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All That's Wrong Right with the World

Walker, Graham, MD

Emergency Medicine News: May 2019 - Volume 41 - Issue 5 - p 10
doi: 10.1097/01.EEM.0000558181.31123.7c



I was recently talking to a friend who had given up reading the news. She admitted she was sacrificing knowledge for the sake of her mental health: The political divisiveness across the country left her with worry of an uncertain future for her children. The frequent and continued mass shootings seem to have left us numb to death and carnage. She told me she still occasionally skims newspaper headlines, but it just wasn't worth it to her anymore to be informed about local, national, or world events.

I can't tell if things are grimmer than they were just 10 years ago because obviously I'm a different person from who I was 10 years ago. The stock market had crashed and banks were being bailed out. I was an intern, completely oblivious to everything except how many hours I had slept on call during my ICU rotation. Now I have a mortgage and a dog, and 10 years ago seems really far away.

Certainly, medicine has always had a negativity bias. By law and regulation, every hospital has to have a quality assurance, quality review, or morbidity and mortality process to systematically evaluate what went wrong. People have often recommended a Good Save award or Great Teamwork recognition, but I'm not seeing hospital accreditors clamoring for a positivity mandate. Sure, we might tell colleagues about a great case, talk about how it is better to be lucky than good, or thank a nurse for her quick thinking during a code. But overall, medicine focuses on the rare bad outcome and mostly ignores all the good ones.

Even our research skews negative. I read a recent study in the Annals of Emergency Medicine looking at discharge diagnoses of back pain and headache. (2019. pii: S0196-0644[19]30027-7.) It included a data set of almost 3.5 million ED encounters, and 0.2 percent of back pain patients and 0.5 percent of headache patients had something bad. The conclusion? A small proportion of ED patients discharged with nonspecific diagnoses of headache or back pain returned with a serious neurologic condition or in-hospital death within 30 days.

I took this as, “Wow, emergency medicine is really good at finding the needle in the haystack! If we think you have nonspecific back pain, 998 times out of 1000 we're right!”

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The Retrospectoscopic Trees

I have also been reading Hans Rosling's book, Factfulness. Dr. Rosling was a famous Swedish physician and global and public health expert, and he argued that we're too negative about the state of the world. Instead, he said the world is rapidly and dramatically improving. Much of what we learned about the world in high school and college is outdated, including the concept of developed and developing nations. Dr. Rosling showed several fascinating graphs demonstrating that much of the developing world has actually improved living standards dramatically and that the world is full of much more gray than black and white when it comes to health, wealth, and progress.

Let's see what you think. Take out your pencils for a pop quiz.

  1. What is the average life expectancy in the world today?
    1. 50 years
    2. 60 years
    3. 70 years
  2. By how much has the worldwide infant mortality rate fallen over the past 25 years?
    1. 10 percent
    2. 30 percent
    3. 55 percent
  3. By how much has the U.S. mortality rate from influenza and pneumonia fallen over the past 25 years?
    1. 0 percent
    2. 20 percent
    3. 65 percent

The average human life expectancy is now 70 years. Infant mortality has fallen 55 percent in the past 25 years. U.S. pneumonia and flu mortality has fallen 65 percent in the past 25 years.

Dr. Rosling asked audiences around the world of differing educational and geographical backgrounds a number of these progress questions, and almost uniformly, all did worse than chance alone (one in three). I imagine that my group of EP readers scored no better. Dr. Rosling tried to make the point that much of our world population is rapidly improving, giving examples of how poorer countries are actually making significant progress faster than the richest ones did and that humans focus way too much on the negative. We never actually reflect on everything that's going right in the world. A 55 percent drop in infant mortality? That's incredible!

This is not to say that we don't have problems. Critics of Factfulness think Dr. Rosling painted a too-rosy world view. But it's certainly a nice reminder of the forest when being asked about the retrospectoscopic trees the next time you're in the middle of a case review or a challenging patient interaction. Modern medicine and public health are far from perfect, but the incremental improvements we make day by day have caused these accelerating, dramatic shifts, and they might just save us from extinction.

Dr. Walkeris an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (, a medical calculator for clinical scores, equations, and risk stratifications, which also has an app (, and The NNT (, a number-needed-to-treat tool to communicate benefit and harm. Follow him on Twitter @grahamwalker, and read his past columns at

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