Tools, Technologies and Training for Healthcare Laboratories

Untruth and Consequences

It's October 2020. Time to take a hard look at truth, untruth, and the consequences of pretending there's no difference.

Untruth and Consequences

October 2020

James O. Westgard, PhD

Please note: this essay discusses American politics.

I recently came across a gem of a book, "Our Malady: Lessons in Liberty from a Hospital Diary", by Timothy Snyder. This short book recounts the author's experiences getting sick in December 2019, first visiting an emergency room in Germany, then getting his appendix out in New Haven, later ending up in an emergency room in Florida, then returning to an emergency room in New Haven, followed by hospitalization for complications from the appendicitis surgery.
The story reminded me of a similar situation that was described by W. Edwards Deming, the quality guru who guided the Japanese recovery after World War II and introduced Total Quality Management to the US. Deming kept notes while he was being treated in a hospital and then described the difficulties of managing quality in our healthcare system, including his personal anecdotes to illustrate the problems.

Snyder's little book provides a great perspective on the US healthcare system today. Snyder is a professor who spends half his time in the US at Yale University (New Haven) and the other half in Austria (Vienna) where he does much of his research. Traveling back and forth between the US and Europe has given him experience with healthcare in Europe and healthcare in the US.

I could relate to Snyder's healthcare experience because of our own experiences. Just before we left for Sweden to spend a sabbatical year, our daughter Kris was playing with some friends and got hit in the head by a baseball bat. We took her to the emergency room at the University of Wisconsin Hospital (where I spent essentially my entire career) late one evening where we waited for hours while they did x-rays, including a full cranial series. Then we waited for someone to come and interpret those x-rays. Then those x-rays weren't good enough and they wanted to take another series. By that time, very late into the night, I said we're taking her home and we left. Next day we returned and they had lost all the x-rays and we needed to start over again. When in Sweden, there was a similar episode where Sten fell and hit his head on a big rock (for the moment, let’s not discuss the frequency of my children bumping up against hard objects, a life lesson that I think served them well). We went to the Emergency Room where a doctor talked to us, looked at Sten, felt his head, and told us to go home and watch him for the next day. If he had any symptoms, which the Doctor carefully described to us, we were to bring him back to the Emergency Room.

That's the same kind of story that Snyder is telling in "Our Malady," but he has many more episodes to talk about because of all the time he spends living in Europe. He also seems to have broken many bones in his body, including at least four ribs playing basketball. He suffers from migraines, which I can relate to, and also comes from a farm background, though in Pennsylvania rather than North Dakota. Snyder’s commentary and analysis includes the current pandemic up through the summer of 2020. He is a historian and has spent much time writing about Eastern Europe pre and post World War II. His 2018 book “The Road to Unfreedom” focuses on the post cold-war period up through recent issues with Russia and the Ukraine. If you want to really understand the situation in Ukraine, you should read The Road to Unfreedom. Unlike “Malady,” “Unfreedom” is not an easy read and requires some serious study.

Health, Freedom, and Truth, in Snyder’s own words

I find Snyder’s ideas to be so insightful and important that I will try to provide a summary of some of them quoting his own words.

"Our malady is particular to America. We die younger than people in twenty-three European countries… The gap between the United States and other countries grew in 2020, since no democracy mishandled the coronavirus pandemic as we have done…
Part of our malady is that there is nothing in our country, not even life and not even death, where we take the position that ‘all men are created equal’ seriously. If health care were available to everyone, we would be not only healthier physically but also healthier mentally… We would be profoundly more free.
The paradox of freedom is that no one is free without help. Freedom might be solitary, but freedom requires solidarity.
You appreciate [health] when it goes away. Truth is like health; we miss it when it fades…
The truth takes work. Facts do not often line up with what we believe, want to believe, or are led to believe. Facts are what we apprehend when we place ourselves at the right distance between our emotions and the world around us…
The death of truth brings the death of people, since health depends on knowledge.
We cannot be free without health, and we cannot be healthy without knowledge. We cannot generate this knowledge by ourselves as individuals: we need a general belief in the value of truth, professionals whose job is to produce facts, and robust institutions that support them…
This crisis is a chance to rethink the possible. Health care should be a right, doctors should have authority, truth should be pursued, children should see a better America."

Why this rings a bell with me!

I have for many years described quality as a complex idea that is similar to truth. The requirement for quality in the courts of our land witnesses must “swear to tell the truth, the whole truth, and nothing but the truth.” I have often used the analogy that the quality of laboratory tests depends on defining how good the test needs to be for medical use (truth), the precision and accuracy of the test method (the whole truth), and the QC procedures that ensure the method is performing as intended (nothing but the truth). An alternate analogy that seems useful today is that the quality of testing for COVID-19 depends on having high clinical sensitivity to identify true positives (truth), high specificity to minimize false positives (the whole truth), and high predictive value to account for the prevalence of disease expected in the population being tested (nothing but the truth). The point is that there are many dimensions to quality that must be properly considered to guarantee the requirements for medical usefulness of laboratory tests. Our covenant with our patients is that we should be knowledgeable about all these technical issues and that we should take them into account to provide the services that are necessary for proper patient care.

I worry that the politics of the last four years has altered our understanding of truth, the importance of science, and the need for a factual reality. Consider the need to wear a face mask and socially distance to help prevent the spread of COVID19. That seems like simple science and factual advice that we all should be able to accept and practice. If we can’t agree on such fundamental truths, then how can we maintain the good faith between medical workers (as well as all other essential workers) who place themselves at risk in service to those members of society who won’t follow such minimal and reasonable precautions? At what point will medical workers decide their jobs are too dangerous and not worth the risk? At what point does the blatant disregard of science destroy the covenant between healthcare provider and patient?

I write these words after a presidential rally on Saturday, October 17, in Janesville Wisconsin. This rally went against the CDC guidance, as well as State of Wisconsin's Health Department guidance, to limit the size of gatherings and require masks and social distancing. It occurred at a time when Wisconsin is the hottest of COVID-19 hotspots in the nation, at a time when a field hospital has just been set up on the Fairgrounds in Milwaukee to accommodate the need for more hospital beds.

This is also happening at a time when a member of our family is waiting for non-elective surgery that has been postponed once already because of the COVID-19 overload. At a time when our national medical system in crisis and disarray, the healthcare programs and laws are under judicial review by the Supreme Court that may abolish patient rights to coverage from pre-existing conditions (which will soon include COVID-19 itself). At a time when our government keeps telling us they have a plan for better and cheaper healthcare (but it is always two weeks away).

These are the consequences of untruth and risky behavior that can be attributed to an alternative reality that disregards science and factual knowledge. There are no alternative facts, only untruths. We are not turning the corner on this pandemic, but climbing to the peak of the next wave. As of this writing, two hundred and seventeen thousand, nine hundred and eighteen Americans are dead and we are still counting.

In this unprecedented time, we have seen the New England Journal of Medicine, Nature, Science, and Scientific American make endorsements for President – some of these publications and organizations have never made a political statement before, but feel compelled to this year. (If you don't know who they all endorsed, follow the links.)

I hope that you, as scientists and citizens, take a stand for truth. Now and throughout your career. You and your patients will be the better for it.


Reference: Timothy Snyder, Our Malady: Lessons in Liberty from a Hospital Diary. New York: Crown Publishing Group, 2020. * Purchasing the book by following this link will contribute to the Connecticut Foodback.