Cost-effective preventive care: seeing the forest for the trees

At last month's Family Medicine Education Consortium Northeast Region Meeting, one of my residents presented some research that she had completed under my supervision. Since I left the staff of the U.S. Preventive Services Task Force four years ago, it has been my sense that the Task Force has substantially lowered its evidence "bar" for recommending a preventive service, an impression confirmed in private discussions with colleagues who closely follow the group's activities. In a JAMA editorial published last year, Drs. Steven Woolf and Doug Campos-Outcalt expressed concerns that the Affordable Care Act, by requiring insurers to fully pay for grade "A" and "B" recommended services, would lead to political pressure on the USPSTF to produce more of these favorable recommendations.

My resident and I hypothesized that if this concern turned out to be correct, we would find that a higher proportion of recommendation statements - both new and updated - published in 2011 or later would be grade "A" or "B" rather than "C," "D," or "I." After reviewing the Task Force's portfolio of active recommendations, she concluded that this is absolutely the case. Of course, not being able to attend the meetings or review their minutes (which are unavailable to the public), we could only demonstrate an association, not causation. Another plausible explanation is that research progress over the past several years has produced more evidence and effective interventions to support providing services which weren't recommended before (e.g., lung cancer screening with CT scans, screening for hepatitis C). That's unlikely to be the whole story, though, since the TF would have generated more new "D" (don't do it) recommendations too, which hasn't happened.

Politics aside, the other problem with linking USPSTF decisions to "free" preventive services is that a group that adamantly does not consider cost in assessing the value of a preventive service increases the cost of health care (and health insurance premiums) every time it makes a favorable decision. Dr. Woolf has argued that effective prevention doesn't have to be cost-saving, only cost-effective, and the vast majority of immunizations and recommended screenings meet this criterion. Even CT screening for lung cancer, according to a recent study, would cost $81,000 per quality-adjusted life year (QALY) gained, if appropriately implemented in a high-risk population similar to that in the National Lung Screening Trial.

But cost-effective services can still end up being terrifically expensive. If the estimated 9 million eligible Americans receive "free" annual low-dose CT scans recommended by the USPSTF at $300 per scan, that's $2.7 billion added to the national health care bill each year - and this doesn't count the costs of all of the follow-up CT scans for abnormalities, consultations, biopsies, and treatments that will ensue. If birth cohort screening finds 2 million previously unidentified adults with hepatitis C who subsequently take the new drug sofosbuvir (Sovaldi) at $84,000 per treatment course, it will cost $168 billion to pay for this drug alone, not counting other medications or costs of care.

Even if paying for these screening tests will ultimately provide health benefits to many (though I have qualms about the evidence for both), they will also make health insurance premiums a little less affordable, and it's nobody's job to decide if the benefits are worth the added costs to the population. In an article in Health Affairs, Dr. Mark Pauly and colleagues argue that complete pooling of risk is justifiable only for preventive services that are highly cost-effective. They propose continuing full coverage for the most cost-effective services, increasing patient cost-sharing for less cost-effective services, and discouraging coverage of services that are not cost-effective according to a societally-determined threshold (they suggest $400,000 per QALY).

Plenty of public health and health equity arguments could be made against this proposal, but what I like about it is that it sees the forest for the trees. Not matter how equally we distribute them (and the U.S. does a poorer job at this than most countries), health care resources are limited, and money spent on marginally effective services is money that's not being spent on countless other things that promote health and make life worth living. It's simply not enough to promote evidence-based preventive care by making all of it "free," regardless of the true costs.

How Schools Make Learning Harder Than Necessary

Keep your "nose to the grindstone" is the advice we often give as an essential ingredient of learning difficult tasks. An old joke captures the problem with the old bromide for success, "Keep your eye on the ball, your ear to the ground, your nose to the grindstone, your shoulder to the wheel: Now try to work in that position."

Over the years of teaching, I have seen many highly conscientious students work like demons in their study yet don't seem to learn as much as they should for all the effort they put in. Typically, it is because they don't study smart. And sometimes the problem is created by the teachers' method of instruction.

In an earlier post, I described a learning strategy wherein a student should spend repeated short (say 10-15 minutes) of intense study followed immediately by a comparable rest period of "brain-dead" activity where they don't engage with a new learning task. The idea is that memory of the just-learned material is more likely to be consolidated into long-term memory because there are no mental distractions to erase the temporary working memory while it is in the process of consolidation.

Now, new research now suggests that too much nose-to-the-grindstone can impair learning.

Margaret Schlichting, a graduate student researcher, and Alison Preston, an associate professor of psychology and neuroscience at the University of Texas tested the effect of mental rest with a learning task of remembering two sets of a series of associated photo pairs.  Between the two task sets, the participants rested and were allowed to think about whatever they wanted. Not surprisingly, those who used the rest time to reflect on what they had learned earlier were able to remember more upon re-test. Obviously, in this case, the brain is not really resting, as it is processing (that is, rehearsing) the new learning. But the brain is resting in the sense that no new mental challenges are encountered.

The university press release quotes the authors as saying, "We've shown for the first time that how the brain processes information during rest can improve future learning. We think replaying memories during rest makes those earlier memories stronger, not just impacting the original content, but impacting the memories to come." Despite the fact that this concept has been anointed as a new discovery in a prestigious science journal, the principle has been well-known for decades. I have explained this phenomenon in my memory books as the well-established term of "interference theory of memory,"

What has not been well understood among teachers is the need to alter teaching practices to accommodate this principle. A typical class period involves teachers presenting a back-to-back succession of highly diverse learning objects and concepts. Each new topic interferes with memory formation of the prior topics. An additional interference occurs when a class period is disrupted by blaring announcements from the principal's office, designed to be loud to command attention (which has the effect of diverting attention away from the learning material). The typical classroom has a plethora of other distractions, such as windows for looking outside and multiple objects like animals, pictures, posters, banners, and ceiling mobiles designed to decorate and enliven the room. The room itself is a major distraction.

Then, to compound the problem, the class bell rings, and students rush out into the hall for their next class, socializing furiously in the limited time they have to get to the next class (on a different subject, by a different teacher, in a differently decorated classroom). You can be sure, little reflection occurs on the academic material they had just encountered.

The format of a typical school day is so well-entrenched that I doubt it can be changed. But there is no excuse for blaring loudspeaker announcements during the middle of a class period. Classrooms do not have to be decorated. A given class period does not have to be an information dump on overwhelmed students. Short periods of instruction need to be followed by short, low-key, periods of questioning, discussion, reflection, and application of what has just been taught. Content that doesn't get "covered" in class can be assigned as homework—or even exempted from being a learning requirement. It is better to learn a few things well than many things poorly. Indeed, this is the refreshing philosophy behind the new national science standards known as "Next Generation Science Standards."

Give our kids a rest: the right kind of mental rest.

Sources:


Schlichting, M. L., and Preston, A. R. (2014). Memory reactivation during rest supports upcoming learning of related content Proc. Nat. Acad. Science. Published ahead of print October 20, 2014.

http://scicasts.com/neuroscience/2065-cognitive-science/8539-study-suggests-mental-rest-and-reflection-boost-learning/

http://www.nextgenscience.org/

Dr. Klemm's latest book, available at most retail outlets, is "Mental Biology. The New Science of How the Brain and Mind Relate" (Prometheus). 

Shared decision-making for lung cancer screening: will it work?

Earlier this month, the Centers for Medicare & Medicaid Services (CMS) officially proposed coverage for annual low-dose computed tomography (LDCT) screening for lung cancer in current or former smokers age 55 to 74 years with at least a 30 pack-year history. In doing so, CMS followed the lead of the U.S. Preventive Services Task Force, which had previously given a "B" grade recommendation for screening in a similar population through age 80 years.

In the November 1st American Family Physician cover article, Dr. Thomas Gates reviewed concepts and controversies in cancer screening. Dr. Gates observed that in the 1960s and 1970s, physicians were misled by lead-time and length-time bias into believing that screening smokers for lung cancer with chest radiography saved lives, when in fact, it did not. He also noted that although LDCT screening has reduced lung cancer and all-cause mortality in a randomized controlled trial, adverse effects include a high false-positive rate, uncertain harms from radiation exposure, and overdiagnosis (leading to potentially unnecessary treatment). For these reasons, the American Academy of Family Physicians decided not to endorse the USPSTF recommendation. In an editorial published earlier this year, AFP Contributing Editor Dean Seehusen, MD, MPH elaborated on arguments against routine LDCT screening.

Notably, CMS has proposed to pay for not only the LDCT itself, but also for a "counseling and shared decision making visit" with a physician to review benefits and harms of lung cancer screening and emphasize smoking cessation (in current smokers) and continued smoking abstinence (in ex-smokers). This element is critical, as Dr. Gates observed in his article:

Perhaps the most important issue with low-dose CT screening is that it is a costly, high-tech response to what is essentially a behavioral and lifestyle problem. Smoking is responsible for 85% of lung cancers; convincing persons to quit smoking (or to not start) is far more effective in preventing lung cancer deaths than low-dose CT screening.

Shared decision-making is increasingly recommended by screening guidelines, but I worry that these difficult discussions may not actually take place, even if family physicians are paid to initiate them with patients eligible for LDCT screening. Will clinicians merely go through the motions and just order the test, as happened with prostate-specific antigen testing for prostate cancer and screening mammography for women in their 40s? What do you think?

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This post first appeared on the AFP Community Blog.

Public Speaking Update

Since I began blogging at Common Sense Family Doctor in July 2009, its posts have been featured in widely read blogs such as KevinMD.com, The Doctor Weighs In, The Health Care Blog, and Gary Schwitzer's HealthNewsReview, and the websites of major national health and news outlets such as Proto Magazine, the Costco Connection, the New York Times, the Wall Street Journal, USA Today, and the Boston Globe. I also wrote the consumer health blog Healthcare Headaches for U.S. News and World Report from August 2010 through September 2011.

Like the vast majority of physicians who blog, I write in my spare time. I have never accepted advertising or paid web links on Common Sense Family Doctor, and the choices of topics for posts are my own and not influenced by financial or other conflicts of interest. In order to support the time I devote to blogging, and to encourage high-quality medical writing and clinical practice, I give lectures and workshops to medical and non-medical audiences on a variety of topics. These include the uses of social media tools in medicine and education, developing and implementing medical guidelines, and the evidence supporting specific prevention recommendations. If you or your organization would like to invite me to speak, please e-mail me at linkenny@hotmail.com or Kenneth.Lin@georgetown.edu.

Upcoming events:

Choosing Wisely: Pearls for Primary Care Physicians
- District of Columbia Academy of Family Physicians
- January 21, 2015

Medical Apps: Topic TBD
- International Consumer Electronics Show, Las Vegas, NV
- January 6, 2015

Cancer Screening: An Updated Primer for Journalists
- National Press Foundation's Cancer Issues 2014, Washington, DC
- December 8, 2014

Past events:

2014

Lung and Bronchial Cancer
- American Academy of Family Physicians Assembly, Washington, DC

Policy and Funding for Preventive Care Programs
- Georgetown University Health Systems, Policy, and Public Health Elective

2013

CT Screening for Lung Cancer: Evaluating the Evidence
- National Capital Consortium Family Medicine Residency, Fort Belvoir, VA

Thinking Like An Editor
- Society of Teachers of Family Medicine Annual Spring Conference, Baltimore, MD

Politics of HIV Testing
- Georgetown University School of Medicine

Burnout Prevention for Healthcare Professionals
- Teaching Prevention 2013, Washington, DC

Evidence-Based Literature Searching: A Primer
- National Capital Consortium Family Medicine Residency, Fort Belvoir, VA

Less is More: New Approaches to Cancer Screening in Primary Care
- Primary Care Coalition of Montgomery County, Maryland

2012

Science and Public Policy in Conflict: PSA Screening
- Johns Hopkins University Bloomberg School of Public Health Fall Policy Seminar

Screening Mammography for Women in their 40s: Exploring the Controversy
- National Capital Area Regional Breast Healthcare Improvement Initiative

Why You Should Stop Screening Patients for Prostate Cancer
- Ephrata Community Hospital (PA)

Identifying and Using Good Practice Guidelines
- Temple University School of Medicine 2012 Family Practice Review Course

2011

Cancer Screening: A Primer for Journalists
- National Press Foundation's Cancer Issues 2011

What to Do When Screening Guidelines Conflict: HIV and Mammography
- Grand Rounds, Georgetown University Department of Family Medicine

Overdiagnosed: Making People Sick in the Pursuit of Health
- William J. Bicknell Lecture (panelist)
- Boston University School of Public Health

For Geeks and Geezers: With Social Media Skills You Can Change the World
- Family Medicine Education Consortium Northeast Region Meeting

Screening for Diabetes: What Does the Evidence Say?
- Spanish Catholic Center of Catholic Charities of Washington, DC

Don't Do It! Preventive Health Services That Harm More Than They Help
- District of Columbia Academy of Family Physicians

Using the Medical Literature to Make Decisions About Preventive Health Services
- Medical Library Association Annual Meeting

2008 - 2010

Medical Blogging and Other Professional Uses of Social Media
- Grand Rounds, Virginia Commonwealth University Internal Medicine

Spilling Ink: An Expert's Guide to Getting Your Work Published
- Society of Teachers of Family Medicine Annual Meeting

COPD Update: A Prevention Perspective
- Maryland Academy of Family Physicians

Imagination and creativity to improve memory

Use imagination and be creative. Learn to visualize when reading the books. Creating imagination is the forging of a link between two previously unconnected ideas for a purpose that might not be apparent at the time

Imagination is the ability to form new images and sensations that are not perceived through sight, hearing or other senses.

It helps make knowledge applicable in solving problems and is fundamental to integrating experience and learning process.

Imagination is the key to both improving memory and improving creativity too. A vivid imagination is going to be a key skill for the 21th century and anything that uses to develop the imagination is also great brain ‘exercise’.

Many memory techniques require the person to think of the most outrageous and exaggerated images to help them remember certain facts or information. The funnier and more out-of-this-world the images, there is better chances to retain data in the mind.
Imagination and creativity to improve memory

For homeless patients, housing is preventive health care

Every year, a medical school course that I teach invites two speakers to tell students their compelling stories about how being homeless negatively affected their health. Conversely, I care for patients whose declining health led to homelessness because they were unable to work and fell too far behind on mortgage or rent payments. The American Academy of Family Physicians and other professional societies, such as the American College of Obstetricians and Gynecologists, encourage their members to provide compassionate and unbiased care to homeless persons, and a recent article in American Family Physician reviewed strategies for managing clinical conditions that commonly occur in this population.

The standard approach to chronically homeless persons with mental illness and/or substance dependence has been to improve control of these underlying medical problems before placing them in permanent housing. The trouble is that not knowing where one will eat or sleep from day to day is about the worst possible environment to improve mental health or recover from addiction. Dr. Kelly Doran and colleagues reported in the New England Journal of Medicine on a pilot program that used New York State Medicaid funds to house high-risk homeless patients:

Placing people who are homeless in supportive housing — affordable housing paired with supportive services such as on-site case management and referrals to community-based services — can lead to improved health, reduced hospital use, and decreased health care costs, especially when frequent users of health services are targeted.

New York health officials hope that much of its investment will pay for itself by reducing acute and emergency care visits, but so far has been unable to convince the Centers for Medicare and Medicaid Services (which only pays for nursing homes through Medicaid) to make a similar investment. Despite a lack of federal support, this "Housing First" approach has been successful in other states too, notably Utah, as James Surowiecki recently described in The New Yorker. Like it because it's the decent thing to do, because it saves money, or both, Housing First has garnered support across the political spectrum.

Some may view advocating for Housing First policies to improve the health of homeless persons to be outside of the scope of family medicine, but I don't. I have come to realize that some of my patients will not be able to fully address their chronic health issues until they have roofs over their heads and the stability and security that comes with having a place to call home. As Surowiecki observed, this approach can be viewed as a cost-effective form of preventive health care:

Our system has a fundamental bias toward dealing with problems only after they happen, rather than spending up front to prevent their happening in the first place. We spend much more on disaster relief than on disaster preparedness. And we spend enormous sums on treating and curing disease and chronic illness, while underinvesting in primary care and prevention. This is obviously costly in human terms. But it’s expensive in dollar terms, too. The success of Housing First points to a new way of thinking about social programs: what looks like a giveaway may actually be a really wise investment.

**

This post first appeared on the AFP Community Blog.

Birth control pills over-the-counter: debate evidence, not politics

I've waited to address this sensitive topic until after the midterm elections, when political slogans such as the phony "war on women" and trumped-up threats to religious liberty were discarded like so many campaign posters. It was curious to see the American College of Obstetricians & Gynecologists (ACOG) and Planned Parenthood attacking Republican Senate candidates for supporting over-the-counter birth control pills without a prescription - a position that, if the pills were free or the candidates were Democrats, they would probably have cheered. (When the American Academy of Family Physicians quietly supported oral contraceptives over the counter earlier this year, it was careful to specify that such purchases be covered by health insurance.)

As outlined in a 2012 ACOG opinion paper, the rationale for granting over-the-counter status to birth control pills goes something like this: unintended pregnancies are common; visiting a doctor for a prescription is inconvenient and unnecessary; oral contraceptives are safer than many medications already available without a prescription; women can screen themselves for contraindications; and women wouldn't stop seeing doctors for other preventive services. There are, however, very few studies that actually support these arguments; much of the literature simply surveys what other countries do regarding contraceptive access and assumes that outcomes are better (or at least not worse). And surprisingly, there's no research whatsoever that shows making oral contraceptives over-the-counter reduces unintended pregnancies.

This hypothesis would be relatively straightfoward to test in a randomized clinical trial. Enroll, say, five hundred non-pregnant, sexually active, pre-menopausal women without contraindications to oral contraceptives who don't want to become pregnant in the next 12 months. Randomly assign half of them to receive birth control pills without a prescription at a convenient pharmacy, and assign the other half to obtain contraceptives the usual way, by requesting a prescription from their family doctor or gynecologist. After a year, compare the numbers of unintended pregnancies and adverse events (deep venous thromboses, strokes, sexually transmitted infections) in each group. Other outcomes could include contraceptive adherence, appropriate use, and use of recommended preventive health care such as immunizations and screenings.

Why hasn't this study been performed already? Some physicians have told me that this question doesn't need to be studied because it's obvious that over-the-counter access to contraceptives would lead to fewer pregnancies. Others have insinuated that even asking the question is "anti-woman" and insensitive to the long history of gender bias in health and men using fertility to control and oppress women.

I say bull. This isn't only a political question, it's also a scientific one. Otherwise, why stop at putting oral contraceptives over the counter? Why not, for example, make it easier for millions of women and men with poorly controlled ("unintended") high blood pressure to treat themselves by making anti-hypertensive drugs over-the-counter? In fact, self-monitoring and self-titration of blood pressure medications is a strategy that is being seriously considered in high-risk populations. A recent randomized trial published in JAMA compared this strategy to usual care in five hundred primary care patients with hypertension and a history of stroke, coronary heart disease, diabetes, or chronic kidney disease. After 12 months, the mean blood systolic blood pressure of the intervention group was 9 points lower than that of the control group, with no difference in adverse events.

The outcome of the hypertension study wasn't obvious. It might easily have gone the other way. And for that reason, it was a question that deserved to be rigorously studied. Similarly, over-the-counter birth control need not be an evidence-free debate. Regardless of where you stand on this issue personally or politically, it's time to stop with the slogans and inform the discussion with science.

Insightful Thinking 101

Genius is defined by creativity. Albert Einstein is often regarded as the epitome of genius. Nobody seems to understand his genius other than to say that it bubbled up like uncorked champagne. But the story of his work paints a different picture. His discovery of Special Relativity, for example, came as a stepwise series of small insights spread over many years of incubation.

Einstein used systematic ways of thinking to unleash his creativity. His success was not magic. There was method to his genius. First, Einstein relied heavily on thinking with visual images rather than words. Many famous scientists claim that their best thinking occurs in the form of visual images, even at the level of fantasy. Words and language, according to Einstein, had no role in his creative thought and math was used mainly to express the ideas quantitatively. Einstein, for example, in one of his fantasies visualized himself riding on a beam of light, holding a mirror in front of him. Since the light and the mirror were traveling at the same speed in the same direction, and since the mirror was a little ahead of the light's front, the light could never catch up to the mirror to reflect an image. Thus Einstein could not see himself. Another example of his use of imagery is his thought experiments visualizing train movements. Although fantasy, such thinking is not the product of a hallucinating mind; there is clear logic and order embedded in the fantasy.

A second reason for Einstein's creativity is that he was unafraid, even as an unimpressive student and a patent clerk without recognition as a scientist, to challenge no less an authority than James Clerk Maxwell when the thought experiment could not be explained by current electrodynamic dogma.

Third, Einstein thought long and hard on this problem for over seven years when he published his seminal paper in1905 at the age of 25.  Actually, he said in his autobiography that he started pondering the problem when he was 16. The point is that the revelation did not happen in an instant—it was the product of incubation. Actually, his ideas were fermenting for years, where he repeatedly thought about alternative possibilities and eliminated those that didn't add up. By the process of elimination incubated over a long time of thinking, the final solution became accessible.

This view of creativity is consistent with the view of Linus Pauling, who won two Nobel Prizes and came within a hair of decoding DNA structure that would have won him a third. He said, "To have a good idea, you have to have lots of ideas." All exceptional scientists generate lots of ideas, and then winnow out the ones that are practical for testing by experiment. In other words, Einstein and Pauling are proof that creativity is not as inaccessible for ordinary people as it seems. There are systematic ways for everyone to become more creative.

These ways of thinking can be taught and used by anyone. Young scientists aspire to have an early experience of working for a time in the lab of a famous scientist, in the hope of learning how to make discoveries. Many Nobel Prize winners have been students of other Nobel Prize winners. Consider the case of Hans Krebs, who discovered the energy-production process in cells. His "family tree" of scientists shows the following relationships of science teachers and mentors:

Berthollet (1748-1822)
   Gay-Lussac (1778-1850)
      Liebig (1803-1873)
         Kekule (1829-1896)
            von Baeyer (1835-1917)
               Fischer (1852-1919)
                  Warburg (1883-1970)
                             Krebs (1900- 1981)

All of these men were famous and each of the last four received Nobel Prizes, which began in 1901. A role model for Hans was Otto Myeroff, who worked in the same institute and who received the Nobel Prize in 1922. This tree is cultural, not biological. There was only one scientist in Hans' biological family tree, a distant cousin, who was a physical chemist.

In the years (1926-1930) Hans studied with Otto Warburg, where he learned the value of inventing new tools and techniques for conducting experiments to test ideas about energy transformation in living tissue. Another important lesson was the value of hard work on ideas. Warburg worked long and hard hours all his life; he was working in his lab eight days before he died, at the age of 81.

* * *

Creativity is a subset of a general learning competency that entails correct analysis, understanding, insight, and remembering. Here, I stress the importance of insight, often referred to as "thinking outside the box." Moreover, I make the claim that this competency can be taught and mastered through practice.

This mode of thinking goes by other names, such as lateral thinking or "thinking outside the box." Whatever you call it, such thinking requires breaking the constraints of predispositions, limiting assumptions, bias, mental habit, and rigid past learning.

See if you can solve the problem below, which is a simple illustration of the common problem of self-imposed limitation of thinking:

Problem: draw four straight lines that connect all dots without lifting the pencil off the paper. Each line starts where the other finishes. Can you do it?

In case you didn't figure it out, here is onesolution:

Many people can't do this task. Reasons for failure here and with other creativity challenges include:

1. Improper understanding of the problem. Failure to recognize what is allowed and what is not.
2. Failure to look beyond the ideas that first emerge.
3. Being so close to a solution that you keep working with the same flawed approach.

Frame the Issue Properly

The sample dot-connection task above illustrates the problems you get into by the way you have framed the problem. When faced with any problem, it is natural to make certain assumptions about facets of the problem that were not explicitly stated. In the above, case, I didn't say that the lines had to stay within the borders of the dots, but many of you probably made that assumption. You were actually free to make the assumption that it was o.k. to do that.

The way we classify things creates a logjam to new ideas. For example, something in Newton's sensory or cognitive world caused him to see the similarity between an apple and the moon in a new way; of course they were both round, solid bodies. But it is not clear what caused him to perceive what is now obvious, namely that both are subject to the effect of gravity. Even seeing the apple fall from a tree would not be a meaningful mental cue for explaining moon motion to most people, because they are not used to thinking of the moon as "falling." Creative thought is affected by the ways in which we classify things. We put apples and moons into categories; but by insisting on describing and naming them, we restrict the categories to which they belong. Apples are supposed to be round, red, and sweet, while moons are large, yellow, rocky, and far away. The names themselves get in the way of thinking of either as a classless object that is subject to gravity. A lesser order of creativity is commonly seen in the simple realization of the significance of obvious associations. The associations may even be negative (e.g., if penicillin is present on a bacteriological plate, the organisms will NOT grow).

A question calls for an answer: a problem, its solution. The trick is not only to ask questions, but to ask questions or pose problems in the most effective ways. A question can easily limit creative thinking if it restricts the space of potential answers. It therefore is important to pose questions in open-ended ways and ways that do not make too many assumptions about an acceptable answer. A major part of the creativity task is proper formulation of the problem itself.

Improving Creative Thinking Ability

People who have looked carefully at the creative process have learned that everyone of ordinary intelligence has latent creative abilities that can be enhanced by training and by a favorable environment. But many of us have not developed our creative capacity. Our brains seem frozen in cognitive catalepsy, boxed in by rigid thinking.

One book that is dedicated to improving creativity is by D. N. Perkins, The Mind's Best Work. He finds that after-the-fact anecdotes about well-known examples of great leaps of creative thought have generally received little or no close scrutiny of the mental processes that led to them. There are too many opportunities for the real mental correlates of creativity to be lost through excitement and distraction (as part of the "eureka" phenomenon), lack of need or desire to reconstruct the thought processes, and faulty skill and memory in reconstructing the process. Experiments where people have been asked to think aloud or report their thoughts during an episode of invention led Perkins to conclude that creativity arises naturally and comprehensibly from certain everyday abilities of perception, understanding, logic, memory, and thinking style.

Generating Insight

As an indication that creativity can be taught and learned, I offer the following personal anecdote.

"Grade = C.  Klemm: Your work shows a lot of industriousness.  Strive for INSIGHT!"

That note was scrawled across an assignment paper I had turned in to my professor, C. S. Bachofer, at Notre Dame. I had worked very hard on that paper, was quite proud of it, and had expected an A. Decades years later, I could still see that message, seared into my memory like a brand on cow hide. It was as if he meant that I was not smart enough. If true, how was I supposed to make myself smarter?  Isn't that a born capacity? You either have it or you don't.

As the years went by, and I became a professor myself, I gradually came to realize that Professor Bachofer was really saying something else.  He was telling me to discover in my own terms and learning style the tactics and techniques that can develop insight capability.  I now know that it IS possible to learn how to become more insightful.  Some of this may be teachable to others.

Idea generation has little to do with intelligence. I remember a graduate student of mine who had great test scores and all As from six years of college work. As was my practice, I tried helping this student develop a thesis project by giving him a published research paper and asking him what ideas occurred to him? After the first paper, he said nothing particular came to mind other than what was reported in the paper. So, figuring I had just picked a paper that was too mundane, I gave him another paper. Again, the same result occurred.  After about four or five tries with the same result, I said, “I’m afraid this is not going to work. You really should not go into this line of work. In any case, if you persist in this ill-advised quest, you will have to find another major professor.”

So how could this student have generated ideas? First, he should have been looking for alternatives. In reading, for example, I focus on what the author did not say. This not only stimulates me to think of other possibilities but also improves my ability to remember what was written. Thinking about something is the best way to rehearse the memory of it.

Thinking of alternatives requires imagination. Young children have lots of imagination. Unfortunately, school tends to stamp that out in the first few years. This is one reason I like to use mnemonic devices to promote memory. All these devices require imagination, and the more you exercise this capability, the better you can get at it.

Idea generation needs to be valued. School tends to devalue creativity. Expectations are to learn what is dished out and pass a high-stakes test on it. What educators value most is understanding and remembering accepted knowledge. Do we believe students are too dumb for higher level thinking? Do we believe that these higher skills are innate and cannot be taught? Do we believe that maybe they could be taught if we only knew how?

The Creative Process

The literature on the creative process is vast, and I can only summarize it here. Have you seen the advertisement from IBM Corporation, in which there was a long alphabetized list of "old English" words? The ad's caption read, "Anyone could have used these 4,178 words. In the hands of William Shakespeare, they became King Lear." King Lear epitomizes the essence of creativity: to take commonly used and understood ideas and recombine them in elegant new ways. 

Some practical advice on how to think innovatively is provided by Beth Comstock, the CMO at General Electric. She was inspired by a brilliant boss who wasn't afraid to offer an idea before its time. Even though many of his ideas were absurd, many were also gems. None of these would have been born had he not been willing to "put it out there." As Einstein said, "If at first the idea is not absurd, there is no hope for it." The point is that creative ideas often come of the oven half-baked. Typically, the recipe has to be modified.

Comstock's advice includes:

1. Nurture the newborn idea. Absurd ideas are all too easy to dismiss. Be patient with them and protect them from early-stage critical analysis. This accepting attitude lies at the heart of effective brainstorming. Get the ideas out on the table. They often will grow or transform into better ideas. Sit on them. Let them incubate.

2.  Commit to a promising idea. Successful ideas are nurtured by passion. If you believe in the promise of an idea, noodle it to fit a meaningful problem. Do your homework. Smooth the rough patches. Ask others to help make the idea better.

3. Tell others, even when you feel embarrassed about how flakey the idea might be. This clarifies your own thinking and at least a few of your listeners may get intrigued and help you improve the idea.

4. Hang in there. Don't be intimidated by negative feedback. Use such feedback to improve the idea. If necessary, put the idea in storage until improvements come to mind, or new technology or resources become available or others people are more accepting. If you believe in your idea, don't give up.

A fundamental aspect of creative thinking is to be flexible in interpreting what you see or hear. Powers of observation include of course the ability to notice things. But just registering a visual or thought input is not enough. Creative brains see what others only look at. That is, creative brains look for implications.

A basic condition for a creative act is to combine known elements into new combinations or perspectives that have never before been considered. Perkins writes of the utility of deliberately searching for many alternatives so that many combinations and perspectives can be considered. Creativity is much more likely to emerge when a person considers many options and invests the time and effort to keep searching rather than settling for mediocre solutions.

The first and fundamental step in the creative process is to have a clear notion of what the problem is and to be able to frame it appropriately. Recall in the opening example how you framed the dot problem determined whether or not you could solve it. The effective thinker begins by first focusing on the structure of the problem rather than its technical detail.

Creative operations require conceiving alternative solutions. These come from each person's permanent memory store, his or her lifetime data base of knowledge and experience. Memorizing does not impair thinking ― it can empower thinking. Other potential alternatives are brought in from such external sources of input as reading, ideas from colleagues, data bases, and other sources. Next, these alternatives can be processed logically (by associating, sorting, and aligning into new or unusual categories and contexts) or more powerfully by the use of images, abstractions, models, metaphors and analogies.

Thus, knowledge is not the enemy of creativity. One's capacity for creativity depends on the store of knowledge. Einstein, for example, would not have discovered relativity if he had not known basic physics in general and Maxwell's ideas and equations in particular. As my friend, Ann Kellet has said, "To think outside the box, you have to know what is inside the box." The trick is to take a fresh look at what is inside the box.

The next stages involve noticing clues and potential leads, realizing permutations of alternatives that are significant, and finally selecting those thoughts that lead to a new idea. There are dozens of thinking tools that stimulate idea. Check out these tools at the Web sites ideaconnection.com, mindtools.com, and myucoted.com.

The process of considering and choosing among alternative approaches involves a progressive narrowing of options in the early stages of creation and a readiness to revise and reconsider earlier decisions in the later stages. Einstein ran into several blind alleys in his discovery journey. This narrowing process requires the creator to break down and reformulate the categories and relationships of thoughts and facts that are commonly applied to the problems and its usual solutions. The creative thinker examines all reasonable alternatives, including many which at first may not seem "reasonable." Each alternative needs to be examined, not only in isolation, but in relation to other alternatives—and in relation to the initial problem expressed in different ways. The practical problem then becomes one of reducing the size of the problem and alternative solution space to workable dimensions. That may well be why one has to be immersed in the problem for long periods, with subconscious "incubation" operating to help sort through various alternatives and combinations thereof.

Note that all of these operations must occur in the working memory, which unfortunately has very limited capacity. That is probably the reason why insight and creativity are so hard to come by. Researchers of the subject of creativity would do well to look for ways to create more capacity for our working memory and to make it more efficient. The most manipulatible factor would seem to be the mechanics of supplying information input from external sources.

The final stages of creativity are more straightforward. They involve critical and logical analysis, which typically forces a refinement of the emerging ideas. Analysis should force the refinement of premature ideas and re-initiation of the search and selection processes. Sometimes, analysis will force the realization that the wrong problem is being worked or that it needs to be reformulated.

If you have but one wish, let it be for an idea

                                                     ― Percy Sutton 

Further Reading

DeBono, Edward. (2009) Think! Before It's To Late. Vermilion. London.

Klemm, W. R. (1990).Leadership: Creativity and innovation, p. 426-439.Concepts for Air Force Leadership, ed. by R. I. Lester and A. Glenn Morton. Maxwell Air Force Base, Alabama: Air University.

Klemm, W. R. (2001)   Hans' Nobel Prize family. http://peer.tamu.edu/curriculum_modules/Cell_Biology/module_3/storytime3.htmAccessed Augst 15, 2014.

Michalko, Michaeal (2001) Cracking Creativity: The Secrets of Creative Genius. Ten Speed Press. New York.

Norton, John D. Einsteins pathway to special relativity. http://www.pitt.edu/~jdnorton/teaching/HPS_0410/chapters_2013_Jan_1/origins_pathway/index.html. Accessed Aug. 14, 2014.

Perkins, D. N. (1981). The Mind's Best Work. Harvard Univ. Press, Cambridge.  

The natural history of symptoms in primary care

Not long ago, I was sitting in my office catching up on some electronic charting when I began to feel chilly, achy, and weak. I went home, skipped dinner, and went straight to bed. Although I felt mostly better the next morning, my appetite didn't fully return until later in the day. My self-diagnosis was a probable viral infection. But the truth was that I had no idea if my symptoms were related to any kind of disease.

Medical education trains physicians to approach patients' symptoms foremost as manifestations of an underlying cause. Only "treating the symptoms," in contrast, can often feel like a sort of failure. But as Dr. Kurt Kroenke reported in a narrative review published in the Annals of Internal Medicine, at least one-third of common physical symptoms evaluated in primary care (including pain, fatigue, dizziness, sleep disturbances, and gastrointestinal symptoms) are "medically unexplained," meaning that they are never connected to a disease-based diagnosis after an appropriate history, physical examination, and testing.

Dr. Kroenke further asserted that viewing symptoms as purely disease-oriented influences the language physicians use to describe them:

The lack of a definitive explanation for many symptoms is further underscored by the use of adjectival modifiers indicating what a symptom is not ("noncardiac" chest pain or "nonulcer" dyspepsia) or implying causal explanations that are weakly defensible ("tension" headache, "mechanical" low back pain, or "irritable" bowel syndrome).

Not only do some symptoms have no obvious causes, but others have multiple possible causes which may be unproductive to approach separately. For example, why does a patient with congestive heart failure, anemia and depression feel tired all the time? Also, symptoms usually occur in a group, rather than in isolation; for example, a classic symptom cluster in cancer patients is SPADE (sleep  / pain / anxiety / depression / energy).

Studies show that about a quarter of symptoms that present to primary care eventually become chronic. Fortunately, very few of these patients harbor a serious missed diagnosis such as an occult infection or cancer. As family physicians know, even if we are uncertain about if or when a particular symptom might improve, communication still has great therapeutic value. "Is this normal, doctor?" is the question I hear most frequently from my patients who have persistent symptoms without diagnoses. I usually respond that there is a wide range of "normal," and what's more important to me is working with him or her to make these particular symptoms more manageable.

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This post first appeared on the AFP Community Blog.