Healthcare Is Broken?

Dandy, Fats, Deacon, Dopey, and Specks — the Crows in Dumbo (1941)

Not long ago, journalist Elisabeth Rosenthal wrote a book named An American Sickness: How Healthcare Became Big Business and How You Can Take It Back (2017). She argued that healthcare in the United States is broken. In a newer book named Under the Skin: The Hidden Toll of Racism on American Lives and on the Health of Our Nation (2022), journalist Linda Villarosa makes a similar though more pointed argument.

Both authors convinced me, although anybody living or traveling in the United States should already know that our healthcare is broken. They should know, not because they read about it, but because they suffered the profound misfortune of experiencing it.

Healthcare in the United States is not just frayed around the edges or a little spotty in the interstices; it is fundamentally, structurally back-asswards. As in, SNAFU!

I noticed this for years before I started reading about it. As a crisis it’s not new news, but every time I think about the depraved system that we (as taxpayers and patients) pay for, my blood boils. I become incensed! Despite the quaint positivist “optimism” of authors like Rosenthal and Villarosa, I still haven’t found an (overpriced) prescription that yanks me back to 98.6.

My understanding of healthcare in the United States comes from direct observation of institutions and practitioners. It comes from vetted reporting like Elizabeth’s in Kaiser Health News and Linda’s in the New York Times. It comes from struggling to navigate labyrinthine policies concocted by the Red Queen in Washington DC and the Queen of Hearts in various State capitals.

Lately my understanding of healthcare has been burnished by Dandy, Fats, Deacon, Dopey, and Specks — the birdbrains on the US Supreme Court. I have also dabbled around the edges of the mind-numbing black hole of scholarly research on health disparities, health inequities, and health illiteracies. The research shows that natives in America are restless about their shitty healthcare but still “love” their wallet-vacuuming health insurance.

So you and I, we’ve already read or at least suspected that healthcare is broken, but what does that mean? In what ways is it “broken”? Let me name the few that stand out in my mind: each of them, coincidentally, evidence-based and incontrovertible.

• Ethically — healthcare in the United States routinely violates the Hippocratic Oath
• Practically — it yields grossly inferior outcomes compared to peer systems and other industries
• Economically — it fleeces and bankrupts millions of patients who have the greatest medical needs
• Morally — it barbarously discriminates against people of color, the poor, and the marginalized
• Pedagogically — it takes much too long and charges way too much to train far too few healthcare workers
• Qualitatively — it routinely makes innumerable medical and administrative mistakes and rarely admits them or accepts blame for them
• Socially — it reinforces unjust health disparities and health inequities in favor of obscene profit margins on services untethered to outcomes
• Technically — it exaggerates the value of biomedical and digital innovations that deliver indecent ROI to their funders
• Structurally — it bewilders providers and patients alike with impenetrable complexity and lack of transparency
• Administratively — it is run as a medical industrial complex rather than human services in the public interest
• Financially— it bills for services like a vampire squid wrapped around the face of a hapless population
• Organizationally — it is balkanized, greedily competitive, and grotesquely inefficient
• Emotionally — it generates feelings of hope followed by fear, loathing, and helplessness in patients and their families

You may wish to quibble with one or more of these shortcomings of healthcare in the United States, especially if you’re a provider whose self-worth and net worth are derived from the broken healthcare system. Quibble away then, but not with me. Every point in my list is demonstrably true for enough people in the United States to make it true for all people in a civil society (if that’s what we are).

More important than quibbles, if you accept that healthcare is broken, then how can it be fixed? The answers so far are lame. They sum up to providing more healthcare. As in, keep doing what we’re doing no matter how miserable the results, but do more of it.

My view is different. I believe healthcare in the United States can’t be fixed. It must be replaced. I won’t go into the details here, because that will provoke a discussion of politics as stupid as it is fruitless.

My view is that healthcare in the United States must be replaced, not repaired, and in the meantime what we can do, as a society and more importantly as individuals, is promote self-care. By empowering each person, regardless of background, to recognize, understand, control, and improve the determinants of their own health.

Mind you, this is not a call to cure incurable diseases (a hobbyhorse of the NIH and nonprofit health associations). It is not a call to concoct drugs that lengthen life while decreasing life’s quality (a hobbyhorse of the health tech sector in Silicon Valley). It is not a call to attach bodies to digital nurses that monitor noncompliance with clinical regimens (a hobbyhorse of clinical entrepreneurs). It is not a call to tell people what they must do about their health (a hobbyhorse of health educators).

Instead, it’s a call to empower people to make their own choices and decisions about their health, and accept the consequences.

I believe the reason we put up with a healthcare system that is broken is because we like having somebody or something, other than ourselves as individuals, to blame for the consequences of our behavior. That’s bullshit and it needs to stop.

Are you unhealthy? Then you should take more responsibility by addressing the causes. If you’re delegating all the responsibility for your health to strangers wearing white coats, you’re putting yourself at the mercy of officials in black coats with matters other than your health on their minds. Good luck with that.

The Magic Circle of Simulation

Nikolai Zykov with hand puppets

Our video games are scientific simulations that promote discovery and adoption of techniques for managing a chronic disease.

The simulations facilitate authentic recognition, understanding, control, and improvement of determinants of health. They reinforce a person’s autonomous ability to avoid, prevent, and mitigate risk. We call this ability constructive health competence (CHC) and describe it in a CHC Model for Metabolic Disorders.

Though our simulations empower people to practice self-care and participatory healthcare in real life, the experience they generate is unreal. It is interactive pretend-play that induces people to believe they can overcome real-world problems — at least in their imagination.

Thus our simulations are works of art rather than education or therapy. They are not used in classrooms or paired with textbooks. They are not FDA approved, dispensed by prescription, covered by health insurance, or recommended by doctors. People use them because they want to, not because they have to; and pay as they would for other entertainment.

In line with popular, commercial entertainment, our simulations are escapist flights of fancy. They let people defeat ineluctable threats to life with impossibly satisfying triumphs. The simulations are constructive fantasies in which players heroically fabricate their health and well-being in a magic circle of play. Such outcomes may be difficult if not impossible to achieve outside a magic circle, but the simulations develop the competence needed to try.

Normally, simulations take place in a facsimile of the real world to promote an illusion that they are true to life. Our contrarian simulations feature aesthetics of adventure, strategy, role-play, and puzzle. They are blatantly fabulous and for that reason more engaging, relatable, enjoyable, and aspirational.

The simulations are “scientific” because they harness evidence-based, mathematical models of determinants of health. Math forces our games to “follow the science,” but models (even behind a dashboard) are unfathomable to most people (even scientists). So we use models the way they do the most good: as puppet masters. Models do an invisible job in our simulations; they form a grid that transparently organizes content and modulates interactivity. Storytelling and stagecraft absorb people’s attention and labor during a simulation. Nobody sees the puppet master; if they did, it would break the circle.

By making science steer but not limit creativity, we gain the benefits of reductionism: the making of complex and onerous but useful subject matter more accessible to people who would otherwise be unwilling to consider or experience it, even with the payoff of greater health and well-being.

A Good Pitch

The Gallery page of our DIY Pitch

A pitch deck is an entrepreneur’s holy grail; the golden keys to funding and growth. With just a few meaty slides slathered with storytelling and wrapped in Q&A, a pitch deck turns innovation into business: it unlocks the potential of ideas to create value.

I’ve watched and read numerous pitches, studied a couple of books and a few articles about pitch design, and come to a conclusion (albeit inconclusively) that there is no such thing as a good pitch deck. There are only good ideas, with evidence to support them, and talent to make them tangible.

My early pitch decks were bad, but slides were not the reason; it was my thinking. My seminal concepts were inspired but crude and unfinished, scatterbrained, superficial, impractical, pompous, facile: a proverbial tale Told by an idiot, full of sound and fury, Signifying nothing.

I designed those pitch decks myself, so I blamed myself for the results, but if creative agents had designed them for me, I would only have others to blame. The decks would still have been bad (though better looking) because my ideas were half-baked; not ready for show time.

Over the past few months, my thinking at least has improved. What used to be emotional aspiration is now roll-up-your-sleeves technical innovation; what used to be idle speculation is now evidence-based hypothesis; what used to be ad hoc fixers is now invested talent capable of executing a plan.

All of these changes occurred within the past year, and they make me feel both confident and vulnerable; confident in the quality of the Humaginarium project, vulnerable to a discovery that even my best shot may not be good enough. Not because of me or my team, nor because of our skills and technology; but because we now fight for competitive advantage in an open field, with no cover and no possibility of retreat. Damn the pivots, full speed ahead!

This new, improved me is perhaps manifest in the DIY Pitch that I’m attaching to humaginarium.com. The pitch violates some of the cardinal rules of pitch design: it doesn’t fit on the head of a pin and can’t pass through the eye of a needle. The full pitch takes about 30 minutes to watch, and that’s why I made it do-it-yourself. The DIY Pitch is consumable in a minute; it can also be used by others who want to pay attention and spend some time. The individual decides what to order and the DIY Pitch delivers.

This is how it works. The DIY Pitch deck is all online, available 24/7 on any device. The home page is a Gallery of 30 pitch pages (i.e. slides). A stakeholder is prompted to choose how to view them:

• Click & Choose — open pages in any order; stop when you’ve seen enough
• Elevator — 1 minute that helps you decide if this project is your thing
• Finance — 10 minutes that help you decide if there’s adequate ROI
• The Full Monty — 30 minutes for all there is to see and hear
• Live Online — 45 minutes of custom presentation with Q&A

No matter which presentation an individual chooses, it can be stopped and changed at will. All presentations are self-paced, though only two are self-directed. Every page has text on the screen and a button that can be pressed for VO narration when wanted (read + listen). Two pages have a PDF download and other PDFs are available to qualified stakeholders.

My MO should be obvious: cut to the chase. I don’t know what excites different stakeholders: making a buck, changing the world, creative excellence, having fun etc. So I make it easy for every individual to get what they want. They’ll decide when, where, and how to be pitched; I’ll provide the information they ask for. That’s as close as I’m likely to get to a good pitch.

What, me worry about my health?

A typical patient with a muddled mind? Let’s not be cynical. (Wikipedia)

Daniell Ofri writes in Covid Vaccination, The Last Mile, that “The COVID vaccine engenders a unique obstinacy that seems to blot out conversation. We doctors and nurses are exhorted to listen to our hesitant patients and hear their concerns, but this is difficult to do when patients don’t even want to talk.”

Which begs the question: Is conversation with a doctor the right way for patients to become informed about their health risks? Since Warner Slack’s declaration of the patient’s right to decide, in the 1970s and perhaps even earlier, a prevailing answer has been YES. Clinician’s and patients are meant to collaborate in problem-solving and decision-making, in order to optimize health outcomes.

The practice of participatory medicine is based on such collaboration, but I wonder if it should be. My trusted advisor Merriam-Webster says that to collaborate is “to work jointly with others or together especially in an intellectual endeavor.” If it is nothing else, a conversation between a doctor and a patient is an intellectual endeavor. It’s a candid, probing, and nuanced negotiation that involves exchanging ideas and making agreements. Is either participant in that conversation normally qualified to have it?

By virtue of their training and experience, clinicians are purportedly qualified. Because of institutional, legal, and emotional constraints, they often are not. They typically don’t have the time or curiosity for intellectual endeavors with their patients. Their expertise is largely formed, not forming. They are doers rather than teachers, fixers rather than investigators. Probing the muddled mind of a patient is unlikely to improve outcomes, and may make them worse.

Patients on the other hand are dreadfully ignorant, untrained, inexperienced, opinionated, myopic; “obstinate” yes, but maybe a kinder way of putting that is self-determined. Many don’t like being told what to do; they don’t like the rigidity of a diagnosis or prognosis that’s been foisted on them out of nowhere; their default position is “I am different”; and they love being in control. And why not? Aren’t they customers in all healthcare transactions? Aren’t they paying, through taxes or an insurance premium or out-of-pocket, for services? Isn’t the customer always right?

When the customer is a patient, the customer is usually wrong. And that is as it should be. They don’t know science. They don’t know medicine. They don’t even know their own bodies and minds beyond what’s visible in a mirror. They are unqualified to collaborate with clinicians and, for different reasons already mentioned, clinicians are unqualified to collaborate with them.

Humaginarium has thought about this conundrum and come up with an elegant solution. At least a partial solution that gets some of those “obstinate” (untutored, unmotivated) patients to a point where they want to talk to experts like Dr. Ofri.

Our solution is health simulation, in which patients get to play doctor, and play scientist, and play patient, all in a fantasy world where nothing real is at stake. In our health simulation, players aren’t told what to do, they’re asked. Players aren’t told what they have, they’re nudged to find out. Players aren’t threatened with consequences of not squashing morbidity, they experience the consequences of their own decisions and failures to act fast enough. If they get sicker in the simulation, they can go back and try again. If they die in the simulation, they can wipe the slate clean and start over. Better luck next time. Practice makes perfect.

Our solution has roots in the playground, where kids like to play doctor. Our simulation is not for kids though; it’s for adults who have to cope with serious chronic illness in real life. That’s about two-thirds of everybody. Playing with serious health conditions in a digital sandbox, working out the determinants of one’s health, is the right way to acquire a constructive outlook. As in: “I’m beginning to understand what happens, in and around a person, when they’re sick like me; I can practice dealing with this in a video game simulation where it’s fun instead of scary; I can enjoy the feeling of being in control, at least in my imagination; I can take my fantasy of overcoming disease back to real life and see how it works there.”

When our simulation gets done with recalcitrant patients, the next time a doctor like Danielle Ofri offers to hear them talk, there is more likely to be a genuine, two-way conversation that looks a lot like intellectual endeavor. You know what I mean?

Twin Peaks

What an ordeal, but it’s over now. I have ascended two snowy peaks that were long troubling my eastern horizon. Casting their chilly shadows at sunrise, glinting stubbornly as the sun set, and murmuring, “You’ll never do this, Bob; go find a nice round hill that’s more your speed.”

Damn it, a nice round hill is not my speed! When I walked the Hill of Tara, despite its fabulous history, I felt tired. When I walked the South Downs, with the Channel sparkling in the dips, I felt lost. I don’t find my meaning in soft, green, sun-dappled hills.

I don’t because they’re easy, and when something is easy, that generally means it’s customary. When something is customary, that means others — many others — have done and enjoyed it, are no longer thinking about it, are taking it in stride. That’s not my thing.

I don’t want to walk to my destination; I want to climb, and I want the climb to be difficult. I prefer forbidding peaks, shimmering in the white radiance of eternity, looming under a canopy of frozen, black cosmos. I prefer slopes that are practically vertical, factories of perilous scree, veneered with a thin layer of redoubtable ice covering rock that is rotten and patiently waiting, like a predator, for its next satisfying kill.

That captures the essence of my twin peaks. They are mountains of the mind rather than earth. In fact they are grant applications: one to the National Science Foundation, the other to the National Institutes of Health. Written in parallel, nearly suffocating me with stress. Why were these grant applications predatory?

Because they attract people like me, to come a little bit closer, to view a delectable feast, to find a comfortable seat at the banquet, only to discover that — oh no! — I’m on the menu. The table has been set, not for me, but for a coterie of peer reviewers, the gourmands of esoterica. To them, I’m not a climber making an inconceivable first ascent, but a contestant in a cooking show. I concoct my new recipes, source my rare ingredients, roast and plate my novel thinking and writing…

And then? Then the gourmands sniff it, nibble it, finger it, turn it in the light, contemplate it, and instantly judge it. Mostly their judgments are superficial and harsh, because peer review is a fast, furious, anonymous, and competitive business; neither leisurely, cordial, nor philosophical. It is as subtle and nuanced as a high-stakes horse race: years in the making, thundering out of the gate, over in a few minutes.

However, in a small fraction of reviews, the peers are impressed, their judgements are profound, or at least have profound implications. And that is why these grant applications are worthy endeavors. They are hard and the probability of success is vanishing. Who could ask for anything more?

What makes an application hard? To begin with, it’s “the ask.” The NSF publishes their ask in document called the Solicitation. The NIH publishes their ask in a document called the Funding Opportunity Announcement (FOA). These documents can be hard to find for the uninitiated, but once found, they are seriously hard to read and interpret. Each is supported by hundreds of pages of PAPPG (NSF) and Applications Instructions (NIH).

Why so labor intensive? A hint of passive aggression at the agencies? Don’t be ridiculous! The ask is hard because it’s written for myriad climbers, each of whose routes and peaks are quite awesomely different. One document guides thousands of different aspirants, so it is inevitably confusing to each of them. Many applicants hire a professional Chingachgook, for a hefty fee, to show them how to plan a route and provision their expedition. I didn’t. After all I trained as a textual scholar back in the Jurassic period, so I know how to parse a damned sentence, even if it’s written by a cabal of technocrats.

Reading the Solicitation and FOA, with accompanying instructions, is followed by writing, which in my case is more aptly described as nit-picking. I rewrote my Project Description (NSF) and Research Strategy (NIH) maybe 400 times. Before getting to the summit, I felt dead certain I would fall off the mountain and end up lying in a ditch.

After writing and nit-picking, the last traverse of the perilous journey is a portal for submitting an application online. NSF has Fastlane and NIH has ASSIST. These portals are supported by, and dependent on, other portals including Research.gov, Grants.gov, eRA Commons, and NCBI. Writing in them is comparable to digging your ice pick and crampons into the aforementioned veneer. As often as not, you fly off the pitch and have to call the HelpDesk to pull you back up.

I cannot say enough good things about the HelpDesk. Nicer, more patient, more helpful people than the telephone agents do not exist, of that I feel sure. If you are one of the livestock who’s been oinking about the “deep state,” I have a suggestion for you. Go write a grant application to fund your nutty worldview. Like most others, you may not be funded, but the experience will fill you with tenderness and respect for the gracious civil servants on a HelpDesk, and for the agency that employs them, and for the state that makes it all possible.

North Face of the Eiger, the “Wall of Death” (photo credit)

“I always take the same perspective with each new adventure. I put myself in the position of being at the end of my life looking back. Then I ask myself if what I am doing is important to me.” Reinhold Messner

Lineage

Lineage is a product of continuity, and continuity is a product of evolution. Lineage has history, pedigree, familiarity, assurance. It reinforces our mental model of how good things happen and work. Because we like what we know and we know what we like, usually.

Innovation is a product of disruption, and disruption is a product of revolution. Innovation lacks history, pedigree, familiarity and assurance. It’s risky and uncomfortable. It may satisfy needs, but it takes a lot of getting used to and learning to trust. We usually don’t like what we don’t already know.

I hold these truths to be self-evident, but like most truths of that sort, they’re fraught with tension. That’s because people typically want to have their cake and eat it. They want lineage and innovation at the same time though the two may be diametrically opposed.

If you have attained lineage or you value and reward it, you probably don’t do innovation. You are less interested in the new than the known. Clayton Christensen coined the term “sustaining innovation” in order to connect the opposites — to argue that some innovators make incremental rather than transformational improvements, but that’s a mare’s nest. Making something better is a process of extending its lineage; it’s not an organizing principle of innovation.

The people who want to have their cake and eat it, those are individuals like ourselves, but also organizations such as employers and federal agencies like the National Science Foundation (“Where Discoveries Begin”) and the National Institutes of Health (“Turning Discovery Into Health”). Those agencies are much on my mind at present, because I’m sending SBIR (“America’s Seed Fund”) proposals to each.

The charter of SBIR is to promote innovation in part by selecting for lineage. That’s why most SBIR funds are given to nicely situated academic teams. Wait, let me clarify. SBIR funds are for corporate entrepreneurial teams, but in reality most of them are led and staffed by academic stakeholders who want to commercialize their previously funded academic research. Such stakeholders provide a project with lineage whereas scrappy inventors have only their wit and passion to recommend them, usually.

Unless memory fails me, as a former academician I’m pretty sure that college professors are generally risk averse. They are conservative, self-centered, they don’t like to put skin in the game, in fact they don’t like playing games with their career but prefer the certainties of job security, organizational hierarchy and the comforting sameness of job responsibilities that change only a little from season to season. The ubiquitous tenure system ensures that innovators are largely excluded from academia because they are disruptive.

That is why SBIR requirements for both lineage and innovation are an unacknowledged oxymoron. Unacknowledged because both are explicitly and unapologetically written into NSF solicitations and NIH funding opportunity announcements.

The best way to qualify for SBIR with these agencies is to derisk a project by summoning lineage as evidence that it’s a sure bet. And yet the best way to qualify for SBIR is to explain that the project is so risky that private investors won’t touch it with a ten-foot pole; therefore taxpayer money should finance it.

Humaginarium is one of those scrappy inventors born of a garage rather than an ivory tower. We have an innovation that is damned risky, and we don’t have lineage among our bona fides. What would you do in our place?

Well, we can’t become less innovative. Innovation is what makes our project meaningful and fun. And we can’t borrow lineage, can we?

Actually we can. Because the technologies we are bringing together have been developing for decades, in many cases with government funding, only not for our purposes. System dynamics, computer modeling of health, bioinformatics, biochemical engineering, predictive simulation, adaptive experiential learning, instructional technology. These are the cross threads of our invention, forming a new fabric of impact and consequence.

Precisely what consequence I can’t reveal here, not because it’s a secret but because I’m out of space. For now, suffice it to say that pretty soon you’re going to love what you don’t already know. That goes double for people with chronic illness.

A griffin of classical antiquity combining the eagle (innovation) and lion (lineage) into a mythic animal that embodies an impossible ideal. (Image courtesy of Pixabay.)

Healthcare

My focus has been on determinants of health. These are the causes of chronic illness that regular folks can perceive in themselves and their surroundings.

Perceive — at a minimum that means to recognize, but it also means to understand because seeing is not necessarily believing. You need to believe something is true and meaningful before you’re willing to take risks and action.

(Precisely what you do is the raison d’être of Humaginarium. We won’t go into that here.)

Much study and reflection had brought me to a conclusion that the determinants of health occur in four categories. I believed all causes of chronic illness fall into one or more of these, but I was wrong.

One category of determinant is the somatic, which is basically your physiology and biochemistry. The somatic is what you see in the mirror and in body scans like CT and MRI. If you are one of the gamers entertained by Humaginarium, you perceive very little of yourself that is somatic. Instead there is fantasy, memory, or even nothing at all.

Another category is the psychosomatic, which is basically your thought processes and emotions. The psychosomatic includes the rational mind and imagination. It also includes feelings that have little to do with cognition and more to do with nerves and hormones. Most regular folks perceive the faintest glimmer of their psychosomatic self, though many may live and die for it.

Yet another kind of determinant is the social, which is basically relationships, dependencies, culture and community. Social determinants of health are not of you or another; they are all that occurs between you and others; all that makes us valuable or useful to each other. Politics, which makes many of us sick, is a social determinant of health that most can’t fathom, as usual for the category.

I thought that the final category is the environmental, which is basically the space that supports life. Metabolism is the cardinal difference between living and not living, but nobody knows how or why it started. We only know it cannot happen without an environment that sustains it. There are no martians and there never will be, Elon.

Now I realize there is a fifth determinant of health; a fifth cause of chronic illness that is painfully obvious but often overlooked. It is healthcare, which is basically the medical industry. It is your primary and specialty care, medical devices, drugs, clinics, hospitals and god almighty insurer. I hate to say this about an industry that vacuums up nearly $4 trillion a year from our collective human capital, but most of us do not understand this determinant of our health, no more than the other four. We perceive only the faintest glimmer of what medicine is — even when it’s being practiced on ourselves.

Five determinants hints at an analogy with Peter Senge’s five disciplines for creating learning organizations. Let’s see if it works. Here they are:

1. “Personal mastery is a discipline of continually clarifying and deepening our personal vision, of focusing our energies, of developing patience, and of seeing reality objectively.” Check! That’s what Humaginarium does with and for folks dealing with chronic illness.
2. “Mental models are deeply ingrained assumptions, generalizations, or even pictures of images that influence how we understand the world and how we take action.” Roger that! Humaginarium is changing mental models of health from spectator to change agent.
3. “Building shared vision — a practice of unearthing shared pictures of the future that foster genuine commitment and enrollment rather than compliance.” Our concept of commitment and enrollment is not in an employer health plan, but in the individual sense of well-being that comes with self-actualization.
4. “Team learning starts with ‘dialogue’, the capacity of members of a team to suspend assumptions and enter into genuine ‘thinking together’.” Our program is 1:1 with and for each individual to become more comfortable in their own skin. That looks to me like a prerequisite for thinking with others.
5. “Systems thinking – The Fifth Discipline that integrates the other four.”

The Fifth Discipline is the title of Senge’s book and also an organizing principle of Humaginarium. Though we do not create learning organizations, we use systems thinking and dynamic models of health and healthcare for a far humbler purpose. To create learning individuals, one by one, millions at a time.

These individuals suffer with chronic illness that they do not control. We can’t cure their illness, but we can lessen their suffering by helping them perceive how much power they have, and can get, to live better.

I Saw the Figure 5 in Gold (1928) by Charles Demuth, bequeathed by Georgia O’Keeffe to the Metropolitan Museum of Art in New York. The painting is a mental model that illustrates The Great Figure (1920), by William Carlos Williams:

Among the rain
and lights
I saw the figure 5
in gold
on a red
firetruck
moving
tense
unheeded
to gong clangs
siren howls
and wheels rumbling
through the dark city.

Robodoc

Doctors learn from their experience with patients. As if you didn’t know. It starts by observing and assisting other practitioners. It expands with supervised diagnosis and treatment. It peaks in autonomous encounters with patients over the entire course of a medical career.

Some of those encounters with patients are routine. Many are unique, exploratory, to some extent baffling. A doctor in those thorny encounters is an investigator, a clue finder, a person who doesn’t know but needs to find out. The patient is ideally there to help. A patient in those encounters is a witness, a fellow pathfinder and problem-solver, maybe even a coach.

I don’t know the proportion of medical education that is face-to-face with patients, but it’s a safe bet that learning from practical experience with patients far exceeds learning that occurs in lecture halls and libraries. Learning with patients is so valuable that it’s been boilerplated in technologies known as a simulated patient and a virtual patient.

The simulated (aka standardized) patient emerged in medical schools during the 1960s, around the time that healthcare started morphing into the wondrous industrial process that we have today. A simulated patient is an improvisational actor (professional or amateur) who performs the role of a real patient with certain knotty health issues.

The actor may have personal experience as a patient with the issues that are simulated, but is also well prepared to make a contrived performance seem real. Like audience members called up to the stage in a comedy club, doctors role-play diagnosis and treatment of the simulated patient.

And it works! So well that role-plays with simulated patients are required for getting a medical license in the United States. Doctors must play to practice. In addition to sharpening clinical skills, the role-play helps doctors improve their social and communication skills and polish their comportment for awkward or embarrassing moments in the office or clinic.

The downside with simulated patients is cost. The simulations are expensive to run, even for an industry that hemorrhages billions in carefree ways. Hence the introduction, starting in the 1990s, of the more economical and scalable virtual patient.

A virtual patient is a digital replicant, like a special-effects monster in a movie. Just kidding, the virtual patient is not like a monster in a movie, but like an avatar in a video game. The avatar is programmed to have health and other issues that must be recognized, understood and treated by the real doctor who plays with it.

The virtual patient is a computer simulation, unlike a live simulated patient, but the purpose is the same: learning medicine by means of role-play. A virtual patient is endlessly replayable and easily modified to simulate different clinical scenarios and produce different outcomes. Virtual patients are much less expensive to run than simulated patients, much more accessible, convenient and versatile to use, and may be just as capable of increasing medical competence.

Which brings me to the question I’m here to ask. If simulated and virtual patients are so good at increasing the medical competence of doctors, why haven’t simulated and virtual doctors been used to increase the health competence of patients? There are one million doctors in the United States receiving the benefits of this lavish educational technology. There are over 300 million patients in the United States who don’t have a clue.

Why not offer this powerful, effective educational technology to patients? Wrong question, because there isn’t a good reason. Better to ask what for, and when.

I call virtual doctors robodocs, which I am entitled to do because I invented them. Before you came to this blog, you probably never heard of simulated or virtual doctors, so don’t argue. We can call them robodocs from now on.

On the other hand… one sec… here it comes… Robodoc™. Now I can charge you to use the term! That would make me feel more like a medical device or drug maker. (Pass the Milk of Magnesia, please.)

What would patients do with a robodoc if one existed for them? They would role-play being a patient to learn how it’s done. They would learn simple things, like how to participate in their medical treatment, how to discuss their condition and needs with a doctor, how to seek the right care in the labyrinthine health marketplace, how to pay as little as possible for care that is needed, how to avoid and prevent the care that is not wanted.

Simple things that must be learned from experience. There is no better way. Doctors know that and so should you.

I gave a name to patient learning from experience — Constructive Health Competence™ — and Humaginarium is building video game simulations to promote it. Video games for adults with chronic illness who depend on the medical industrial complex much more than others have to.

And yes, robodocs will be present in our video games. Helping real patients find their way.

Robodocs are virtual doctors that make role-play for patients feasible, both technically and economically. Playing with them lets patients safely practice their performances in the doctor’s office, lab, ER, ambulance, clinic, hospital and assisted care facility where the gold-plated meters are running and ordinary life and well-being are on the line.

Please don’t say that it can’t work. Simulated and virtual patients are already working for a million doctors including yours. Don’t say that it won’t work. Entertaining video game sims are already working for hundreds of millions of consumers including your coworkers, friends and family.

Instead ask what difference we can make if it does work. The answers are pretty straightforward: happier, healthier patients and fewer, smaller medical bills.

These are fruits of patient empowerment that is no longer the first priority of providers, payers and candlestick makers. To hell with that, let’s get it on.

“You’ll need to sign these forms and get labs before the doctor can see you.“

Poster

The Institute for Healthcare Advancement is hosting the 20th Annual Virtual Health Literacy Conference on May 25-27, 2021. You can register for free and learn by attending live sessions on your device.

My contribution to the conference agenda is a poster about Constructive Health Competence (CHC), which combines health literacy with other useful skills that are likewise lacking across most of the population.

An image of the poster follows this text. The image is rather large and perhaps will be slow to open. Those who wish to read it can open it large in the browser or download it. In the conference, the poster is accompanied by my voice-over. I am inserting the script of that here.

This poster acknowledges an Achilles’ heel of health literacy. The crazy assumption that folks will understand and use the information they read.

That’s not true of many people. The average adult in our midst reads like a child in middle school. Half of all adults can’t even do that. Others read better, so long as the text isn’t health information.

That’s because health information is not written in a vernacular. It’s by and large a professional rhetoric, a technicalese that requires higher education to understand and use.

Yet health literacy is not a professional or cultivated competence. It’s just regular folks being able to understand their healthcare, in order to inform their medical choices and decisions.

We can agree that health literacy is an important skill, too important to let language get in the way. So this poster outlines a fix for the Achilles’ heel. The fix removes textual obstacles to understanding complex information, and replaces them with pleasurable sensations.

Sensations are the fodder of art and entertainment; in this case, AAA video games. Visual and behavioral sensations are catalyzed by game mechanics and aesthetics. This is the stuff of visceral experience rather than quiet study.

That’s why playing video games is constructive. A game is a multifaceted kit that lets players themselves build the knowledge and skills they need to win. And in our games, the way to win is to defeat the illness lurking within.

So, assume we disconnect health literacy from language literacy. Can we now build effective health promotion? Nay, more is wanted. We add scientific literacy, another competence that most folks lack. We provide opportunities for regular folks to understand and use biomedical and social sciences in the game. We believe they can and they will.

The project enhances these literacies with health acumen, an ability to deal with perplexing unknowns that make us afraid or angry or depressed or unable to resist. And with medical self-efficacy, the ability to get anxious clinical situations under personal control.

The poster sums it up as constructive health competence. And because CHC emerges in the magic circle of play, regular folks can get into it. They can escape from suffering into a fantasy that brings them back to their true selves. Selves that are not dominated by chronic illness.

Copyright 2021 Humaginarium LLC

Yin and Yang

“Do I have a split personality?” The question may arise when we hold two contrasting or conflicting beliefs, at the same time, and instead of trying to resolve or erase them, we let their differences flourish. Indeed, we may expect benefits from the tension.

There are different ways to perceive a split. On the one hand, we may cringe in the presence of cognitive dissonance, a symptom of unbalance and stress. On the other hand, we may proudly quote F. Scott Fitzgerald, who wrote “The test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function.”

(He wrote function, not prosper. Just making that clear to contrarians in our midst.)

Oxymorons are beloved by folks with a split personality. Take the oxymoron serious games, for example. Games are played, and by definition gameplay is amusing, frivolous, entertaining, somewhat meaningless. A wonderful miniseries, The Queen’s Gambit, weaves an entertaining tale of struggle and conquest by a chess player, but chess itself is just a game. When you learn how to play it, the only benefit is that you now know how to play it.

(The miniseries has other ideas.)

So why pair game with serious, when serious is mindful, thoughtful, analytical, earnest. I once asked Clark Abt, who coined the oxymoron as the title of his book in 1970. He said that his editor came up with the title, it seemed catchy, and he didn’t think more about it.

When Oscar Wilde wrote The Importance of Being Earnest, A Trivial Comedy for Serious People, he had just this sort of oxymoron in mind. As an aesthete of the decadent fin de siècle, he thought a great deal more about it. Ultimately, it cost him his life.

Well then, there are two contrasting or conflicting beliefs whirling through my mind these days, not fatal but nonetheless twisty. They are video games and health promotion.

I believe in both. There’s even an oxymoron that I coined, scientific entertainment, in order to pace Clark and jolt readers or listeners into paying closer attention to my project. So far, I have preserved my ability to function, though I’m still striving to prosper.

So does Humaginarium create video games or health promotion? The answer is, both at the same time. Yes, I know that you can survey the field of health promotion and not find a single video game sprouting in its barren soil. You can likewise survey the video game industry and not find anything that quacks like health promotion. That’s because video games and health promotion have nothing to do with each other.

(Until now.)

While claiming that Humaginarium makes video games and health promotion, at the same time, and expects to benefit mightily because of it, I am challenged every day to put them in order, to prioritize, to say we do one in order to do the other (not the other in order to do the one).

This challenge was a damned nuisance until I referenced it to the concept of yin and yang, or dualistic-monism (another oxymoron): a “fruitful paradox.” Yin and yang are complementary (rather than opposing) forces that interact to form a dynamic system, in which the whole is greater than the sum of its parts.

Thus I arrived at the wheels within wheels of a conceptual breakthrough:

— Video games that are health promotion
— Art that is science
— Play that is work
— Freedom that is limiting
— Pleasure that is painful
— Silly that is smart
— Vulnerability that is strength
— Knowledge that is power

This list could go on. You probably have examples of your own.

The taijitu symbol famously depicts dualistic-monism. I chose a version of the symbol for this post, that reminds us, with markings around the circumference, that yin and yang are not reducible to this and that, subject and object, you and me. Instead it is a vortex of possibilities, in which every inferred possibility is accommodated and allowed to flourish. It is all-inclusive and balanced.

Not coincidentally, the quest of Humaginarium is for balance, or homeostasis. We are not trying to make sick people well, we are trying to make them happy. That may be the germ of our ultimate oxymoron.

Tai Chi Pa Kua Tu, the diagram of Tai Chi with Eight Trigrams, from Wikipedia