Sense and Sensitivity: Trouble at the Airport, Trouble in Health Care.

Steven Lewis

Abstract: Umar Farouk Abdulmutallab (UFA), the thwarted Christmas Day Northwest bomber, has an almost comically perfect résumé as a potential terrorist. His own dad outed him to the authorities. He spent an unusual amount of time in Yemen. The computer screen virtually screamed DON'T LET THIS GUY ON THE PLANE. Nabbing the culprit should have been no more difficult than whipping Sarah Palin on Jeopardy. Yet the man figuratively wearing an orange suit with an arrow pointing to his pant leg labelled "explosives" managed to board the plane and begin to assemble his bomb until other passengers beat him up.

The solution is obvious - at least it is to the Americans and copycat Canadians. Make everyone come to the airport earlier and wait in long lines for screening. Make 85 year old grandmothers take off their shoes, abandon their shampoo, walk through whole body scanners, and don't let them pee during the last hour of the flight. More activity, more cost, more delay will mean better security. Everyone, don't you know, is a terrorism threat. There is not a citizen with an ounce of common sense unaware of how bone-stupid this is. The Americans are simply too rich for their own good. In spite of the hundreds of billions they spend on intelligence, homeland security, and the military, the Yanks seem always to end up with a Rube Goldberg contraption that never works. They are the Masters of Muda - wasted time and effort, useless work. What if it's not in spite of, but because of? Only those with huge resources can afford to pursue inelegant solutions. When looking for a needle, they begin with the biggest haystack; often they heap more hay on the hill before they start the search. When looking for a terrorist, suspect everyone - or at least pretend to, even if you don't, just so you look like you're not profiling. Above all, look like you care, and run around like you're committed. Call a code orange. Examine everything and you'll miss nothing. Achieve perfect sensitivity, and the specificity will take care of itself. But it doesn't. Casting the net too wide creates two fundamental problems. One is that it creates cynicism and ennui among the personnel who need to be motivated and alert to the very small number of passengers who pose a real threat. Second, it creates too many false positives and too much data: even a massive intelligence system can't process it all and prioritize vigilance effectively. The result of that is truly terrifying: even when the system worked - UFA was a known, fingered threat - it failed. And where anything short of 100% success is potentially fatal, surely it's time to rethink the approach, or outsource the whole enterprise to Israel, which seems to have learned a thing or two about how to safeguard El Al. Health care faces this dilemma every day: the more we seek sensitivity (picking up every conceivable case), the more we forego specificity (identifying only the real cases). How many false positives (healthy people labelled as sick) is one less false negative (sick people labelled as healthy) worth? What risk is worse - overtreating thousands for a false alarm (a common result of overscreening for prostate cancer) or undertreating some for an undetected remediable condition (a common result of colon cancer underscreening)? Here's where we need to find a way to trust calculation over psychology. If you or your loved ones die because a bomber used the airplane washroom as a lethal weapons lab or a battery of physicians missed a diagnosis, there is cold comfort in numbers and probabilities. The natural reaction is to rail and demand more, damn the cost and the collateral damage. We must not stop until tiny risk becomes zero risk. Every failure is a system failure; a stone unturned is an opportunity lost. But there is another option. Acknowledge the reality of our times and accept that the quality of individual and civic life goes hand in hand with a certain amount of risk. Terrorists are going to kill innocent civilians. The pool of potential terrorists remains very small and it is sloppy thinking to infer that if you don't put 85 year old women through the security wringer, Al Qaeda wizards will recruit one to blow up the flight to Dubuque. It is folly to respond to every failure with a massive assault on common sense; learn its root causes and deal with it more strategically, not least by recognizing the consequences of too blunt an approach. So it is in health care. People are going to die because of missed diagnoses, just as people will die because of overdiagnoses. If you spend your life worrying about every tic and blemish morphing into a lethal tumour, you will climb onto a diagnostic treadmill and lead a life that is literally pathological. Hypersensitivity is the spirit of the times; it drives up utilization and costs and defines normal as an exceptional condition. Put another way, there is danger in investing too much confidence, money, and psychic energy in increased sensitivity while paying too little attention to specificity. And given the way humans work, it's a self-defeating strategy. When too much is important, nothing is important; an obsession with sensitivity will become an analgesic that numbs us to the real deal. Somewhere, sometime, a bleary-eyed, conscientious person will miss something important amid the expanding clutter of supposedly relevant phenomena. The key to great detective work is to narrow the list of suspects. In airports and in health care, the challenge is to know whom to leave alone.

An Intractable Conflict of Interest

(see previous entries)
If the Canadian Institutes of Health Research exists to promote the public interest, why has a VP at Pfizer been named to its governing body?

Francoise Baylis

Canadians are being invited to sign a petition against the appointment of Dr. Bernard Prigent, a senior executive of Pfizer, to the Governing Council of the Canadian Institutes of Health Research (CIHR) So far, over 3,000 Canadians have signed, including senior health researchers, clinicians, ethicists, health policy experts, as well as ordinary Canadians who understand that this appointment represents a significant threat to the integrity of CIHR by entrenching an intractable structural conflict of interest.

To quote from one of the signatories, “You don’t put the rooster in charge of the hen house.” The duty of pharmaceutical companies (e.g., Pfizer) is to make money for their shareholders. The duty of CIHR is to promote the public interest. The interests of shareholders and the interests of Canadians are not one and the same.

CIHR was created in 2000 as an arms-length federal agency responsible for funding health research in Canada. The 2009-2010 total budget for CIHR was just under a billion dollars. This is a lot of money and it is important that Canadians understand how their tax dollars are being spent.

The CIHR Governing Council sets the strategic direction for CIHR and determines where money should be invested. According to the CIHR Act, its members are “to contribute to the achievement of the objective of the CIHR in the overall interests of Canadians.” The prime directive of CIHR is to improve the health of Canadians by “accelerating the discovery of cures and treatments and improvements to health care, prevention and wellness strategies.”

Lately, this mission has been taking a back seat to a different objective: the commercialization of health research. On November 30, 2009, in describing the objective of CIHR to the Standing Committee on Health, the President of CIHR, Dr. Alain Beaudet, spoke about the agency as though its mandate was to stimulate the Canadian economy. There was nary a mention of promoting, assisting, and undertaking research to improve the health of Canadians. What was once supposed to be a means to that end has now become an end in itself.

This worrying trend is most evident in the recent appointment of Dr. Prigent, the Vice President and Medical Director of Pfizer Canada, to the Governing Council . Pfizer is the largest pharmaceutical company in the world with 2008 revenues of over $70 billion. It also has the dubious distinction of having the largest criminal fraud fine in the history of the U.S. Department of Justice (the full bill was $2.3 billion for the illegal marketing of certain pharmaceutical products). And now our federal government has honoured Pfizer with a seat at Governing Council where decisions are made about how to invest your health research dollars.
Sadly, not everyone objects to this appointment.

Some argue that Dr. Prigent was appointed as an individual, not as a representative of the company for which he has worked for the past 25 years. Dr. Prigent is not described as a leader in Pfizer, but as “a leader in the promotion of Research and Development within the Canadian Life Science Sector.” Supporters further note that Governing Council members are expected to place personal agendas aside, and promote the best interests of CIHR, the broad research community, and all Canadians. But if Dr. Prigent puts those interests above those of his company, how will he answer his shareholders? He has a legal obligation to serve the interests of the corporation.

Supporters of the Pfizer appointment further remind us that all members of the CIHR Governing Council must observe the Conflict of Interest Act, the Ethical Guidelines for Public Office Holders, and the Guidelines for the Political Activities of Public Office Holders as a condition of appointment. This is as it should be. But adherence to these guidelines does not address the structural conflict of interest. Dr. Prigent cannot serve two masters with potentially conflicting interests. Moreover, if Dr. Prigent sees and understands the deep-seated conflicts, he will need to recuse himself from the very discussions where advice from the business sector is needed.

Another reason given for supporting his appointment is that the CIHR Act mandates improving the health of Canadians by “encouraging innovation, facilitating the commercialization of health research in Canada, and promoting economic development through health research in Canada.” Conveniently, this forgets about the parts of the Act that refer to “promoting, assisting, and undertaking research that meets the highest international scientific standards of excellence and ethics and that pertains to all aspects of health” and “fostering the discussion of ethical issues and the application of ethical principles to health research.” Are these parts ignored because they set standards that Pfizer cannot meet? Pfizer’s well-documented history of transgressions against the integrity of science goes well beyond the most recent $2.3 billion settlement.

A third defence of the appointment is that the CIHR Governing Council has long recognized a gap in its membership relating to the commercialization of research. I disagree with this view insofar as there has always been a person with business expertise on the Council to advise on such matters. But, assuming there is a more specific gap requiring someone with international experience in pharmaceutical innovations, it could be filled by an individual without the intractable conflict of interest faced by Dr. Prigent (or any other active member of the pharmaceutical industry). Why not choose a retired member, or someone who has worked in the pharmaceutical industry but now works in another industry, in academia, or for a non-profit company instead?

Francoise Baylis is Canada Research Chair, bioethics and philosophy, Dalhousie University.

RE: Appointment of Dr. Bernard Prigent to the Canadian Institutes of Health Research (CIHR) Governing Council (GC)

(See previous entry) The basic assumption in Steven Lewis' argument is that because Dr. Pringent works for a pharmaceutical company and may have an obligation to protecting shareholder interests, he will not be able to play an unbiased or in anyway valuable role on the Governing Council (GC).

By using such language as, "Seemingly countless systematic transgressions of pharma against scientific integrity and honest marketing", Lewis appears to imply that no representative of “evil-pharma” deserves a seat on the Council.

While making no apologies for pharma's sales practices, in light of the recent "climategate" scandal and the countless examples of systematic transgressions of researchers against scientific integrity, one could easily make a similar case for not having any scientists on the GC. I am not sure that this would be in line with what Lewis is trying to achieve.

Furthermore, as pointed out by David Allison, Professor of Biostatistics at University of Birmingham, Alabama, in a letter to Science [1] and in an article in the International Journal of Obesity [2], it appears that scientists are not in any way "immune" to taking a biased view of scientific data. Indeed, one may argue that industry driven bias may be far less perfidious (because the cards and intentions are on the table for everyone to read) than the many biases that are far more difficult to recognize, like the ideological (anti-industry) "white-hat” bias, self-aggrandization bias, or simply the all-too-prevalent “love-for-their-favorite-hypothesis” bias.

In fact, if we accept Lewis' argument against having representative of "evil-pharma" at the table, we may as well exclude all industries (certainly no food industry, no energy companies, no banking, no private health care, no information technology, no medical devices, in fact, no representation from any sector that is primarily driven by profit and could potentially benefit from strategic decisions made by the GC).

In contrast to what Lewis implies, I would readily assume that everyone on the GC likely represents a constituency or interest group and brings a bias to the table even if their views are only coloured by their personal perspectives, ideologies, views, or beliefs. Indeed, I have no doubt that were I to be offered a seat at the GC, in my role as Scientific Director of the Canadian Obesity Network, I would do my best to promote more investment in obesity research and vehemently oppose any attempt of other GC members to cut funding for obesity because of their personal beliefs that obesity is simply a "self-inflicted" matter of choice and does not deserve public funding to address (incidentally, it turns out that individual choice has surprisingly little to do with the obesity epidemic after all [3]).

Nor does the argument that a seat on the GC would provide an unfair advantage to Prigent, and thus Pfizer, over its competitors fly. The same could easily be said for any researcher who sits on the GC. Indeed, I have sat on numerous scientific review panels that have provided me with (unfair?) insight into the projects of my (scientific) "competitors" and I have often had the opportunity to steer committees towards funding projects that I thought and felt were more important and away from others that I believed (for whatever reasons) were perhaps less deserving of funding. The notion that scientists on committees are not in someway representing their own views, areas of interest, and ideologies is naive and unfounded. Nor do I expect representatives from research institutes, foundations, patient-advocacy groups or any other constituency to be fair and unbiased towards all possible decisions of the GC. In fact, it is this very diversity of opinions and interests that makes for a strong and effective Council.

I believe that having an industry representative at the table provides an important voice in the discussion, a chance to bring in arguments and views that may be important to consider and insights that may not be immediately obvious to GC members with little insight or experience in the private sector. The "holier-than-thou" argument presented by Lewis is simply discriminatory and unfair in singling out one member on arguments that may in principle apply to all members of the GC
Finally, simply in light of a democratic process one could even make the argument that the pharma industry, as a major tax payer and player in the health sector, very much has a right to sit at this table - after all a significant chunk of public funding that the GC will decide over comes from the taxes that this very industry pays into the government coffers - no taxation without representation?

Rather than demonizing or declaring outrage about the appointment of representatives of certain constituencies to the GC, the simplest way to deal with any actual or perceived conflicts of interest is to have these openly declared (my guess is that it is likely far easier for Pringent to identify and declare his obvious areas of conflict than for most other members on the Council, who I am sure all have interests and biases of their own). It is easy enough (and hopefully common practice during GC sessions) to expect Pringent (and others) to excuse themselves from voting or even from being in the room when matters are discussed where such a conflict occurs.

Excluding anyone with a putative personal, professional, ideological or political conflict of interest from the GC will most likely result in not having a council at all.

Arya M. Sharma, MD/PhD, FRCPC
Professor and Chair of Obesity Research and Management
University of Alberta

1. Allison DB. The antidote to bias in research. Science. 2009;326:522-3

2. Cope MB, Allison DB. White hat bias: examples of its presence in obesity research and a call for renewed commitment to faithfulness in research reporting. Int J Obes. 2009. [Epub ahead of print]

3. http://www.drsharma.ca/obesity-lifestyle-choice-or-lifestyle-chance.html

Where There’s Smoke, There’s Pfizer: Sparks Fly Over Recent CIHR Appointment

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Where There’s Smoke, There’s Pfizer:  Sparks Fly Over Recent CIHR Appointment

The Canadian Institutes of Health Research (CIHR) Governing Council (GC) has a new member:  Dr. Bernard Prigent, the Vice-President of Medical Affairs for Pfizer Canada. 

Steven Lewis, former (and founding) member of the Governing Council is outraged.

In an essay to be published on Tuesday by Longwoods Publishing (and pre-released here) he writes:

·         Seemingly countless systematic transgressions of pharma against scientific integrity and honest marketing have been documented in grisly detail. 

·         How does a Pfizer VP remain agnostic about whether an institute as the Institute for Health Services and Policy Research should be renewed if it supports research that shows a Pfizer drug is dangerous or identifies the massive public subsidies that flow to drug companies?

·         Dr. Prigent’s company recently paid a whopping $2.3 billion for fraudulently marketing Bextra, a painkiller withdrawn from the market in 2005, and 3 other drugs.  Dr. Prigent’s signature adorns the confessional letter that alerted Canadian practitioners to the company’s malfeasance. 

·         There are innumerable alternatives to get commercialization advice -- all of them cleaner and more transparent. 

·         As a member of GC, Dr. Prigent,  will from time to time have access to information that his competitors do not, and he can exert a steering effect where they cannot.

“Given these facts,” notes Mr. Lewis, “one is hard pressed to view the appointment as anything other than a deliberate provocation.”

According to Mr. Lewis, at least  3300 people have signed a petition protesting the appointment, many of them prominent researchers, ethicists, and public policy experts.  He warns that the government and the CIHR want this to go away; their biggest allies are silence and resignation. He calls for more people to sign the petition, write their MPs  and write op-eds for local newspapers. 

The complete essay is posted here:

http://www.longwoods.com/product.php?productid=21198

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For more information contact:

(Author) Steven Lewis at Steven.Lewis@shaw.ca

(Editorial Director) Dianne Foster Kent at dkent@longwoods.com or (business hours 416 864 9667)

Steven Lewis is a health policy and research consultant based in Saskatoon, and Adjunct Professor of Health Policy at the University of Calgary and Simon Fraser University (where he was Visiting Scholar in 2007). Previously he headed a health research granting agency and spent 7 years as CEO of the Health Services Utilization and Research Commission in Saskatchewan. He has served on various boards and committees, including the Governing Council of the Canadian Institutes of Health Research, the Saskatchewan Health Quality Council, the Health Council of Canada, and the editorial boards of several journals including Healthcare Papers and Open Medicine. His published work covers topics such as reforming and strengthening Medicare, improving health care quality, primary health care, regionalization, and the management of wait times.

Longwoods Publishing Corporation  (Longwoods) publishes academic and professional information and journals covering health and health care ideas, policies and practices and works in collaboration with governments, institutes, health care organizations, academe, and the the private sector including the Institute for Health Services and Policy Research and pharmaceutical companies.

Degrees of Separation: Do Higher Credentials Make Health Care Better?

Lewis, Steven

Somewhere around 2050, the last registered nurse without a university degree will ride off into the sunset. Manitoba had gamely held out as the last province to retain the diploma option, but it, too has thrown in the towel. Raising entry-to-practice credentials (ETPC) in health disciplines is the new pandemic. Among recent developments:

Nursing: decades-long evolution from hospital-based to college-based diplomas, and then baccalaureate degree ETPC Medicine: lengthened the family medicine residency to 2 years from 1 in the early 1990s; major cause of subsequent doctor shortages Physiotherapy: conversion to master's-level ETPC almost complete Occupational therapy: ditto Pharmacy: talk of moving to a PharmD ETPC; the University of Toronto has pitched it to the Government of Ontario, and Quebec has made similar noises Various technologists and technicians: regular push for baccalaureate ETPC In a world that values education as an intrinsic good, these have to be admirable developments. Professions devoted to the public good and humbly aware of their limitations raise their ETPC as part of the journey to continuous improvement. Higher ETPC has to create better-prepared graduates, improved system quality, and a better patient experience. If a diploma is good, a degree is better; if a baccalaureate is adequate, a doctorate is superior. Sounds sensible, right? Let's examine what we've learned about this phenomenon over the years[i]. First, no one can pin down where raising the ETPC starts. Many have looked, and more knowledgeable and savvy people than I cannot trace a change back to its origins. The best guess is that the movements begin in faculty lounges or around the board tables of professional associations. While we don't know how the credential upgrade begins, we know how it doesn't. Employers never demand increased ETPC; on occasion they explicitly oppose it. No one has ever produced evidence that those practicing with the about-to-be-abandoned credential were harming the public. Governments never instigate the changes. Second, increasing the credential does not necessarily mean more training. Take the therapies. Until recently, you got to be a physiotherapist by taking a 4-year university degree in, sensibly, physiotherapy. Now you take a 2-year master's program following an undergraduate degree in anything. Same with OT - my brilliant and talented niece got her MSc on top of her architecture degree, consisting of about a year in the classroom and a year of practical experience. We are to take it on faith that we get a more capable entry-level therapist in half the time it used to take, armed with a degree that sounds more advanced. Nursing has been even more artful. First, it bid adieu to an intensive, roughly 23-month diploma program in favour of the 4-year, but less jam-packed baccalaureate program. The degree students actually spend less time in practice settings during their training. The transition to a degree-only program predictably reduced the numbers of graduates. Employers and governments grew alarmed at forecasts of a 100,000+ shortage of RNs on the horizon. No worries, responded the universities. We've got a solution. Presto - there are now 11 programs across the country that will give you a nursing degree on top of, say, a fine arts degree in 2 years! Follow the bouncing ball: two years wasn't sufficient to turn out a competent entry-level nurse fifteen years ago, but now it is again. Excellent. (Advice to students: demand a master's degree for your troubles, just like the physios and OTs. Of course, this would confuse regulators, irk nurses with 4-year baccalaureate degrees, and cause riots among nurses with real master's degrees. The physios and OTs had the good sense to eliminate the undergraduate option altogether.) Third, at least in some jurisdictions, universities, wielding their academic freedom, have acted with remarkable vigour to satisfy professions' aspirations for increased ETPC. The University of Saskatchewan - my alma mater and annual recipient of my donations, in case this essay prompts it to withdraw my degrees - decided on its own not to enrol a new class of physiotherapy students a couple of years ago, as part of its campaign to adopt the MSc as the ETPC. It somehow forgot to notify the government or obtain its permission, although it invoked the Cool Hand Luke defence. One might think the Premier or Minister of Advanced Education might have called up the President to inform him that this ringing exercise of institutional autonomy suddenly made a few million dollars vanish from the university's budget. Nah; bygones. Fourth, the ETPC movement has created subtle changes in the meaning of advanced degrees. I believe the technical term is "phoney baloney." These so-called professional master's degrees and doctorates require none of the rigour, research, or external scrutiny that used to be hallmarks of advanced education. While purveyors of these degrees acknowledge that they are different in important respects, they know full well that the public makes no such distinctions. The biggest assault on standards is where the advanced degree sits on top of an undergraduate degree in a different discipline. The master's-level PT and OT training has to be basic because no one has any grounding in the subject matter prior to entry into "graduate" studies. Fifth, no one seems to know or care about the practical consequences of raising ETPC. People will disagree about the wisdom of the nursing conversion, but shouldn't we at least be curious about the consequences? (I'm not picking on nursing here; it's just that nurses outnumber the other professions combined, so the implications are huge.) For example: How much did it cost? The transition reduced supply, which shifted bargaining power to nursing unions and led to bidding wars among the provinces. Every higher-than-normal contract settlement produced a domino effect across the country. I'm all for paying nurses well, but no one consciously decided that we ought to spend several billion dollars to make nursing more lucrative. Is it several billion? Well, if 200,000 nurses are getting 20% more than they would have had the diploma option remained in place, and the average nursing salary is $60,000, that would be $12,000 more per nurse x 200,000 nurses = $2.4 billion annually. Is nursing care better? We have no clue. There is some (largely American) research that attributes hospital care outcomes to RN staffing levels, but the studies have deliberately avoided comparing diploma vs. baccalaureate degree nurses. Hint: you can read a tonne of quality improvement literature without coming across any references to ETPC as a key factor. Are nurses happier? I hope not, because they remind us weekly of their collective misery and plummeting morale, so it would be terrible if this reported malaise is actually an improvement over their state of well-being prior to degreeing up. Has the class structure of nursing education changed now that the profession is degree-only? Are fewer working class kids inclined to choose a career in nursing because it is much more expensive and time-consuming to acquire the credential? What about Aboriginal peoples, recent immigrants and other minorities? You would think that public policy makers might be interested in some case studies of the consequences of these decisions. Uh-uh. A number of us have proposed a research agenda to get to the bottom of these monumental changes and produce real evidence to resolve the ongoing debates. It might cost a few million dollars to do the work comprehensively, but we're dealing with multi-billion-dollar issues. The failure to commission the research betrays not just a stunning lack of curiosity; it is wilful ignorance that will condemn decision-makers to the same sort of ad hoc, ill-informed choices that have created the current mess. But, one might counter, even if the ETPC changes were in a sense unnecessary, there are worse sins than overeducating the health care workforce. Not so fast. One of the reasons professions raise ETPC is to increase their status and credibility in the academy. They do this in part by developing complex theory and creating specialized identities. Merging these identities into unified interprofessional teams is a challenge under any circumstances; even stronger and more fragmented identities forged in longer education programs will hardly make this easier. Furthermore, graduates with higher credentials will expect to work at a higher level and many will be disappointed and bored by the everyday but important work of patient care. All that said, there is no definitive proof that increasing ETPC has been a colossal mistake. I'm saying merely that it might have been, but we know embarrassingly little about the consequences. And if we're going to require more education for health care newbies, we need to debate the form that education should take. Too many practitioners know nothing about the social determinants of health, health systems, policy, economics, and the arts of citizenship. Maybe they need to broaden their educational horizons rather than deepen their discipline-specific identities. That nurse with a BFA and a two-year nursing degree may indeed turn out to be admirably educated for the challenges of working in a variety of contexts. But let's not confuse that prospect with the ETPC essential to making health care better. ------------------------------------------- [i]Before I get into the analysis, full disclosure: as a public representative on the Canadian Nurses Association Board of Directors in the early 1990s, I cast the lone vote against what was then known as the BN 2000 resolution. For the past 6 years I have sat on the federal-provincial-territorial Coordinating Committee on Entry to Practice Credentials (we have a gift for catchy titles). So I have been around this topic for some time, and while it cannot compete with my obsession with baseball statistics, it ranks right up there among my day job preoccupations.

What Elinor Ostrom can Teach Healthcare

by Neil Seeman

Remember the "tragedy of the commons"? I learned the concept in first-year economics class at Queen's University - not in real economics class, but in the dorm room. The cleaning staff fluffed the pillows and vacuumed the carpets each Monday. Students would raze the place over the ensuing days. By Thursday the place was a pigpen.

We undergraduates lived the tragedy of the commons. Acting independently in our own self-interest, we destroyed the shared but limited resources of the common area: the pull-out sofa bed for out-of-town guests; the dart board; the ping pong paddles. In the hierarchy of student needs, these things ranked very highly; yet we ruined them. Why so? More typically referenced examples of the tragedy of the commons tend to involve natural resources, like fish. If everyone in a village who fishes has equal rights to eat out of the same lake, human behavior (even if everyone in the village is kind-hearted) will lead inevitably to a disappearance of stocks. How do we regulate this? Thanks to the influential article by the late biologist Garrett Hardin in Science in 1968, the paradox of the "tragedy of the commons" - Hardin used the example of herders sharing a common plot of land and then eroding its value due to individual self-interest - has flummoxed economists for the last 50 years. The tragedy-of-the-commons problem is highly relevant to not-for-profit hospitals and public sector healthcare: how do we align collective self-interest to support public goods? Elinor Ostrom, 76, one of this year's Nobel Laureates in Economic Science (shared with Oliver E. Williamson), devoted her career to cracking this riddle. A researcher at the University of Indiana and Arizona State University, Ms. Ostrom's work as a "collective action scientist" well preceded what we now call "good governance". Just as intriguing as her research is the way she went about attacking the problems she sought to solve.   Practical Economics Economist David Henderson has described Ms. Ostrom's Nobel as a victory for "practical economics" as opposed to abstract formulas. Public reaction to her award, as measured by my quick sentiment analysis on Twitter, the social network, has been highly positive (try this: log on to Twitter, and search for "Congrats" and "Ostrom"). (Compare this to negative sentiment, and shock, registered in response to President Obama's Peace Prize win.) Lost in the media parade over Ms. Ostrom on account of her being the first woman to win the economics Nobel has been her work itself. ("The important thing about Lin Ostrom," 2002 Nobel laureate Vernon Smith said, "is not that she is the first woman to win the prize but that she richly deserved it.") Ms. Ostrom challenged the tragedy of the commons as an absolute rule, and, upon reviewing dozens of governance case studies, discovered cases of communal ownership in poor regions that worked smoothly - i.e., where people's interests in the "commons" were aligned, and as a result the common resources did not disintegrate. Among the case studies she uncovered that worked were those that had a manner of property rights system in place, despite the lack of private ownership in the resource itself. This led her to propose a series of rules for governing commonly pooled resources. These included the idea that rules should clearly define: who gets what; good conflict resolution methods; that people's obligations to keep the resource in good condition be proportional to the benefits they reap from the resource; that monitoring and punishing be done by the users or someone accountable to the users; and that users should be allowed to participate in setting and modifying those rules. The Power of the Case Study One lesson to be had from Ms. Ostrom's work is the power of case studies. Her practical case-study approach and field work led her to attack the paradox of the tragedy of the commons methodically, and in ways that economic theory never could. In real life, Ms. Ostrom found, the tragedy of the commons theory did not unfold the same way all the time. She examined user-managed fish stocks, pastures, woods, lakes, and groundwater basins. Some common resources were overused and depleted, but some were managed well. She set forth her findings in her 1990 book, "Governing the Commons." What is the secret to successful management of the commons? "One of the most important factors is whether local people monitor each other," Ms. Ostrom said in a news conference after her award was announced. "Not officials, locals. I'm not denigrating that officials can do something very positive. But what we have ignored is what citizens can do, and the importance of real involvement of the people involved…". This, to me, sounds like a good argument for involving every responsible citizen who consumes publicly funded health care to formulate its ethics and rules. In a word: engagement. About the Author Neil Seeman is a writer, and Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College at the University of Toronto.

The End of Healthcare Consultese?

By Neil Seeman

A new motion passed unanimously by the British Medical Association urges the NHS to scrap management jargon. For example, physicians have been asked to use “patient” and ditch “client” and “service user.”

People who thirst for plain English in healthcare and in all service sectors – I count myself among them – have been losing this battle. In a journal article in 1994, Richard Peck described the then-“adjectival All-Star” of healthcare: “seamless.” He wrote: “Virtually no one attending a healthcare conference in the ‘90s will avoid hearing the word “seamless” at least a few times. It is the Holy Grail of would-be managers of the healthcare system, an ideal: patients moving effortlessly from one level of care to another, as necessary and without a hitch – without doubt, without misadventure …”.

Fifteen years later, “seamless” still reigns. According to the British Medical Association, management-speak dehumanizes health professions: “performer” (aka “doctor”); “efficiency savings and disinvestments” (aka “budget cuts”); and “service user” instead of “patient.” The UK-based Plain English Campaign promotes clear language in all public communications, noting that language confusion among doctors and patients can be a life-or-death issue.

The Plain English Campaign states: “Since 1979, we have been campaigning against gobbledygook, jargon and misleading public information. We have helped many government departments and other official organizations with their documents, reports and publications. We believe that everyone should have access to clear and concise information in plain English.”

Some NHS hospitals and trusts have received the Plain English Campaign’s annual Crystal Mark for clarity, while other institutions have been shamed with its opposite, the “Golden Bull” award. The Campaign’s medical writing course teaches “writing short sentences; using bullet points; being ‘active’ not ‘passive’; and using verbs to emphasize action.” Sessions feature lessons on how to craft hospital appointment letters and patient information leaflets.

What People Want

There are legitimate arguments against so-called “plain language”: sometimes what is straightforward to one is offensive to another (e.g., the word “blind”); hence words such as “non-sighted” emerge. Language, especially English, is like an arctic floe – slow and serene, and then disruptive. This year Miriam-Webster added many jargon-laden words that address concerns about the environment (carbon footprint), medicine (cardioprotective), pop culture (flash mob), and, in particular, online activities (sock puppet, vlog, webisode).

Given the natural drift of language, especially in healthcare, can we learn from patients to determine which words they prefer? I think so.

We can learn from online analytics – looking at the actual language people use every day – found in millions of postings scattered on the World Wide Web. When talking about their real healthcare experiences, people describe themselves as “patients” about five times more frequently than as “consumers”; and people call themselves “consumers” about seven times as much as they call themselves “clients”.

Most of the objections to the word “patient” seem to come from academics who decry the supposed paternalism associated with the word; or from those who prefer “consumer” on principle – they don’t like the “medical model” of health. My interpretation: Regular people overwhelmingly prefer “patient”.

This is just one example, and not scientific. (For what it’s worth, this approach seems to confirm small studies. In one such study, 75% of 133 people in community care preferred to be called “patient” by their GP – vs. “client” or “service user”. In another study, the author surveyed 101 people attending a back-pain clinic and found that 74 preferred “patient.”)

Words such as “client” and “consumer” and “service user” have been thrown about in conferences and vision statements for many years, but they don’t stick with the public. When a word doesn’t stick, we should shelve it.

It would be helpful if dictionaries would expunge stale meanings with the same vigour with which they embrace new ones year after year. Then, perhaps, the experience of patients everywhere might be a bit more seamless.

About the Author

Neil Seeman is a writer and Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College at the University of Toronto.