The Letter of Recommendation: A Two Way Legal Instrument

Letters of recommendation (LORs) are a common part of the job application. Employers rely on them to help choose new hires. Many physicians have written reference letters for their peers and trainees. It is important to appreciate that LOR is a legal instrument that holds not only the applicant accountable but also the writer. It is a signed document that is retained in the employee’s files and its origin can be traced.

I will describe the case of a physician group which was successfully sued for writing an inaccurate reference letter for a former colleague. Litigation involving inaccurate and misleading references in the broader employment arena will be discussed to highlight the nature of liability in LORs.

Background

An anesthesiology group was successfully sued for providing misleading information about a former colleague in a reference letter. Two separate cases reached the Fifth Circuit Court of Appeals involving the group. In neither case was the verdict of the Appellate court in favor of the group.

Kaldec Medical Center v. Lakeview Anesthesia Associates

The case revolved around an anesthesiologist with a drug problem. He worked at Lakeview Anesthesia Associates (LAA). LAA served Lakeview Medical Hospital (LM). LM conducted an internal investigation after staff became suspicious of the anesthesiologist’s drug abuse.

LM discussed the findings with LAA. The anesthesiologist failed to improve, despite a warning.  On one occasion, the anesthesiologist did not answer his pager on call and was in an impaired state in the call room. LAA dismissed the anesthesiologist for cause stating “you have reported to work in an impaired physical, mental, and emotional state. Your impaired condition has prevented you from properly performing your duties and puts our patients at significant risk . . . .”

LM and LAA did not report the anesthesiologist to any disciplinary agency such as the state board of medical examiners or the National Practitioner’s Data Bank. LM locked away the files concerning his investigation. The LAA partners recorded only that the anesthesiologist was “no longer employed by [the group].”

The anesthesiologist applied for a locum tenens in another state. The new hospital, Kaldec Medical Center (KMC), requested references for credentialing. LAA submitted letters with effusive praise such as “excellent” clinician and “asset to any anesthesia service”. LM furnished a letter, indifferent in tone, stating only the dates he was on active medical staff. Neither LAA nor the LM disclosed his drug abuse.

The anesthesiologist was credentialed at KMC. Soon suspicion about substance abuse emerged. On one occasion a patient had to be revived with Narcan after he gave excess morphine during a surgery.

In the relevant suit, he was anesthetizing a 31-year-old mother for a tubal ligation. She had agreed to tubal ligation following an uneventful delivery of her third child. During the procedure, the patient had a cardiopulmonary arrest. The anesthesiologist failed to note the arrest. The patient suffered anoxic brain injury leading to a permanent vegetative state. The anesthesiologist confessed to abusing Demerol and entered a drug rehabilitation program. The patient’s family sued the anesthesiologist and KMC. They settled out of court.

KMC and its insurer filed against LAA and LM. KMC sought damages for failing to disclose the anesthesiologist’s drug use in the reference letters. Since the lawsuit crossed state boundaries it was taken up by the Federal District Court in Louisiana.

KMC claimed that it was misled by the LAA/LM into hiring the anesthesiologist, the defendants had a duty to inform truthfully and they breached that duty through omission and misrepresentation, and reasonably relying on inaccurate information led to KMC’s damages. 

The court agreed and found the defendants proportionately liable for the damages, and divided the damages ($8.5 million) as such: LAA 25%; LM 25%; KMC 17%; anesthesiologist 33%.

The case was appealed in the Federal Fifth Circuit Court. The circuit court reaffirmed most of the district court’s decision. The court reasoned that there may have been an ethical obligation but no fiduciary or contractual duty to disclose information about the physician’s past negligent behavior. The court admitted that no court in or outside of the state had ever imposed this duty on an employer.

However, and this is a crucial point, the court stated that in an absence of duty when an employer volunteers to disclose information about an employee, it assumes a duty to disclose accurately. In other words, writing the letter was a choice that LAA and LM made, and by doing so had assumed a duty not to misrepresent.

The court found affirmative and negligent misrepresentations in the letters from LAA. The court remarked that their letters were “false on their face and misleading”. Regarding the issue of legal cause, the court found that any negligence by a new employer does not absolve the former negligent parties, namely the LAA and LM, from liability.

The court noted that since the anesthesiologist had used narcotics while on duty, it was foreseeable to LM and partners that he could do so again. By omitting his drug abuse in their communication with KMC the defendants should have foreseen that the employer may “miss the warning signs” of the anesthesiologist’s behavior which was dangerous to patients. The federal circuit court upheld the federal district court’s ruling on KMC, LAA and the anesthesiologist.

The Federal Fifth Circuit Court absolved LM from liability. The court concluded that LM’s letter was a contrast to the letters from LAA, which commented on his performance. LM had revealed nothing about the anesthesiologist’s performance or character, good or bad, and was not misleading. The court cleared LM and readjusted the liability between KMC, partners at LAA and the anesthesiologist.

Preau v. St. Paul Fire & Marine Insurance Company.

In a related case, the Federal Fifth Circuit Court ruled that a physician’s professional insurance was not responsible for liability arising from letters of recommendation.  One of the LAA partners filed a suit against his insurer in the federal district court for refusing to cover the damages. The partner argued that the insurance should cover him against bodily injuries incurred by the patient who had died in KMC. The insurer refused, citing that commercial general liability policies protecting a physician from direct bodily injury do not cover third party claims resulting from misrepresentations from reference letters.

The district court sided with the partner. The Federal Fifth Circuit Court disagreed and overturned the district court’s verdict. The circuit court stated that the financial claim against the partner was not for the deceased patient’s bodily injuries but for the breach of duty to be truthful in references that it owed to KMC. The LAA partner had to pay the damages out of his pocket.

Duty to disclose accurately versus duty to disclose

Liability from inaccurate reference letters is not new and several state and federal court cases have examined it before.

In Cohen v. Wales, Moore v. St. Joseph Nursing Home, Inc., Richland School District v. Mabton School District, and Johnson v. United Parcel Service, courts have maintained that there is no duty to disclose someone’s character or performance in the absence of a special relationship between the parties. However, there is a duty to not to misrepresent if one elects to write, as seen in Randi v. Muroc Joint Unified School District, Gutzan v. Altair Airlines, Davis v. Board of County Commissioners of Dona Ana County, Govea v. City of Norcross, and Singer v. Beach Trading Co. Additionally, as seen in Nationwide Mut. Ins. Co. v. Lake Caroline, Inc., commercial general liability policies may not cover damages as the result of intentional falsification.

In Cohen, a teacher’s former employer was not liable for failing to disclose past charges of sexual misconducts, leading to hiring at a new school where the teacher abused another student. In absolving the former employer from liability, the court remarked that “[the] mere recommendation of a person for potential employment is not a proper basis for asserting a claim of negligence where another party is responsible for the actual hiring.”

Similarly, in Moore, the representative of a murdered security guard who was killed by a co-worker sued the assailant’s previous employer for not disclosing his drug and alcohol abuse and history of violence. The former employer was open that it provided no information other than the dates of employment. The Michigan Court of Appeals agreed and ruled that the employer had no duty to disclose or warn the new employer of an employee’s dangerous tendencies.

In Richland, a school district fired its employee, a custodian, after learning that the employee was forced to resign from his previous job in return for dismissal of three counts of child abuse. The school district then sued the previous employer for not disclosing the charges in the recommendation letter.  The school district argued that the employer violated a duty to disclose, especially for a job where children were involved. The case went into appeals. The Washington Court of Appeals sided with the former employer and ruled that there was no duty to disclose so long as the letter did not comment about the employee’s character.

In Johnson, the Kentucky Court of Appeals ruled that a duty to disclose a person’s performance or character does not exist. In Johnson, the estate of a deceased employee who was killed by a co-worker brought suit against the assailant’s former employer for failure to disclose his aggressive behavior.

Misrepresentations can hold an employer to liability, as ruled by the California Supreme Court in 1997 in Randi. In Randi, an employer failed to disclose the vice principal’s alleged sexual misconduct, mentioning only the positive aspects of the vice principal’s tenure. He was hired at a new school where he allegedly molested a female student. The previous employer was found negligent.

In Gutzan, the Federal Third Circuit Court of Appeals held that false statements could hold the writer liable. In Gutzan, an employment agency falsely mitigated a candidate’s criminal record.

Specifically it said that the candidate’s assertion that an accusation of sexual misconduct was a false accusation was verified, when there was no verification. Because of the reassurance, Altair Airlines hired him, where he sexually assaulted a colleague. The agency was found liable for misrepresentation.

In Davis, a jail wrote positively about a guard even though he had sexually assaulted female prisoners. The guard was hired at a hospital where he sexually abused a patient. The New Mexico Court of Appeals ruled that in choosing to write, the writer had a duty to not misrepresent.

In Govea, a police officer voluntarily resigned after an internal investigation found negligent behavior on duty. The officer had left a loaded firearm in an unattended motor vehicle. In return for voluntary resignation, the employer agreed to not disclose his negligence. In a new job, the officer gave a minor his gun to play with and the minor shot and killed himself. When the officer’s past events came to light, the new employer sued his previous employer for failure to disclose his carelessness. The case was decided by Georgia Circuit Court of Appeals, which ruled that by failing to disclose accurately the employer was liable.

In Singer, the employer submitted incorrect information about an employee’s job title. Specifically, the employer said that she had worked as a customer service representative, instead of her actual role of a manager, as she had written on her resume. Because of the discrepancy the new employer dismissed her. The employee sued the former employer for defamation and the New Jersey Supreme Court held that providing false information to an employer in a reference letter held the former employer liable for damages that resulted from reasonably relying on the information.

In Nationwide, the Fifth Circuit upheld that an organization covered for bodily injury and property damage was not covered for “injury arising out of oral or written publication of material, if done by or at the discretion of the insured with knowledge of its falsity.”  The case involved an organization that was covered by Nationwide’s Commercial General Liability Coverage. The organization had a contract dispute. When sued, the organization sought protection under the insurance. Nationwide refused on the grounds that liability from making intentionally false statements, the basis of the contract dispute, is not protected by insurance, an argument that the circuit court upheld upon appeal.

The cases underscore four points: (1) one is not required to write about someone’s character or performance, (2) if one elects to write, they have a duty not to misrepresent competence or character that could affect performance, (3) failing in that duty could hold one personally responsible for damages, and (4) damages due to misrepresentation may not be covered by general liability policies.

Implication for Physicians

How should physicians write a letter of recommendation in lieu of its legal significance? The answer will vary between individuals and organizations; and many have developed their own rules and guidelines. There are three questions to ask: what is a legal instrument? When is there a duty to disclose in the legal instrument? And what constitutes as breach of that duty?

A legal instrument is a formally- executed written document that can be attributed to its author, which records and expresses a legally enforceable act, process, or contractual duty, obligation, or right and therefore evidences that act, process or agreement. Courts have maintained that LORs are legal instruments, opening its authors to liability for misrepresentation.

The duty to disclose is complicated. A mandated duty to disclose exists only in “special circumstances such as a fiduciary or confidential relationship between the parties, which, under the circumstances, justifies the imposition of the duty.” The courts have not imposed a duty on individuals to write LOR.  By ruling that LORs are legal instruments, the courts have imposed a duty that the letter’s content be truthful.

What constitutes a breach of duty? Under Louisiana law, the elements for intentional misrepresentation are:  (1) misrepresentation of a material fact, (2) made with intention to deceive, and (3) causing justifiable reliance with resultant injury.  The elements for negligent misrepresentation are: (1) existence of a duty to supply correct information, (2) breach of that duty by omission or affirmative misrepresentation, and (3) breach causing damages to plaintiff based on reasonable reliance on the misrepresentation. Additionally, where there is silence, misrepresentation arises when there is a mandated duty to disclose the information.

In summary, while writing the LOR is not a duty, if a person chooses to write, he or she must not misrepresent.

Conclusion

The case is extreme. The reference letter was opposite the character of the anesthesiologist. The partners of LAA praised a colleague they had fired for abusing anesthetic medication. The disconnection between the LOR and reality was wilful. The lessons are taut and reinforce the adage “if you do not have something positive to write about a person do not agree to write the LOR”.

Reference letters may become bland and contain non-exculpatory statements which offer no information about a physician’s competence, work ethic or citizenry. This is fine if physicians also wrote letters which were full of praise, and if there was a correlation between the blandness of a letter and incompetence of the physician. New hiring departments could read between the lines and the value of a letter of reference to discern would be retained. Silence may serve as a red flag. The author who is reluctant to disclose in writing could discuss a physician’s competence over the phone.

The most salient part of this case is that the liability was covered by neither the physician’s professional nor umbrella insurance policy. The extrapolation to minor transgressions of competence and professionalism should be resisted, though. There is a distinction between crime and gross professional misconduct in a physician (essential facts) and sub-optimal work ethic, undesirable temperament or citizenry (unpleasant facts). The key is not to misrepresent. Writers of letters of recommendations should follow the Golden Rule: write in the letter what they expect to read were they the employer.

Varon Sethi, MD is a radiologist at Penn.

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Coconut Flour Banana Spice Muffins

Walker and I had our first overnight trip without Vienna in Chicago earlier this week. Vienna has traveled with us on every trip so far, but this business trip would have been a little more difficult. Even though she was with my parents and I had absolutely nothing to worry about, I still missed her like crazy. So yeah, I was that mom texting with my mama most of the 36 hours we were gone. LOL! Side note: Vienna loves her grandma and grandpa so much, she didn’t mind one bit!

Now the reason for these muffins: The day we left, I whipped these up in the morning because Vienna loves them and so do I! I wanted her to have some healthy, yummy snacks and I wanted to bring some with us on the plane. I created these based on the deliciousness of my Pumpkin Chocolate Chip muffins. Once you’ve got the formula nailed for coconut flour, you can create anything! 

Whether you’re making these for yourself or for little ones, they are a wonderful addition to breakfast with a smoothie or an afternoon power snack. I make them “mini” size so they are perfect for little hands and then you have no food guilt (not that you should anyhow) when you eat three or four of them. 

Coconut Banana Spice Muffin-05935

Coconut flour is a super nutritious flour to use. I mean, check out some of these benefits:

  • It contains about 16 grams of protein per cup, making it higher in protein than many grain-based flours.
  • Coconut flour is incredibly high in fibre, with a whopping 40 grams of the stuff that helps keep your digestive system moving per cup!
  • Coconut flour, like other coconut products, contains medium-chain fatty acids that help support a healthy metabolism and balanced blood sugar levels.
  • Coconut flour is gluten-free!

Coconut Banana Spice Muffin-05915

As for what puts the “spice” into these flavourful mini muffins, I added cinnamon and nutmeg, but you could also add ground ginger too.

  • Cinnamon is packed with anti-inflammatory antioxidants! Cinnamon is ranked an impressive #7 on the ORAC scale that ranks the antioxidant levels in foods. Cinnamon’s anti-inflammatory properties are so strong that studies have shown that it can help relieve muscle soreness, PMS pains, severity of allergic reactions, and other age-related symptoms of pain.
  • Cinnamon is a natural anti-microbial, anti-biotic, anti-fungal, and anti-viral agent.
  • In the 17th century, spice wars between Indonesia, Portugal and the Netherlands nearly rendered the nutmeg tree extinct. Thank goodness it was able to recover!
  • The nutmeg fruit actually produces two different spices: mace is harvested from the outside of the fruit, while nutmeg comes from grinding up the kernel.
  • Nutmeg (and the mace that comes from the same plant) has some completely unique disease-preventing phytonutrients. Trimyristin and myristicin can help soothe certain parts of the nervous system while stimulating others, so nutmeg can spice your mood up as well as your food!

 Coconut Banana Spice Muffin-05924

Coconut flour Banana Spice Muffins
2016-09-25 16:28:10
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Ingredients
  1. 1/2 cup coconut flour
  2. 2 tsp baking powder
  3. 1 tsp ground cinnamon
  4. 1/4 tsp ground nutmeg
  5. 2/3 cup mashed bananas
  6. 1/4 cup maple syrup
  7. 1/2 cup coconut oil, melted
  8. 4 eggs, whisked
  9. 2 tsp vanilla extract
Instructions
  1. Combine all the dry ingredients in a large mixing bowl. In a separate bowl, whisk together the wet ingredients.
  2. Then add the wet to the dry ingredients.
  3. Place batter into muffin tin cups.
  4. Bake at 350 degrees F for 15-20 minutes or until a fork inserted into the middle of the muffin comes out clean.
  5. Makes 15-20 mini muffins. Or 12 if you make them larger.
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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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Fail to Scale: Why Great Ideas In Healthcare Don’t Thrive Everywhere

In the world of fine wine, it is well known that some types of wine grapes grow only in very specific climates and ecologies. The concept borrowed from the French is “terroir” (ter-WAHR). Terroir explains why the finest champagne grapes grow only in a small district in northeastern France, characterized by rolling hills and a chalky limestone subsoil that provides a steady level of moisture and imparts a mineral note to the wine’s flavor.

Health policy advocates have sought for generations to propagate promising forms of health care organization across the country. Yet one finds repeatedly that some forms of organization that prosper in one part of the country fail to thrive in others. Is it possible that the concept of terroir also applies in health care?

The Case Of Kaiser Permanente

Kaiser Permanente’s health plans would be a great example. Kaiser has been a darling of health policy advocates such as Alain Enthoven, Paul Ellwood, and others because of its integrated structure, global risk, and salaried employment model of physician practice. Yet, despite repeated federal interventions, beginning with the Health Maintenance Organization Act of 1973, Kaiser only recently exceeded 10 million in enrollment for the first time in its 71 year history. Moreover, 82 percent of that enrollment is in two states—Oregon and California—where Kaiser originated. The percentage of Kaiser’s enrollment that derives from its origin states is basically unchanged in a decade.

What was the “terroir” that enabled Kaiser to flourish in these states? Kaiser’s growth rested on a combination of the prevalence of large scale multispecialty group practice, a tradition of prepayment for health services (as opposed to indemnity insurance), and large unionized employers tied to trade, ship building, and defense contracting after World War II. As the unionized sector of employment was displaced by growth in other economic sectors, Kaiser’s substantial presence in large Pacific Coast markets (San Francisco, Sacramento, Portland, Los Angeles, and San Diego) lowered the cost of additional enrollment.

Kaiser has presences in other markets like Denver, Hawaii, and the District of Columbia that have grown modestly. But it never achieved West Coast levels of dominance in these markets, and ambitious attempts during the 1990s to become a “national” health insurer ended in costly failure.

Independent Practice Associations

Kaiser’s dominance in Pacific Coast markets encouraged the growth of another innovation — the risk-bearing Independent Practice Association (IPA). In order to defend their franchises against Kaiser’s steady growth, state medical societies in the 1970s encouraged their members to form rival IPA networks that preserved solo practice.

Private practicing physicians using these IPAs and insurgent payers like PacifiCare and HealthNet formed broad regional alliances during the 1980s. IPAs like Hill Physicians, Brown and Toland, and Monarch accepted delegated risk from these health plans through capitated contracts. These IPAs also developed management services organizations that supported small practices and facilitated billing and documentation for these managed care contracts, enabling them to compete for business with the vast Kaiser groups. Delegating risk to physician organized care systems helped some health insurers to keep pace with Kaiser’s growth, at least for a time. Absent the Kaiser threat, it is highly unlikely that these IPAs would have attracted enough physicians willing to support them.

One of the most successful of these risk-bearing physician enterprises, HealthCare Partners (HCP), spawned its own salaried multi-specialty group practice and grew to the point where it was acquired by DaVita in 2011 for $4.4 billion. Yet even with a very successful business model, HealthCare Partners has failed to thrive outside the Los Angeles basin. In Albuquerque, Las Vegas, Philadelphia, and Florida, HealthCare Partners has struggled to achieve either market influence or profitability. Visions of scaling up the HCP model to a national brand have thus far eluded DaVita, disappointing the company’s shareholders and challenging its management. DaVita is fighting a terroir problem.

Provider-Sponsored Health Insurance

Another example of a terroir effect can be found in provider-sponsored health insurance. There have been multiple waves of provider-sponsored health plan development since the early 1970s, characterized by a high failure rate. Adverse selection (e.g., enrolling a disproportionate number of their own patients, or people who are expected to become patients), a lack of capital, a failure to achieve a critical mass of enrollment, and in-house conflicts with hospital and physician subsidiaries have been the the main autopsy findings.

However, formidable provider-sponsored health plans survived the withering market entry process, including Presbyterian in Albuquerque, Select Health for InterMountain in Utah, Geisinger in Pennsylvania, Optima for Sentara in Virginia, and Priority Health for Spectrum in Western Michigan. Many of these plans and their dominant provider systems developed in more rural areas with limited health plan choices. Humana and PacifiCare were the only provider sponsored plans to reach public markets, but only after they were corporately separated from their sponsoring hospitals.

Nationally, about 15 million people were enrolled in provider-sponsored health insurance plans in 2015, two-thirds in managed Medicaid and Medicare Advantage segments. That translates into a total market penetration of about 5 percent of the total covered population (public and private), and about 3 percent of the commercial market.

Yet in Wisconsin, provider-sponsored health insurers today account for nearly 40 percent of the covered population. The very same conditions that fostered Kaiser’s growth played a role in Wisconsin — a long history of multi-specialty practice, plus a collectivist political tradition that inhibited protectionism on the part of solo practitioners, and a strong union-driven health benefits climate plus the factor of a significant rural population with limited health plan options.

Very Little About The Health System Is Actually National

Other candidates for terroir-type explanations of striking regional variation: the wide prevalence of industrial-scale Medicare fraud in certain sunbelt communities like southern California and south Florida, the inability of the investor-owned hospital sector to achieve a significant presence in the Midwest or Northeast, the incapacity of hospital managements and physician communities to work collaboratively in wide swathes of the sunbelt, the limited success of the accountable care organization (ACO) phenomenon in the Midwest or Far West, and the limited development of economic clusters in the life sciences such as are found in Cambridge, Massachusetts, Silicon Valley, and San Diego.

In our experience, there seems to be almost nothing except Medicare that is truly national about our health system. Fort Lauderdale, Florida, Hastings, Nebraska, and Seattle, Washington are actually in different countries culturally and politically. Those significant cultural and political differences have economic and historical roots, and uniquely color the traditions of medical practice and health care organization that prevail in those communities.

The existence of marked regional differences in health system organization and financing is not news to the health services research community. Starting in the 1990s, Paul Ginsburg and colleagues at the Center for Studying Health System Change documented the markedly different development paths taken by health care players in 12 urban markets.

Looking Beyond Economic Factors In Health System Change

For the past 40 years, American health policy has been dominated by economists. Their economic models presume universality in how physicians respond to incentives. These models captivate politicians and their handlers, and seem to come in waves, like memes in fashion or popular culture. Yet, over and over again, mechanistic, marginalist economic explanations of how incentives shape physician behavior play out unevenly in different regions of the country, and have resulted in a lengthening string of policy disappointments.

A failure to understand and respect the role that local culture and market conditions for health system innovation profoundly limits the effectiveness of “single bullet” policy solutions. After a while, veteran policy observers find ourselves saying (as we did with the ACO) “Wouldn’t it be great if, before mounting our trusty steeds and charging up the same box canyon, people would simply ask, ‘What happened the last three times we tried to do this?’ Why did innovations fail in some parts of the country and succeed in others? The checkered record of the CMS Innovation Center might be attributed in part to a failure to understand and respect the effects of terroir on health system innovation.

Perhaps a healthy respect for non-economic factors in health system behavior—often rooted in local and regional circumstances and in institutional culture—might be a corrective for those who see sweeping “national” solutions to complex problems. To paraphrase the famous line from the movie Cool Hand Luke “What we have here is failure to replicate.” Absent a respect for local and non-economic factors, we will continue the wasteful practice of sowing our policy seeds on barren ground.

Authors’ Note

Jeff Goldsmith is National Advisor to Navigant Healthcare. Lawton Burns is James Woo Kim professor at Wharton. Authors would like to acknowledge the assistance of Lauren Crowther of Navigant Healthcare in research for this article.

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How to Make a Better (and Healthier) Cup of Coffee

Well hello there! Walker here: husband, father and coffee lover and I wanted to wish you Happy National Coffee Day!

In the holistic health community, coffee doesn’t always get a lot of love. It’s a stimulant that can cause a whole host of undesirable effects, including digestive problems, elevated cortisol (stress hormone) levels, anxiety, and – when abused – can make other conditions far worse, such as adrenal fatigue.

On the other hand, research has shown that a cup of coffee can have positive health benefits, including lower rates of cardiovascular disease, liver disease and can even prevent cancer!

So who’s right? Both sides perhaps.

You see, coffee, like many other commodities, ranges drastically in quality, and I think quality may be the difference between a healthy cup and a not-so-healthy cup.

Note: When I say coffee, I’m referring to black coffee. Mocha-frappa-lattes and such do not apply.

coffeehopper

As an enthusiast who enjoys the drink but knew relatively little about it, I reached out to our good friend and coffee Czar Alan Smith of Rise Cafe to break down what makes a great cup.

Alan’s been in the coffee industry for 19 years and definitely knows his stuff. We sat down for a coffee and a quick chat. Here’s what I learned:

It all starts with the bean

Coffee starts as a cherry on a tree, which is grows naturally in bio-diverse, mountainous rainforest environments. In its natural environment, no pesticides or chemicals are needed to allow the tree to thrive – natures natural balance takes care of that.

How-to-pick-a-good-Coffee-Bean

Unfortunately, like most foods and produce, coffee has become industrialized and large producers have brought crops off the mountains to the valleys where they can yield a larger harvest. Here, the coffee plant is treated with chemicals, pesticides and herbicides to help it survive outside of its natural habitat.

Like many other industrialized agricultural practices, mono-cropping introduces a whole other set of problems.

So how do you know if you’re buying a quality bean? Look for these labels:

  1. Fair Trade: It means farmers are being paid a fair price for their product, which means they can afford to keep their land, and continue to harvest the best product possible on the best land.
  2. Organic: Ensures no chemicals or pesticides were used on the crop. Also beneficial for farmers because they aren’t exposed to toxic chemicals.
  3. Bird-Friendly: The gold standard In Alan’s opinion. Bird-friendly status is issued by the Smithsonian Migratory Bird Center and guarantees that not only is the coffee 100% organic, but that it was produced in a high-quality shaded, bio-diverse environment. Basically, it was grown the way coffee was meant to be grown.

Roast, grind, repeat

After the cherry is picked, it’s dried to a “green bean,” when it becomes extremely shelf stable (up to 10 years). After it’s dried, the green bean is roasted, which takes its stable fats and converts them into volatile oils that start to oxidize immediately. As of this point, the bean is on the clock.

Roasted-Coffee-vs-Green-Coffee

A roasted bean has a shelf life of seven days before it goes rancid. That bitter cup of black coffee you just had? That’s because all of the oils have fully oxidized and have gone bad.

The shelf life of a ground bean is even shorter: 24 hours to be exact.

Which brings us back to industrialized coffee: the big three producers (Sara Lee, Kraft and Nestle) roast, grind and package their products months in advance, which means if you buy coffee from the coffee aisle in the grocery store, you’re likely drinking a rancid, oxidized gross cup of coffee every morning.

And no, vacuum sealing or storing beans in a freezer does not help.

So how can you make sure you are getting a fresh cup?

  1. If you’re going to a cafe, make sure they’re freshly grinding the beans.
  2. Check the roast date. Reputable cafes will know when the beans were roasted, and if you’re buying coffee for home, a roasting date should be clearly stamped on the package.
  3. Roast your own beans. 450F for 15min will do the trick!
  4. Basically, stay away from grocery store brands.

So there you have it! I hope some of this info helps you in your pursuit for a better cup of joe. Much like anything else we eat, freshness and quality are absolutely key. Only then will we optimally benefit from the positive health effects of food, including coffee.

Thanks again to Alan for lending his expertise! If you’re in Toronto, check out his excellent cafe Rise Espresso Bar.

coffeesign

P.S. Here are some fun coffee facts!

  1. Ethiopia is the birthplace of coffee.
  2. Rumor has it, the stimulating effects of coffee were first observed when a farmer noticed his goats were full of beans (both literally and figuratively!) after eating the cherries from the coffee plant.
  3. Lloyd’s of London’s original business was insuring coffee and sugar shipments.

Do we have any other joyous coffee lovers out there? Let me know your favourite way to enjoy a cup or your favourite coffee shop (I’m always looking for good ones to check out) in the comments below!

Walker Jordan

Walker knows the ins and outs of running a successful business. The owner of a boutique health and wellness studio which he sold in 2011, Walker now oversees growth and strategy, runs day-to-day operations and manages new business for Joyous Health. He is the most organized person we know! He has a love of shiny fast cars and he can make Brussels sprouts taste like heaven.

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Peanut Butter vs Almond Butter

Back in my day (I feel old just saying that!), peanut butter sandwiches were the back-to-school food of choice. Walker still loves peanut butter and will put it on anything. But as delicious as it is, it is also the most problematic of nut butters (okay, technically, it’s a legume butter). There are so many severe and potentially life-threatening peanut allergies showing up these days that most schools have banned peanuts and peanut products outright.

But leaving aside the allergy issue, peanut butter has nutritional issues as well. Like many other kid-targeted foods, popular peanut butter brands are often full of added sugar (sometimes as much as a teaspoon of sugar per serving), as well as GMO soybean oils and modified and hydrogenated palm and vegetable oils (which is where we get trans fats from). Peanuts are also particularly susceptible to aflatoxin mold, a naturally occurring toxin that can cause liver damage and has carcinogenic effects. While the FDA monitors the levels of aflatoxin in American-grown peanuts, I’d prefer my nut butters to have as few toxic molds, thanks! While aflatoxin is occasionally found on almonds, because almonds are tree nuts, their levels of this particular mold are much lower!

I’ve been using almond butter in my recipes for a while now, and I find it makes a great peanut butter substitute, but peanut butter does have a lot of good nutritional points (if you buy the good stuff without all the sugar and other additives), so let’s see how my fave nut butter stacks up against the most popular nut butter.

Both peanut butter and almond butter have similar calorie counts, so we’re going to have to dig a little deeper to figure out which is most nutritious. Besides, I want you to . . .

JH_JoyousInspo_Count

Both nut butters are great sources of heart-healthy monounsaturated fats (as are all nuts), but almond butter has even more. Healthy fats are essential not only for heart health, but also for feeling full to prevent sugar cravings and for healthy skin and hair, so almond butter’s also a beauty food!

In terms of macronutrients, peanut butter has more protein, but almond butter has more fiber, so it’s basically a draw until we get to the micronutrients. While peanut butter has slightly more B vitamins and selenium, almond butter is richer in vitamin E, iron, calcium and magnesium. These nutrients are tougher to come by, and people are more likely to be deficient in iron or calcium than most B vitamins, so I think almond butter packs the more useful nutritional punch here.

Added bonus: because almonds aren’t susceptible to aflatoxin mold the way peanuts are, it’s way easier to grow them organically, making clean almond butter way easier to find!

Still unsure almond butter is better than peanut butter? Want me to draw you a chart? Consider it done!

Peanut_v_Almond_RevisedIG

Even if you’re the most careful label-reader in the world, the best way to make sure that your nut butter has nothing but the good stuff is to make it yourself. My Cinnamon Almond Butter is just that: almonds, cinnamon and a pinch of salt. Almonds are so flavourful on their own that you really don’t need anything else!

Cinammon Almond Butter-4

Almond butter is the perfect swap in pretty much any recipe where you would normally use peanut butter, but one of my favourite ways to use almond butter is to pair it with chocolate! Check out my Chocolate Almond Butter Milkshake, my Strawberry Almond Butter Chocolate Cups, or my classic Gluten-free Chocolate Chip Almond Butter Cookies for some almond-spiration!

Strawberry Almond Butter Chocolate Cups

What healthier swaps have you made for favourite childhood foods? Share them with me in the comments below!

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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Building Better Metrics:  Focus on Patient Empowerment

flying cadeuciiGrowing up during the 1970’s and 80’s, the “Little House on the Prairie” television series was an iconic part of my childhood.  Doc Baker was the physician and veterinarian for all of Walnut Grove, in spite of limited resources.  Medical lessons were everywhere in the beloved television series:  Mary experiencing onset of blindness (most recently attributed to viral meningoencephalitis, likely from Measles), the death of Laura’s infant son by unknown cause, and Rose’s survival after smallpox infection.

When patients ask me how to start solid foods, how to get a baby to sleep through the night, or how to treat minor injuries or burns, I frequently wonder if they would have asked the town doctor these same questions one hundred years ago.

Probably not, because they would know to watch their baby for hunger cues, let infants cry it out at night, or slap some egg white, aloe, or honey on their wounds or burns to prevent infection back then.  Empowering patients to treat themselves where appropriate has tremendous value to cut down on cost and consumption of precious resources.  It was also how medicine was practiced more than a century ago.

The other night I was reading comments of a local mom group on social media, when a question came up about how to treat thrush while breastfeeding.  A patient’s mother commented they should use gentian violet; paint their own nipples and their infants’ mouth lightly as well.  A mom asked, “What is gentian violet?” This mother discussed its antibacterial and antifungal properties and its topical use for oral candidiasis.  I felt a huge sense of pride watching her share knowledge with other mothers.  The cost of a 1oz. bottle of gentian violet is currently $3.69.

Crystal violet (aka gentian violet) was first developed in 1883 by Alfred Kern; it is still listed today by the World Health Organization as a valuable topical antiseptic agent.  Gentian violet has antibacterial, antifungal, anthelminthic, and antitrypanosomal properties. Today, it is used for:  Marking the skin for surgery preparation, treating Candida albicans and related infections, such as thrush, yeast infections, tinea, jock itch, ringworm, and even Impetigo, primarily before the advent of antibiotics. Educating mothers on thrush and the use of gentian violet occasionally helps them avoid seeking care when unnecessary.

Patient-centered care is often talked about as a virtue worthwhile to attain because it puts them at the heart of their healthcare team.  Empowerment goes one step further by actually giving power and authority to the patient.  It is a very important concept that is often missed in the world of big-box medicine today.  There is actually an organization devoted to this concept called the European Network on Patient Empowerment (ENOPE.)  According to them, an empowered, activated patient:

  • Understands their health condition and its effect on their body.
  • Feels able to participate in decision-making with their healthcare professionals
  • Feels able to make informed choices about treatment.
  • Understands the need to make necessary changes to their lifestyle for managing their condition.
  • Is able to challenge and ask questions of the healthcare professionals providing their care.
  • Takes responsibility for their health and actively seeks care only when necessary
  • Actively seeks out, evaluates and makes use of information.

Empowering patients to care for themselves with shared decision making is the reason my doors are still open.  Fee-for-service can be a fiscally valuable model because for one office visit, a patient can receive diagnosis, treatment, and education from a single professional.  Physician ownership encourages patient empowerment because it prevents doctors from spinning their wheels needlessly.  There is no benefit to seeing a patient over and over for the same chief complaint. We want our schedule open for other patients who need our help.  To avoid the journey overwhelming burnout, we need to lighten the load in our offices.

Over the last century, health care has morphed from a system valuing individual responsibility to one grounded in physician dependency.  Patients are viewed as clients who ravenously consume scarce resources, while physicians dispense answers and guidance for a price deemed too high by bureaucrats to be sustainable.  Knowing how invested patients are in understanding their conditions and their willingness to take responsibility for their good or bad choices are metrics worth tracking. It is important to remember physicians make recommendations, educate their patients, and would do best by engaging in shared decision making with those patients.  That entire process saves money and improves how patients view their quality of care.

A 3 year old girl came in with a history of 3 days of vomiting this week.  “I have been pushing oral rehydration solution with a syringe like you taught me,” she said.  Her mother knew how to check for signs of dehydration using urination frequency and a few other tricks I have taught over the years.  She knew when vomiting persisted in spite of proper rehydration attempts, it was time to bring her daughter in for evaluation. Her child had lost less than 0.5kg due to her mother’s excellent care and diligence.  I could not have been more proud and shared that with her.  At this point, it was reasonable to prescribe her a medication to reduce nausea and vomiting, but no ER visit was necessary because this mother had confidence in her skills to care for her child properly, and if she needed her PCP, she knew I would be there.

Better metrics must be about being better able to empower our patients.  They are tired of being told how to birth their children, how to immunize them, how to lose weight, quit smoking, or exercise more, and how to treat their elevated blood pressure and cholesterol numbers.  I am not suggesting we stop sharing our expertise and making recommendations based on good science.  However, patients want to make their own informed choices and we need to let them.  Doc Baker had it right.  Take another look at his practice model in “Little House on the Prairie.”  A system incentivizing self-reliance is far more sustainable in the future and is where we should strive to be.

Nina Al-Agba is a pediatrician in Washington State.

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Advancing Health IT and Preventing Data Blocking through Model Contract Language

As we move to transform the health care system into one that delivers more coordinated care across various clinicians and providers, it is important that data is available to providers and patients when and where they need it. To achieve this goal of ensuring the flow of health data and, ultimately, better care, the country has invested in the technology and infrastructure to connect patients’ clinical experiences.

That is why CMS and ONC are working together to make sure this investment stays on the right track. We are simplifying regulations, taking steps to require open technology, and have released a Health IT Playbook to help clinicians assess their needs and navigate the electronic health record (EHR) market. In addition, today we are releasing an EHR contracting guide  – EHR Contracts Untangled: Selecting Wisely, Negotiating Terms, and Understanding the Fine Print – that will help clinicians and hospitals make sure that contract terms do not inhibit the utility of their EHR technologies. Quite simply, our health care system cannot realize the promise of EHRs if information cannot flow across practices – and to and from patients – easily and in a cost-efficient manner.

The growing maturity of the health information technology market presents health care providers with new, varied, complex, and often confusing choices about EHR systems. From the small practice manager exploring new cloud-based EHR products and services, to the CIO contemplating a major EHR procurement, making the right choice for a practice – and advancing interoperability – hinges on having reliable, easy-to-understand information. But we have heard from providers in the field, professional associations, and other observers that such information can be hard to find. Moreover, EHR contracts can be confusing and may result in data blocking and other practices that limit opportunities to use EHRs to deliver safer and more efficient care.

We have discussed data blocking in the past – the practice of knowingly and unreasonably interfering with the exchange or use of electronic health information. One way that blocking occurs and prevents data from moving to follow the needs of the patient doesn’t involve the technology itself, but the business practices that can prevent interoperability. This subtle form of data blocking can occur through language and terms found in contracts for EHRs and other health information technologies.

The new EHR contracting guide is a key resource that will help providers address data blocking and other challenges as they continue to adopt and leverage health IT to improve the way they deliver care. In today’s EHR marketplace, many vendors use “standard form” contracts when offering their products and services. Providers all too often agree to these contracts – which are prepared from the vendor’s perspective – without fully understanding the “fine print” or without negotiating rights and obligations that can ensure that the technology will meet their needs and expectations.

The new guide will equip providers (and their advisors) to ask the right questions when selecting an EHR and better communicate their requirements to potential vendors, all while managing the expectations of both vendors and providers and providing a framework for negotiating reasonable contract terms that reflect best practice contracting principles. The recommendations found in the guide also promote connectivity and protect against data being blocked – such as by unanticipated connection fees, restrictions on data exchange, or contract terms that prevent users from reporting and sharing information about the performance of their EHRs. The guide offers specific strategies to help providers as they plan for the purchase of an EHR system and negotiate key terms with their EHR vendors. In short, this guide helps hospitals and doctors cut through the clutter, and assists them in implementing a new EHR system in a way that supports their workflow and their patients.

Some topic area highlights from the guide include:

  • the critical planning steps that all providers should take to properly understand and communicate their requirements to potential EHR vendors;
  • contracting practices and negotiation strategies that providers can use to achieve fairer and more balanced EHR contracts;
  • legal rights and obligations that providers may wish to include in their EHR contracts – as well as those they may wish to avoid; and
  • practical pointers and example contract terms that illustrate how providers might implement more favorable terms in their EHR contract.

A carefully negotiated EHR contract that incorporates the approaches recommended in the guide will help maximize a health care provider’s opportunity to avoid problems when implementing and using their EHR, and will help create a more informed and balanced relationship between the health care provider and their EHR vendor. We also hope the guide will help health care providers and their health IT vendors negotiate contracts that allow the technology to connect the clinical experience among all providers and settings in a way that supports both practices and patients.

The guide, along with the Health IT Playbook, not only helps to support the interoperable flow of health information, but the Administration’s efforts to foster a cost efficient health care system. Ensuring patient data is available to clinicians – and patients – when and where it is needed can improve coordination among providers, prevent duplicative appointments or diagnostic tests, and decrease costs to patients and the overall health care system.

Andy Slavitt is Acting Administrator for the Centers for Medicare and Medicaid. Lindell Washington is National Coordinator for Health IT.

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