Monday, November 23, 2015

Ancient grains are not just old plants!

Just in time for Thanksgiving preparation, I ran into Maria Speck the other day, and we started talking about ancient grains.  She published her second cookbook on the topic a few months ago, and I've now had a chance to look through it.

Beyond some really beautiful pictures by Erin Kunkel, there's lots to view in this compendium.  Of course there's background information from amaranth to wild rice, with stops along the way for freekeh, millet, sorghum, and more.  We learn, too about the absorption method of cooking, contrasted with the pasta method and others.  Should we rinse?  Soak? Toast?  How do we know when it's done?  There are handy charts with cooking times, so we can be more secure about planning ahead.

And then, of course, the recipes. By the dozen, in all kinds of categories.

This encyclopedia is a joy to read.  I'm looking forward to sampling its contents.

"They really need to know"

In her day job, Susan Hackley is chief administrative and financial officer for the Harvard Program on Negotiation, but her prior experience in a variety of public policy and other positions offers her a crisp view on many issues facing the country and the world.  She decided to devote her observational skills to a new project, "A Child's Guide to War," when she realized that for American children aged 13 and younger, we have been at war their entire lives.

As noted:

A Child’s Guide to War is a documentary film project that is helping to bridge the civilian–military divide in the United States.

A wide gulf exists in America between those who have served in the military and their families and those who haven’t. While respect for the military is high, real knowledge is not.

Through the film, a public television program, teaching materials and public meetings we are hosting, we will help Americans better understand the role of the military in our democracy and the role of civilians in understanding, respecting and appreciating the service of those who solemnly swear to protect our country.

This is a work in progress, but you can see some tidbits in this short video produced in Indiana, where Susan and crew interviewed children whose mom or dad has been to war and asked: "What is it like?"  "What do you worry about?"  "What makes you proud?"

There's something compelling about the straightforward answers given by these children.

"My dad's not a killer."

"I just put my thoughts aside."

"They really need to know."

 Take a look and, if you feel moved, please support this effort.

Sunday, November 22, 2015

Oops! Wrong book.

If I sent you a copy of Monique's book, and it has an inscription already to someone else, please send it back. You will help improve marital relations at this end!

Serendipity is allowed

How's this for a lesson plan?

Serendipity is allowed . . . and even encouraged.

It is a philosophy set forth by Ed Moriarty, an instructor at MIT's Edgerton Center.  Opening the doors of the strobe lab for "that Saturday thing," as it is called by the students, Ed provides mentorship and asks challenging questions of children and adults of all ages who drop by to play and experiment.

Here is learning at its most creative, combining physical manipulation of electrical components with thoughtful observation.  There is no syllabus, just the joy of learning.

We were giving some friends a tour of MIT and we had explained that the philosophy of play is an important component of life at MIT.  We walked by the strobe lab at an opportune moment and were immediately hijacked by Ed. He said, "Hey, come in here. I want to show you some stuff."

He borrowed a circuit that eight-year-old Amelia had constructed and asked us, "What kind of shadow is created when you have three small diodes shining red, blue, and green and put a finger in front of one of them?"

"What if you hold up several fingers and the shadow falls on someone's face?"

Or as above, "What happens when water comes out of a sixty cycle-per-second pump and is illuminated by a sixty flash-per-second strobe?"  This little boy learned that the stream of water is actually composed of droplets, not a continuous stream.

As noted on the Edgerton Center website:

Always willing to follow students’ lead and to let them discover their own voice, Moriarty offers the intellectual and emotional support that enables students of all ages to learn to engineer by doing.

What do we do in classrooms?  Well, for the most part, we throw away spontaneity and and shoehorn students into tightly constrained curricula.  They learn the facts, but they often lose the creativity and joy of learning that comes from impulse and experimentation.  They soon forget the surprises that serendipity can bring.

Saturday, November 21, 2015

A leadership lesson learned?

As turmoil continues around the world, back here in Massachusetts there's been a kerfuffle surrounding Governor Charlie Baker's remarks about limiting Syrian refugees' access to the state. Several of us, including me, we appalled by what he said. Among those was US Representative Seth Moulton.  Moulton's criticism was, in turn, deemed partisan by the Governor, an accusation Moulton roundly denied. The Governor, too, said that his remarks had been taken out of context, and he appeared upset that he had been accused of a lack of compassion. Indeed, he declined to sign a letter from other Republican governors asking President Barack Obama to suspend efforts to resettle Syrian refugees in the U.S.

A friend on Facebook noted, with regard to this last item:

At least our governor is intelligent enough to listen to his constituency. And it shows we can push him on things, which is a good thing. Bravo Baker for listening and learning from your people.

The question that I ask today is what lesson was learned and how might other leaders also learn from this episode.  If the only lesson Charlie learned from the events was that he had gotten out too far in front of an issue relative to public sentiment and that therefore he had to backtrack, that's just a lesson in politics.

If, however, he learned another leadership lesson, then there is a better result for him personally and for the state.  You see, what Charlie did in his initial comments was to fan a spark of fear, resentment, and xenophobia among at least some people in the state. It does not matter whether Charlie's words were taken out of context. He grabbed the moment and became a lightning rod.

For example, here's one comment from Michele that I received on my blog post:

So if I don't like what this government is doing or the people that are running this country, I should pack up a couple tiny things, my very small children and move to another country? I joined the Navy. I was honored to work beside the Marine Corps. So instead of trying to fix my country I should move and expect everyone else to take care of me? My Grandfather remembers the government coming to his father's house to offer aid to farmers hit by the depression. He proudly refused. Where is the working through adversity attitude? Why is everything "give me help"?

I replied:

Michele, please take a look at some of the pictures and read the stories from these folks. This is not about working through adversity. This is about having your community destroyed, losing your housing and possessions, with threats of bombs every day.

She answered:

I know. I sobbed when their stories started coming through. My concern is my children, Paul. As is their concern I am sure. I am not willing to sacrifice my children's safety as they are not either. We are making decisions based on the same priorities. 

We should in no way discount people's fears when bad things happen in the world. But acknowledging that fear is not the same as fanning it.

Charlie doth protest too much when he claims his words were taken out of context.  The overall context was that a slew of mainly Republican governors were saying approximately the same thing at the same time.  The Governor needs to understand that the moral stature of an elected official is such that his job during times of stress is to bring people together, to appeal to their better instincts and values, and not to their fears.

When he says that "my job is protect the people of Massachusetts," he is both saying too much and too little.  Too much because no one person can protect six million.  Too much because, on this issue, he has no jurisdiction in any event.  Too little because his job is to help maintain a sense of community during a period of unrest.  Too little because his job is to remind us of our underlying values and shared history.

The question for Governor Baker is whether he learned that leadership lesson, not just a passing lesson in politics.

Thursday, November 19, 2015

How to secure more block time

While I hate to promulgate stereotypes about any particular group of medical specialists, this short video is too good to leave without broader dissemination.

Blog roll revisions

I've just finished editing the blog roll on the right hand side of my blog's home page.  I've deleted sites that have been inactive for six months or more.  If yours is no longer listed and you think it should be, please let me know.  Likewise, if you have a new (or old) blog to which I've not linked, please let me know.

Wednesday, November 18, 2015

Blind science

Thanks to Brian Klepper for alerting me to this:

Here's a poignant personal story about modern medicine from my friend Michael Millenson. Michael is a journalist who has played a significant role in ushering in the quality and safety movements in American health care.

The lede:

When I was a newborn — a preemie struggling to survive in a hospital nursery’s incubator — an article deep inside The Washington Post saved me from becoming blind.

The article — on Page A22 — discussed research showing that too much oxygen in an incubator could cause babies to lose their sight. When my worried parents phoned the hospital, they were told doctors had also seen the piece and promptly adjusted the incubator’s air mixture. What none of them knew was that the sight in my right eye had already been destroyed by what is now called retinopathy of prematurity, or ROP. Fortunately, the vision in my left eye remained intact, saving me from a lifetime in the dark.

That was way back in 1953. Yet just a few months ago, a federal judge dismissed a lawsuit involving premature babies enrolled in a study of what incubator oxygen level was best. The infants’ parents said they hadn’t been fully informed of all the risks to their infants. I was stunned. In 2015, how can the oxygen level in incubators still be endangering babies?

Tuesday, November 17, 2015

A gift from Monique

As we approach the Thanksgiving holiday here in the US, I'm reminded that it is almost the anniversary of Monique Doyle Spencer's death.   Here's a repeat of a post from 2013.  I just found a few more copies of the book.  If you'd like one, free, just leave a comment with your full name and snail mail address.

When Monique Doyle Spencer wrote The Courage Muscle, A Chicken's Guide to Living with Breast Cancer, she couldn't find a publisher willing to take the book on.  It was funny, you see, and all the publishers thought it was inappropriate to have a funny book about cancer.  She showed me a draft, and I said that our hospital would publish the book, and we did.  Since then, it has brought good-humored hope and advice to patients and families around the world.  As one reviewer said:  "It should become a textbook for the medical professions and a guidebook for all who must confront, or support those who do, breast cancer. It is a beautiful book, beautifully written, that sweetly balances gravitas, zaniness and one person's truth. The author's humanity is in full, accessible display for all to see, share and learn from."

Monique died on Thanksgiving weekend in 2011, and along with our fond memories of her, the book remains.  I happen to have several dozen copies, as does her husband Michael.  We have decided to offer them at no cost to the readers of this blog.  First come, first served, until we run out.  Just submit a comment with your name and snail mail address, and we will send one off to you in a few days.

To whet your appetite, here is a story about Monique's humor.  It occurred a few months before in 2011.  Michael tells it:

Bobby McFerrin gave a marvelous concert, showing his voice as an instrument, to a packed house at Symphony Hall.  Afterwards he came to the front of the stage and sat, legs dangling, to answer questions. After a bit, Monique plunged in, without being acknowledged, and asked about whether he was asked to do "Don't Worry Be Happy."  I could feel the audience cringe.  McFerrin gracefully answered the question and said he does not perform the song and was sorry to disappoint.  Monique shot back, "I did not say I liked it."  The audience broke out laughing and McFerrin fell to the floor and lay down on the stage, doing the same.

Monday, November 16, 2015

Why, Governor Baker?

I've worked for a lot of governors and have known a lot of governors, and I have always appreciated their need to balance what they might want to say about an issue with the political realities of their job.  But the best of our leaders are the ones who rise above the exigencies of local politics and manage to display a sense of commitment to human needs and values during periods of political stress--and in so doing remind us that compassion is often the best antidote for fear and unrest.

So it was with a tremendous sense of loss that I heard of Governor Charlie Baker's comments about Syrian refugees. Loss as in a lost opportunity to bring people together rather than being divisive. And lost admiration on my part as the Governor stooped to a level that I could never have imagined coming from his mouth.

According to the Boston Globe, here's what he said:

In the wake of the deadly terrorist attacks in Paris, Massachusetts Governor Charlie Baker has joined a group of nearly two dozen American governors who announced Monday they would not allow any Syrian refugees to move to their states.

“I would say no as of right now,” Baker told reporters at the State House Monday. “No, I’m not interested in accepting refugees from Syria.”

“My view on this is the safety and security of the people of the Commonwealth of Mass. is my highest priority,” he added. “So I would set the bar very high on this.”

“I think at this point in time we’d have to be very cautious about accepting folks without knowing a lot more about what the federal government’s plan looks like and how it’s going to be actually implemented and executed,” he said.

"As a general rule, I don’t like, completely without any knowledge at all, to just say yes or no to anything. I mean, I’m a data guy I always have been and always will be,” he said.

He also said, “I’m always going to be willing to at least hear what the federal government has to say.” But he added, “Hearing what they have to say does not mean saying yes.”

Mr. Baker is smart enough to know that, as Governor, he has no jurisdiction on such matters. Immigration policy is solely in the hands of the US government.

So, is he making his remarks to try to influence federal policy or simply to grandstand on the issue?

But what would it mean to stop the flow of refugees from a country that is literally being destroyed before our eyes?  I recently met one such refugee.  She and her husband and baby boy lived in Damascus.  Their home was taken over by the rebels.  It was then bombed by the Government.  They were homeless and were left with no possessions.  They managed to escape through Lebanon and thence to the US, where she is now enrolled in a graduate program at one of the state's great universities. Their local religious community has welcomed them with open arms and has helped them adjust to their new lives. The family is eternally grateful to the US and people here for giving them a chance to live a normal and productive and peaceful life.

Taking the Governor at his word, this family would have been stopped at the border.

Is he really so insensitive and uncaring about people in distress that he means what he says?  Or, does he not really mean what he says but just feels it expedient to say it? I'm not sure which is worse.

I forget right now, but it was either historian Theodore H. White or Arthur M. Schlesinger who, in summarizing his years of studying American history, said, "Never underestimate the tendency of the US public to become xenophobic." True leaders recognize that danger and work against irrational fear of foreigners: They do not stimulate it by dipping into the mire of anger and fear.

Sunday, November 15, 2015

I told you so

There are a lot of terrible lessons that come from the sad case of Amy Reed and other women who have developed more widespread cancer as a result of morcellation of uterine growths.

Here's a comment from a pathologist friend:

I remember, when these morcellators first came out, saying to the gyn's that if a woman had an unexpected endometrial cancer, I would not be able to stage it because you can't tell how deep it went into the uterine wall when the uterus is in pieces. And yes, we were puzzled about the leiomyomas, too. We used to have a rule that you took so many microscopic sections per centimeter of leiomyoma (i.e. larger ones are more likely to be sarcoma) to look for sarcoma. But how could you tell how big it was or which one was which from pieces?

We were ignored of course. It all goes back to how new things are introduced - there is no vetting process at all.

Let's consider this deeply. Pathologists are highly trained MDs who specialize in the identification of anatomical and cellular abnormalities. They are the doctors upon whom other doctors rely for diagnosis of and phasing of cancer. In this case, they made it clear to the doctors who take care of women with potentially cancerous conditions that a piece of equipment and a technique employed by those gynecologists could eliminate diagnostic clarity. And yet, the technology was adopted.

This story represents an institutional failure of the highest order. Underlying that failure, I would assert, is the ongoing medical arms race. Manufacturers design a product that makes life easier for one segment of the medical world.  FDA approval with regard to safety is limited in scope. Because data emanating from usage of the device is inherently inaccurate or incomplete (i.e., a needle in a haystack level of precision), it remains in use notwithstanding harm that has been caused.

But doctors also need to consider the story and reflect on how their own behavior can be destructive.

The pattern. Stories start:

About ten years ago, reports started surfacing in the medical literature of women with severe pelvic pain or unexplained bleeding who all had something in common: they had undergone morcellation years prior. Doctors reported finding growths in the abdominal cavities that could be traced back to the fibroids and uteruses that had been removed. This was troubling enough in itself—it had been assumed that missed particles, without a blood supply, would simply be reabsorbed—but it also raised the possibility that cancer could be spread too.

Serious concerns emerge:

Between 2008 and 2010, case reports of disseminated leiomyosarcoma by researchers in New Delhi, Montreal, Boston and Osaka were published. In at least one instance, the new tumour growth was definitively linked to the original specimen. Other papers compared outcomes for women whose undetected LMS had been morcellated versus not morcellated, and they found that morcellating an LMS tumour made it more likely the cancer would spread, and, according to at least one paper, more likely that the woman would be dead within five years.

By 2011—two years before Reed’s surgery—morcellation had become a full-on conversation among cancer doctors. Jeong-Yeol Park, a gynecological oncologist at the Asan Medical Center in Seoul, Korea and the lead author on one of the morcellation comparison papers, presented his findings at the Annual Meeting on Women’s Cancer. In an Oncology Times article about the talk, Bobbie Gostout, chair of gynecology at the Mayo Clinic in Minnesota, commented: “I don’t think there’s an acceptable, safe morcellator out there ... We are exposing our patients to a risk that to me seems out of bounds.”

Nonetheless, inertia rules, as per what happened after a review of Amy's case and an impassioned plea from her surgeon husband Hooman Noorchashm:

By the end of the meeting, little had been achieved. The Brigham would not lead the world in banning morcellators or even curtail their use in its own operating rooms. A few days earlier, the hospital had circulated an internal memo acknowledging that the risk of accidentally morcellating a sarcoma might be much higher than previously thought. It suggested that all surgeons get informed consent from patients before using the device. With that, the hospital felt that the matter had been dealt with.

Likewise, across town:

Isaac Schiff, head of obstetrics and gynecology at Massachusetts General Hospital (MGH), another Harvard affiliate . . . recalled being alarmed by the case of a morcellated fibroid turning out to be a sarcoma and he brought it up at a faculty meeting on December 12, 2013. There, he and his colleagues changed the hospital’s informed consent procedures.

Meanwhile, the person trying to be the agent of change is himself attacked, as incumbents in the system started to eat their young:

Now, though, the Brigham moved to isolate Noorchashm. The day after the December meeting with CMO Ashley, senior hospital staff circulated an internal email instructing Noorchashm’s colleagues to not communicate with him directly but instead to go through official channels. His job also became a sticking point. 

His descent was steep and lonely. In a matter of weeks, Noorchashm had gone from being a Harvard-affiliated surgeon, a golden boy with a shining future, whose life and identity revolved around the operating room, who got up at 4:30 every morning and seldom made it home in time to kiss the kids goodnight, to someone whose major scheduled activities involved dropping his children off at school in the morning and listening for their buses in the afternoon.

Tragedy upon tragedy upon tragedy. And totally avoidable, if from the start, the thoughtful voices from the pathology profession had been taken into account. Rosemary Gibson (in The Wall of Silence) has written elegantly about the underlying problem, a problem the profession steadfastly refuses to address:

The people who provide health care to patients are organized in different tribes. . . . Virtually no training exists to help them learn how to work together, so instead of learning to understand and respect one another's role, there are chasms among the tribes.

Measuring . . . nothing

At his talk at Harvard last week, the Aga Khan reflected on the state of things in the world and spent a moment on the role of technology.  He noted one adverse result:

The more we communicate, the harder it can sometimes be to evaluate what we are saying. More information often means less context and more confusion. 

We were treated to a prime example of this during Saturday night's debate among the Democratic candidates for president.  As we watched the debate, we were presented with a visual hodgepodge.  The candidates were in the middle of the screen.  To the right was a semblance of a Twitter feed, showing real-time reactions to the debate from . . . .  Wait, from whom?  Who knows.  The chosen tweets were the ones some CBS functionary had decided were noteworthy enough to share with the millions of people viewing the debate.  Who were these chosen gods and goddesses of political observation, the ones whose 140-character notes were deemed thoughtful, entertaining, or controversial enough to warrant national exposure? Why were their opinions relevant, helpful, or important in any way?  How did their comments help us as citizens reach our own conclusions about the effectiveness of the candidates?

As if that weren't enough, CBS presented the following chart directly underneath the debating candidates:

When we consider all of the possible metrics about the political world, could we come up with something less meaningful that the "relative number of tweets per minute about three candidates during a debate?" What possible probative value about anything does such a metric offer? Simple answer: Not a damn thing.

A superb reporter, Carey Beth Goldberg, in a note to me, said:  "This is one more example of how the ability to measure something online doesn't mean you should."

She then said:

"There was a really good piece on On The Media about how just measuring clicks is misguided too  -- based on a story about spooning (?!?)"

That article is worth a click! 

Friday, November 13, 2015

Listen to people you don’t like!

The Aga Khan delivered the Samuel L. and Elizabeth Jodidi Lecture at Harvard University yesterday.  He has been a strong proponent of pluralism in the world and has devoted billions of dollars in resources from the Aga Khan Development Network to enhancing education, health care , culture, and economic development in the world's poorest countries in Asia, Africa, and the Middle East. The full text is here, but I offer a pertinent excerpt, with lessons about an increasingly divisive level of political debate in the US and elsewhere:

In looking back to my Harvard days (in the 1950s), I recall how a powerful sense of technological promise was in the air — a faith that human invention would continue its ever-accelerating conquest of time and space. I recall too, how this confidence was accompanied by what was described as a “revolution of rising expectations” and the fall of colonial empires. And of course, this trend seemed to culminate some years later with the end of the Cold War and the “new world order” that it promised.

But even as old barriers crumbled and new connections expanded, a paradoxical trend set in, one that we see today at every hand. At the same time that the world was becoming more interconnected, it also become more fragmented.

We have been mesmerised on one hand by the explosive pace of what we call “globalisation,” a centripetal force putting us as closely in touch with people who live across the world as we are to those who live next to us. But at the same time, a set of centrifugal forces have been gaining on us, producing a growing sense — between and within societies — of disintegration.

Whether we are looking at a more fragile European Union, a more polarised United States, a more fervid Sunni-Shia conflict, intensified tribal rivalries in much of Africa and Asia, or other splintering threats in every corner of the planet, the word “fragmentation” seems to define our times.

Global promise, it can be said, has been matched by tribal wariness. We have more communication, but we also have more confrontation. Even as we exclaim about growing connectivity we seem to experience greater disconnection.

Perhaps what we did not see so clearly 60 years ago is the fact that technological advance does not necessarily mean human progress. Sometimes it can mean the reverse.

The more we communicate, the harder it can sometimes be to evaluate what we are saying. More information often means less context and more confusion. More than that, the increased pace of human interaction means that we encounter the stranger more often, and more directly. What is different is no longer abstract and distant. Even for the most tolerant among us, difference, more and more, can be up close and in your face.

What all of this means is that the challenge of living well together — a challenge as old as the human-race — can seem more and more complicated. And so we ask ourselves, what are the resources that we might now draw upon to counter this trend? How can we go beyond our bold words and address the mystery of why our ideals still elude us?


A pluralist, cosmopolitan society is a society which not only accepts difference, but actively seeks to understand it and to learn from it. In this perspective, diversity is not a burden to be endured, but an opportunity to be welcomed.

A cosmopolitan society regards the distinctive threads of our particular identities as elements that bring beauty to the larger social fabric. A cosmopolitan ethic accepts our ultimate moral responsibility to the whole of humanity, rather than absolutising a presumably exceptional part.

Perhaps it is a natural condition of an insecure human race to seek security in a sense of superiority. But in a world where cultures increasingly interpenetrate one another, a more confident and a more generous outlook is needed.

What this means, perhaps above all else, is a readiness to participate in a true dialog with diversity, not only in our personal relationships, but in institutional and international relationships also. But that takes work, and it takes patience. Above all, it implies a readiness to listen.

What is needed, as the former Governor General of Canada Adrienne Clarkson has said, and I quote, is a readiness “to listen to your neighbour, even when you may not particularly like him.” Is that message clear? You listen to people you don’t like!

Thursday, November 12, 2015

Bad behavior among the youngsters on the pitch

I came across this cartoon on Facebook (with thanks to UK surgeon Isam Osman) and it prompted me to write about a trend I've noticed while refereeing youth soccer games. I've seen a tendency for younger and younger players to imitate the bad behavior that is evident in professional matches.  By younger, I mean nine-year-old boys. 

What kind of behavior?  The first set are comments or complaints about the referee's calls (or non-calls).  "Didn't you see that?" is one comment.

Or, on the other side, when a player is whistled for a foul, the "What me?" reaction is more and more prevalent.

The second set--per the cartoon above--is a tendency to "take a fall" when gently nudged, in the hope the referee will call a foul against the other team and issue a free kick to the "aggrieved" party.

It used to be the case that you didn't see this stuff until the boys were a bit older. Now, the little boys have learned it.

Of course, these tactics work against the interests of the boys who use them, in that they stop playing while they engage in their demonstrations, while the other team just keeps playing--often in possession of the ball.  But that lesson is often missed, especially when the coaches aid and abet the bad behavior in their own comments--or in their silence.

Meanwhile, in contrast, check out this bit of good-hearted sportsmanship from a 2011 Manchester United vs Everton match: