union Commission has voiced support for them.

We already have a hodgepodge system designed to keep folks with COVID-19 from traveling. Many airlines are requiring proof of non-infectivity to board a plane – these are distinct from VPs. The methods adopted vary from airline to airline: United uses Travel Ready Center, American uses VeriFly while others use Common Pass. Saga cruises are the first in the UK to demand proof of vaccination, but not everyone is on board with the concept. The World Travel and Tourism Council stated its opposition to allowing travel only by those who have been vaccinated, on the grounds that it is discriminatory.

Discrimination concerns

The concept of gaining advantage from one’s immunological status is not a new one. In New Orleans in the mid 19th century, great economic value was attached to those who survived the onslaught of epidemic waves of yellow fever. A mix of structural racism and a system valuing “immunocapital” ranked men and women highly if they were yellow fever survivors. Those that had not had the disease yet found it difficult to obtain work or obtain credit and women could not marry. Slaves were similarly revalued, with larger assessments attached to survivors. This legacy of viral discrimination casts a long shadow over current discussions surrounding vaccination passports.

Also problematic is the fact that not everyone will be eligible for VPs. Some people can’t be vaccinated for medical reasons but would still like to participate in whatever activities the passports enable (such as travel opportunities). These individuals will likely file complaints if they are denied VPs, arguing that they’re discriminatory in nature. Vaccine opponents will no doubt also file lawsuits seeking to block the use of VPs, claiming they represent an attack on their freedoms and personal choice.

Others may be shut out of VP programs because they don’t have the computer skills to register online, a problem that’s turned out to be widespread with the vaccinations. Don’t have any ID? In some places this prevents the most vulnerable from getting the COVID-19 vaccine, and therefore VPs as well. Many Black and marginalized communities are already deeply suspicious of the medical establishment, and wary of receiving a COVID-19 vaccine. Restrictions that prevent these groups from participating in various societal activities because they don’t have VPs will echo the Jim Crow days of poll taxes and literacy tests that were required to vote.

Enforcement issues

VPs bring up a similar issue as mask mandates: who is going to enforce them? It is one thing for a cruise line to do so, since reservations are required and extensive paperwork needs to be filled out in advance. Who is going to keep non-vaccinated people out of restaurants or concerts that require proof of vaccination? We’ve already seen anti-maskers storm department stores, ignore requirements to wear masks on planes and even kill a security guard who confronted them.

Black market for vaccine passports

Many airlines are now requiring proof of a negative COVID-19 test before they will let their customers fly. This has led to a black market for fake negative COVID-19 test results for those who are looking to game the system. Similarly, bogus cards claiming that the cardholder was exempt– for medical reasons – from having to wear a mask, have been manufactured and distributed. It’s not hard to imagine that a similar market will emerge for VPs.

Overcoming vaccine hesitancy

Given the multitude of issues and concerns listed above, moving forward with issuing vaccination passports seems highly problematic. If the primary purpose of having VPs is to drive up immunization rates, that can be better accomplished by running public service announcements and ads illustrating how liberating it is to start doing normal activities once vaccinated. A nationwide campaign to do just that is already in the works. I personally can think of a better use for the time and money that will be spent on establishing VPs: use them to focus efforts on overcoming vaccine hesitancy in concert with combatting the high tide of online vaccine misinformation and disinformation.

Source: Technology Networks

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