Optimizing Ourselves into Oblivion

The short story “Anekdote zur Senkung der Arbeitsmoral” (“An anecdote about the lowering of work ethic”) is one of the most famous stories written by the German author Heinrich Böll. In the story, an affluent tourist encounters a poorly clad fisherman who is comfortably napping in his boat. The assiduous tourist accidentally wakes up the fisherman while taking photos of the peaceful scenery – blue sky, green sea, fisherman with an old-fashioned hat – but then goes on to engage the lounging fisherman in a conversation. The friendly chat gradually turns into a sermon in which the tourist lectures the fisherman about how much more work he could be doing, how he could haul in more fish instead of lazing about, use the profits to make strategic investments, perhaps even hire employees and buy bigger boats in a few years. To what end, the fisherman asks. So that you could peacefully doze away at the beach, enjoying the beautiful sun without any worries, responds the enthusiastic tourist.

I remembered Böll’s story which was written in the 1960s – during the post-war economic miracle years (Wirtschaftswunder) when prosperity, efficiency and growth had become the hallmarks of modern Germany – while recently reading the book “Du sollst nicht funktionieren” (“You were not meant to function”) by the German author and philosopher Ariadne von Schirach. In this book, von Schirach criticizes the contemporary obsession with Selbstoptimierung (self-optimization), a term that has been borrowed from network theory and computer science where it describes systems which continuously adapt and “learn” in order to optimize their function. Selbstoptimierung is now used in a much broader sense in German culture and refers to the desire of individuals to continuously “optimize” their bodies and lives with the help of work-out regimens, diets, self-help courses and other processes. Self-optimization is a routine learning process that we all engage in. Successful learning of a new language, for example, requires continuous feedback and improvement. However, it is the continuous self-optimization as the ultimate purpose of life, instead of merely serving as  a means to an end that worries von Schirach.

She draws on many examples from Körperkult (body-cult), a slavish worship of the body that gradually replaces sensual pleasure with the purpose of discipling the body. Regular exercise and maintaining a normal weight are key factors for maintaining health but some individuals become so focused on tracking steps and sleep duration on their actigraphs, exercising or agonizing about their diets that the initial health-related goals become lose their relevance. They strive for a certain body image and resting heart rates and to reach these goals they indulge in self-discipline to maximize physical activity and curb appetite. Such individuals rarely solicit scientific information as to the actual health benefits of their exercise and food regimens and might be surprised to learn that more exercise and more diets do not necessarily lead to more health. The American Heart Association recommends roughly 30-45 minutes of physical activity daily to reduce high blood pressure and the risk of heart attacks and stroke. Even simple and straightforward walking is sufficient to meet these goals, there is no need for two-hour gym work-outs.

Why are we becoming so obsessed with self-optimization? Unfortunately, von Schirach’s analysis degenerates into a diffuse diatribe against so many different elements of contemporary culture. Capitalist ideology, a rise in narcissism and egotism, industrialization and the growing technocracy, consumerism, fear of death, greed, monetization of our lives and social media are among some of the putative culprits that she invokes. It is quite likely that many of these factors play some role in the emerging pervasiveness of the self-optimization culture – not only in Germany. However, it may be useful to analyze some of the root causes and distinguish them from facilitators. Capitalist ideology is very conducive to a self-optimization culture. Creating beauty and fitness targets as well as laying out timelines to achieve these targets is analogous to developing corporate goals, strategies and milestones. Furthermore, many corporations profit from our obsession with self-optimization. Companies routinely market weight regimens, diets, exercise programs, beauty products and many other goods or services that generate huge profits if millions of potential consumers buy into the importance of life-long self-optimization. They can set the parameters for self-optimization – ideal body images – and we just obey. According to the German philosopher Byung-Chul Han, such a diffusion of market logic and obedience to pre-ordained parameters and milestones into our day-to-day lives results in an achievement society which ultimately leads to mental fatigue and burnout.  In the case of “working out”, it is telling that a supposedly leisure physical activity uses the expression “work”, perhaps reminding us that the mindset of work persists during the exercise period.

But why would we voluntarily accept these milestones and parameters set by others? One explanation that is not really addressed by von Schirach is that obsessive self-optimization with a focus on our body may represent a retreat from the world in which we feel disempowered. Those of us who belong to the 99% know that our voices are rarely heard or respected when it comes to most fundamental issues in society such as socioeconomic inequality, rising intolerance and other forms of discrimination or prejudice. When it comes to our bodies, we may have a sense of control and empowerment that we do not experience in our work or societal roles. Self-discipline of our body gives our life a purpose with tangible goals such as lose x pounds, exercise y hours, reduce your resting heart rate by z.

Self-optimization may be a form of Ersatzempowerment but it comes at a great cost. As we begin to retreat from more fundamental societal issues and instead focus on controlling our bodies, we also gradually begin to lose the ability to dissent and question the meaning of actions. Working-out and dieting are all about How, When and What – how do I lose weight, what are my goals, when am I going to achieve it. The most fundamental questions of our lives usually focus on the Why – but self-optimization obsesses so much about How, When and What that one rarely asks “Why am I doing this?” Yet it is the Why that gives our life meaning, and self-optimization perhaps illustrates how a purpose-driven life may lose its meaning. The fisherman prompted the tourist to think about the Why in Böll’s story and perhaps we should do the same to avoid the trap of an obsessive self-optimization culture.

Reference:

von Schirach, Ariadne. Du sollst nicht funktionieren: für eine neue Lebenskunst. Klett Cotta, 2014.

 

Note: An earlier version of this article was first published on the 3Quarksdaily blog. 

Politics Trump Healthcare Information: News Coverage of the Affordable Care Act

The Affordable Care Act, also known as the “Patient Protection and Affordable Care Act”, “Obamacare” or the ACA, is a comprehensive healthcare reform law enacted in March 2010 which profoundly changed healthcare in the United States. This reform allowed millions of previously uninsured Americans to gain health insurance by establishing several new measures, including the expansion of the federal Medicaid health insurance coverage program, introducing the rule that patients with pre-existing illnesses could no longer be rejected or overcharged by health insurance companies, and by allowing dependents to remain on their parents’ health insurance plan until the age of 26. The widespread increase in health insurance coverage – especially for vulnerable Americans who were unemployed, underemployed or worked for employers that did not provide health insurance benefits – was also accompanied by new regulations targeting the healthcare system itself. Healthcare providers and hospitals were provided with financial incentives to introduce electronic medical records and healthcare quality metrics.

As someone who grew up in Germany where health insurance coverage is guaranteed for everyone, I assumed that over time, the vast majority of Americans would appreciate the benefits of universal coverage. One no longer has to fear financial bankruptcy as a consequence of a major illness and a government-back health insurance also provides for peace of mind when changing jobs. Instead of accepting employment primarily because it offers health benefits, one can instead choose a job based on the nature of the work. But I was surprised to see the profound antipathy towards this new law, especially among Americans who identified themselves as conservatives or Republicans, even if they were potential beneficiaries of the reform. Was the hatred of progressive-liberal views, the Democrats and President Obama who had passed the ACA so intense among Republicans that they were willing to relinquish the benefits of universal health coverage for the sake of their political ideology? Or were they simply not aware of the actual content of the law and opposed it simply for political reasons?

A recent study published by a team of researchers led by Sarah Gollust at the University of Minnesota may shed some light on this question. Gollust and her colleagues analyzed 1,569 local evening television news stories related to the ACA that were aired in the United States during the early months of when the health care reform was rolled out (between October 1, 2013, and April 19, 2014). They focused on analyzing local television news broadcasts because these continue to constitute the primary source of news for Americans, especially for those who are age 50 and higher. A Pew survey recently showed that 57% of all U.S. adults rely on television for their news, and among this group, local TV new (46%) is a more common source than cable news (31%) or network news (30%).

Gollust and colleagues found that 55% of the news stories either focused on the politics of the ACA such as political disagreements over its implementation (26.5%) or combined information regarding its politics with information on how it would affect healthcare insurance options (28.6%). Only 45% of the news stories focused exclusively on the healthcare insurance options provided by the law. The politics-focused news stories were also more likely to refer to the law as “Obamacare” whereas healthcare insurance focused news segments used the official name “Affordable Care Act” or “ACA”. Surprisingly, the expansion of Medicaid, which was one of the cornerstones of the ACA because it would increase the potential access to health insurance for millions of Americans, was often ignored. Only 7.4% of news stories mentioned Medicaid at all, and only 5% had a Medicaid focus.

What were the sources of information used for the news stories? President Obama was cited in nearly 40% of the stories, whereas other sources included White House staff or other federal executive agencies (28.7%), Republican (22.3%) or Democratic (15.9%) politicians and officials. Researchers, academics or members of think tanks and foundations were cited in only 3.9% of the news stories about the ACA even though they could have provided important scholarly insights about the ACA and its consequences for individual healthcare as well as the healthcare system in general.

The study by Gollust and colleagues has its limitations. It did not analyze TV network news, cable news, or online news outlets which have significantly gained in importance as news sources during the past decade. The researchers also did not analyze news stories aired after April 2014 which may have been a better reflection of initial experiences of previously uninsured individuals who signed up for health insurance through the mechanisms provided by the ACA. Despite these limitations, the study suggests that one major reason for the strong opposition among Republicans against the ACA may have been the fact that it was often framed in a political context and understated the profound effects that the ACA had on access to healthcare and the reform of the healthcare system itself.

During the 2016 election campaign, many Republican politicians used the idea of “repealing” the ACA to energize their voters, without necessarily clarifying what exactly they wanted to repeal. Should all the aspects of the ACA – from the Medicaid expansion to the new healthcare quality metrics in hospitals –be repealed? If voters relied on the local television news to learn about the ACA, and if this coverage – as is suggested by Gollust’s study – viewed the ACA predominantly as a political entity, then it is not surprising that voters failed to demand nuanced views from politicians who vowed to repeal the law. The research also highlights the important role that television reporting plays in framing the debate about healthcare reform. By emphasizing the actual content of the healthcare reform and its medical implications and by using more scholars instead of politicians as information sources, these media outlets could educate the public about the law.

There are many legitimate debates about the pros and cons of the healthcare reform that are not rooted in politics. For example, electronic medical records allow healthcare providers to easily monitor the results of laboratory tests and avoid wasting patient’s time and money on unnecessary tests that may have been ordered by another provider. However, physicians who are continuously staring at their screens to scroll through test results may not be able to form the interpersonal bond that is critical for a patient-doctor relationship. One could consider modifying the requirements and developing better record-keeping measures to ensure a balance between adequate documentation and sufficient face-to-face doctor-patient time. The ACA’s desire to track quality of healthcare delivery and penalize hospitals or providers who deliver suboptimal care could significantly improve adherence to guidelines based on sound science. On the other hand, one cannot demand robot-like adherence to guidelines, especially when treating severely ill, complex patients who require highly individualized care. These content-driven discussions are more productive than wholesale political endorsements or rejections of the healthcare reform.

Healthcare will always be a political issue but all of us – engaged citizens, patients, healthcare providers or journalists – need to do our part to ensure that this debates about this issue which directly impacts millions of lives are primarily driven by objective information and not by political ideologies.

Reference:

Gollust, S. E., Baum, L. M., Niederdeppe, J., Barry, C. L., & Fowler, E. F. (2017). Local Television News Coverage of the Affordable Care Act: Emphasizing Politics Over Consumer Information. American Journal of Public Health, (published online Feb 16, 2017).

Note: An earlier version of this article was first published on the 3Quarksdaily blog.

 

Gollust SE, Baum LM, Niederdeppe J, Barry CL, & Fowler EF (2017). Local Television News Coverage of the Affordable Care Act: Emphasizing Politics Over Consumer Information. American journal of public health PMID: 28207336

We Have Become Exhausted Slaves in a Culture of Positivity

We live in an era of exhaustion and fatigue, caused by an incessant compulsion to perform. This is one of the central tenets of the book “Müdigkeitsgesellschaft” (translatable as “The Fatigue Society” or “The Tiredness Society“) by the German philosopher Byung-Chul Han. Han is a professor at the Berlin Universität der Künste (University of the Arts) and one of the most widely read contemporary philosophers in Germany. He was born in Seoul where he studied metallurgy before he moved to Germany in the 1980s to pursue a career in philosophy. His doctoral thesis and some of his initial work in the 1990s focused on Heidegger but during the past decade, Han has written about broad range of topics regarding contemporary culture and society. “Müdigkeitsgesellschaft” was first published in 2010 and helped him attain a bit of a rock-star status in Germany despite his desire to avoid too much public attention – unlike some of his celebrity philosopher colleagues.

The book starts out with two biomedical metaphors to describe the 20^th century and the emerging 21^st century. For Han, the 20^th century was an “immunological” era. He uses this expression because infections with viruses and bacteria which provoked immune responses were among the leading causes of disease and death and because the emergence of vaccinations and antibiotics helped conquer these threats. He then extends the “immunological” metaphor to political and societal events. Just like the immune system recognizes bacteria and viruses as “foreign” that needs to be eliminated to protect the “self”, the World Wars and the Cold War were also characterized by a clear delineation of “Us” versus “Them”. The 21^stcentury, on the other hand, is a “neuronal” era characterized by neuropsychiatric diseases such as depression, attention deficit hyperactivity disorder (ADHD), burnout syndrome and borderline personality disorder. Unlike the diseases in the immunological era, where there was a clear distinction between the foreign enemy microbes that needed to be eliminated and the self, these “neuronal” diseases make it difficult to assign an enemy status. Who are the “enemies” in burnout syndrome or depression? Our environment? Our employers? Our own life decisions and choices? Are we at war with ourselves in these “neuronal” conditions? According to Han, this biomedical shift in diseases is mirrored by a political shift in a globalized world where it becomes increasingly difficult to define the “self” and the “foreign”. We may try to assign a “good guy” and “bad guy” status to navigate our 21^st century but we also realize that we are so interconnected that these 20^th century approaches are no longer applicable.

The cell biologist in me cringed when I read Han’s immunologic and neuronal metaphors. Yes, it is true that successfully combatting infectious diseases constituted major biomedical victories in the 20^th century but these battles are far from over. The recent Ebola virus scare, the persistence of malaria resistance, the under-treatment of HIV and the emergence of multi-drug resistant bacteria all indicate that immunology and infectious disease will play central roles in the biomedical enterprise of the 21^st century. The view that the immune system clearly distinguishes between “self” and “foreign” is also overly simplistic because it ignores that autoimmune diseases, many of which are on the rise and for which we still have very limited treatment options, are immunological examples of where the “self” destroys itself. Even though I agree that neuroscience will likely be the focus of biomedical research, it seems like an odd choice to select a handful of psychiatric illnesses as representing the 21^st century while ignoring major neuronal disorders such as Alzheimer’s dementia, stroke or Parkinson’s disease. He also conflates specific psychiatric illnesses with the generalized increase in perceived fatigue and exhaustion.

Once we move past these ill- chosen biomedical examples, Han’s ideas become quite fascinating. He suggests that the reason why we so often feel exhausted and fatigued is because we are surrounded by a culture of positivity. At work, watching TV at home or surfing the web, we are inundated by not-so-subtle messages of what we can do. Han quotes the example of the “Yes We Can” slogan from the Obama campaign. “Yes We Can” exudes positivity by suggesting that all we need to do is try harder and that there may be no limits to what we could achieve. The same applies to the Nike “Just Do It” slogan and the thousands of self-help books published each year which reinforce the imperative of positive thinking and positive actions.

Here is the crux of Han’s thesis. “Yes We Can” sounds like an empowering slogan, indicating our freedom and limitless potential. But according to Han, this is an illusory freedom because the message enclosed within “Yes We Can” is “Yes We Should”. Instead of living in a Disziplinargesellschaft(disciplinary society) of the past where our behavior was clearly regulated by societal prohibitions and commandments, we now live in a Leistungsgesellschaft (achievement society) in which we voluntarily succumb to the pressure of achieving. The Leistungsgesellschaft is no less restrictive than the Disziplinargesellschaft. We are no longer subject to exogenous prohibitions but we have internalized the mandates of achievement, always striving to do more. We have become slaves to the culture of positivity, subjugated by the imperative “Yes, We Should”. Instead of carefully contemplating whether or not to pursue a goal, the mere knowledge that we could achieve it forces us to strive towards that goal. Buying into the “Yes We Can” culture chains us to a life of self-exploitation and we are blinded by passion and determination until we collapse. Han uses the sad German alliteration “Erschöpfung, Ermüdung und Erstickung” (“exhaustion, fatigue and suffocation”) to describe the impact that an excess of positivity has once we forgo our ability to say “No!” to the demands of the achievement society. We keep on going until our minds and bodies shut down and this is why we live in a continuous state of exhaustion and fatigue. Han does not view multitasking as a sign of civilizational progress. Multitasking is an indicator of regression because it results in a broad but rather superficial state of attention and thus prevents true contemplation

It is quite easy for us to relate to Han’s ideas at our workplace. Employees with a “can-do” attitude are praised but you will rarely see a plaque awarded to commemorate an employee’s “can-contemplate” attitude. In an achievement society, employers no longer have to exploit us because we willingly take on more and more tasks to prove our own self-worth.

While reading Han’s book, I was reminded of a passage in Bertrand Russell’s essay “In Praise of Idleness” in which he extols the virtues of reducing our workload to just four hours a day:

In a world where no one is compelled to work more than four hours a day, every person possessed of scientific curiosity will be able to indulge it, and every painter will be able to paint without starving, however excellent his pictures may be. Young writers will not be obliged to draw attention to themselves by sensational pot-boilers, with a view to acquiring the economic independence needed for monumental works, for which, when the time at last comes, they will have lost the taste and capacity. Men who, in their professional work, have become interested in some phase of economics or government, will be able to develop their ideas without the academic detachment that makes the work of university economists often seem lacking in reality. Medical men will have the time to learn about the progress of medicine, teachers will not be exasperatedly struggling to teach by routine methods things which they learnt in their youth, which may, in the interval, have been proved to be untrue.

Above all, there will be happiness and joy of life, instead of frayed nerves, weariness, and dyspepsia. The work exacted will be enough to make leisure delightful, but not enough to produce exhaustion. Since men will not be tired in their spare time, they will not demand only such amusements as are passive and vapid. At least one per cent will probably devote the time not spent in professional work to pursuits of some public importance, and, since they will not depend upon these pursuits for their livelihood, their originality will be unhampered, and there will be no need to conform to the standards set by elderly pundits. But it is not only in these exceptional cases that the advantages of leisure will appear. Ordinary men and women, having the opportunity of a happy life, will become more kindly and less persecuting and less inclined to view others with suspicion.

While Russell’s essay proposes reduction of work hours as a solution, Han’s critique of the achievement society and its impact on generalized fatigue and malaise is not limited to our workplace. By accepting the mandate of continuous achievement and hyperactivity, we apply this approach even to our leisure time. Whether it is counting the steps we walk with our fitness activity trackers or competitively racking up museum visits as a tourist, our obsession with achievement permeates all aspects of our lives. Is there a way out of this vicious cycle of excess positivity and persistent exhaustion? We need to be mindful of our right to refuse. Instead of piling on tasks for ourselves during work and leisure we need to recognize the value and strength of saying “No”. Han introduces the concept of “heilende Müdigkeit” (healing tiredness), suggesting that there is a form of tiredness that we should welcome because it is an opportunity for rest and regeneration. Weekend days are often viewed as days reserved for chores and leisure tasks that we are unable to pursue during regular workdays. By resurrecting the weekend as the time for actual rest, idleness and contemplation we can escape from the cycle of exhaustion. We have to learn not-doing in a world obsessed with doing.

Notes: An earlier version of this article was first published on the 3Quarksdaily Blog. Müdigkeitsgesellschaft was translated into English in 2015 and is available as “The Burnout Society” by Stanford University Press.

Byung-Chul Han (2015). The Burnout Society Stanford University Press

The “Invisible Web” Undermines Health Information Privacy

“The goal of privacy is not to protect some stable self from erosion but to create boundaries where this self can emerge, mutate, and stabilize. What matters here is the framework— or the procedure— rather than the outcome or the substance. Limits and constraints, in other words, can be productive— even if the entire conceit of “the Internet” suggests otherwise.

         Evgeny Morozov in “To Save Everything, Click Here: The Folly of Technological Solutionism“

 

We cherish privacy in health matters because our health has such a profound impact on how we interact with other humans. If you are diagnosed with an illness, it should be your right to decide when and with whom you share this piece of information. Perhaps you want to hold off on telling your loved ones because you are worried about how it might affect them. Maybe you do not want your employer to know about your diagnosis because it could get you fired. And if your bank finds out, they could deny you a mortgage loan. These and many other reasons have resulted in laws and regulations that protect our personal health information. Family members, employers and insurances have no access to your health data unless you specifically authorize it. Even healthcare providers from two different medical institutions cannot share your medical information unless they can document your consent.

Health Information Privacy via Shutterstock

The recent study “Privacy Implications of Health Information Seeking on the Web” conducted by Tim Libert at the Annenberg School for Communication (University of Pennsylvania) shows that we have a for more nonchalant attitude regarding health privacy when it comes to personal health information on the internet. Libert analyzed 80,142 health-related webpages that users might come across while performing online searches for common diseases. For example, if a user uses Google to search for information on HIV, the Center for Disease Control and Prevention (CDC) webpage on HIV/AIDS (http://www.cdc.gov/hiv/) is one of the top hits and users will likely click on it. The information provided by the CDC will likely provide solid advice based on scientific results but Libert was more interested in investigating whether visits to the CDC website were being tracked. He found that by visiting the CDC website, information of the visit is relayed to third-party corporate entities such as Google, Facebook and Twitter. The webpage contains “Share” or “Like” buttons which is why the URL of the visited webpage (which contains the word “HIV”) is passed on to them – even if the user does not explicitly click on the buttons.

Libert found that 91% of health-related pages relay the URL to third parties, often unbeknownst to the user, and in 70% of the cases, the URL contains sensitive information such as “HIV” or “cancer” which is sufficient to tip off these third parties that you have been searching for information related to a specific disease. Most users probably do not know that they are being tracked which is why Libert refers to this form of tracking as the “Invisible Web” which can only be unveiled when analyzing the hidden http requests between the servers. Here are some of the most common (invisible) partners which participate in the third-party exchanges:

Entity                                      Percent of health-related pages

Google                                                78

Facebook                                            31

Twitter                                               18

Amazon                                              16

Experian                                             5

What do the third parties do with your data? We do not really know because the laws and regulations are rather fuzzy here. We do know that Google, Facebook and Twitter primarily make money by advertising so they could potentially use your info and customize the ads you see. Just because you visited a page on breast cancer does not mean that the “Invisible Web” knows your name and address but they do know that you have some interest in breast cancer. It would make financial sense to send breast cancer related ads your way: books about breast cancer, new herbal miracle cures for cancer or even ads by pharmaceutical companies. It would be illegal for your physician to pass on your diagnosis or inquiry about breast cancer to an advertiser without your consent but when it comes to the “Invisible Web” there is a continuous chatter going on in the background about your health interests without your knowledge.

Some users won’t mind receiving targeted ads. “If I am interested in web pages related to breast cancer, I could benefit from a few book suggestions by Amazon,” you might say. But we do not know what else the information is being used for. The appearance of the data broker Experian on the third-party request list should serve as a red flag. Experian‘s main source of revenue is not advertising but amassing personal data for reports such as credit reports which are then sold to clients. If Experian knows that you are checking out breast cancer pages then you should not be surprised if this information will be stored in some personal data file about you.

How do we contain this sharing of personal health information? One obvious approach is to demand accountability from the third parties regarding the fate of your browsing history. We need laws that regulate how information can be used, whether it can be passed on to advertisers or data brokers and how long the information is stored.

 

Here is the Privacy Policy Summary for WebMD, a commonly visited health information portal:

   We may use information we collect about you to:

 ·         Administer your account;

·         Provide you with access to particular tools and services;

·         Respond to your inquiries and send you administrative communications;

·         Obtain your feedback on our sites and our offerings;

·         Statistically analyze user behavior and activity;

·         Provide you and people with similar demographic characteristics and interests with more relevant content and advertisements;

·         Conduct research and measurement activities;

·         Send you personalized emails or secure electronic messages pertaining to your health interests, including news, announcements, reminders and opportunities from WebMD; or

·         Send you relevant offers and informational materials on behalf of our sponsors pertaining to your health interests.

 

Users are provided with instructions for how they can opt out of the tracking and receiving information from the (undisclosed) sponsors but it is unlikely that the majority of users read the privacy policy pages of the various health-related websites. It is even less likely that users will go through the cumbersome process of requesting that all their information be kept private and not passed on to corporate sponsors.

Perhaps one of the most effective solutions would be to make the “Invisible Web” more visible. If health-related pages were mandated to disclose all third-party requests in real-time such as pop-ups (“Information about your visit to this page is now being sent to Amazon“) and ask for consent in each case, users would be far more aware of the threat to personal privacy posed by health-related pages. Such awareness of health privacy and potential threats to privacy are routinely addressed in the real world and there is no reason why this awareness should not be extended to online information.

 

 

 

Note: An earlier version of this article was first published on the 3Quarksdaily Blog.

Reference:

Libert, Tim. “Privacy implications of health information seeking on the Web” Communications of the ACM, Vol. 58 No. 3, Pages 68-77, March 2015, doi: 10.1145/2658983 (PDF)

 

Libert, T. (2015). Privacy implications of health information seeking on the web Communications of the ACM, 58 (3), 68-77 DOI: 10.1145/2658983

New Study Shows Surgical Checklists In Operating Rooms Are Less Effective Than Assumed

The patient has verified his or her identity, the surgical site, the type of procedure, and his or her consent. Check.

The surgical site is marked on a patient if such marking is appropriate for the procedure. Check.

The probe measuring blood oxygen content has been placed on the patient and is functioning. Check.

All members of the surgical and anesthesia team are aware of whether the patient has a known allergy? Check.

Surgeon – via Shutterstock

These were the first items on a nineteen-point World Health Organization (WHO) surgical safety checklist from an international research study to evaluate the impact of routinely using checklists in operating rooms. The research involved over 7,500 patients undergoing surgery in eight hospitals (Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, WA) and was published in the New England Journal of Medicine in 2009.

Some of the items on the checklist were already part of standard care at many of the enrolled hospitals, such as the use of oxygen monitoring probes. Other items, such as ensuring that there was a contingency plan for major blood loss prior to each surgical procedure, were not part of routine surgical practice. The impact of checklist implementation was quite impressive, showing that this simple safety measure nearly halved the rate of death in surgical patients from 1.6% to 0.8%.  The infection rate at the site of the surgical procedure also decreased from 6.2% in the months preceding the checklist introduction to a mere 3.4%.

Checklists as a Panacea?

The remarkable results of the 2009 study were met with widespread enthusiasm. This low-cost measure could be easily implemented in hospitals all over the world and could potentially lead to major improvements in patient outcomes. It also made intuitive sense that encouraging communication between surgical team members via checklists would reduce complications after surgery.

A few weeks after the study’s publication, the National Patient Safety Agency (NPSA) in the United Kingdom issued a patient safety alert, requiring National Health Service (NHS) organizations to use the WHO Surgical Safety Checklist for all patients undergoing surgical procedures. In 2010, Canada followed suit and also introduced regulations requiring the use of surgical safety checklists. However, the data for the efficacy of such lists had only been obtained in observational research studies conducted in selected hospitals. Would widespread mandatory implementation of such a system in “real world” community hospitals also lead to similar benefits?

A recently published study in the New England Journal of Medicine lead by Dr. David Urbach at the University of Toronto has now reviewed the surgery outcomes of hospitals in Ontario, Canada, comparing the rate of surgical complications during three-month periods before and after the implementation of the now mandatory checklists.  Nearly all the hospitals reported that they were adhering to the checklist requirements and the vast majority used either a checklist developed by the Canadian Patient Safety Institute, which is even more comprehensive than the WHO checklist or other similar checklists. After analyzing the results of more than 200,000 procedures at 101 hospitals, Urbach and colleagues found no significant change in the rate of death after surgery after the introduction of the checklists (0.71% versus 0.65% – not statistically significant). Even the overall complication rates or the infection rates in the Ontario hospitals did not change significantly after surgical teams were required to complete the checklists.

 

Check the Checklist

 

The discrepancy in the results between the two studies is striking. How can one study demonstrate such a profound benefit of introducing checklists while a second study shows no significant impact at all? The differences between the two studies may hold some important clues. The 2009 study had a pre-checklist death rate of 1.6%, which is more than double the pre-checklist death rate in the more recent Ontario study. This may reflect the nature and complexity of the surgeries surveyed in the first study and also the socioeconomic differences. A substantial proportion of the patients in the international study were enrolled in low-income or middle-income countries. The introduction of a checklist may have been of much greater benefit to patients and hospitals that were already struggling with higher complication rates.

Furthermore, as the accompanying editorial by Dr. Lucian Leape in the New England Journal of Medicine points out, assessment of checklist implementation in the recent study by Urbach and colleagues was based on a retrospective analysis of self-reports by surgical teams and hospitals. Items may have been marked as “checked” in an effort to rush through the list and start the surgical procedures without the necessary diligence and time required to carefully go through every single item on the checklist. In the 2009 WHO study, on the other hand, surgical teams were aware of the fact that they were actively participating in a research study and the participating surgeons may have therefore been more motivated to meticulously implement all the steps on a checklist.

One of the key benefits of checklists is that they introduce a systematic and standardized approach to patient care and improve communication between team members. It is possible that the awareness of surgical teams in the Ontario hospitals in regards to patient safety and the need for systematic communication was already raised to higher level even before the introduction of the mandatory checklists so that this mandate may have had less of an impact.

 

Looking Forward

The study by Urbach and colleagues does not prove that safety checklists are without benefit. It highlights that there is little scientific data supporting the use of mandatory checklists. Since the study could not obtain any data on how well the checklists were implemented in each hospital, it is possible that checklists are more effective when team members buy into their value and do not just view it as another piece of mandatory and bureaucratic paperwork.

Instead of mandating checklists, authorities should consider the benefits of allowing surgical teams to develop their own measures that improve patient safety and team communication. The safety measures will likely contain some form of physical or verbal checklists. By encouraging surgical teams to get involved in the development process and tailor the checklists according to the needs of individual patients, surgical teams and hospitals, they may be far more motivated to truly implement them.

Optimizing such tailored checklists, understanding why some studies indicate benefits of checklists whereas others do not and re-evaluating the efficacy of checklists in the non-academic setting will all require a substantial amount of future research before one can draw definitive conclusions about the efficacy of checklists. Regulatory agencies in Canada and the United Kingdom should reconsider their current mandates. Perhaps an even more important lesson to be learned is that health regulatory agencies should not rush to enforce new mandates based on limited scientific data.

 

Urbach DR, Govindarajan A, Saskin R, Wilton AS, & Baxter NN (2014). Introduction of surgical safety checklists in Ontario, Canada. The New England Journal of Medicine, 370 (11), 1029-38 PMID: 24620866