Very Bad Numbers

By ANISH KOKA, MD

The date is July 17th, 2014. It is 10am in the Dirksen Senate building, and the congressional subcommittee on health and aging is about to focus on patient harm. The educating will be done by some of the leaders in the medical field, Ashish Jha and Tejal Gandhi from Harvard, Peter Pronovost from Johns Hopkins. The star of the proceedings is John James, a toxicologist, a PhD from Texas, and the founder of Patient Safety America.

The tone is set from the beginning by none other than Bernie Sanders. In somber tones, he relays that hospitals can make patients worse, and that a recent study suggests medical errors is America’s third leading cause of death behind only heart disease and cancer. Hospitals are killing patients, and something needs to be done about it. The panelists then go on to speak strongly about the ongoing epidemic of patients dying in hospitals, and re-enforce the staggering numbers introduced by Bernie Sanders.

Headlining the proceedings is an unassuming gentleman named John James. He has a Ph. D in pathology, and he worked as a Chief Toxicologist at NASA. He is at the congressional proceedings, and is one of the lead activists in patient safety because of personal tragedy. His 19 year old son died in the summer of 2002 due to “uninformed, careless, and unethical” care by cardiologists. He proceeded to write a book, “A Sea of Broken Hearts” that details the errors he believes cardiologists made in his son’s care that lead to his death. Of note 2 cardiologists that were sought by Dr. James’ lawyers believe the care his son got did not violate the standards of care. A further 2 appeals to the Texas Medical Board also rendered two opinions from two other separate cardiologists that the standards of care in this case were not only met, but exceeded. Dr. James, armed with information he has carefully selected from a number of different sources, strongly disagrees.

Dr. James is now a crusader for patient rights. He writes of a broken health care system on his website, and more importantly wrote a paper in 2013 in the Journal of Patient Safety that estimated 400,000 patient deaths per year that were due to medical error. No physicians on the panel or elsewhere seem to have any issue with this number, and this has become fairly widely accepted. Even Captain ‘Sully’ Sullenberger, the hero pilot who landed a plane in the Hudson, noted that this was the “equivalent of three jumbo jets going down every day with no survivors.”

As a busy clinician who spends much of his time in the hospital, it doesn’t feel like patients are dying daily because of medical errors. But of course, data necessarily must trump feelings. So, I decided to read John James’s landmark paper.

Venrock headlines Health 2.0’s Digital Health Investor Conference, WinterTech 2016

By DEEPA MISTRY

Health 2.0’s WinterTech conference on January 13, 2016 at the Julia Morgan Ballroom in San Francisco, CA showcases the latest in digital health investing featuring leaders from Venrock, Canvas Venture Fund, Helix, Doximity, Grand Rounds, Livongo, Omada Health, and more. Learn about the latest financing and market trends of digital health and hear directly from the start-ups creating the biggest waves in the industry.

Key sessions include:

• The VC and her CEO will include Silicon Valley VC Rebecca Lynn, Partner at Canvas and her CEO, Jeff Tangney, CEO & Founder at Doximity. The pair will provide an insider’s view of the investment, evolution of the business model, and how the two collaborate.
• Fireside Chat will feature Health 2.0’s Co-Chairman Matthew Holt leading a one-on-one discussion with Bryan Roberts, Partner at Venrock, whose investments include health IT, biotechnology, diagnostics, and medical devices.
• 3 CEOs will feature top journalists conducting separate 15 minute interviews with three of digital health’s biggest CEOs: Owen Tripp from Grand Rounds, Glen Tullman from Livongo Health, and Sean Duffy from Omada Health.

Conference panels include:

• Investing In Consumer Health: With perspective and insights from leading companies and investors, Lisa Suennen, Managing Partner at Venture Valkyrie will moderate a panel of speakers including Ankur Luther, Executive Director at Morgan Stanleyand more.
• New Clinical Tools and Platforms: Dena Bravata, Co-founder & CMO, Lyra Health will join a panel of speakers sharing how they enable a smarter health care system. These innovations make the delivery of care quicker, faster, and cheaper with new technologies for analyzing patient data, diagnostics, and improving day-to-day workflow and collaboration.
• Meeting in the Middle: The Convergence of Life Sciences and Health Tech: Justin Kao, SVP of Corporate Development at Helix and Jeffrey Brewer, Founder & CEO at Bigfoot Biomedical will dive into how the rise of wearable sensors and other connected devices continues to evolve alongside advanced genomic analysis and big data in personalized medicine. This convergence promises to make health care more accurate, accessible, and affordable.
• The New Consumer Health Ecosystem: Everyone is talking about consumers. Many millions of dollars have been invested in health care tech for consumer-facing services. Most consumers have yet to use any of the new technologies. This panel featuring Peter Ohnemus, CEO, & President from Dacadoo and others will assess the ecosystem and quantify how close we are to success.
• Apply to attend the Health 2.0 exclusive investor breakfast, hosted before WinterTech, where you’ll have a chance to discuss business models, examine trends, and explore portfolios before the mainstage kickoff. Past investors include Qualcomm Ventures, Morgan Stanley, Ziegler, StartUp Health, Boehringer Ingelheim and more. Submit your application here.

Health 2.0 WinterTech is the only event dedicated to digital health and investing during the nation’s leading healthcare investment mecca, JPMorgan Week. The event brings together historically distinct industries in health to challenge the current landscape to become user driven, informed, and financially profitable for all players involved. Register before prices increase at the end of the day today!

About WinterTech
Through fireside chats, interviews, and compelling panel discussions, WinterTech is back for its second year, bringing together the top names in health care tech and investing including innovative startups, entrepreneurs, VCs, policy makers and more.

Deepa is the Marketing & Operations Manager at Health 2.0.

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Cost, Value & Tools

By PETER PRONOVOST, MD

Like a pro golfer swears by a certain brand of clubs or a marathon runner has a chosen make of shoes, surgeons can form strong loyalties to the tools of their craft. Preferences for these items — such as artificial hips and knees, surgical screws, stents, pacemakers and other implants — develop over time, perhaps out of habit or acquired during their training.

Of course, surgeons should have what they need to be at the top of their trade. But the downside of too much variation is that it can drive up the costs of procedures for hospitals, insurers and even patients. When a hospital carries seven brands of the same type of product instead of one or two, it’s not as likely to get volume discounts. Moreover, if hospitals within a health system negotiate independently of one another, they may pay drastically different prices for the exact same item.

Carrying many brands of a given item may also increase risks for error and patient harm. Staff members need to be trained and competent in a variety of tools; the greater the number of tools, the greater the risk for error.

These physician preference items are no small contributor to health care costs. Around the year 2020, medical supplies are expected to eclipse labor as the biggest expense for hospitals, according to the Association for Healthcare Resource and Materials Management. Higher costs for physician preference items are major drivers of this increase.

At Johns Hopkins Medicine, when we sought to reduce the costs of supplies, we knew it couldn’t be led by finance alone, and it shouldn’t focus solely on costs. One of the enduring lessons in health care improvement is that change progresses at the speed of trust. As such, change happens best when it’s done “with” clinicians and not “to” them. We have turned to our clinical communities — peer groups of experts from across our health system’s six hospitals who work together to tackle issues related to quality, patient safety and value of care. There are now 19 clinical communities across Johns Hopkins Medicine in such areas as surgery, joint replacement and blood product utilization. These communities provide a venue for members — who previously had scant opportunities to collaborate across Johns Hopkins-affiliated hospitals — to tackle common problems, share best practices and make changes that benefit the entire organization.

To foster trust, we agreed on two key principles. First, physician choice in supplies would be maintained, although physicians would be made fully aware of the savings and risks of different items. Second, physicians would benefit from some of the savings. While the law forbids us from putting money back into their pockets, we can use the savings to support their programs, such as by investing in equipment or participating in a registry, to help them better monitor quality.

Working within those principles, our Spine Clinical Community convened “about a dozen surgeons, nurses, anesthesiologists and other clinicians to decide what Johns Hopkins should pay as the true value — instead of the list price — for products used in spinal surgery,” according to our Dome newsletter. With the clinical community’s analysis providing the justification for lower prices, the contracting manager informed vendors that all Johns Hopkins affiliates would pay the same price for these items. The new pricing schedule that resulted from this is projected to save the health system $3.3 million a year.

The article explains: “The key is drawing upon the expertise that Johns Hopkins clinicians collectively hold. A product analysis prepared by a dozen or more surgeons from across Johns Hopkins Medicine holds significant sway during supply contract negotiations. ‘Without it, vendors can more easily charge a premium for a product that isn’t unique,’ says Sibley Memorial Hospital neurosurgeon Joshua Ammerman, a clinical lead for the Spine Clinical Community.”

The article points to another money-saving campaign, an effort by our Blood Management Clinical Community to reduce the number of red blood cell units that are transfused unnecessarily. While it had been standard to give two units at a time, in many cases, the evidence calls for just one unit. Now, when staff members place red blood cell orders for patients with hemoglobin levels at or above the optimal threshold, a pop-up alert informs them that transfusion requirements can be decreased while avoiding adverse outcomes. Through this and other strategies, we hope to conserve more of this limited, lifesaving resource by 10 percent, for an annual savings of $2.8 million.

Within any hospital or health system, there can be huge variability in how care is delivered. That variability may drive up costs while undermining quality. Some might be tempted to point the finger at physicians and limit their autonomy. But we have found that the solution, in fact, requires that we engage physicians more deeply, mine their wisdom, and ask them to lead these efforts to enhance safety, quality and value.

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When Natural’s Not Enough

Part of my job over here at Joyous Health is to answer reader questions. If you’ve emailed Joyous Health, or commented on the blog or social media pages, you’ve probably spoken with me at some point. Interacting with the Joyous Community is one of the favourite parts of my job, but there’s one question I have a tough time with, and it usually goes something like this:

“I have [health concern or condition] and I’m absolutely determined to treat it naturally, but my doctor says I need medication. What should I do?”

Another variation I see a lot goes like this:

“I’ve been taking [medication] for years, and I really want to come off it, but my healthcare team thinks I need to keep taking it. What should I do?”

You might be wondering why I find this so challenging. Well, here’s the thing, I’m a big fan of taking charge of your own healthcare and being your own best patient advocate. And I’m a big fan of holistic and complimentary healing modalities. I’m also a woman who takes prescription medication designed to alter my brain chemistry to deal with a specific medical condition and I have no plans to come off it in the immediate future. I’m okay with that, and despite some of the feedback I’ve gotten from the holistic health community, I do not feel that my comfort with taking prescription anti-depressants in any way conflicts with my interest in treating things holistically.

While I was in school, I remember a teacher telling us how she had just found out her dad was diagnosed with cancer and that he was undergoing chemo. She told us how angry she was that she didn’t have the chance to give her dad natural options before he had to start chemo. I remember getting angry too, but I wasn’t angry the way she was. I was angry that she’d presume to think she knew more than her dad about what he needed. After all, it was his cancer, and he had the right to decide what he wanted to do about it.

Earlier this year, I was diagnosed with generalized anxiety disorder and major depressive disorder. My fantastically supportive friends and family tried to help make sure I ate right, socialized more, went to therapy, exercised, meditated, and all the other things depressed people are supposed to do.

But I didn’t get better. In fact, I got worse.

At some point in our lives, most of us are going to face a health concern that all the green juices and yoga can’t fix. If left untreated, almost any health issue has the capacity to develop into something life threatening. While I could write at least a dozen posts on dealing with anxiety and depression, those are stories for another day, because for these purposes, you could take anxiety and depression and replace it with any other health condition. It just so happened that severe clinical depression was my healthcare Waterloo.

So I went back to the doctor, and several different prescriptions and dosage adjustments later, things started to get better. I felt that sharing my story might help do a tiny part to dispel some of the stigma around mental health issues, so I slowly started to share my story. Most people were happy for me, but I did come up against a minority in the holistic health community who felt like my decision to take anti-depressants was some sort of betrayal of the values of holistic care. Here’s a a sampling of conversations I’ve had with various Well-Meaning People:

Well-Meaning Person 1: “I was depressed once, but then I went on this yoga retreat and …”

Kate: “Yeah, I don’t want to take away from your experience, but I don’t think this is the same thing.”

WMP 2:“But you’re planning on coming off them soon, right?”

K: “Why would I want to do that when they’re still working?”

WMP 3-14: “Oh, you don’t need those, you just need to take [probiotics, fish oil, other supplement du jour].”

K: “Thanks for your advice, but I’m really not in the mood to rock the pill-taking boat right now.”

And my personal favourite:

WMP 99+: “You know anti-depressants are linked to weight gain, right?”

K: [in my most sarcastic voice possible] “Oh yeah, ‘cause being skinny and too depressed to eat is making me so happy right now.” [eye roll]

As frustrating as this experience has been, it has reinforced my firm belief that holistic health care is about balance, and that includes balance between the natural and the pharmaceutical. Opting to take a prescription medication that makes you feel better does not kick you out of the holistic health club.

If I could share one piece of advice from my journey as a patient, it would be this:

You are the boss of your healthcare team, with the right to hire and fire any members as you see fit. The most important thing when you’re trying to decide if a healthcare practitioner is right for you is not that they’re the most “natural” option for you, but that no matter what their stance, designation and training, they are qualified for the position they’re looking to fill on your team, and that they listen to you and respect and meet your physical, mental and emotional needs as a patient.

Kate McDonald Walker

Kate is our resident self-professed research nerd. Kate is a Toronto-based student of holistic nutrition, yoga teacher, and health and wellness writer. She is a passionate advocate of integrative approaches to wellness and believes in making the journey to lasting health and wellness as straightforward, sustainable and enjoyable an experience as possible.

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How to Stay Healthy Through the Holidays (Video)

In the past I used to gain 5lbs after everything I indulged in throughout December. Then I was on a mission to shed that extra weight that made my clothes feel tight and my shirts just a wee bit uncomfortable come January. However, now I just make smarter choices and can enjoy the holidays as well as start off the New Year right without a weight loss goal in mind. 

If your jeans feel quite a bit tighter after the holidays then I think my tips will come in super handy!

Here’s the video:

Summary of my points:

1. Choose your indulgences wisely.

Instead of store-bought pumpkin pie or cookies, have a slice of your mama’s home-baked pie instead. Indulge in smaller quantities of high quality food. Less is more!

2. Don’t go hungry.

Heading to a holiday party? Don’t show up hungry. This is a recipe for stuffing yourself like a turkey! Eat a healthy dinner before an evening cocktail party. This will keep your appetite in check.

3. Skip the fried foods.

You know those frozen hors d’oeurves that you can buy from the grocery store? Skip them. More often then not they are pre-cooked, often pre-fried

4. Alcohol in moderation.

Avoid the sugary cocktails. Wine is your best choice. Drink a glass of water between every single alcoholic drink.

5. Release the guilt.

If you do go a bit overboard at your holiday office party, don’t beat yourself up about it. Just get back on track the very next day with my tips in the video.

6. BYOF: Bring Your Own Food

Many of you read joyous health and use the recipes because they are allergen-friendly AND of course, delicious!. So, in that case you may be someone who can’t eat a whole heck of a lot of foods at your Auntie’s holiday dinner. That’s okay! Just bring something you CAN eat. Don’t let your dietary restrictions prevent you from enjoying yourself so this is why being prepared and making something you love to share with others is a great idea.

I hope your next holiday party is super joyous!

Joy McCarthy

Joy McCarthy is the vibrant Holistic Nutritionist behind Joyous Health. Author of JOYOUS HEALTH: Eat & Live Well without Dieting, professional speaker, nutrition expert on Global’s Morning Show, Faculty Member at Institute of Holistic Nutrition and co-creator of Eat Well Feel Well. Read more…

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Closing the Loop on The Need for Better Telemedicine

By ANDREW ALTERDORFER

I’ve had the great privilege of presenting our virtual care company, CirrusMD, to potential customers and investors at some of the premier health technology conferences this fall, making the cut for both the Health 2.0 Traction event and this week in the finals of the mHealth Summit and HIMSS Venture+ event. (Breaking: we won the mHealth Summit and HIMSS Venture+ mature startup company award!)

Still, we often get an initial response, “Who needs another telemedicine company with the likes of Teladoc and American Well raising big rounds this year?” One writer even went so far as to share the thought in Forbes on the fragmentation of the digital health landscape after Health 2.0.

I want to take the opportunity to use an analogy to explain why were are different from other telemedicine offerings on the market, and why we are getting such great traction and recognition. In fact, we’re working to “unfragment” the healthcare landscape by closing up some very loose ends that occur in a typical telemedicine experience.

Today, finding our way to an unfamiliar address is easy with Google Maps or a GPS system. We just enter an address and go. The system knows where we are, where we are headed, can offer several options on how to get there, even make local recommendations along the way based on people who know the area. That’s where telemedicine needs to be, but not where it is with many of the major vendors.

Imagine if you didn’t know where you were, where you were going, and had no map. You’re lost and you find an old pay phone. You dial a number on a billboard that says “Directions and other Help”.

“Hi, I’m lost, and I have a flat tire and a bent rim,” you say.

“Where are you?” a voice asks.

“Wyoming.”

“Where in Wyoming?”

“Um, on a side road, that’s about all I know.”

“Where are you headed?”

“Somewhere better than here.”

“Well if you can get to a major highway I might be able to help you. I have a map of the major highways.”

“But I only have a bicycle.”

“Well, I can tell you how to fix your tube, but for a rim and tire, you’ll need to go to find a store. Good luck!”

That’s where many telemedicine customers are today. They can get a hold of someone, but the person on the other end of the line has little information on who or where the patient is, little idea of where the patient is in their care plan, and limited ability to effectively direct them on where they need to go. The professional on the line will have little understanding of how well the patient is capable of getting where they need to go and might have a different set of maps from what the patient and their care team have used in the past. At best, they can offer imprecise advice. That advice can only get the person vaguely in the right direction and the person won’t be able to speak to the same person again. There’s little to no opportunity for follow-up and course correction.

Having cohesive medical direction is equivalent to making sure everyone is working from the same map. When you move from one disconnected physician, to another, you may get very different advice, particularly when there is no common management or reciprocity between these two unaffiliated providers. Standards of care may, and often do, vary from practice to practice. That can cause conflicts and misdirection.

A longitudinal history ensures everyone agrees on where the patient is on “the map”. It assures that the best decisions are made under the context of care continuity. To maintain coordination, virtual care providers must have access to the patient’s primary medical record, and bricks and mortar/physical providers must have access to and notification of any virtual encounters that occur.  Additionally, the virtual and physical providers must be able to communicate and coordinate with one another around a patient’s care plan. A patient can wind up going around in circles.  Without the complete view of the patient, different decisions can be made in their care, and those decisions can lead to less than optimal outcomes. We see this happening with many of the virtual care services on the market today, especially for patients that have more complicated medical histories (remember 50% of adult Americans are living with a chronic condition).

We recently had an encounter with a patient suffering from a chronic condition who was traveling in Europe and lost their medications. They had a secure text conversation over the CirrusMD platform, and the physician was able to review their medical record and notes from the patient’s regular specialist and access their medications list.  The doctor knew that replacement medications were available over the counter in Europe and instructed the patient on what to get. The doctor then helped the patient manage their condition over several days to ensure that they were comfortable with the new medications and that the flare-up was being controlled.

That’s the power of telemedicine that knows the patient, their history and their care plan.

On another occasion, an individual with a debilitating chronic disease asked us, “If the person on the other side of the connection does not know my pathology, my meds, my symptoms with my disease, should they really be giving me medical advice?” The short answer, we believe, is “no”. We ensure our patients and physicians have access to the information needed, and the patient’s record is kept up to date through data integrations to HIEs and EMRs.

Documenting where the patient is with follow-up as they move through their care plan is also critical. Telemedicine solutions must ensure a patient receives the proper follow-up care, whether that care is in a physical clinic or via telemedicine. Virtual follow-ups are not currently enabled with the majority of telemedicine services on the market right now, and they cannot provide physical, in-person follow-ups as the doctors are generally not connected to the patient’s local healthcare establishment.  Without the ability to enable follow-up, a telemedicine visit becomes an island, a one-off event known only to the patient, and they can quickly become lost again.  This leads to fragmentation in patient care.

Finally, to guide a patient effectively as they go forward, providing the right referrals for follow-up care is also critical. To provide proper direction, you have to know the local area and where to go for the right service. Our doctors are local to the patient and have that ability.

It will be very difficult for the majority of telemedicine services today to provide common medical direction, longitudinal data access, follow-ups and referrals. With most vendors you’ll likely get a new doctor every time you call, and even if they are licensed in your state (which doesn’t mean they are in your state), they may know next to nothing about the patient, they are operating under very loose clinical guidelines with high variability in quality of care from doctor to doctor, and in some cases the telemedicine physician’s recommendations may fly in opposition to a patient’s current care providers.

We can and are doing better with our clients. We are bringing telemedicine solutions that are more consistent and work in context of a patient’s local healthcare landscape and offer full data continuity between virtual care providers and their regular doctors.

Our closed-loop telemedicine methodology solves these issues with the ability to bring physical and virtual continuous care together, including: a complete and consistent map (a more complete view of the patient with a care plan developed under consistent standards of practice), a continuous pathway of access (opportunity for follow-up and ongoing management), and local knowledge of the area to make specific recommendations on how to get what’s needed to get on track (ability to do local referrals).  With closed-loop telemedicine, we’ll know where patients are, where they are headed with more precise direction all along the way.

Andrew Alterdorfer is the CEO of CirrusMD

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How to Safegaurd your Career in Treacherous Healthcare Times

By MICHEL ACCAD, MD

Dear medical student,

I am honored by the opportunity to offer some advice on how to safeguard your professional career in a treacherous healthcare system.

I will not elaborate on why I think the healthcare system is “treacherous.”  I will assume—and even hope—that you have at least some inkling that things are not so rosy in the world of medicine.

I am also not going to give any actual advice.  I’m a fan of Socrates, so I believe that it is more constructive to challenge you with pointed questions.  The real advice will come to you naturally as you proceed to answer these questions for yourself.  I will, however, direct you to some resources to aid you in your reflections.

I have grouped the questions into three categories of knowledge which I am sure are not covered or barely covered in your curriculum: economics, ethics, and philosophy of medicine.

I have found that reflecting on these questions has been essential to give me a sense of control over my career.  I hope that you, in turn, will find them intriguing and worth investigating.

One more thing before we proceed.  Don’t be overwhelmed by the depth of the questions posed and don’t attempt to answer them today, in a week, or in a year.  In many ways, these are questions for a lifetime of professional growth.  On the other hand, I believe that the mere task of entertaining these questions in your mind will be helpful to you.

So here we go:

Your understanding of economics

Sample questions:

• Is there a shortage of doctors? Is there a glut?  How would you know?  How can you anticipate the demand for services in your specialty of interest?
• As a physician, how should your economic value (i.e., your earnings) be determined?
• Who will ultimately be the hand that feeds you?
• Will you and the hand that feeds you see things similarly in regards to how your work should be valued?
• How does a society become prosperous and how does it become poor?
• What is a fair way to distribute resources in society?
• Does the national debt matter? How could it affect your career?

If you don’t have some clarity about the answers to these questions, you may be proceeding in your professional life with some naïve optimism and inadequately prepared to safeguard yourself financially.

Granted, knowledge of economics does not always mean you will be immune from the effect of economic realities that are beyond your control.  But economic knowledge will afford you to take these realities into account as you make informed decisions about your career path, and allow you to weather any potential storm better than if you were caught by complete surprise.

Granted, economists themselves often disagree with each other, and economics may be the only discipline where the Nobel committee can grant a prize to two economists with completely opposing views.

Nevertheless, there is great benefit to having some grasp of economic principles.  And if these seem flimsy on the surface, it’s usually because politicians and economists let their political views confuse their economic discourse, and not because basic, well-reasoned economic principles are themselves faulty.

If you want to get started, I can recommend to two excellent and easy-to-read introductory texts: How an Economy Grows and How it Crashes by Peter and Andrew Schiff and Economics in One Lesson, a classic collection of essays superbly written by Henry Hazlitt.

Your understanding of ethics

Sample questions:

• Do the ends ever justify the means? If so, when and why?  If not, why not?
• Are there ethical principles that should always be respected? If so, which ones and why?
• Should medicine aim to provide the most good for the greatest number? Why or why not?
• Should doctors serve both the individual and society? Can they?
• How important is it to have good moral character? Why? (And what does that mean?)
• What is the goal of medicine?

Make no mistake about it, medicine is first of all an ethical endeavor.  Medicine is not about applying medical science or medical techniques, but about doing the right thing for the patient.

Science will inform you about the best means to achieve certain goals, and good techniques will help you achieve them.  But neither science no technology can tell you what those goals should be.

We live in a pluralistic society where basic ethical principles are frequently a matter of dispute.  This lack of ethical consensus and the potential for conflicts to arise understandably contribute to keeping ethics education to a minimum.

You, however, will benefit from having as clear an understanding of your own ethical principles as possible.  Otherwise, sooner or later you will realize that being ambivalent about the right course of action could cost you.

Whether it’s a matter of properly allocating financial resources in the care of patients, or issues of life, death, and justice, you don’t want to be in a position where hesitancy interferes with your ability to take a stand or make firm decisions, especially once you have committed to a job or a position where you are expected to make decisions.  (Remember, that’s what “M.D.” stands for).

Ethical principles are not necessarily obvious nor intuitive, otherwise, there would be no ethical conflicts in society.  The more you can articulate and defend the principles that you stand for, the better prepared you will be in a system where ethical conflicts are likely to be increasingly common.

You may wish to familiarize yourself with Principles of Biomedical Ethics by Beauchamp and Childress.  I do not necessarily endorse its content, but this is a commonly cited and influential text which reflects mainstream ideas about medical ethics.  This should only be a start.

Philosophy of Medicine

Sample questions:

• Is obesity a disease? Why or why not?
• Is hypercholesterolemia a disease?
• If a disease is defined by a cut-off number (say, BMI>30) is it a “real” entity? Is it a “social construct?”
• What is a disease?
• Do you agree with the W.H.O. definition of health? Why or why not?
• What does “normal” mean in a medical context?
• Should the medical community define what is healthy and what is not? If so, using what criteria?
• What can science tell us about health and disease?
• What are the main current problems in the philosophy of biology?
• What is a human being?

I hope you have found these philosophical questions somewhat relevant to the practice of medicine.  I believe that they are.

Unfortunately, not many people agree with me.  Instead, the common attitude is to think that these questions are difficult to answer and that medicine has made great strides without having to resolve them.  Why make a philosophical fuss?

I think a philosophical fuss is definitely in order when the healthcare system is teetering on the brink.  Deep seated problems often mean that we’ve been operating on assumptions that need revisiting.

As mere doctors, we may not always solve philosophical problems, but we should be able to recognize the assumptions on which medical doctrine and healthcare policy rest.  Sometimes, those who promote a certain viewpoint will prefer that its assumptions remain unexamined.  I think we can all benefit from having philosophical antennas.

Because the field of “philosophy of medicine” is virtually non-existent as an academic discipline, there is no standard textbook I can point you too.  However, there are two compendia of essays that were edited in the last decades and that address some of the questions I have raised here.  These are Concepts of Health and Disease: Interdisciplinary Perspectives, edited by Caplan, Engelhardt, and McCartney in 1981, andHealth, Disease, and Illness: Concepts in Medicine, edited by Caplan, McCartney, and Sisti in 2004.  Either one would be a good place to start.

Are you still with me?

If you are, you have realized that what I am giving you is a massive reading assignment.  I’ll admit it.  If I could summarize my recommendation in one word it would be this: Read!

Read more.  If you haven’t done so already, you need to develop the habit of reading all the time and of reading long form: books and long essays.  Read outside of your comfort zone.  Reading is the only activity that will quickly give you real knowledge that you need not only to survive, but to really thrive in these tumultuous times.

And don’t get discouraged by the sheer volume of the knowledge to be gained.  As I said earlier, the point here is to stimulate your curiosity about the proper questions, at a time when medical school demands are likely to quash you sense of wonderment.

Rome was not built in a day, and all you have to do is to keep on hand some material to gently chew on at your own pace, not to embark on an ill-advised intellectual binge for wisdom.  Once you get into that habit, you will find out that knowledge is not only empowering, but it is liberating.

And you’re not training to become a doctor to be at the mercy of an unhealthy system, are you?

Michel Accad is a cardiologist based in San Francisco. 

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Curry Cauliflower Quinoa Stew

Yesterday we had Walker’s grandma over for lunch and we enjoyed the last of my mom’s quinoa chili that she brought us last time she visited. Since we finished it off I thought to myself …”what can I make that will be warm and comforting, plus last a few days… just like chili”. So last night when we went to the grocery store to pick up a few things I spotted the perfect organic cauliflower.

I’ve made something similar (curry cauliflower) several times, but just never put it on the blog because I haven’t had a chance to record the recipe. This incredibly flavourful and warming stew is the epitome of comfort food …but joyous-comfort-food because it’s nourishing as well as super yummy.

Just like it says on this sweet tea towel, food eaten together really is better. It’s so easy after a long busy day to want to take this bowl of stew to the couch, turn on the tube and tune-out. While it’s totally okay to tune out and chill out, I think it’s really important to enjoy meals together as a family more often then not. Growing up, we always enjoyed our meals together as a family and now that I’m older I know it wasn’t always easy for my parents. They both worked full-time but somehow managed to pull it off. That didn’t stop my brother from hiding his veggies behind the fridge… I still don’t know how he did it without my parents knowing!

Since this was a one-pot meal and it was very fulfilling we didn’t need anything else to go with it. Although… I’m sure Walker would have loved some naan bread.

This recipe is very rich in fiber from all three of the main ingredients: cauliflower, chickpeas and quinoa; high in plant-based protein; high in anti-inflammatory compounds due to the spices in curry powder; very detoxifying — cauliflower is a detox superfood and seriously satisfying.

You may notice I used canned coconut milk and canned chickpeas because they are time-savers. If you have more time, you can skip the canned goods by making your own coconut milk and cooking chickpeas from dry. You could also make it in a slow cooker (just add the coconut milk very last before eating). It’s the perfect one-pot meal for busy families and I hope you love it as much as Walker and I did. Vienna did too — not weird farts, haha!

Curry Cauliflower Quinoa Stew

2015-11-24 18:10:40

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Ingredients

1. 2 tbsp coconut oil
2. 1 large onion, chopped
3. 2-3 tbsp curry powder*
4. 4 cups cauliflower, chopped into bite-size florets
5. 1 (796mL) can whole or diced tomatoes, do not drain
6. 2 cups water**
7. 3/4 cup quinoa
8. 1 can (400mL) garbanzo beans (chickpeas), drained
9. 1-2 small tomatoes, roughly chopped
10. 1 can (400mL) full fat canned coconut milk***
11. 1/2 cup chopped fresh parsley
12. Optional: 1 tsp dried chili flakes
13. Sea salt and pepper to taste

Instructions

1. Melt coconut oil in a large soup pot on medium and add onions. Sweat the onions and then add the curry powder, saute for 2 minutes.
2. Add the cauliflower, canned tomatoes, 2 cups of water and quinoa and bring to a soft boil then reduce to a simmer for 15 minutes until cauliflower starts to become tender and quinoa cooks.
3. Add sea salt and pepper to taste.
4. Add chickpeas and remove from heat. Let cool slightly before adding coconut milk to prevent it from curdling. Add chopped tomato (the heat of the stew will warm it). Add chopped parsley just before serving.
5. Serves 6 to 8.

Notes

1. *Choose the best quality spices for plenty of flavour. I use certified organic curry powder by Simply Organic.
2. **Once you put all the liquids in the pot (water and canned tomatoes) it will seem like a lot of liquid but it boils down and the quinoa soaks up a lot of water. The consistency should be that of a stew. If it’s too thick, add 1 more cup water as needed
3. ***I do recommend canned because you’ll get all the creamy fat which is FULL of flavour and nutrition that you won’t get in tetra-pack coconut milk

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We enjoyed this for dinner last night and I’m so glad I’ve got leftovers in the fridge right now because this means less cooking for us this week and more enjoying

Have a joyous day!

Joy McCarthy

Joy McCarthy is the vibrant Holistic Nutritionist behind Joyous Health. Author of JOYOUS HEALTH: Eat & Live Well without Dieting, professional speaker, nutrition expert on Global’s Morning Show, Faculty Member at Institute of Holistic Nutrition and co-creator of Eat Well Feel Well. Read more…

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Obamacare is failing? Not so fast.

By JOE FLOWER

What is the hue and cry about this time? United Healthcare is saying it has lost large bales and wads of money on Obamacare exchange plans, and just may give up on them entirely. Anthem and Aetna allow that they are not making very much either. Some new not-for-profit market entrants have gone belly up, and the others are having a hard time.

Before we perform the Last Rites over Obamacare, perhsp we should think for a moment about the hit ratio of the first 711 Wolf Reports from Boy W. Cried and ask a few questions.

First: Do we trust implicitly the numbers that the health plans are giving out in press releases, citing unacceptably high medical loss ratios? Medical loss ratios (MLRs) are self-reported. Yes, there is a certain amount of accountability. The numbers have to square with expenses given on their corporate tax forms and so on, but there is wiggle room in just what is reported and how. If is a reasonable supposition that if you wanted to look for the professionals with the greatest skill in juggling numbers, you would find them working for insurance companies, especially health plans, because the stakes are so high. These numbers people at the top of their game have huge incentives to report a high MLR, so if there is wiggle room, I am sure they will find it.

Beyond that, MLR is reported by state, by market segment (large group, small group, individual), against what portion of a premium is “earned” within that reporting period, and by calendar year rather than any company’s financial year. To say, “Our MLR is X” is to claim that X the correct aggregate number across their entire multi-state system, from all their subsidiaries, appropriately weighted for the size of each region. We don’t have access to those numbers, just to what they are telling us. There are plenty of reasons for them to want to report the highest MLR they can get away with, plenty of reasons to be skeptical of the numbers they are giving out, and plenty of reasons not to base drastic policy changes on such pronouncements.

But let’s get down to business here. So they lost money (or barely made it) in 2014 and 2015, and they are projecting the same in 2016? Doesn’t this mean that they misjudged the cost of healthcare, so they need to raise premiums? And they didn’t realize this soon enough to do raise them appropriately for the 2016 year?

Sounds like somebody (or a pile of somebodies) made faulty business judgments. This is not too surprising, given that these are new business models in new markets. Pricing, risk analysis, and utilization projections are hard enough in established markets, doubly difficult in emerging ones, and exponentially more difficult for a new company scrambling to grab any market share at all, like the failed cooperatives.

Well, waah. Welcome to competition, market capitalism, all that stuff. None of this is in the least surprising.

But does it mean that “Obamacare has failed”? Does it even mean that these companies have failed in Obamacare markets? No, it means what it is: These companies have failed to make the profits that they hoped for in the opening three years of Obamacare. And they are telling us all about their pain so that the government (through regulation) or the body politic (by repealing Obamacare) will make it easier for them to churn a profit.

So what’s the real problem here? In any kind of economy, you need to price your products so that (in aggregate, over time) your total cost of ownership is less than what you sell your products for. There’s your margin, the oxygen of your business. These folks are claiming that the aggregate total cost of ownership of what they are selling (access to healthcare) is close to what they are selling it for. Hmmm. That’s a problem. It has two paths out: Lower the total cost of ownership (get the actual costs of healthcare down) or raise the premium.

How about getting aggressive about the real cost of healthcare? Two problems with that part of the equation: 1) It’s really hard and takes years. 2) It does not benefit just them. It will benefit the whole market. So it’s not a path to greater profitability.

A health plan’s profit (margin) is some percentage of the total cost of care for the people they cover. So they have an incentive on the one hand to cover a lot of people (that is, increase their market share). They have an incentive to keep their premiums competitive not in absolute terms but relative to other payers in each regional market. On the other hand, they have no incentive to get aggressive about actually lowering the underlying real costs of healthcare for the whole market. That would not give them a competitive advantage.

What’s the business concern with raising their premiums appropriately? The concern is that these lower-cost narrow network exchange plans are price inelastic. If they raise their premiums, they will lose market share. But wait, if the cause really is the underlying high costs of healthcare, won’t everyone’s premiums have to go up the same amount? This complaint sounds more like an assumption that others can provision the market more efficiently, keep their premiums more competitive, and gobble up market share.

Again, is this a failure of the Obamacare model? Or is it actually proof of concept? To say that the Obamacare exchanges are failing because some companies might give up on them is to imagine that the purpose of Obamacare, the metric on which it should be measured, is to make health plans comfortable and profitable. Wrong.

The core idea of the Obamacare exchanges has been that health plans should compete on a level playing field to see who could offer the best service and the best access to healthcare at the lowest price. That’s what markets are for. The assumption built into this logic is that some organizations will do it better than others, some will not be good at it, and the market will shake out. If nobody ever failed in the Obamacare exchanges, then we would have to say that they failed to establish anything resembling a true market.

Joe Flower is a healthcare futurist and author. He is a contributing editor with THCB.

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A Radical Policy Proposal: Go Easy On Older Docs

By DIANE EVANS, MD

Through Dec. 15, federal regulators will accept public comments on the next set of rules that will shape the future of medicine in the transition to a super information highway for
Electronic Health Records (EHRs).  For health providers, this is a time to speak out.

One idea:  Why not suggest options to give leniency to older doctors struggling with the shift to technology late in their careers?

By the government’s own estimate,in a report on A 10-Year Vision to Achieve an Interoperable Health IT Infrastructure, a fully functioning EHR system, for the cross-sharing of health records among providers, will take until 2024 to materialize.The technology is simply a long way off.

Meanwhile, doctors are reporting data while the infrastructure for sharing it doesn’t exist.  Now, for the first time, physicians will be reporting to the federal government on progress toward uniform objectives for the meaningful use of electronic health records.  Those who meet requirements will be eligible for incentive payments from Medicare and Medicaid, while those who don’t may face penalties. In addition, audits are expected to begin in 2016.

Amid this shift to a new, data-driven healthcare system, the nation needs older doctors to keep practicing to meet presentneeds of an aging population, as well as an expanded Medicaid system. If burdensome reporting rules encourage retirements, as some studies indicate, the building of an information highway may result in the unintended consequence of a bottlenecked road to seeing a physician.  The likely result:  Nurse practitioners will deliver a greater share of the nation’s healthcare.

Some critics say the medical profession exaggerates a coming shortage of physicians.

Yet concierge medical practices are growing in number, luring those willing to pay a premium to see a doctor quickly for extended-time visits.

Last year, the New York Times reported on long wait times for doctor appointments as a new norm, and not just in traditionally under-served rural areas.  The article pointed to one study that found patients waiting an average of 66 days for a physical examination in Boston, and 32 days for a cardiologist appointment in Washington.

Think of what the wait times would be if mass retirements materialized, as suggested by findings of a 2014 survey of 20,000 physicians by The Physicians Foundation. Thirty-nine percent indicated plans to accelerate retirement due to changes in the healthcare system.Others reported plans to cut back on patient caseload or seek different jobs.

The potential for disruption is even more startling when you consider the number of older doctors in practice.  According to R. Jan Gurley, a physician writing on the  blog of the University of Southern California’s Center for Health Journalism, one in three doctors is over 50, and one in four is over 60 – despite roughly 20,000 newly medical school graduates a year.

Because of what’s at stake — potentially the very underpinnings of our nation’s healthcare system — health providers should speak out forcefully during the government’s open comment period.  Yes, it is late in the rulemaking game for EHRs.But new rules are being written for 2018 and beyond, and modifications are being made to rules in effect through 2017.

Would an outpouring of thoughtful, well-documented recommendations make a difference?  In a democracy, the answer should be yes.  The value of keeping older doctors in practice far outweighs the benefit of driving them crazy as they try to meet reporting requirements with often-clumsy EHR technology.  The challenge is to find a middle ground.

Diane Evans is a former Akron Beacon Journal editorial writer and columnist, and now publisher of the recently introduced MyHIPAA Guide, a news and information service for HIPAA-covered organizations trying to stay up with the seismic shift to a data-driven electronic health system. MyHIPAAGuide.com is hosting a forums discussion that is open to all who would like to share insights on key points that should be conveyed to CMS and government regulators. 

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