Monday, January 15, 2018

"Hot Spot For User Entry Error": Hawaii missile alert: How one employee ‘pushed the wrong button’ and caused a wave of panic

A short post.

I believe this WaPo story vividly demonstrates issues I've seen in what Australian colleague Dr. Jon Patrick & I call "bad health IT." 

We came up with the simple-to-comprehend terminology "Good health IT/Bad health IT" in his living room in Sydney after my presentation to the Health Informatics Society of Australia in 2012 on health IT trust (, to replace my earlier terms "health IT done well" vs. "done poorly."

It was not just "one employee who pushed the wrong button."  A team of apparently incompetent IT personnel and utterly incompetent IT managers - completely devoid of any understanding of human-computer interaction - were, in essence, standing behind this this employee and guiding his hand.

The Hawaii mishap vividly demonstrates bad IT in the most critical of settings - badly conceived, designed & implemented, lacking appropriate safeguards, usually by people who do not know the domain, and often who are, dare I say, lacking common sense.

Questions that the incident raises include:
  • How [in God's name] were such critical items as "Test missile alert" and "Missile alert" (the real thing) residing in the same menu?  Who came up with such bad, terse labeling as well?  [A "hot spot" for user entry error] 
  • Why were there no reasonable safeguards? 
  • Why was it easy for anyone to make a big mistake?
  • Why was no system in place for rapid retraction?

The answers translate back to - well, I probably don't need to say it.

Hawaii missile alert: How one employee ‘pushed the wrong button’ and caused a wave of panic
Washington Post

... Around 8:05 a.m., the Hawaii emergency employee initiated the internal test, according to a timeline released by the state. From a drop-down menu on a computer program, he saw two options: "Test missile alert" and "Missile alert."

This is  a classic example of what can be called a "hot spot for user entry error."

... He was supposed to choose the former; as much of the world now knows, he chose the latter, an initiation of a real-life missile alert.

... "Based on the information we have collected so far, it appears that the government of Hawaii did not have reasonable safeguards or process controls in place to prevent the transmission of a false alert," Pai said in a statement.

... Part of what worsened the situation Saturday was that there was no system in place at the state emergency agency for correcting the error, Rapoza said...."In the past there was no cancellation button. There was no false alarm button at all,"

.... "Part of the problem was it was too easy - for anyone - to make such a big mistake," Rapoza said. "We have to make sure that we're not looking for retribution, but we should be fixing the problems in the system.

It would not be unreasonable to predict that U.S. armed forces were put on alert, perhaps even scrambling fighter planes near the Korean peninsula - moves that other countries could detect.

This "mishap" could have caused N. Korea or other hostile country to react, and led to catastrophe.

The utterly incompetent IT personnel and their utterly incompetent managers who birthed such a cornucopia of IT atrocities should be severely punished.

-- SS

Jan. 16, 2018.  Update, update.  Who's got the button?

This new WaPo story shows the "unholy" menu - a jumbled mess.

Was this designed by an expert in human-computer interaction?  I think not...


-- SS

Sunday, January 14, 2018

How To Challenge Health Care Corruption Under a Corrupt Regime?

Introduction: the Corruption of Health Care Leadership as a Major Cause of Health Care Dysfunction

For a long time we have argued that health care corruption is a major cause of health care dysfunction.  As we wrote in August, 2017, Transparency International (TI) defines corruption as

Abuse of entrusted power for private gain

In 2006, TI published a report on health care corruption, which asserted that corruption is widespread throughout the world, serious, and causes severe harm to patients and society.
the scale of corruption is vast in both rich and poor countries.

Corruption might mean the difference between life and death for those in need of urgent care. It is invariably the poor in society who are affected most by corruption because they often cannot afford bribes or private health care. But corruption in the richest parts of the world also has its costs.

The report got little attention.  Health care corruption has been nearly a taboo topic in the US, anechoic, presumably because its discussion would offend the people it makes rich and powerful. As suggested by the recent Transparency International report on corruption in the pharmaceutical industry,
However, strong control over key processes combined with huge resources and big profits to be made make the pharmaceutical industry particularly vulnerable to corruption. Pharmaceutical companies have the opportunity to use their influence and resources to exploit weak governance structures and divert policy and institutions away from public health objectives and towards their own profit maximising interests.

Presumably the leaders of other kinds of corrupt organizations can do the same. 

When health care corruption is discussed in English speaking developed countries, it is almost always in terms of a problem that affects somewhere else, mainly  presumably benighted less developed countries.  At best, the corruption in developed countries that gets discussed is at low levels.  In the US, frequent examples are the "pill mills"  and various cheating of government and private insurance programs by practitioners and patients.  Lately these have gotten even more attention as they are decried as a cause of the narcotics (opioids) crisis (e.g., look here).  In contrast, the US government has been less inclined to address the activities of the leaders of the pharmaceutical companies who have pushed legal narcotics (e.g., see this post). 

However, Health Care Renewal has stressed "grand corruption," or the corruption of health care leaders.  We have noted the continuing impunity of top health care corporate managers.  Health care corporations have allegedly used kickbacks and fraud to enhance their revenue, but at best such corporations have been able to make legal settlements that result in fines that small relative to their  multi-billion revenues without admitting guilt.  Almost never are top corporate managers subject to any negative consequences.

While we at Health Care Renewal have written about this for years, we saw little improvement.  However, in the past few years we began to feel a little more encouraged.  For example, we had long complained that US law enforcement had not been devoting enough effort going after the corruption of the leadership of large health care organizations, thus effectively allowing these leaders' impunity. However, the US Department of Justice during the Obama administration made some modest attempts to decrease such impunity.  One such measure was the formation of a Health Care Corporate Strike Force.

As reported by,

the strike force was created in the fall of 2015, with five dedicated lawyers working on about a dozen of the most complex corporate fraud cases in the health care space.

Andrew Weissmann, the then-chief of the DOJ’s fraud section, told a health care conference in April 2016 that the section was placing 'a heightened emphasis' on corporate health care fraud investigations. He pointed to the recently established Corporate Fraud Strike Force that he said would focus resources in investigation and prosecution of larger corporate health care law violations, as opposed to smaller groups or individuals.

Unfortunately, that strike force was downsized by the Trump administration as we noted in July, 2017.  Perhaps that could have been viewed as just a minor setback.

Yet as the year wore on, it became obvious that the corruption was becoming an even bigger problem.  In fact, it was becoming even more systemic, and worse, it appeared that the administration itself was fundamentally corrupt.

The Systemic Corruption of the Trump Regime

In December, 2017, the Los Angeles Times published a list by Adam Johnson of the "top 10 under-coverd news stories of 2017."  His third entry was:

3. President Trump's unprecedented non-Russia corruption

Time will tell the extent of President Trump’s connection to Russian officials and how it may or may not have influenced his campaign but — regardless — Trump has led the most nakedly corrupt administration in modern American history, enriching himself, his family and his friends and hiring a Cabinet of political cronies and billionaires. Many journalists have done great work revealing this corruption, but these stories have not turned into full-blown scandals, let alone harmed the president.

The article used as a source a website, entitled "Tracking Trump's Conflicts of Interest" published by the Sunlight Foundation.  It includes a spreadsheet of literally hundreds of conflicts.

In January, 2017, Washingon Monthly published two related articles on President Trump's conflicts of interest and corruption.  The first was "Commander-in-Thief," which categorized Mr Trump's conflicted and corrupt behavior.  The second, "A Year in Trump Corruption," was a catalog of the most salient cases in these categories in 2017.

Commander-In-Thief opened with this explanation,

official Washington has tolerated an entire other class of corrupt and potentially unconstitutional behavior being carried out in plain sight, as Trump uses the presidency to enrich himself and his family. He has installed immediate relatives at the helm of the Trump Organization, continued to accept payments from foreign governments and private interests, and lavishly billed the government for using his own properties—all without guaranteeing that he will prioritize his duties as president over his own bottom line.

No president ever entered office with the type of immense personal fortune and ongoing business interests that Trump has. Trump’s vast business empire spans more than 500 companies in twenty-five countries and has earned him an estimated net worth of $3.1 billion. Traditionally, on taking office, presidents have placed their assets in a “blind trust” whose trustee is legally barred from telling the beneficiary about the trust’s holdings. Jimmy Carter famously placed the family peanut business into a blind trust in 1977. Ronald Reagan, George H. W. Bush, Bill Clinton, and George W. Bush all followed suit.

Trump’s trust agreement is a little different. For one thing, it’s not blind—Trump’s children have admitted to providing their father with regular business updates. For another, the agreement allows him to withdraw profits and assets from the trust at any time. That means Trump has a direct and ongoing financial interest in any policy decision that could affect his businesses.

Much of this has happened in broad daylight. The mainstream media has covered Trump’s conflicts doggedly. But the steady drip-drip-drip of evidence hasn’t captured the public’s attention like Russia has, or motivated any serious response by the government—no investigations are under way, either in Congress or the executive branch. This despite the fact that the infractions raise the same terrifying possibility as Trump’s possible collusion with Russia: the sacrificing of American interests in the service of the president’s personal gain.

[the Trump Chicago, an example of Mr Trump's vast business empire]

The article noted that at the time of publication,

The only active effort to investigate Trump’s profiteering is happening through civil lawsuits in New York, D.C., and Maryland federal courts. The plaintiffs challenging Trump’s behavior include the watchdog group Citizens for Responsibility and Ethics in Washington (CREW); some 200 Democrats in Congress, led by Connecticut Senator Richard Blumenthal; attorneys general in Washington, D.C., and Maryland; and hotel and restaurant owners who compete with Trump. They all argue that Trump is in blatant violation of a provision in the Constitution meant to ensure that the president can’t exploit his office for profit.

Note that since those articles were written, Democrats in the House of Representatives have called for a serious investigation by the House Oversight Committee of how the Trump Organization is exploiting his presidency for financial gain, although the likelihood that their political opponents would condone such an investigation seems small (look here).

The article posited that Mr Trump's corrupt activities fit into three categories.

Corruption Type 1: Foreign Emoluments

Mr Trump appears to be benefiting from payments or the equivalent from foreign governments, an apparent violation of the Foreign Emoluments Clause of the US Constitution.

Foreign interference in our political system was of grave concern to the framers of the Constitution. They knew that when a federal officeholder receives gifts, money, or other benefits from foreign governments, his judgment is compromised and his loyalties are divided. So they wrote a strict rule into the text of the Constitution, the Foreign Emoluments Clause, which provides that federal officeholders may not 'accept of any present, emolument, office, or title, of any kind whatever, from any king, prince, or foreign state' without Congress’s approval.

Unlike with bribery statutes, a violation of the Foreign Emoluments Clause doesn’t require proof that an official gave something in return. It’s designed to protect against not just quid pro quo corruption, but also the mere appearance of improper influence on government officials.

Note that the Constitution also provides that

Before he enter on the Execution of his Office, he shall take the following Oath or Affirmation: — 'I do solemnly swear (or affirm) that I will faithfully execute the Office of President of the United States, and will to the best of my Ability, preserve, protect and defend the Constitution of the United States.'

So any presidential violation of the Foreign Emoluments clause is also an example of what we have previously called mission-hostile management.

The Foreign Emoluments clause is basically a prohibition of a particular kind of conflict of interest, payments to the President by foreign leaders or states. However, many examples of violations of this clause by Mr Trump also suggest corruption. "Commander-in-Thief" describes

foreign governments’ lavish spending at Trump’s hotel and restaurants, particularly at the Trump International Hotel just steps away from the White House, in some cases at the prodding of Trump’s agents. After the election, the Trump International hosted more than 100 foreign diplomats for a tour, sending them home with goody bags and brochures in an attempt to encourage their patronage. Former Mexican diplomat Arturo Sarukhan has said that the State Department urged diplomats to stay at the Trump International while on official visits.

Delegations from at least eight countries have obliged. In September, Malaysian Prime Minister Najib Razak and other members of his administration were seen hobnobbing in meeting rooms at the hotel, bringing in what is estimated to be hundreds of thousands of dollars in revenue. Saudi Arabia has spent more than a quarter of a million dollars—$190,000 on lodging, $78,000 on catering, and $1,600 on parking—at the hotel in connection with its lobbying against legislation that would allow American citizens to sue foreign governments over terrorist attacks.

And the Kuwaiti embassy suddenly changed the venue for its National Day celebration last February from the Four Seasons to the Trump International, paying an estimated $40,000 to $60,000. A source with knowledge of the conversations between the hotel and the embassy told ThinkProgress that Trump Organization members had pressured the Kuwaiti ambassador to cancel the embassy’s 'save the date' reservation at the Four Seasons, where it had held the event in the past. Perhaps it’s purely a coincidence that neither Saudi Arabia nor Kuwait were among the Muslim-majority nations singled out by Trump’s travel ban.

[Trump International Hotel, Washington, DC]

Recall the Transparency International definition of corruption, abuse of entrusted power for private gain.  That the Trump Organization, owned mainly by Mr Trump, and likely still run according to his wishes by his children, actively promoted foreign governments pay for overpriced hospitality services which would directly profit Mr Trump.  Given that Mr Trump is supposed to lead foreign policy in the interests of all US citizens and according to the US Constitution, this seems to be a gross example of abuse of entrusted power, and is obviously for private gain.

"Commander-in-Chief" listed various other examples of violations of the Foreign Emoluments clause.  Moreover, the companion article, "A Year in Trump Corruption," listed pages of examples of the more prominent known violations, starting with the case of the 100 foreign diplomats above, and ending with

Oct. 31, 2017: Mexico’s former U.S. ambassador Arturo Sarukhan tweets that the State Department is encouraging diplomats to stay at the Trump International Hotel during official visits.

Corruption Type 2: Domestic Emoluments

Mr Trump appears to be directly benefiting from payments made by the US government, in violation of the Domestic Emoluments Clause.  Per "Commander-in-Thief," 

The framers weren’t just worried about foreign influences. They intended the Domestic Emoluments Clause to ensure that Congress, other parts of the federal government, and the states 'can neither weaken [the president’s] fortitude by operating on his necessities, nor corrupt his integrity by appealing to his avarice,' as Alexander Hamilton wrote in the Federalist Papers. It entitles the president to receive a salary (currently $400,000 a year) and benefits fixed by Congress, but prohibits him from taking any other profits from the public—whether from the federal government or from any of the states.

Trump violates this provision, many constitutional scholars have argued, when state or federal entities patronize his properties and spend taxpayer money.

Again, this provision also prohibits a certain kind of conflict of interest, that produced were a president to personally profit from activities of the US or state governments.

One sort of example the article provided was

Trump doesn’t just rely on others to put money into his businesses—he patronizes them himself with stunning frequency, having spent more than 100 days at them, nearly a third of his presidency, while in office. Unlike any previous president, Trump’s vacation properties are for-profit enterprises, meaning each visit funnels public money to Trump’s business, mainly in the form of exorbitant security costs. Secret Service has blown through its budget due to Trump’s frequent travel expenses, requesting an additional $60 million to protect the first family in March. Trump’s detail reportedly paid Mar-a-Lago, Trump’s luxury club in Palm Beach, Florida, at least $63,000 between February and April, and has spent at least $144,975 on golf cart rentals at Trump properties in New Jersey, Virginia, and Palm Beach as of November. And last spring, the Defense Department signed a $2.39 million eighteen-month lease for space in Trump Tower for a military office meant to provide various presidential services, including access to nuclear launch codes.

In this example, Mr Trump's personal decisions, for example to vacation at one of his own properties, automatically entail major expenses by the government he is supposed to lead.  These these USG government expenses thus become revenues for none other than Mr Trump.  Again, it seems easy to argue that such decisions are abuse of entrusted power for private gain.

Again, the companion article listed multiple other examples, beginning with

Nov. 14, 2016: Six days after the election, Trump receives all-but final approval from the National Park Service for a $32 million historic preservation tax credit for the Trump International Hotel.

And ending with:

Nov. 15, 2017: USA Today reports that, thanks to Trump’s refusal to divest from his businesses, the federal government has assigned at least 10 Justice Department lawyers and paralegals, at salaries ranging between $133,000 to $185,000 in public money, to defend Trump in four lawsuits alleging violations of the Emoluments Clause.

Corruption Type 3: Slimy, but Probably Legal

Mr Trump has also taken advantage of his office to increase revenues to the Trump Organization, which he owns.  Per "Commander-in-Thief,"

Many presidents have been independently wealthy, but none before Trump entered the White House with a massive on-going business empire—or brazenly used the office to drive up that empire’s value.

Some examples given were

Almost immediately following his inauguration, the annual membership rate at Mar-a-Lago, which Trump has dubbed his 'Winter White House,' doubled, from $100,000 to $200,000, reflecting Trump’s eagerness to capitalize on the market value of access to the leader of the free world. In February, Mar-a-Lago management sold a tennis shirt featuring a '45' on the sleeve in reference to Trump, the forty-fifth president. By April, rates at the Trump International Hotel had jumped to at least $660 per night, an increase in hundreds from before his election. And in November, the president plugged his New Jersey golf course during a foreign policy speech in Seoul.

The companion article again listed numerous examples, starting with the increase in the Mar-a-Lago membership rate, and after examples involving Mr Trump's Trump International Hotel in Washington, DC, and various other Trump resort and hotel properties, ending with:

Dec. 31, 2017: Trump ends 2017 the way he started it: with a private gala at Mar-a-Lago. This time, tickets are up to $600 for club members and $750 for guests.

Again, given that these cases involved the president trading on his office and the advantages of gaining personal access to him to increase revenues at the hospitality properties he owns, it seems easy to argue that they involved abuse of entrusted power for private gain.


In the rare instances in which health care corruption has been discussed publicly, one sometimes sees ideas about addressing corruption affecting various health care organizations.  For example, in October, 2016, Transparency International announced its Pharmaceuticals & Healthcare Programme, based in the UK. It would

target global, national and local interventions. Ongoing research and the lessons drawn from regional and national projects will be used to influence global policy to produce structural change within the health sector; promote global best practice standards to strengthen transparency and accountability; and support national and local interventions and solutions.

That is all well and good, and will hopefully lead to some improvements globally.  But such recommendations are based on tacit assumptions, particularly that well-intentioned governments will at least consider such changes in policy.

We in the US are now in a different situation. In an interview published by Vox, historian Robert Dallek said,

Often you see a lot of corruption result from a lack of oversight, but I think this administration is quite different in that Trump really sets the tone for all this. He encourages it, really. The fish rots from the head, and the stench of this administration starts at the very top.

IMHO, when the fish is rotting from the head, it makes little sense to try to clean up minor problems halfway towards the tail.  It would be silly to expect that the Trump regime would want to "produce structural change within the health sector; promote global best practice standards to strengthen transparency and accountability; and support n ational and local interventions and solutions" all to reduce corruption in health care.  Why would a corrupt regime led by a president who is actively benefiting from corruption act to reduce corruption?

The only way we can now address health care corruption is to excise the corruption at the heart of our government.

Friday, January 05, 2018

Ill-Informed, Incompetent* Health Care Leadership: the Case of President Trump's Interview in the New York Times

[* - see discussion of definitions below]

On December 28, 2017, the New York Times published an impromptu interview by reporter Michael S Schmidt with President Donald J Trump at one of Mr Trump's private golf clubs.  Excerpts from the transcript appeared here.  An analysis of 24 points made by the president appeared in the Washington Post.  A number of commenators later weighed in on the interview.

The interview touched on some major issues in health policy relevant to Health Care Renewal.  I will first present in full the transcript of relevant part of the interview by health care topic.  Then I will present comments from the Washington Post article, and then by some of the commenators.

That all sounds rather mundane, but even this stolid method of presentation cannot conceal how things quickly ran off the rails.

Relevant Interview Excerpts

President Trump's Health Care Policy Expertise

I know more about the big bills. … [Inaudible.] … Than any president that’s ever been in office. Whether it’s health care and taxes.

I know the details of health care better than most, better than most. And if I didn’t, I couldn’t have talked all these people into doing ultimately only to be rejected.

Association Health Plans, and Sales of Health Plans Across State Lines

Also, beyond the individual mandate, but also [inaudible] associations. You understand what the associations are. …

[Cross talk.]

TRUMP: So now I have associations, I have private insurance companies coming and will sell private health care plans to people through associations. That’s gonna be millions and millions of people. People have no idea how big that is. And by the way, and for that, we’ve ended across state lines. So we have competition. You know for that I’m allowed to [inaudible] state lines. So that’s all done.

Now here’s the good news. We’ve created associations, millions of people are joining associations. Millions. That were formerly in Obamacare or didn’t have insurance. Or didn’t have health care. Millions of people. That’s gonna be a big bill, you watch. It could be as high as 50 percent of the people. You watch. So that’s a big thing. And the individual mandate. So now you have associations, and people don’t even talk about the associations. That could be half the people are going to be joining up. … With private [inaudible]. So now you have associations and the individual mandate.

The Affordable Care Act (ACA, "Obamacare") and Its Mandate

But now that the individual mandate is officially killed, people have no idea how big a deal that was. It’s the most unpopular part of Obamacare. But now, Obamacare is essentially. … You know, you saw this. … It’s basically dead over a period of time.

The Washington Post Article on Trump's Claims

 The article began:

We combed through the transcript and here’s a quick roundup of the false, misleading or dubious claims that he made, at a rate of one every 75 seconds.

President Trump's Health Care Policy Expertise

Lawmakers who dealt with Trump on taxes and especially health care privately told reporters they were shocked how little he knew about these issues.

Association Health Plans, and Sales of Health Plans Across State Lines

Trump is referring to an executive order, mentioned above, but it has no force in law on its own and no one has yet joined these associations. The rules spelling out how the executive order would work have not been issued yet, so Trump is simply making up his 'millions' number.

Trump signed an executive order encouraging the formation of health plans across state lines. But there is still a law in place that exempts insurance companies from aspects of federal antitrust law and ensures that individual states remained the primary regulators of insurance.

The Affordable Care Act (ACA, "Obamacare") and Its Mandate

While the individual mandate was an important incentive for Americans to seek health insurance, it was only one part of a far-reaching law that remains intact. The repeal does not take effect until 2019, and enrollment in Obamacare has remained strong. The Congressional Budget Office says the marketplaces are expected to remain stable for years.

Commenators' Take on Trump's Statements

Ezra Kelin wrote a commentary for Vox published December 29.  Yuval Levin wrote a commentary for the National Review published the same day

President Trump's Health Care Policy Expertise

Klein wrote:

In psychology, there’s an idea known as the Dunning-Kruger effect. It refers to research by David Dunning and Justin Kruger that found the least competent people often believe they are the most competent because they 'lack the very expertise needed to recognize how badly they’re doing.' This dynamic helps explain comments like the one Trump makes here.

Association Health Plans, and Sales of Health Plans Across State Lines

Klein wrote:

I can, with some effort, untangle what Trump might have been trying to say here, but it’s so incoherent, so suffused with half-related ideas and personal obsessions (why did Trump feel the need to bring up McCain’s vote?), that it’s hard to say for sure.


At best, Trump is saying something that is comprehensible but incorrect. He signed an executive order making it easier to form association health plans, which are health plans formed by groups of small businesses, and making it easier for those plans to skirt Obamacare’s insurance regulations and to contain small businesses from multiple states.

As of now, and Trump doesn’t seem to realize this, it’s just an executive order — the rules defining and implementing it have not been written, so it is not yet happening, and we don’t know how it will work in practice, much less how many people may eventually sign up. Nor does the order get rid of the prohibition on selling insurance across state lines for most people — it’s only for this one kind of plan which can include members in multiple states, and which will only serve a tiny minority of the health insurance market.

Levin wrote:

My best guess is that at some point President Trump was briefed by his staff about the executive order he signed in October that, among other things, instructed his administration to expand the scope of association health plans. The word salad we find here is what remained of that briefing (or maybe of a conversation with a knowledgeable AHP supporter, like Rand Paul) after it was minced and digested by the president’s mind into a mess of little unconnected proofs of his own acumen and prowess. Trump appears to believe that millions of people are joining such plans, but in fact his order has yet even to be translated into a proposed rule, so that it has had no practical effect so far. He describes his order (I take it) as 'a big bill'—and this from the man who earlier in the same interview said  'I know more about the big bills. … [Inaudible.] … Than any president that’s ever been in office'. But maybe he just meant a big deal. He suggests that half of some presumably significant group of people will join such plans, and that in combination with the zeroing out of the individual mandate these plans will somehow drive Democrats to make a deal on health care.

The Affordable Care Act (ACA, "Obamacare") and Its Mandate

Neither commenator specifically addressed this issue

General Comments on Trump's Approach to Health Care

Both commentators were very concerned about Trump's approach beyond any questions of truthfullness of claims or arguments about whether proposed policies would be good for the country.

Klein wrote:

Whatever Trump is saying, it does not reveal much familiarity with health policy, or even with the status and limits of his own actions. And yet Trump believes himself, on policy, to be the most informed president in American history. As the Dunning-Kruger effect suggests, he doesn’t know how much he doesn’t know, and that, combined with his natural tendency toward narcissism, has left him dangerously overconfident in his own knowledge base.

Even worse:

This is the president of the United States speaking to the New York Times. His comments are, by turns, incoherent, incorrect, conspiratorial, delusional, self-aggrandizing, and underinformed. This is not a partisan judgment — indeed, the interview is rarely coherent or specific enough to classify the points Trump makes on a recognizable left-right spectrum.


I am not a medical professional, and I will not pretend to know what is truly happening here. It’s become a common conversation topic in Washington to muse on whether the president is suffering from some form of cognitive decline or psychological malady. I don’t think those hypotheses are necessary or meaningful. Whatever the cause, it is plainly obvious from Trump’s words that this is not a man fit to be president, that he is not well or capable in some fundamental way. That is an uncomfortable thing to say, and so many prefer not to say it, but Trump does not occupy a job where such deficiencies can be safely ignored.

Levin wrote:

After reading this, it is advisable to take a moment to wonder at the absurdity of life, to offer a quiet prayer of thanks for the fact that any of us is still alive, and then to pursue—yet again, and surely not for the last time—that recurring question of our era: What in the world is the president talking about?


I have no doubt these claims began as duly grounded and modest statements of fact in some policy discussion. But they have ended up as worse than nonsense—worse, I say, because the only function they are left to perform is to affirm the president’s belief in things that aren’t true.

This is a narrow example of a broader pattern, of course. It doesn’t matter all that much if the president doesn’t really know anything about Association Health Plans. He’s got bigger problems to worry about. But it’s hard to deny that he seems to approach those bigger problems in the same general way, and that the broader pattern is therefore itself a very big problem, given the nature and demands of the modern presidency.


We have frequently criticized the leadership of big health care organizations as ill-informed, incompetent, ignorant of or even hostile to the values of health care professionals, deceptive, self-interested, conflicted or even corrupt. The President of the United States is the country's most important health care leader, since all government agencies that deal with health, health care, health care policy, etc report to him.  Unfortunately, we have previously discussed examples of how the president appeared to be an ill-informed or incompetent health care leader, for example here

So it would be easy to just say that his responses in his recent interview as discussed above just corroborate this opinion. 

However, in his latest interview with a reporter from the New York Times, it was not that the President of the United States deferred on issues of health policy to health policy experts.  It was not that he was evasive, or exaggerated.  It was not that he advocated policies that were controversial.  It was not even that what he said was untrue.

As per the title of Levin's commentary, it was that the President created a word salad.  What he said often made no sense.

This goes way beyond ill-informed or incompetent leadership as we have used these terms previously.   When we have discussed incompetence, it was in the sense of ordinary English usage.  For example, per, incompetent means "lacking qualification or ability; incapable." 

We have seen many leaders of big health care organizations who did not seem to have adequate qualifications or abilities to run such organizations, even though they might be perfectly intelligent, well-educated, generally capable people.  Such leadership often seemed to be a consequence of the doctrine of managerialism promoted in business schools that people trained in management should lead every type of human organization and endeavor.  Management by people from the disciplines most relevant to the mission and nature of particular organizations should be eschewed.  So managers, not physicians or other health care professionals, should lead health care organizations.  Following that theme, managers, or those like them, rather than health care professionals and health policy experts should lead health policy. 

However, managers who run health care organizations, or make policy, have an unfortunate tendency to be ill-informed (as well as unsympathetic if not hostile to health care professionals' value and the health care mission, and subject to perverse incentives that often put short-term revenue ahead of the health of patients and the population.)

In one sense, President Trump is the ultimate embodiment of managerialism.  He is a life long businessman, whose highest academic training resulted in an MBA from the Wharton School, with no demonstrated knowledge of or experience in public policy, the law, or the US Constitution.  Yet for years he has felt free to make pronouncements about any subject which caught his eye. 

Yet as we first noted here, the problem goes beyond the ignorance about health care of the managerialist health care manager.  How he thinks about health care at times seems incoherent, confused, or demented.  Questions about the President's competence, in terms of his ability to sustain rational thought, have become a national concern (e.g., look here and here.)  An approach to this has got to be devised at the highest levels of US government, but independent of Mr Trump.

Meanwhile, in the hope that the country can recover from this, maybe the case of President Trump's word salad will remind us that we have to rethink who should become leaders of health care organizations.

Monday, January 01, 2018

A Remedy for Corruption

Do I really have a remedy for corruption? I wish I did. But, I have lately found an effective balm for the sickening discouragement that it is easy to feel when confronted day after day with another instance of the medical industry’s price-gouging corruption, purposeful distortions, and callous disregard of patient  welfare. That remedy is a new podcast from Australia: Ray Moynihan’s The Recommended Dose. 

If you don’t already recognize Moynihan’s name, he’s an author of Selling Sickness and he’s had a persistent interest in overdiagnosis and medicalization. He describes the podcast as “interviews promoting healthy questioning in medicine” and most, though not all, of the interviewees are medical professionals somehow associated with evidence-based medicine and/or Cochrane. Many interviewees have practiced in unfamiliar countries and settings; hearing about problems and issues there is broadening for a U.S. listener.

So far there are eight episodes, and not a dud in the lot. Moynihan interviews the people as human beings, not just as experts, so you get a real feeling for their lives and motivations, including background, interests, and motivations. He doesn’t hesitate to go a bit afield, as in Episode 7 where he interviews a novelist! His conversation with Sarah Moss covered literature and themes related to medicine very enjoyably.

Other episodes I particularly enjoyed were: 
  • Episode 2. Psychiatrist Allen Frances discusses mental health, including his role in the DSM and how he regrets the direction later editions have taken. On another topic, he thinks diagnosing Trump remotely with some psychiatric disorder is unenlightening; it’s more the US public, he says, that is insane than Trump.
  • Episode 4. South African Jimmy Volmink recounts how Cochrane was contacted by the government to look into the evidence for using antiretrovirals for prevention of mother-to-newborn HIV transmission; government officials stressed they were particularly interested in harms of these toxic chemicals. A big project resulted, concluding that side effects were comparatively minor, and the treatment tremendously effective. Decision makers (who had clamored for the study) then proceeded to disregard the results. That was an interesting insight into an environment where the pressures were to make treatments look less effective than they are rather than more effective than they are, as is generally the case in the U.S. setting. Volmink comments that people are “very keen to use evidence when it supports what they already want to do.” (Fortunately the study was still of great use when the Treatment Action Campaign took the government to court.)
  • Episode 6. Indian psychiatrist Prathap Tharyan discusses being on a team to assist people after a tsunami and what evidence shows people need after disasters (spoiler: it’s not mass debriefing/counselling for everyone). It concludes by a recording of Tharyan’s singing Leonard Cohen’s Alleluia; I feared it would be embarrassing, but it was sublime.
  • Episode 8. An optimistic interview with Julian Elliot, who is working on access to evidence including in low-income countries. His reflections on working on HIV treatment in Cambodia were interesting. But the highlight of the episode for me was when Moynihan reflected that there are two elements in science, innovation and evaluation. The public, Moynihan says, appreciates medical innovation, but not evaluation, important though it is. (What a factor that is in the many “medical reversals” Vinay Prasad and Adam Cifu write so eloquently about!) 
I have to compliment Moynihan on his excellent diction. I usually find Australians really hard work to listen to. Although Moynihan’s accent is strong, he speaks so clearly that it’s a pleasure to listen to him and not difficult for this American to understand what he’s saying at all.  Such beautiful clarity is a fantastic asset in making accessible the meat of the podcasts.

The Recommended Dose vividly showcases some of the many people who make medicine and life still wonderful and beautiful (in parts); and who live with intelligence, determination, courage, and humor despite obstacles.  That’s an excellent medicine for the heart and mind, and I recommend it without reservation.