Human Understanding, Randomness, Free Will, and Delusion – Part V

Kent Bottles

Posted 3/17/12 on Kent Bottles Private Views

I am just as tired of this five-part blog post as you are. That is assuming anyone has bothered to read all five parts (one of my twitter followers nicely tweeted that he liked my posts, but enough already with this particular post that seems to be going on forever). I am happy to announce that this is the final installment. I am unhappy to announce that the seventeen really smart people whose writings I have read for Parts I through IV really have not been able to answer my simple question, “What is going on in the world of Kent Bottles.” The seventeen experts who have accompanied me on this journey so far are: Tom and Ray Magliozzi, Nikoli Tesla, Misha Angrist, Ricki Lewis, Jackie Fenn, Mike Gazzaniga, Kurt Godel, Edmund Gettier, John Barrow, Karl Popper, Francis Crick, Raymond Tallis, Terrence Dean, Benjamin Libet, Tim Crane, and Robert Laughlin.

In Part V of our exploration, we have to deal with one more really smart person and one really dumb person.

The really smart person, whose views I do not always agree with, is Donald Rumsfeld, the youngest and oldest person in the history of the United States to hold the position of Secretary of Defense. Rumsfeld is famous for many things, but I want to focus on his classification of knowledge: known knowns (things we know to be true), known unknowns (things we know we don’t know), and unknown unknowns (things we are unaware that we don’t know).(http://www.youtube.com/watch?v=GiPe1OiKQuk)

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Human Understanding, Randomness, Free Will, and Delusion Part IV

Kent Bottles

Posted 3/16/12 on Kent Bottles Private Views

In many ways this long and meandering four-part blog post is entirely Michael S. Gazzaniga’s and Benjamin Libet’s fault. We have already met Gazzaniga and his left-brain interpreter theory that resulted from studying split-brain patients who underwent surgery to treat epilepsy. Gazzaniga has explored what these studies mean in several books, all of which are written in a way that the layperson can understand. David Wolman has recently published in Nature a nice overview article that would be a good place to start for someone just starting to grapple with their brain’s inherent need to explain things, even when the brain does not have a clue as to what is really going on (http://www.nature.com/news/the-split-brain-a-tale-of-two-halves-1.10213)

As shocking as my brain’s need to confabulate to make sense of a world that increasingly makes no sense is the work of Benjamin Libet of UCSF who stimulated the brain of an awake patient undergoing surgery; he discovered a time lapse between stimulating the cortex that represents the hand and when the patient signaled they were conscious of sensation in the hand. In more recent studies, John-Dylan Haynes showed that the outcomes of an inclination can be encoded in brain activity up to 10 seconds before the patient is conscious of it. Chung Siong Soon also expanded Libet’s work when he showed that regions in the cortex associated with voluntary movement lit up on fMRI scans five seconds before the subject was aware of making a choice. Song concluded that a network of control areas in the brain “begins to prepare an upcoming decision long before it enters awareness.” This phenomenon has been labeled Bereitschaftspotential, which I cannot pronounce, or readiness potential, which is easier for me to say. Gazzaniga summarizes the staggering implications of these experiments:

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Human Understanding, Randomness, Free Will, and Delusion: Part III

Kent Bottles

Posted 3/12/12 on Kent Bottles Private View

In this exercise I am trying to understand what is going on in my world. Car Talk with the Magliozzi brothers is popular with 4 million listeners because they attempt to fix real world problems that callers have with their cars.Genomics, proteomics, and gene therapy have captured the attention of the public and science journalists because they attempt, so far with limited success, to move us from diagnose and treat to predict and prevent which should help us lead longer and more satisfying lives. In Part I and Part II, we saw that even experts like Ray and Tom Magliozzi sometimes are stumped and that science does not always deliver what I desperately need and want: a clear and truthful understanding of what is going on in my world.

Neuroscience and evolutionary psychology are fascinating subjects to read and claim to provide a framework to give me what I want. The natural sciences claim to give an explanation for everything in my world, including me as a human being. However, the explanation the scientists offer clashes with my understanding that I am a conscious person who has a coherent and unified self that is capable of exercising free will. I am a little worried that my left-brain interpreter is making up this story, but that is how I feel.

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Human Understanding, Randomness, Free Will, and Delusion Part II

Kent Bottles

Posted 3/10/12 on Kent Bottles Private Views

In Part I we explored how human beings jump to conclusions when they think they understand reality. This usually occurs when the explanation makes sense, and all of us tend to generate reasons why things are the way they are. It makes sense that understanding our genome would allow us to predict what diseases we are predisposed to developing and to try to do something to avoid getting the disease. Predict and prevent make sense. It makes sense that gene therapy should work because it is so logical and understandable. If you replace the defective gene with the correct gene you should cure the disease.

Why do we humans assume we have the capacity to understand reality?

“This what our brain does all day long. It takes input from other areas of our brain and from the environment and synthesizes it into a story.”

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Human Understanding, Randomness, Free Will, and Delusion Part I

Kent Bottles

Posted 3/10/12 on Kent Bottles Private Views

Just because something makes sense does not mean it explains reality. And yet we are always trying to make sense of a world that scientists increasingly believe is totally random. And if the world is totally random, why do I think I have free will?

I usually do not listen to Car Talk, but I did happen to be driving in Gladwynne when Sally of North Salem, New York proclaimed, “I stumped the Car Talk guys.” Their immediate response is important. One brother said, “No, we do not have any experience with it. We haven’t given you an answer, but we will.” The other brother chimed in, “It doesn’t mean we don’t have an answer.”

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Topol & Agus on the Future of Medicine

Kent Bottles

Posted 2/10/12 on Kent Bottles Private Views

Speaker after speaker at the January 26, 2012 Care Innovations Summit in Washington, DC concluded that increasing the quality and decreasing the per-capita cost of health care is the dominant political, social, and economic issue of our time. More than one expert called for a “jailbreak.” Before January 26, “jailbreak” for me meant either an obscure English reality television show or an expression applied to overriding the software limitations deliberately placed on computer systems for security or administrative reasons. The speakers in DC seemed to be calling for a jailbreak out of the prison of the status quo of the American health care delivery system and into an era of digital medicine and understanding the ill patient as a complex emergent system that does not need to be fully understood to be cared for.

Two new books make the case that American medicine is at an inflection point and about to undergo “its biggest shakeup in history.” Eric Topol, MD in The Creative Destruction of Medicine:How the Digital Revolution Will Create Better Health Care (New York: Basic Books, 2012) is no fan of the traditional approach which he labels as “conservative to the point of being properly characterized as sclerotic, even ossified.” David B. Agus, MD in The End of Illness (New York: Free Press, 2011) applies systems biology to his field of oncology and concludes: “Cancer is not something the body has or gets; it’s something the body does.”

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Notes on the Care Innovation Summit

Kent Bottles MD

The Care Innovation Summit, Washington, DC, January 26, 2012

Sponsored by CMS, West Wireless Health Institute, and Health Affairs

Anyone who is concerned about the future transformation of the United States clinical delivery system should pay attention to the Care Innovations Summit. The selection of presentations as well as the content that was discussed says volumes about where CMS believes payment is headed. Speaker after speaker stated that decreasing the per-capita cost of health care and increasing the quality patients receive is the dominant political, social, and economic issue for all Americans.

Marilyn Tavenner, the new Acting Administrator for the Centers for Medicare and Medicaid Services, outlined what she saw as the major accomplishments of the past few years. Her list included providing partial relief for 3.8 million seniors who hit the prescription drug “doughnut hole,” creating high risk pools for 45,000 Americans, creating a consumer website, allowing young adults to stay on their parents’ health care insurance until age 26, eliminating denial of coverage for patients with pre-existing conditions, eliminating lifetime and annual health care insurance maximums, increasing the coverage of many prevention measures, creating pilots to explore how to base payments on quality not volume, and getting the Innovation Center up and running.

Atul Gawande, MD, the Harvard surgeon and New Yorker author, presented the morning keynote. Gawande, the author of three books on health care (Complications, Better, and The Checklist Manifesto), said the “cost of health care is destroying the American dream.” In Massachusetts the state government sent nearly a billion dollars to local schools to pay for smaller class sizes and better teachers’ pay, but every dollar was diverted to covering higher health care costs. For each dollar added to school budgets, the costs of teacher health benefits took a $1.40.

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Health Hackers and Citizen Scientists Shake Up Medical Research

Kent Bottles

Posted 12/05/11 at Kent Bottles Private Views

Whether you call it Health 2.0, Medicine 2.0, or e-Health 2.0, the Internet is changing medicine in ways that challenge the status quo. This article explores how a group of amateurs who call themselves “health hackers” and “citizen scientists” are trying to use the Internet to connect with other patients, run experiments, and conduct clinical trials on their own diseases.

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Physician Executives Should Support Patient Engagement/Activation

Kent Bottles

Posted 10/18/11 on Kent Bottles MD Private Views

The doctor/patient relationship is certainly changing and evolving. A term I hear a lot today is:“patient engagement/activation.” Why is this concept so important and what does it mean? What can physician executives do to make it easier for our patients to become engaged and activated?

Judith Hibbard has pioneered the study of patient engagement, and she noted that one needs knowledge, skills, and emotional support to actively engage in one’s health care. She identified four behaviors associated with engagement and activation:

Self management
Collaboration with provider
Maintaining function/preventing declines
Access to appropriate and high quality care

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Reverse Innovation & The Cost Crisis of American Healthcare

Kent Bottles

First posted 9/10/11 on Kent Bottles Private Views

The realization that the American health care system must simultaneously decrease per-capita cost and increase quality has created the opportunity for the United States to learn from low and middle-income countries. “Reverse innovation” describes the process whereby an inexpensive innovation is used first in countries with limited infrastructure and resources and then spreads to industrialized nations like the United States.

The traditional model of innovation has involved the creation of high end products by companies in industrialized nations and the spread of these products to the developing world by adapting them to function in low and middle-income countries. Reverse innovation reverses the direction of spread with the United States borrowing new ideas and products designed for less wealthy countries in order to deliver health care more efficiently. (1)

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Avatars, Computers and Robots Are Coming To Primary Care

Kent Bottles

First posted 8/19/11 on Kent Bottles Private Views

Within in five years primary care providers will begin being replaced by sociable humanoid robots, avatars, and computer programs. Within ten years you will no longer hear any complaints about medical students choosing specialty residencies over family practice because the role of the physician will be completely redefined to complement a rules based approach to the diagnosis and treatment of many diseases. This transformation is inevitable because of demographics, economics, and progress in artificial intelligence, but the academic leaders of medical education and health policy are largely ignorant and unprepared for this massive disruption.

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The Department of Human Nature: The Pervasive Sins of Doctors and Others

Kent Bottles

First posted on 7/19/11 on Kent Bottles MD Private Views

The essence of professionalism is to be constantly striving to take better care of our patients. “The aspiration to do better, coupled with commitment and a sense of personal responsibility will drive knowledge seeking” and empathy and compassion for those who are our patients. And yet we know that during medical school students become less compassionate and less altruistic; the largest drops in empathy have been documented between the beginning and the end of the first year and between the beginning and end of the third year of education.

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Not Everything in Health & Wellness Can Be Reduced to a Single Number

Kent Bottles

First posted 6/26/11 on Kent Bottles’ Private Views

“To measure is to know.” Lord Kelvin

“If you can not measure it, you can not improve it.” Lord Kelvin

Vs.

“Asking science to explain life and vital matters is equivalent to asking a grammarian to explain poetry.” Nassim Nicholas Taleb

“Technology is at its best when it is invisible.” Nassim Nicholas Taleb

How can technology help us live healthier lives? Why did Google Health fail? Why are Klout and Twitter Grader publicly issuing a number to me by name about how influential I am? What do Lord Kelvin and Nassim Nicholas Taleb have to teach us?

I was taught in medical school and pathology residency that health was defined as absence of disease; this definition pleased me because not much important could happen to the patient until I peered into my microscope and rendered a diagnosis. I looked up to Virchow and Rokitansky who were the most important and influential physicians in the most advanced medical centers in the 19^th century.

In the mid-20^th century the World Health Organization (WHO) famously stated: “Health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or injury.”

“The dialogue between Asclepios, the god of medicine, and Hygieia, the goddess of health – the external intervention and the well-lived life – goes back to the beginning. Only in the twentieth century did the triumph of ‘scientific’ modes of inquiry in medicine (as in most walks of life) result in the eclipse of Hygieia. Knowledge has increasingly become defined in terms of that (and only that) which emerges from the application of reductionist methods of investigation.”

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Why I Am an Information Flaneur

Kent Bottles

First published 6/13/11 on Kent Bottles Private Views

While reading the New York Times Sunday Book Review (in a hard copy format that got my fingers dirty with ink) I came across this quotation in a Evgeny Morozov book review of The Filter Bubble by Eli Pariser:

[Citizens] should not be content as mere passive recipients of tweets, pokes and bytes; they should aspire to become what some Internet scholars call “information flâneurs,” treading the unbeaten paths in cyberspace and defying the narrow categories stealthily assigned to them by Web services.

Here is a video of Eli Pariser discussing the filter bubble.

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