About a month ago, within the space of a few weeks, three important voices reminded us about obvious, but too often forgotten, issues in healthcare.
The Princess of Wales was diagnosed with cancer after undergoing abdominal surgery in January 2024. We don’t know the details of her abdominal surgery or her actual cancer diagnosis. And that’s the point. She chose to keep her medical issues in a tight circle. No one should be forced to reveal information about their health to anyone. But things went from bad to worse when she released obviously altered photos of herself with her children. This fuelled speculation about her health and, eventually, forced her to confront the diagnosis through a public video message. What is the learning? That, in this day and age, no matter the issue (health-related or otherwise), there is an insatiable desire for news and gossip. Nothing is off-limits. And health privacy is a thing of the past. The move to electronic medical records (that can easily be hacked) and the frenzy of social media have collided to form a toxic mix.
In the middle of March in North America, the queen of daytime talk shows and a household name and face, Oprah Winfrey, held a television special entitled ‘Shame, Blame and the Weight Loss Revolution’. The upshot of this conversation with America was that you no longer need to feel ashamed about your weight. But rather that, for some, obesity is a disease that requires medication. And, most importantly, that it’s not ‘your fault’. There are many learnings that we can take from this. Here are two. Firstly, there is much truth to the idea that obesity is a disease for which people have long been ridiculed as lacking discipline or willpower. If nothing else, Oprah’s pronouncements may have helped lessen the stigma around obesity and being overweight. Her fireside chat with America may have been the most honest weight-related conversation that the country has ever seen. And in a country where the Centers for Disease Control and Prevention (CDC) has estimated the prevalence of obesity to be north of 40% and where the annual medical spending on obesity is approaching $200bn, this is important. Black adults had the highest age-adjusted prevalence of obesity and those from low income and educational backgrounds are disproportionately affected by obesity. Oprah speaks to many of these people in ways that others cannot. Here’s the other learning. Access for the new medications that Oprah revealed she has been taking to help with her weight management is challenging. False hope is sometimes worse than no hope. Although surely not purposeful, Oprah’s special may have misrepresented the availability of new medications and the degree to which they can be used purely as weight-loss tools.
A giant in the field of behavioural economics, Daniel Kahneman passed away in March. When asked about his role as the elder statesman of the field, he pronounced himself to be the grandfather of behavioural economics, according to a recent New York Times obituary and profile. His impact on our understanding of decision-making is without parallel and he opened our eyes to the influence this can have on healthcare. In his most recent book coauthored with Cass Sunstein and Olivier Sibony, entitled Noise: A Flaw in Human Judgement, Kahneman devotes an entire chapter to what he calls ‘guidelines in medicine’. Kahneman points out that when a patient gets a second opinion on a particular diagnosis and that opinion differs from the initial diagnosis, we have ‘noise’. He reminds us that noise is everywhere in healthcare. Perhaps the learning from Kahneman in this chapter and, indeed, woven through his entire body of work, is that medical decision-making is highly variable and subject to much inter-rater variability, which he refers to as a low kappa score or value. As Kahneman points out in his chapter, ‘a kappa value of 1 reflects perfect agreement; a value of 0 reflects exactly as much agreement as you would expect between monkeys throwing darts onto a list of medical diagnoses’. Knowing this, he implores us to consider using guidelines more as a means of reducing noise and variability.
Healthcare is delicate. Not in an eggshell kind of way, but in a way that screams that we are moving too fast. That kind of delicate. Social media and health privacy has changed. The arrival of GLP-1 agonists and the role they play in shaping our thinking about obesity is seismic. And while ‘noise’ in healthcare decision-making was elucidated decades ago, we may be on the cusp of a new frontier in the use of algorithms to eliminate it.
This is my takeaway from these important voices and lessons.
This column appeared in the April edition of PME. Read the full issue here.
