GlassHospital

Demystifying Medicine One Week at a Time

Category: media (page 1 of 9)

Health is More than Health Care

When we think about achieving good health, it’s natural to think of visits to the doctor for “checkups” and age-appropriate interventions like vaccinations or cancer screening.

But here’s something you might not know: The “health care system” as we know it, an American industry on which we collectively spend $3 trillion annually, only accounts for one-fifth of our overall health.

Twenty percent? How can so much spending impact so relatively little of our well-being?

 

Well, it turns out other factors collectively have a much greater impact:

 

Genetics: To whom we are born impacts our health profoundly. If our parents are blessed with long, healthy lives, then we are much more likely to be, too.

 

Education: The better our education, individually and collectively, the more we can achieve in life. Education is tied to income (something we all know), but it also correlates directly to health outcomes in aggregate. Cutting investments in common and higher education is sabotaging our children’s future — not just in earning potential, but in real health: more suffering and earlier death.

 

Employment: The ability to earn a living wage means that people can be financially solvent and participate in the consumer economy. Given a choice, almost no one would choose handouts. People want meaningful work — work that employs our skills and engages our minds.

 

A diverse economy that grows new businesses means more job opportunities that not only pay the bills but allow us to invest in our families, homes, and communities.

 

Environment: It’s well known that those residing in certain Tulsa ZIP codes have life spans on average 11 years less than those in more affluent parts of the city (This difference has actually lessened from 14 years over the last decade.) Mayor G.T. Bynum has made reducing this disparity one of his administration’s central goals, as celebrated in a recent editorial in this newspaper.

 

We also know that when our neighborhoods are safer, we increase the likelihood that we will move our bodies more — which along with nutrition is the single greatest predictor of good health.

 

And of course: Nutrition! Access to healthy food and safe water is something that most of us take for granted. But many areas north, east and west of downtown Tulsa are literal food deserts — places with greater than two-mile gaps between locations where fresh fruits and vegetables can be purchased. And our Tulsa public transportation options barely ease this burden.

 

Nutrition and exercise are the two health determinants over which we have the most direct individual control. (How are you doing with those New Year’s resolutions so far?)

 

We can’t choose our parents, or therefore our genetics. But collectively, if we are in agreement that we want Tulsa to be a place of improving health, we do have a lot of say in how we manage our neighborhoods, our food supplies and our educational attainment.

 

At the University of Oklahoma-University of Tulsa School of Community Medicine the curriculum emphasizes study and advocacy of these so-called social determinants of health — beyond the “traditional” organ-based pathologies. We believe that interdisciplinary understanding of these factors — which can lead to exorbitant stress — will help to reduce the burden of ill health in our population as we age.

 

Tulsa has an opportunity to become a “Blue Zones” city like Shawnee and Fort Worth, Texas, recent cities that have contracted with Healthways to make structural changes to spur better health. The Blue Zones idea comes from the discovery of the five places in the world where citizens live the healthiest and longest lives because of exercise (walking most places), nutrition (more plant-based diets), and social connectedness.

 

We have the ingredients here in Tulsa to take on such a challenge, and working through the updated Community Health Improvement Plan that will soon be released by the Tulsa Health Department, we can all choose to live healthier lives — both individually and as a community.

 

Amazingly, we can do all of this regardless of our need to interact with our “health care system.”

 

Note: This essay appeared as an op-ed in today’s Tulsa World

Medical Revolution(s)?

9780465050642This week an essay in the New England Journal of Medicine asks if our collective learning to handle uncertainty should be ‘the next medical revolution.’ It caught my eye because many of the medical educators I follow on social networks were abuzz about it.

Coincidentally, I’m reading a fuller-length exploration of medical uncertainty, a book called “Snowball in a Blizzard,” by Steven Hatch, an infectious diseases doc at UMass.

Both the essay and the book remind us to have humility: though medical technology and scientific knowledge have leapt ahead and continue to hurtle forward, our profession’s abilities to diagnose, treat, or predict future health outcomes with precision remain stubbornly elusive.

The metaphor of the ‘snowball in a blizzard’ comes from the world of radiology–in particular mammograms. That’s what radiologists who read mammograms are looking for on the images they see. It’s challenging and inexact work. Often they miss tumors that are cancerous; to correct for this, it’s natural that radiologists need to be extra cautious and have women with anything even remotely suspicious follow up for more images and possibly biopsies. [With negative biopsies, such mammograms become known as ‘false positives.’]

I agree with the thesis that we should all become more comfortable with uncertainty. But it will be challenging.

As patients, we want our doctors and scientists to be able to give us predictions that are accurate.

  • Is this the right diagnosis?
  • Will this treatment work?
  • How long have I got?

As doctors, we wish we had greater ability to answer these questions.

As ‘consumers,’ we are fed an unending stream of media that tell us what we ‘should’ do, what we ‘need’ to be healthy, and what will make us live longer. Much of it never offers the necessary caveats about the inexactness of the science. This will be an uphill battle.

I was pleased to see a chapter in Hatch’s book devoted to health media, featuring Gary Schwitzer and his website HealthNewsReview.org. Gary has devoted his latter career to debunking medical hype. His site is well worth perusing.

The Evolution of Hospitals

I-love-Lucy-assembly-line-300x223Once upon a time, a hospital was a place you went if you were sick. Doctors would (ideally) figure out what was wrong, offer treatment, and you would convalesce.

The longer you stayed in a hospital, the more the hospital could charge you (your insurance, really — if you had it).

This all changed in 1983, with the advent of the DRG system (it stands for Diagnosis-Related Group). Almost overnight, the incentives for hospitals changed. With DRG payment, the hospital would get one ‘bundled’ payment for the whole hospitalization based on the patient’s diagnosis. Average length of stay for hospitalized patients went from thirty days (imagine: a month(!) in a hospital). Hospital executives saw the need to minimize length of stay — depending on the payment for each diagnosis, there would be an inflection point when a patient staying beyond a certain number of days would result in financial loss.

‘Throughput’ became the term of art. (Like widgets on an assembly line.)

Now the average time someone spends in a hospital is a little more than four days. (Of course, for mothers with normal births, this is even less — about 2 days. Many surgeries that used to necessitate several days in the hospital are now done on an outpatient basis. Length of stay in those situations: zero.)

A recent essay on this topic in the New York Times by Dr. Abigail Zuger brought back memories for me. I once had a teacher tell me, “No one should ever need to be in a hospital. Except for some cardiac conditions that require immediate care, the only people winding up in hospitals are frail elders, and those with social problems and no place to go — the mentally ill, the destitute, the homeless.” I remember feeling a bit shocked by this, but as I reflected on it, I realized he had a point. I should start with the assumption, he told me, “that almost no one really needs to be there and they’re better off at home.”

The modern condition leads us to keep people in hospitals for as short a duration as possible. But something is clearly lost. As Dr. Zuger writes:

Hospitals were where you stayed when you were too sick to survive at home; now you go home anyway, cobbling together your own nursing services from friends, relatives and drop-in professionals.

Patients often go home feeling brutalized by all the blood draws, hospital food, and lack of sleep. Rare is the patient who says, “I feel better now — can I go home?” Often we send them home before they feel ready.

It sounds a bit cruel, and like there’s a perverse incentive at play. But keeping people in the hospital is also inherently risky. Hospitalization can cause infections, loss of muscle and coordination (especially in older folks), falls, and delirium. So getting people out as quickly as possible is in many ways the right thing to do.

The truth, however, probably lies somewhere in the middle.

e-Patient Dave

406px-Dave_deBronkart-20091229Last week I had the good fortune to meet Dave deBronkart, a man known throughout the world by the simple moniker “e-Patient Dave.”

Dave’s story is widely known: diagnosed with metastatic kidney cancer at age 56 in 2007, he was given a prognosis of six months to live. By scouring the internet and crowdsourcing ideas for newer therapies (and their pitfalls), Dave tried an at-the-time-experimental therapy (with an efficacy of 20% back then) called IL-2.

Happily, it worked. Next year Dave will reach his tenth anniversary of being cancer free.

The world is a much better place with Dave in it. Taking the full measure of his experiences in health care, Dave has become one of the leading voices of participatory medicine — the (not-so) revolutionary idea that patients should be directly involved in their own health care.

He is now a sought after public speaker, thinker, advocate, and collaborator.

He gave a TED talk in 2011 that you can view at the bottom of this post. Last year, I shared a blog post he wrote about his wife Ginny’s amazing experience undergoing quadricep-sparing bilateral knee replacements from orthopedic surgeon Howard Luks.

One thing I always thought was that the term ‘e-patient’ referred to ‘electronic,’ as in ’email.’ In fact, Danny Sands, who has long been Dave’s primary care doctor, is one of medicine’s earliest adopters of using email to correspond with his patients. He also was instrumental in setting ground rules for its use (e.g. never use email in an emergency).

But as I found out in preparing to meet with Dave, the “e” in ‘e-patient’ actually stands for

  • EMPOWERED
  • ENGAGED
  • EQUIPPED
  • ENABLED

Dave and the e-patient movement, united behind such advocacy groups as the Society for Participatory Medicine (S4PM) seek to use the collective power of engaged clinicians and patients to find the best available help at the time it’s needed.  From the S4PM website:

Participatory Medicine is a model of cooperative health care that seeks to achieve active involvement by patients, professionals, caregivers, and others across the continuum of care on all issues related to an individual’s health. Participatory medicine is an ethical approach to care that also holds promise to improve outcomes, reduce medical errors, increase patient satisfaction and improve the cost of care.

There’s no doubt that there are people in my profession who still cling to the ideal of the doctor being the repository of information, who view the patient as more of a passive ‘customer.’

For some patients, too, this is still a comfortable model. And that’s OK, if that’s what you want. But there’s a whole world of engaged docs and patients out there that want to interact in many of the new ways: via email, through social media, using patient portals (special protected systems that allow you to reach your health care team or look at results), even video chats (telemedicine, anyone?).

I learned some of Dave’s interesting backstory: He graduated from MIT, calling his time there ‘vocational school.’ That’s because his best takeaway skill was typesetting — he was trained to typeset the school newspaper. Throughout the 70s an 80s Dave held a number of jobs in the field, where he found one of his best skills was being a translator: explaining engineering-speak to the sales people, and explaining the needs of sales people to the engineers.

I spent more than two hours with Dave — including an interview in a library followed by a lunch. The man is a tour de force. I look forward to continuing our dialogue.

Column Laurel

Good news dept:

2016-Column-Contest-560x469Dear loyal GlassHospital readers–

GlassHospital was recently recognized by the National Society of Newspaper Columnists as a finalist for columnist of the year in the Online, Blog, and Multimedia Category with >100,000 readers. This is for work published on the world’s best health care site, NPR’s Shots blog [to which I attribute such high readership — you loyalists on this site are in much more select company].

I was awarded third place, behind a Reuters columnist who works to bring broader understanding of Islam to a large general readership, and a columnist from The Street who writes frequently to expose scams and complicated investment schemes that over-promise and under-deliver. Given all that’s going on in the news cycles of late, I think this makes perfect cosmic sense.

I do my best to share NPR work on this site to attract you over there, but if you’re interested in the columns for which I won the award, links to them are below.

  1. From August 2015 — Suicide: not a natural cause of death
  2. From April 2015 — How should we educate 21st century doctors?
  3. From September 2015 — For older folks, pruning back prescriptions can bring better health

Thanks for reading!

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