Tuesday, November 18, 2014

Ebola Tests: Sensitivity and Specificity

Yesterday's headlines on USA Today included one that stated "Nebraska Patient Cases Raises Questions about Ebola Test."  The reason for this is the fact that the Nebraska patient was a physician treating Ebola patients who came down with symptoms and was tested and found not to be Ebola positive before other clinicians eventually realized (and found in a later test) that the man in question did have Ebola.  If the physician had been treated earlier, it is possible that his outcome--being brought back to the US and treated--may have been different from the unfortunate death he suffered.

I'd like to comment on this because it raises some really important issues about diagnostic tests.  I would have expected to find some previous writing on this, but I do not.  So here it goes.

People either have a condition or do not.  We refer to those who have the condition as positive and those who dont' as negative.  Sometimes it is good to be "positive."  With the Ebola virus, it is obvious that being positive is a very bad thing.

Test results are also positive or negative.  (Some tests are uncertain, but for the time being we will ignore that.)  So, the result at the end of a diagnostic test suggests that a person either has or does not have a condition.

What makes this most interesting is the fact that there are some people who are truly positive and for which the test identifies the person as positive.  Similarly, there are some people who are negative and whom the test identifies as negative.  These are both desirable outcomes.

However, there are also two other groups.  There are some people who are positive whom the test incorrectly identifies as negative.  And there are some people who are negative whom the test incorrectly identifies as positive.  

A test's ability to correctly identify those who are positive as positive is called sensitivity.  A test's ability to correctly identify those who are negative as negative is called specificity.

In different situations, clinicians and policy makes focus on either sensitivity or specificity.  Sometimes it is important not to over identify cases.  If the consequences of being positive are fairly small, there will be future attempts to diagnose, and further identification and treatment is costly, we can focus on making sure to identify negatives properly--specificity.  Or if there are strong negative connotations and stigmas associated with being positive it can be important to correctly identify negatives.

However there are other cases in which failing to identify a positive case can be deadly.  This is true with Ebola.  This is why in other cases sensitivity is critical.  This does not mean that there should not be concerns about specificity.  If we had a lot of people mis-identified as positive this would require an enormous amount of resources and there may be side effects of the treatment.

The main "question" I think we should asking about the Ebola test is whether there is a way to develop a test that is more sensitive.  And quickly.  And if the government can support that and someone can find it, there may be a profit to be made from an innovation for humanity.  

Sunday, November 16, 2014

Introversion, Analytics, Storytelling

As part of my position as Vice Dean of Education I get to meet a lot of students who have a lot of issues.  This year, I made it a point to also meet students who don't have big issues but who are, in fact, doing great things for the School at which I work.  So, I arranged a series of lunches with leaders of student organizations.  There were many interesting and fun outcomes of the series of four lunches I had a couple weeks back.

One lunch was notable for discussions of introversion, analytics, and storytelling.  You may wonder how those fit together.  Here is how that came about.

First, introversion.  At this particular lunch there were four students.  Some of the lunches I had were largely student driven around issues that applied either to the specific student organizations or around generic student issues.  Two of the lunches were more driven by discussing issues about research or career interests or personal stories.  In this particular lunch, the fourth of the week, the students all knew that I am a runner.  At some point the discussion transitioned to be about management style and personality types.  As I had been leading the conversation, I started with, "Many people don't believe this, but I tested strongly as an introvert on the Myers-Briggs test.  One of the students looked at me quizzically as I said this--body language that said, "Why would people not believe you?"  This student has a keen understanding of what the MBTI really gets at.  I've heard it described as not whether you like crowds but where you go for "recharging" or where you draw your strength.  Many long distance runners--particularly those who are willing to do the longest workouts on their own-are great candidates to guess they would be pretty strong introverts.  Using that time away to think and recharge.  So, that was interesting point number one.

The other two came when the same student, inquisitive about my change from a faculty member at the School of Public Health to a largely administrative role at the business school asked, "Do you still use any of the skills?  And how do they help?"

I gave two answers.

First, I talked about analytics.  While it is certainly the case that I am interested in different data as an administrator and the types of analyses are different, I still need to be analytic.  That is a skill that dates back to my days as a faculty member.  In fact, I would suggest that it is a pretty fundamental part of my personality and dates at least as far back as the future problem solving exercises that I was asked to participate in as part of the academic enrichment program provided by my school district when I was growing up.

Second, I talked about storytelling.  As someone who writes a blog, I'm sure that readers are not surprised to hear that I would focus on storytelling.  The key is how to link that to both research and administration.  While my research reports were never as gripping as a best selling Tom Clancy novel, good research reports tell stories.  Non-fiction, of course.  But stories nonetheless.  And, as a leader, I have to get other people to move in a direction I want them to.  How best to do that?  By telling stories that illustrate the vision of what I want to achieve.  So, maybe I could have called it communication rather than story telling, but the idea is clearly there.

So, that is how I managed to talk about introversion, analytics, and storytelling all as part of an hour long conversation with four students at the Business School.  And I look forward to continuing to have opportunities to share wonderful and interesting stories about my view of the world with as well as about learning from the students who come to the Carey Business School.  

Friday, November 14, 2014

Affordable Care Act and Strains on the System

This has been an interesting week for issues surrounding health insurance for me.  I was surprised by the amount of the increase in my out-of-pocket premium each pay period for health insurance for 2015.  The explanation was not that all of my employer's health insurance premiums were going up so substantially.  Rather, the main issue was that with my raise, I passed a threshold that led to a higher out-of-pocket premium expectation.  Not completely unreasonable.  Just there.

Then, today, I saw an article in the Wall Street Journal.  The article talks about the link between the Affordable Care Act, expansion of Medicaid, and strains on the health care system.

This is not a completely unexpected result.  There may be other data that I have not seen that counter what I read in the article.  If so, I'd like to see them.

However, the key here is that the Affordable Care Act was designed primarily to do one thing--get more people insured.  At least that was my read of the act.  But I did not read every word, and apparently, at least some involved in designing it thought that the lack of transparency was a distinct political advantage.  (You can see a quote from a fellow health economist here.  The fact that anyone in my profession would make such a statement makes me sad.)

When more people get insured, it takes care of only one part of access--the affordability of care.  And the article in the WSJ even points out that in one state to make sure that new enrollees could be covered by Medicaid, it was necessary to tighten up the management of care for existing enrollees.  That leads to an interesting question about sustainability and the "social utility function."  Is it better to give excellent coverage to a smaller number or moderate coverage with lots of controls to a smaller number.

Additionally, the fact that only affordability changed is showing up in how long it takes people to get care sometimes.  And the waiting list is growing for others to get care as more people who were previously not using anything other than the ER engage in the system.  Predictable--totally.

What does this mean?  Was the Affordable Care Act bad?  That, I believe, still remains to be seen.  Was the law put in place without a holistic view of how to solve the problem of access to health care under budget constraints?  Yes.  Could the United States ever implement a holistic reform?  Not likely given the political environment.

So, while the Affordable Care Act may have solved some problems it has created others.  Does that mean it was worse than no legislation at all?  Hard to say.  Does it suggest there is room for improvement?  Yes.  Where will that improvement come from?  Likely from private sector innovation that finds a way to provide affordable access to care to keep a population healthier while making a profit.  The best way to have a healthy bottom line is to run a business in a healthy community.  This wraps all the incentives together nicely if someone or some organization can figure it out.    

Tuesday, November 4, 2014

New Technology in Prostate Biopsies

On the professinal side, I am often looking at new opportunities to screen, diagnose, or treat and asking the economic question--what makes this a good buy?  Some, of course, migth simply say, "It is more effective so why would we not want to use resources for it?"  And given the value that is assigned to life, that is often a reasonable supposition.  However, given the limited resources that are available for medical care and public health efforts, it is also often worth while to ask a few deeper questions and determine whether a use of resources is the best use of resources or not.  

On the personal side, my blogging began with a memorial service for a fellow parent at my kids' elementary/middle school who lost a battle with prostate cancer.  So, when there are new ways to guide screening, biopsies, and making a progosis, they almost always catch my interest.

An article in today's Wall Street Journal focused on the potential use of MRI's to guide biopsies to determine whether prostate cancer is agressive and should be treated agressively or whether it is more likely that the tumor, despite its presence, is clinically insignificant.

The article does a good job of describing everything that would go into an economic, cost-effectiveness evaluation without doing one and without, it appears, one having been completed so far.  Specifically, there is a higher cost to have the MRI prior to the biopsy--but from the patient's point of view some of that is paid by the insurer.  There are some aggressive cancers that are detected by the MRI technique and, as importantly, some cases that are rules as "not signficant" after which a patient can avoid being over treated.  Then, to make matters more complicated, there are also a fair number of cases missed despite the MRI.

Thus, an economic evaluation would have to compare the clear and readily identified cost of the procedure (potentially from different perspectives) with the value of more appropriate identification of aggressive cancers and the value of avoiding over-treatment (not just lower costs but potentially better quality of life that results from avoiding the side effects of surger to remove the prostate like incontinence and sexual dysfunction, and then account for the costs associated with still missed cases.

This would not be a simple analysis.  And while we may have quality of life and life expectancy measures for each of the resulting outcomes, this is a complicated situation in which the fear of a missed case or the disappointment with finding out that the cancer was not as bad as expected should be taken into account.  These types of quality of life issues are dynamic and complex.  

How should a decision be made?  The technology has some distinct advantages.  These should be presented to patients.  However, this does seem to call for shared decision making between the patient and urologist with as much information as possible shared in a way that is comprehensible until there is clear data to suggest whether the MRI is truly economically preferred.   

Tuesday, October 28, 2014

Finding Out for What I Am Known

Over the past two days, I have had the opportunity to find out what I am known for in the way I run my career.  It was interesting mostly because I had not realized just how much some of the details of my life had made an impression on others.  

First thing.  Yesterday I, a fellow faculty member, and a staff member had a lunch with some students.  It seems like whenever I have a lunch with a relatively small group of students, running comes up.  I guess that should not surprise me given how much of a part of my life running is.  And students know that.  One student was surprised that I made an effort to get a "less than 600 calorie entree".  And my colleagues know that.  What was interesting though was a comment after lunch when I was speaking with the fellow faculty member and staff member about my running.  My fellow faculty member asked if I'd gotten in my run yesterday.  I commented that I had, and the staff member commented on how much people know I am an early morning runner.  In fact, the staff member pointed out that she had gotten emails from me very early, then noticed a pause, and then another set of emails.  The pause was my run.  It was just fascinating to me to see how much the rhythm of my day is noticed by my coworkers.  It makes me wonder whether anyone ever plans around that.  And if I ever stopped exercising so much how would that change the relationship I have with my colleagues.  Right now people know I'm up very early but there will be a break.  If I were just going straight on through that would lead to a different work flow.  If nothing else, if and when I stop running so much and so regularly, I should make sure to communicate to others how that will change the work flow.  Clear communication about changes in process is clearly a best business practice.  

The other thing that caught my attention was a former student posting on social media that she she traveling to a meeting "Kevin Frick-style".  This was to indicate going to a meeting and back on the same day.  (Although she did point out that in her case at least she was staying in country compared to my recent trip to Ireland and back in 30 hours.)  Again, people have taken note of the way that I work.  My goal of planning trips in the shortest time possible has clearly defined my professional life to date.  I've been all sorts of places with very little sight seeing.  I doubt I will ever (at least as long as I have kids at home) stop making trips as short as possible.  But there may come a day.  And that would be another change in business practice that I would need to communicate to my colleagues clearly.  It would make it possible for me to see a lot more of the areas where I go for meetings.  It would make the timing of professional meetings less hectic.  It would allow me to be less stressed as long as I could keep up with communication with my colleagues while away.

So, looking ahead, it will be interesting to see if ten years from now I am known for the same things.  If not, what will I be known for?  And how will I communicate effectively to colleagues about how my habits affect the way that I do business and can do business with colleagues.  

Wednesday, October 22, 2014

Another Take on Business with Humanity in Mind

This phrase is the line that describes what we intend to teach at the Johns Hopkins Carey Business School.  It is fascinating that each faculty member and each student seems to (and, in fact, is encouraged to) have her own interpretation of what this means.  The Dean likes to interpret it as thinking of stakeholders beyond he owners (be it a privately held business interest or a shareholder held corporation).  The stakeholders can include customers, employees, and the community in which the business exists, just to name a few.

Earlier this week, I had the opportunity to meet with colleagues from Shenandoah University.  We had a fascinating conversation about the two schools, about a joint research opportunity focusing on the economics of breastfeeding for low income mothers and families, and about a possible collaborative symposium.  As we discussed the symposium we talked about the interesting overlap of interests between the faculty and community at the two universities and how they would compare and contrast. 

When I was speaking with a colleague at Carey after the conversation with the colleagues from our sister university, I was talking about the interesting issues faced by our colleagues in Virginia.  Specifically, my colleagues had told me about the city of Winchester in which there is some “old money” with grand houses, some multigenerational poverty, and some housing in which mostly recent immigrants live.  My colleague thought that alone would make an interesting basis for a discussion of business with humanity in mind—seeing the fascinating cross section of humanity that any business—health care (where the conversation with our colleagues from Shenandoah began) or otherwise—would have to keep in mind when planning around stakeholders.  What is even more interesting is that Baltimore has the same.  Both near the main university campus in the Homewood area of the city and near the business school.  Not so much “old money” in Harbor East, but certainly a lot of money.

Any business that has to keep in mind populations that include high income, multi-generation poverty, and brand new immigrants will face many challenges as the potential effects of business decisions on these different populations vary in complex ways.  Some businesses will cater to one or the other.  Other service organizations, e.g., health care, will have to consider staffing and resource allocation and outreach that touch each population in different ways.  One goal of an education at Carey is to have our graduates thinking about the many, varying effects and bringing that thinking to the decision making process in the organizations in which they will some day become leaders. 


I look forward to seeing how we can bring our faculty, students, and communities together to struggle with these issues and to help all of both schools’ stakeholders to understand better how to conduct business with humanity in mind across a wide variation of settings. 

Monday, October 20, 2014

3 Life Lessons

In the past week, I have encountered three life lessons that are good for life and good for business.

The first is to make a good impression. I did this twice in flying today and in both cases what otherwise would have been a transactional interpersonal event became a pleasant interaction. The first was paying to move up from C04 to A06 on my flight. I asked politely. I engaged the employees in a discussion about the choice to move up. They commented on someone who once had an A17 boarding spot and wanted to move up. They gave me a favorable comment on how I was dressed. I wasn't in my best or newest suit. But they asked if I was going to a meeting. I told them I'd just been at a professional conference. They noted that people don't get dressed up to fly any more. My boss's advice about making an impression on people even extended to the airport. Second, when I got back to BWI, I had managed to misplace my ticket from entering the parking garage the day before. So, I went to the information desk inside upon landing and introduced the question by saying, "I know this is a stupid question to have to ask." I was neither panicked about the question nor demanding of an answer. The person appreciated it and helped immediately and directly.

The second lesson is to be careful of with whom I surround myself. This, in some ways, goes along with making an impression. Consider President Obama's choice for the Ebola czar. A political operative with no public health experience. He can manage but does he understand what he is managing. Many people have asked. It made an impression--and for most, not a good one. I think that surrounding myself with the smartest person I can attract who knows more about something than I do is a good approach. My hires represent that and we are working to create the type of organization I hope to work in. And those I inherited with whom I surround myself are people who can take what I am good at--vision, creativity, and bringing people together for process--and move it to completion.

Once I have made an impression based on my own personality and activities and the personalities and activities of those around me, I have the opportunity to think about a legacy. Sometimes this is really long-term. On the personal side, an award for sportsmanship in cross country was just given for the first time two days ago where I grew up--made from my Boston Marathon 2013 shoes. That is a great legacy. Sometimes it is just a process--I'm known for being someone who leads an interesting journey, is willing to share his journey, and who cares about others' journeys. I am trying to get a vision for the legacy that I want to leave at Johns Hopkins. It begins with first impressions. It continues with those with whom I surround myself. It requires me to complete things.

These three life lessons fit well together for personal life and for business. With a good first impression, a movement from transaction to pleasant interaction, surrounding myself with the right people, and a vision for legacy, something wonderful can be built.