Friday, April 29, 2016

Is uterus transplantation ethical?

I am not a woman. I cannot contemplate the physical and emotional experience of carrying a pregnancy and birthing a child. I imagine that it is a singular experience that is as deep and awesome today as it has always been. We have all seen the explosion in reproductive technology with in vitro fertilization, surrogate mothers, fertility agents and other emerging techniques. This process, beyond the high costs, can create anguish for those who are on this journey.

I have felt in many instances that the ethical ramifications of some of these techniques are minimized or dismissed. Sadly, we often do stuff because we can, not because we should. Do we really think we can stop human cloning?

Recently, a woman in Cleveland had a cadaver uterus placed during an extremely demanding 9 hour operation on February 24, 2016. This was the first time this was performed in the United States. Only a handful of these operations have been performed worldwide. This woman, who has adopted children, was born without a uterus and yearned to carry a pregnancy. As this operation was part of a clinical trial, I assume that it was paid for out of grant funds. Shortly after surgery, a complication developed and the uterus was urgently removed.

Uterine transplants are not a 1-day affair. To prepare, the recipient's eggs are harvested and then embryos are created and frozen. Then, the complex process of finding a donor is triggered. The donor organ is harvested and must be transported to the recipient. Then, the all-day transplant surgery occurs. The patient is then kept on anti-rejection drugs. A year later, the embryos are implanted. Deliveries are performed by Caesarean sections. After the desired number of pregnancies, the uterus is removed so that the anti-rejection drugs can be withdrawn.

The cost of all this is unfathomable, assuming that no complications occur that would require additional care. It is certainly possible that a woman could go through the entire process and not carry a baby to term. Indeed, very few successful pregnancies have occurred worldwide.

I request that readers contemplate the following concerns regarding uterine transplant.
• Can society justify this massive cost for a procedure that is not necessary to save a life or cure a disease?
• Is it ethical to risk a healthy patient's life with highly complex surgery even if she consents to it?
• Is it ethical to maintain anti-rejection drugs, which have risks of severe complications, for years to preserve the transplanted uterus?
• Is there a right to pregnancy that the medical profession is obligated to satisfy regardless of the financial, emotional, and ethical costs?

If this technique gets perfected, then it might become possible to implant a uterus in a man. Then, perhaps, I will have the opportunity to experience the profound wonder that has eluded my gender since the beginning of time.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Monday, April 25, 2016

Patient-centered service

American health care has a customer service problem. No, customer service in the U.S. is terrible when it comes to healthcare. No, the customer service in the U.S. health care system is horrendous. No, health care has the worst customer service of any industry in the U.S.

There. That seems about right.

What makes me utter such a bold statement? Experience. I regularly hear the following from people when they come to my practice:
• “You are the first doctor who has listened to me.”
• “This office makes me feel comfortable.”
• “I didn't have to wait!”
• “Where's all the paperwork?”
• “Your office staff is so helpful. They really care about my needs.”
• “This is the first time I've been happy to come to the doctor.”
• “It's amazing to have a doctor who cares about how much things cost.”
• “You explain things to me.”
• “You actually return my calls.”

Each of these things is said as a sincere compliment, with a degree of wonder in their voices. People simply are not used to getting any customer service. By these compliments, I must assume that the majority of people's experience with a physician's practice is:
• They do not feel listened to by their doctor.
• Doctors' offices are uncomfortable.
• Visits usually involve long waits and extensive (and pointless) paperwork.
• Office staffs are usually unhelpful and don't act like they care about people's needs.
• People are never happy to go to the doctor's office.
• Doctors seldom pay attention to the cost of the care they give.
• “Care” from doctors is often poorly explained, and so patients often leave confused.
• Attempts at communication are seldom fruitful.

Add to this the ridiculous wait times, the unreasonable and confusing cost of care, and the plunging morale that people routinely face in medical practices, and you get a frightening picture of a system supposedly dedicated to helping people. What other industry has such a damning set of “normals.” Airlines? Cable TV companies? DMV offices? I have to confess, this makes my job much easier; it's a very low bar to cross. Basically, people are amazed that I don't totally suck. That makes me glad for me and my patients. That makes me really sad for most people.

The obvious question that arises from this is, how did the service that people expect to receive from their doctors get to be so terrible? Shouldn't professionals who dedicate their lives to helping others, even saving lives, be even remotely concerned about the way these people are treated?

As always, the answer lies more in the system itself than in the people working in that system. The simple truth is that in our system the patient is not the customer; the third-party payor is the customer. The product sold at hospitals and doctors' offices is not health care, it is CPT and ICD codes, for which they are paid proportionate to the number and severity of those codes. The patients, instead of being the customer, are the raw materials from which codes are extracted. This means that the best business practice for healthcare providers is to extract as many codes from the most patients in the shortest time possible. So the system rewards the exact things people don't want from their doctors.

You get what you pay for.

There is one piece of evidence that convinces me that the system is the corrupting force that wrecks customer service: me. I spent 18 years in that system and have now been outside of it for the past 3. Since working in a system where I am paid directly by my patients:
• I am always thinking about improving the experience my patients have in my office because they can always leave me.
• I am constantly trying to save them money. Part of this is to justify their “extra” payment to me, but much of it is simply because it is what they want. Making them happy keeps them coming back.
• I have centered my practice around communication and access because that is what my patients (my customers) value the most.
• My office is clean and comfortable. We routinely offer people coffee or tea. I often talk to patients in my office (they sit on a comfy couch), not in the exam room.
• I make it a point to explain things to people so they are comfortable and confident in the care I give. I tell people, “if I can't explain why you need to take any medication, don't take it.”
• I put a priority on getting to know new patients to understand their priorities.
• People almost never have to wait in my office (except when they come early).
• We always tell people the cost of what we are doing and of the medications we are prescribing. When people can't afford medications, we do whatever we can to bring the cost down. One of my nurses dedicates many hours to getting free medications from drug companies for low-income patients.

I do these things for 1 simple reason: my patients are my customers. The more customers I have, the better income my business gets. My patients won't stay my patients for long if my service gets anywhere near the norm for doctors' offices. There is a bonus, of course: it's the nice thing to do. My business model makes being nice an asset, not a liability.

I've read rants by doctors who rail against the idea of patients being customers. If the patient is the customer, they argue, then aren't we obligated to give them antibiotics or pain medications when they ask for them? Doesn't this obligate us to follow the oft-quoted maxim, the customer is always right? This, of course, is total horse hockey (for both regular business and healthcare). Good service is simply good business. But more than that, good service as a physician has a much bigger effect. This is what I've seen over the past 3 years:
1. Treating my patients with courtesy and respect make it far more likely that they will show the same to me. They seem to like me more.
2. That respect (and affection) makes it more likely they will listen to what I say.
3. This means that compliance with medications and other treatments is far higher than it ever was. I am able to hold off on antibiotics and handle pain medications much better.
4. People don't avoid coming to see me, and so I can catch problems earlier. This has had life-saving consequences on several occasions.
5. When I show respect for people's time and money, they are much more trusting of me. People open up to me more about things they don't say to others. They believe I really care, and my office doesn't contradict that fact.
6. Because I care about their lives, they have taken a much higher interest in my life. They encourage me to take days off, ask me about my family, and basically treat me as a person who they care about. Because they do. They value me because they believe I value them. This makes me much happier.
7. Good service also makes my staff much happier, as they are beloved by my patients and highly valued by me. This too improves the overall care people get in my office.

In short, good customer service makes being a good doctor much easier and much more enjoyable.

Of course, I've had people come to me hoping I'll be a Pez dispenser for Percocet or Zithromax. These folks are disappointed when I instead take the time to discuss the proper use of these medications. Some leave me. But many who have come with this intent in mind have been so surprised at being treated with caring and respect that they listen to what I say and continue in my practice.

The vast majority of people truly want a doctor they respect and actually like. This may come as a shock to many of my jaded colleagues who routinely face the ire of people stuck in waiting room purgatory, ignored or disbelieved by doctors, and treated as objects instead of people. They think that people are angry because they don't like doctors. They view the people on their schedule as, at best, the hungry masses they must placate and, at worst, as their adversaries they must conquer. Then they wonder why their patients are so unhappy?

The past 3 years has taught me otherwise. People want to like their doctors. We just haven't given them any reason to do so.
Friday, April 22, 2016

Do heartburn medicines cause dementia?

Proton pump inhibitors, or PPIs, are among the most common drugs prescribed in the United States. They are extremely safe and highly effective for gastroesophageal reflux disease (GERD). Are there potential side-effects? Of course. Look up the side effects of any of your medicines and you will soon need an anxiety medicine to relieve you of side-effect stress. The side-effect lists of even our safest medicines are daunting.

PPIs are associated with a growing list of potential serious side-effects, at least according to the lay press. A few clicks on your computer, and you will find that these medicines can cause pneumonia, Clostridium difficile colitis, malabsorption of nutrients, bone fractures and anemia. The latest report to emerge links these drugs with dementia. In the past 2 weeks, I've been questioned about this repeatedly by my patients. One stopped her medication from fear that her heartburn medicine might be incinerating her neurons.

While no drug, including PPIs, is entirely safe, I have never seen a serious PPI side-effect, having prescribed them to thousands of patients. I'll bet that your gastroenterologist and internist can boast a similar track record. Doesn't that experience mean something?

The lay press, in my view, often covers medical science carelessly and without context. The science underlying the above listed PPI side-effects is extremely thin. Yet, the headlines describing them can sound authoritative and persuasive. Remember the adage of local TV news, if it bleeds it leads? Same concept.

Which of these 2 headlines or sound bites would be more likely to appear?

Nexium, superb heartburn fighter, may have questionable effect on bones, although results preliminary.

Nexium leads to hip fractures!

The scientific studies that link PPIs to bone disease or dementia are not high quality research studies. These studies are done on large populations of individuals and do not demonstrate any actual causative effects of the medicines. When you read the word associated, as in Nexium is associated with cognitive decline, you can accurately interpret that statement to mean there is no proof that Nexium causes dementia. Association is a weak link which has results from a weak study.

For the same reason, favorable results from similar studies should be viewed with great skepticism. Next year we may read that Nexium is associated with a reversal of male pattern baldness and enhanced libido. (If this hypothetical were to truly occur, then I hope that I can time my stock purchase just prior to the announcement.)

So, if heartburn patients have forgotten their keys somewhere, there is no need to flush your heartburn medicines down the toilet. You are not losing your mind, just your keys. Remember, much of what we read and hear in the lay press is associated with ignorance.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Thursday, April 21, 2016

Paleo meat meets modern reality

The Oldways Common Ground conference I was privileged to co-chair with Walter Willett last November had no shortage of riveting moments, as the recent posting of conference videos reminds me. But one really stood out.

Boyd Eaton is arguably the founding father of our modern understanding of, and preoccupation with, the Paleolithic diet. He shares credit with a very short list of others, among them his frequent co-author, Mel Konner. But there is no question that Boyd is on that short list. You can be confident that whoever provides you guidance on the Paleo diet concept gets their guidance from someone who gets their guidance from the work of Prof. Eaton. His work is all but universally recognized as part of the bedrock of our understanding.

What stood out, then, was Prof. Eaton's call for people to eat less meat. Not none, necessarily, although that's an option; but considerably less.

Let's be clear, Prof. Eaton is in no way “anti” meat. He readily acknowledges his own taste for it. He feels that all humans share that taste, whether they choose to indulge it or not, or even acknowledge it. And, he argues, rightly, that we are constitutionally, adaptationally, physiologically omnivorous.

But after allowing for all that, Prof. Eaton says, in essence: too bad! There are two basic reasons for his position, one the lesser, one the greater.

The lesser issue is the nature of the meat in question. That mammoth is no longer a choice is a given. Is modern meat like the meat our Stone Age ancestors ate?

The work of Prof. Eaton and his colleagues provides a very clear answer: not much. I have noted before that people routinely wave the “Paleo” banner as an excuse for eating pastrami, and that's baloney. Prof. Eaton agrees. For the rather dramatic nutritional and compositional differences between the modern meat that prevails, and the meat our Stone Age ancestors are thought to have eaten, I refer you to Dr. Eaton's original papers.

Those trying to have their side of beef and eat it, too, often talk about narrowing the gap between modern meat, and the kind of meat we “should” all eat. Pure meat. Ethically raised, free to range, well fed, organic, and all that. The trouble, of course, is that there simply isn't enough free range on the surface of the planet to raise enough animals that way to feed 8 billion quasi-carnivores. Mass production conspires against all of the very methods the “as long as it's pure” crowd espouses.

So, if you advise everyone to eat meat, but then add provisos about the purity of the meat, only one of two things can ensue. Either everyone ignores you, in which case your advice was rather pointless. Or people listen, in which case the demand for meat you've now fostered decimates the production methods you claim to favor. The production methods that supplant them give us meat nothing like that of our Stone Age ancestors.

The greater reason is, quite simply, the global human population and its impact on the planet. The Stone Age was home to scattered, isolated bands of Homo sapiens. There are now ever closer to 8 billion of us. Prof. Eaton states quite categorically that 8 billion Homo sapiens cannot have a meat-centric diet without ravaging the Earth; period.

This by no means makes our Paleolithic adaptations irrelevant; they still help define who we are, and inform what we need. Prof. Eaton's papers present estimated intake ranges for many nutrients, which may provide guidance toward optimal levels by clarifying native levels.

Dr. Eaton commented to me that the Paleo model advocates a higher protein diet than do many nutritionists, especially for children and teenagers, at least until full height is attained. There is lively debate in this area, in part because what was optimal for a physically demanding, 4-decade life span may or may not be so for a generally less strenuous but far longer life. Either way, Dr. Eaton goes on to say that we should get our protein, at whatever level, predominantly from plant sources now. (He noted in addition that the very well planned meals at the Oldways conference proved to him how delicious a plant-based, high protein meal could be.)

All too often, discourse on diet devolves into ideology when it should be bound to epidemiology. All too often, we approach dietary proclivities with nearly religious fervor, and fail to separate church and plate. All too often, some label like “Paleo” ignites fierce passions, and our imaginations, and we follow both into fantasy land. This is a reality check, from a uniquely qualified authority.

The modern reality is that we aren't in the Stone Age anymore. We can certainly learn from our Paleolithic experience, but we cannot replicate it in the 21st century, among our billions, and Tweet about it. When one of the world's foremost authorities speaks out on the implications of that, everyone waving the Paleo banner should set down their smartphone for a moment, and pause to listen.

This column was reviewed and approved by Dr. Eaton before publication. Both Dr. Eaton and Dr. Melvin Konner are members of the Council of Directors of the True Health Initiative.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
Wednesday, April 20, 2016

The ethics of performance measurement

For years I have argued that performance measurement has significant potential for unintended consequences. But today, I read an article that crystallized my concerns in an important new light. The article is written about the ethics of studying work hours, “Leaping without Looking — Duty Hours, Autonomy, and the Risks of Research and Practice.” As I read the article, the implications of the ethical arguments stimulated my thoughts about performance measurement.

While I hope you will read the entire article, these lines have particular relevance here: “Bioethicist and legal scholar Michelle Meyer has described our ‘tendency to view a field experiment designed to study the effects of an existing or proposed practice as more morally suspicious than an immediate, universal implementation of an untested practice.’ She argues that people in power often rely on intuition in creating and implementing wide-reaching policies.”

Most physicians would argue that people in power (Centers for Medicare and Medicaid Services and insurance companies) have relied on intuition in creating and implementing performance measures. Please reread the above paragraph and consider seriously the problem here. Performance measures have had serious untoward consequences. Patients have suffered because of overly aggressive diabetes control, overly aggressive hypertension control and the 4 hour pneumonia rule. In the Britain's NHS P4P program care improved only slightly for targeted care but deteriorated for unmeasured parameters.

With respect to performance measurement, I have long argued that we need prospective randomized controlled trials prior to adopting any performance measure. Advocates will argue that we cannot afford the time or money needed to perform such studies. But if we accept a non-0 probability of adverse patient outcomes due to a performance measure, how can we ethically adopt such a measure?

Imposing a performance measure can have a similar impact as a new pharmaceutical agent. If we really believe the dictum primum non nocere then we have a moral obligation to object to the potential that a policy could induce negative patient outcomes.

We should not consider this concept as radical or only hypothetical, as we have clear examples of measurement impacting patient care, outcomes and even access to care. We could argue that performance measurement raises important concerns about professionalism, if indeed concern about our report cards changes how we provide patient centered care.

These ideas are important. I thank Dr. Rosenbaum for writing a brilliant piece that made me think. If only we could get “people in power” to think.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Friday, April 15, 2016

Transparency 2.0

I had the opportunity recently to speak about our practice of posting patient comments and survey scores on our physicians' web pages. The conference at which I presented was devoted to “transparency and innovation” and it became clear to me that making patient satisfaction scores public, while innovative today, will be universal pretty soon. The same forces that convinced us to go this far—rising consumerism among care-seekers, the ubiquity of ratings and information for other goods and services, and the evolution of payment models away from fee-for-service—will compel us to provide more and more information to patients and potential patients.

What might that look like? Here are a few possibilities.

Operational transparency. We provide information to patients about the care that others have experienced “in the exam room” with their physicians, but not about other things that matter to patients, like how easy it is to get an appointment, or how long the average wait in the office is, or how quickly we provide lab results. It is now not uncommon now to see highway billboards indicating average wait times in local emergency departments. I think we will soon be expected to provide similar information for our physician offices.

Price transparency. As more and more people face higher out of pocket costs because of high-deductible health plans and limited (or no) out of network benefits, consumer price-sensitivity will continue to rise. Obviously, acting on prices requires knowing the prices. Even if patients may be reluctant to “shop by price” I believe they will choose price certainty over price uncertainty, and providers will be pushed to provide more and better information about the actual costs that patients face.

Outcome transparency. There was a big splash recently when CMS and a bunch of private payers announced (another) effort to harmonize their quality measures in order to reduce the burden of collection and reporting on providers. Nearly all of those measures are about processes of care, rather than about how patients actually fare with the care they receive. That seems to me a little like continuing to work on perfecting the horse and buggy instead of acknowledging that patients want to drive a car. I agree with Porter and Lee, who (again) outlined the need to move to measuring outcomes of care, and especially those outcomes that matter most to patients, such as functional recovery or freedom from pain and disability.

I think that organizations that take the lead in providing information like this will win big. What do you think?

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.
Thursday, April 14, 2016

Truth about saturated fat

Folks, hold your horses; I know just what's going on here.

My friendly adherents (thank you; I love you, too) are here for another refreshing installment of “stuff I already knew was right and love to Tweet.” My detractors (back at ya’, bub) are here knowing in advance they will disagree with everything, in eager anticipation of throwing up all over this column and me (I always carry an umbrella) in social media.

So, for starters, let's establish this: the “I only consider information I already know to be true” mentality, in either direction, is far more toxic to us than even our most egregious forays into the realm of Frankenfood. If your brain is mired in such gunk, saturated fat is unlikely to hurt you further, although it certainly won't help.

Stated differently, the relentless pursuit of confirmation of the opinion you already own—be you reader or writer, seller or buyer—is not even in the same part of the animal kingdom as the pursuit of truth.

Believe it or not, there is a discernible truth about saturated fat, hard to perceive through the smoke of all the overcooked arguments though it may be. Let's give it a go.

We have known for a long time—many years—that all saturated fat is not created equal with regard to health effects. The details of a discussion encompassing, for instance, just stearic acid, lauric acid, palmitic acid, and myristic acid—to say nothing of caprylic, caproic, butyric, enanthic, and so on—could take many interesting pages. Suffice to say: some saturated fatty acids are quite convincingly established to be harmful, and others are not.

This is not a place to go into great detail about diverse sources of evidence, although I do spend considerable time in just such places. Here, it's appropriate to note that “convincingly established” refers not to one favored study, not the latest spate of hyperbolic headlines, and not someone's effort to sell the newest book of dietary revelation, but the weight of evidence. As someone who has contributed to and reviewed the literature in question, and written extensively about assessment of evidence, I find the weight of evidence most compelling when it in turn is a product of hybrid vigor. Specifically, we know what we know most reliably when mechanistic studies in cell culture and animal models align with biomarker studies in people, and when those in turn align with outcome studies of intervention trials in people, and when those in turn align with observational epidemiology at the level of whole populations.

Our knowledge of saturated fat is informed by just such evidence, spanning species, decades, methods, and populations.

Regarding mechanisms of effect, there is one especially salient refrain among those championing saturated fat for health: it tends to raise HDL levels. Yes, that is true. But does that actually validate the agenda of the “eat more meat, butter, and cheese” crowd? No, for 2 reasons.

First, the obvious 1. You can have low HDL but feel fine and never get heart disease; or have enviably high HDL, but have a massive MI. Which would you prefer?

The point is that none of us really cares about our blood levels of HDL, or any other moiety for that matter, other than as proxies for health outcomes that actually affect our lives. High HDL is desirable only if and when it signifies a lower risk of cardiovascular disease. That's what actually matters.

But doesn't a higher HDL reliably guarantee lower heart disease risk? Absolutely not, and for a reason that is all but intuitive with a simple analogy.

Consider, for instance, an argument that good urine output is an indicator of healthy kidneys, vitally important for control of blood volume and consequently, blood pressure (an established fact). Now, consider that a high intake of, let's say, pickles, increases urination. The obvious argument by the International Confederation of Pickle Pushers is: See! Good urine output is good for blood pressure, and pickles increase urine output, so pickles are good for blood pressure!

But don't sign up for the pickle-juice diet just yet. You see what's going on, right? The rather massive sodium load from pickles is actually prone to raise blood pressure, and blood volume, and the urine output is simply the body attempting to keep up, and compensate.

I don't know for sure if that applies to the effects of saturated fat on HDL, but I find no clear indications in the scientific literature that it does not. In other words, maybe a rise in HDL from saturated fat intake is a genuinely good thing, and attenuates the rather obvious harms of excess saturated fat intake from the usual sources. But we can't reliably reach that conclusion. Maybe HDL goes up because confronted with more saturated fat, the body NEEDS more HDL. Maybe “saturated fat raises HDL” actually translates to: saturated fat stresses the body, and the body does what it can to compensate.

That is conjecture at this point, but so is the contention that higher HDL automatically means that saturated fat is doing us “good.” The far more important issue is: what happens to heart disease risk?

That question has been answered, at least in the real world where most of our saturated fat does, indeed, come from variations on the theme of meat, butter, and cheese, and not from cacao beans and coconut.

Mechanistic studies suggest less inflammation and atherogenesis when saturated fat intake is reduced, and replaced by unsaturated fats. Intervention studies show similar benefits when a baseline diet with many liabilities, a high load of saturated fat among them, is replaced with either a Mediterranean diet high in unsaturated fats, or a diet low in total fats. Dramatic declines in cardiovascular disease at the population level over a span of decades, have been observed in North Karelia, Finland, where a reduction in saturated fat intake was among the priority interventions.

Also in the real world, the longest-lived, most vital populations on the planet vary widely in their intake of total fat, but none has a high intake of saturated fat. The idea that a diet high in saturated fat “could” be as good is a leap of faith. The call to “jump” is more often than not issued by those with something to sell you.

Another crucial, and often neglected matter—with regard to saturated fat specifically, and nutritional epidemiology in general—is the “instead of what?” question. We are, for example, hearing these days that “butter is back.” Instead of what?

Push on that issue, and you are told: instead of stick margarine. Well, that was tossed on the rubbish heap of bad ideas over 20 years ago! Or, maybe we are told: instead of the bagel. But who ever actually chooses between a bagel and butter? The bagel, a generally dubious idea in its own right, invites the butter.

What this really distills down to is the simplest of marketing ploys: use a sound bite to tell people what they want to hear, and then only acknowledge the subtleties of truth in the fine print. Is butter back relative to olive oil? Hell no! Is it back relative to apples?

While routinely ignored, or willfully neglected, this “instead of what?” question was the particular focus of a recent study in about 85,000 people. When members of this group reduced their intake of saturated fat over time, the health results varied directly with the replacements. When saturated fat calories are supplanted by trans-fat calories, things go from bad to worse. When they are replaced with refined starch or added sugar, things are equally bad both times. While some point to such data to say, “see, raising saturated fat intake does not raise heart disease rates!” they actually show: excesses of saturated fat and sugar seem to be almost exactly, comparably bad for us.

Notably, when saturated fat calories from the customary sources—bacon-cheeseburgers, Reuben sandwiches, and pepperoni pizza come to mind—are replaced with either unsaturated fat (from nuts, seeds, olives, avocado, and fish), or with calories from whole grains—rates of cardiovascular disease decline significantly.

The truth about saturated fat is not unsettled. What is unsettled is: Can we handle the truth?

Saturated fat need not be exonerated, let alone canonized, to make the case that excess sugar is bad for us, too. Our appetite for sound bites and hyperbolic promises, and our antipathy for the more measured character of reliable truth, does nothing to advance our health. It does encourage us to keep fixating on nutrients while neglecting foods; to argue over foods while neglecting overall dietary patterns; and to keep inventing new ways, and reinventing old ones, to eat badly.

Until we decide to change it, that, sadly, is the truth.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
Wednesday, April 13, 2016

Why most published research findings are false

In 2005 Dr. John Ioannidis, a Greek researcher who is best known for his critiques of the science of medicine, published a paper titled “Why Most Published Research Findings are False.” This was not from the point of view of a science denier—actually closer to the opposite. Ioannidis loves good science, but points out that the vast majority of scientific studies today are biased, often asking the wrong questions and making the wrong inferences. In the case of medicine, this often means that claims of the effectiveness of a treatment or diagnostic test are exaggerated and often just plain wrong. This stems partly from the fact that positive and exciting results lead to further funding for the researcher involved and that the sources of this funding are often entities such as drug companies that stand to benefit from a certain outcome.

Recently Dr. Ioannidis published a new article, much more accessible than the first, entitled “Evidence Based Medicine Has Been Hijacked: A Letter to Dr. David Sackett.” The first was very much based on math and statistics. He observed that most studies, when repeated, came up with different results. This was particularly true of studies with smaller numbers of subjects and ones where the effect sizes were small. Such studies were more likely to come out of fields in which there was money to be made out of a positive result and ones in which the field of study was particularly hot and therefore several groups were competing to get results.

The second and most recent article is a conversation with one of Ioannidis' most important mentors, a man named David Sackett who was possibly the first person to introduce the concept of evidence-based medicine. By this he meant combining understanding of science and research with clinical judgment and experience. This idea was inspiring to John Ioannidis and his relationship with David Sackett was profoundly influential in his career. David Sackett died in May of 2015. He was apparently not only a wonderful clinical teacher but a great and appreciative listener. Dr. Ioannidis has been explaining his hopes and frustrations to the David Sackett who remains very much alive in his mind, and in this article Dr. Ioannidis shares with his internal Dr. Sackett his frustration with what has become of evidence based medicine. It is a delightful article and well worth a read. In it he laments the growing body of crappy and biased research upon which much of our advice to patients is now built.

This article is important for all practicing physicians to read and yet, when I tried to find it, the journal in which it was published asked that I part with around $32 to see it. This felt a bit ironic. The article by the man who champions truth and transparency was guarded by trolls who wanted $32 a pop. But then it became free, and if you click on the link above, you will be able to read it. I'm not sure there is a moral to this part of the story, but I'm guessing that the irony was noted by Dr. Ioannidis who told the journal editors that they could do whatever they wanted with the rest of the content of their issues, but they could jolly well make his article available for free. Still, in addition to the bias present in medical studies, lack of free access to the original articles further dilutes any truth to be found in them. Any scientific study that is likely to be “click bait”--that is to say interesting enough to readers that they will click on a link to read more about it--is written up by a journalist who will strip it of any actual detail and spin it any way that will engender further clicking behaviors. I venture to say that the vast majority of learning about clinical research by practicing physicians is through articles written about articles. These are produced by companies such as Medpage Today whose entire mission is to make money through advertising based on the number of times we click on their headline news. Their articles on articles appear to us to be a vital service, though, because most research articles are not free to us in their entirety and keeping up on the breadth of medical knowledge by subscribing to a vast number of journals is neither efficient nor affordable.

These are fascinating things to think about. My present distilled words of wisdom are:
1. Read Ioannidis' article while it's still free, before the journal changes its mind.
2. Don't take what passes for science too terribly seriously, especially if the effect is small or it goes against common sense and what you know about human physiology.
3. Really don't base your practice off of news releases about articles you haven't read or thought about.
4. Agitate for free and open access to important scientific research so you can read it critically for yourself.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.
Tuesday, April 12, 2016

Do stuff

*details changed to protect anonymity (as always)

“Live while you got all your rhythm in your hips still, okay?”
—Mrs. Sanders

If you looked at Mrs. Sanders' life, you'd count it a success. Five children, all of whom were mostly healthy and all of whom grew up to be gainfully employed with families of their own. More grandbabies than the fingers on two hands could count. And a marriage that had lasted more than 50 years. Yes. If you looked at her life, you'd use those spiritual words spoke often by the Grady elders for lives like hers, “blessed and highly favored.” Descriptors for lives filled with the things that matter the most.

Her health was good. Beyond some degenerative arthritis in her knees and some very mildly elevated blood pressure, Mrs. Sanders had very few medical problems. She could do for herself and was even still driving. Again, the kind of thing we all envision when wishing upon stars for our futures as senior citizens.

Mr. Sanders had passed on a few years before. Not necessarily suddenly, but it wasn't drawn out either. Just enough time to get things in order and to allow people to get to him and love on him. His death was surrounded by family and the aftermath of it all was mostly okay since it fit into the natural order of the rhythm of life. And, yes, losing him broke Mrs. Sanders' heart. But honestly, it didn't seem to break her.

Nope.

So the point of telling you all of this is to say that this woman seemed to have a pretty peaceful life. It seemed to have followed the narrative that little girls act out with their Barbie dolls, you know? But every time I saw her, there was this sadness about her. Nothing overly somber or extraordinarily awful. Just this undercurrent of melancholia that cloaked the room whenever I was in her presence. And honestly I'd assumed it was all related to missing her husband. After all, they had been married for over fifty years. But truthfully, I'd known her before his passing and even before he'd gotten ill. And even then, I'd felt the same way.

“How are you?” I asked her toward the end of our visit.

“Am I?” Mrs. Sanders pointed at her chest to make sure she understood the question. I nodded. She released this weak chuckle and said, “I'm here.”

“Just here?”

“Well, naw. Ain't nothing wrong, if that's what you mean. Guess I ain't sure what you mean, Miss Manning.”

I pressed my lips together and kept my eyes on hers for a beat. In that split second, I reflected on the time last year that I'd screened her for depression with a series of questions. She caught on to what I was doing and interrupted me. “I ain't depressed or nothing like that if that's what you gettin’ at.” And after I completed those questions, it became pretty apparent to me that she wasn't.

But still. Each time I felt it. And even if it didn't mean there was some pathology there, I really wanted to understand it.

“You know what, Mrs. Sanders? Sometimes when I see you, you seem like. . .I don't know. . .kind of sad-like.” Sad-like? I cringed at my own language. I sighed. “I don't know. It's hard for me to put my finger on.”

Mrs. Sanders offered me a warm smile and then reached out to touch my hand. “I ‘preciate your concern. I'm okay, baby.”

“You sure?”

This time she squinted her eyes and smiled. The expression seemed to suggest I was naïve. I wasn't sure how to feel about that. Straightening up my spine, I trained my eyes on hers, making certain not to crack a smile in return. Her face became serious and pensive. Finally, she spoke.

“Miss Manning? How many kids you got?”

“Two.”

“And how long you been married?”

“Twelve years.”

“How old your kids is?”

“Ma’am? Oh. Nine and ten. Boys.”

She pursed her lips when I said that last part. “Wheeewwwweeeee. Boys is something. Something indeed. They keep you busy, too.” Mrs. Sanders shook her head and then paused. It looked like she was trying to decide what to say next. Or whether what she wanted to say was worth saying to me. She blinked her eyes slowly, glanced down at her pocket book and then back at me again. Mrs. Sanders leaned her head sideways and asked me this: “What you do for fun?”

She caught me off guard with that. “For fun?” I let out a nervous chuckle.

“Better yet, for you. For your own self.”

“Umm. Well. I … I actually do lots of stuff for myself. I mean. … I do a lot for my family, too. But I do stuff for myself.”

“Good,” Mrs. Sanders replied quickly. “Good.”

I waited. I could tell she had more to say.

“My life been good, you know? But honestly, Miss Manning? I spent my whole life doing for everybody but me. Like, we got married when I was young and started having babies. And I stayed home with them and was near my sisters so we all saw ‘bout each others' kids, too. And my kids grew up to make me real, real proud. They good people. They got to do a lot of good things and I'm glad. But I guess the more time go by the more I realize I ain't never get no chance at nothing.”

“Tell me what you mean by that.”

“I mean. . .I ‘on't know. Guess I jest mean I ain't never been able to choose something that I wanted to do just ‘cause. Just ‘cause it's what I wanted to do or where I wanted to go. Seem like every decision was connected to somebody else needs or wants. And now I find myself wishing I had done some more stuff for me. For me.”

Mrs. Sanders eyes glistened with tears. She swallowed hard and cleared her throat after saying that. Then she looked slightly embarrassed for disclosing those thoughts. Or perhaps ashamed of uttering them aloud. That said, I could tell she was serious. And honestly? There wasn't much I could say to any of that. This woman was nearly eighty and had thought about this long and hard. I certainly didn't want to trivialize it all with some Pollyanna statement, particularly one that came across canned and void of empathy.

“I'm sorry.” That's all I could think to say. And I said that because I was sorry. Not sorry in that way I was when her husband of fifty two years went on to glory. But sorry nonetheless.

I could see how things had ended up this way. I mean, like her, I'm a mom and a wife, too. And in my mind I've always noted that those mothers and wives set on the highest pedestals are the most selfless. What's also weird is that it's hard to even realize that something is being denied of you, you know? Because everything you hear and see tells you that your definition of joy gets revised the day you become a mother and/or a spouse. And that this is what you were made to do and that this idea alone should be enough.

Right?

So yeah. I got it. I got what she was saying. I did. “It's not too late, Mrs. Sanders,” I finally said. “Your health is good. There are definitely things you could still do.”

“I know,” Mrs. Sanders replied. “I know. And I don't want to seem like some ol’ charity case that stay sad. I'm not. I do some stuff. But, see, what I can't have back is doing it as a younger woman. With curves and in high heels and with young woman sass. Young enough for people hold the door for you because they think they got a chance to court you, not jest ‘cause they got enough home training to respect their elders.” She gently laughed at her wittiness. I did, too.

“I get it,” I finally said.

“Do stuff, Miss Manning. See ‘bout them men of yours. But do stuff for you, too. Live while you got all your rhythm in your hips still, okay? I tells my daughters that. I do. Wish somebody had’a told me the same.”

“Yes, ma’am,” I whispered. Then I stuck it on a post-it note in my head for later.

Last week, I went to Paris, France. Despite my 45 years on earth, I'd never been. A college sorority sister took a job there this summer and inboxed me on Facebook a few months back urging me to come for the Semi de Paris--that is, the Paris Half Marathon. She explained that it sells out pretty quickly and encouraged me to “just sign up” and figure out the logistics later.

And so I did. Register, that is.

But honestly? I never truly considered going. I mean, not really. Sure, I'd registered for the race, but still. Could I really see myself going all the way to Europe for a race? One that wasn't connected to my kids or work? That answer was a solid no. It wasn't because I don't have support. Harry loved the idea of me running strong through cobblestoned streets and past historic landmarks. Especially in Paris, a city to which I'd never been. And I did, too.

But.

I think I purchased that race number because I liked the idea of it more than anything else. Buying that registration would be affirmation that I really did consider going. Which, in a lot of ways, was nearly as significant to me.

Nearly.

A few weeks after I'd submitted my payment for the race, I was casually talking to my colleague-friend Ira S. With my feet kicked up on a chair in his office, I mentioned this opportunity to do this race in Paris and my friend living in France. He immediately began speaking as if there was no question about whether or not I planned to go. But Ira is different than me. He speaks other languages, has lived in other countries and is, in my mind, more worldly than me. Of course doing this would be a no brainer to him. But to me, it was simply a pie-in-the-sky notion. So I told him the truth. That there was no way I'd go thorough the hassle of getting all the way to Paris just for me to go and run some race. That is, one just for me and the experience.

Ira immediately began listing the litany of reasons that I should go. That life was for living and that if I tried as hard as I could and it didn't work out, that was one thing. But automatically counting myself out would be something I'd regret later. And you know? I inherently knew he was right.

Of course, I can't say that I never do anything. I've had some amazing experiences as an adult woman that called for an understanding and supportive spouse and some hands on deck from others. But nearly all of those things have been either local or stateside. Which means they could occur over a three day (or two and a half day) weekend. Nothing calling for a passport or acquaintance with another language. And I can't say that it was because of lack of opportunities. I think it was more lack of consideration, you know?

Yeah.

And so. I went. And from the moment those wheels went up and that plane rose into the heavens, I knew. I knew that it would be a pivotal experience and one that would enrich my life. And you know? It was amazing. Just. … yeah.

Another of our college sorority sisters routed a business trip from Barcelona through Paris to join us. And, in the end, we became three girls about town together. Feeling the pulse of the city, testing out our rudimentary French in cafes and on trains, window shopping and laughing so hard that we could hardly breathe. I'm so glad that I went.

So very glad.

For nearly the entire time, I thought of my family. But I also thought of me.

And you know what? I thought of Mrs. Sanders, too. I went a little harder, laughed a little louder, imagining myself as an octogenarian reflecting on this time. I sure did.

Look. I don't know all the answers. But what I do know is that my trip to Paris taught me that I really should push a bit outside of my pragmatic mom-work-wife life box some more. To put my own life experiences on the table for discussion. Especially the outlandish ones that require jumping through a bunch of hoops like this one did.

Yeah.

I hate that Mrs. Sanders has regrets. Because regrets suck. Even the little twinge-y ones that niggle at you when you know you should otherwise be happy with the hand you've been dealt. My guess is that Mrs. Sanders' narrative is one to which many women can relate. I feel honored that she trusted me with those feelings. I'm also grateful to Ira for helping me to picture myself as worthy of that experience in Paris.

When I see Mrs. Sanders again, I'll tell her of how she inspired me. And hopefully she can take solace in knowing that she helped another woman do at least one thing that she otherwise wouldn't have, and perhaps shielded her from some potential regret.

“Live while you got all your rhythm in your hips still, okay?”
—Mrs. Sanders, Grady elder.

Words to live by. And to live it up by, too.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.
Monday, April 11, 2016

Patient-centered care, part 1

Three (and a half) years ago, when I left my old practice, I was near burnout. I was exhausted, not because of the amount of time I was spending—it was actually about the same, if not less than I had worked before—but because of an ever-increasing gulf between me and my patients. I have always tried to give care that focused on the person with me in the exam room, but did so against a growing current constantly pushing me away from my patients, a current emanating from the system that was built to serve them.

My early adoption of computerized records (1997) was not because of my fondness for technology, but because I felt it was the quickest and most efficient way to organize and retrieve the information necessary for good care. I was obsessed with improving work-flow in the office, as any efficiency would buy me a little more time to focus on clinical care. As this obsession grew, the gulf between me and the other physicians in the practice, who didn't share my focus on patients, grew inextricably and irrevocably wide. The end result was a “divorce” from my partners. I was ushered out with a nice plaque, some cake, a buy-out check, and a firm “pat” on the back as I walked out the door.

Three years does a lot to crystallize one's view of the past and why things really happened. I didn't really understand the cause of the divorce while it was happening; how it could happen that within a very short time I went from a sure future as senior partner to an outsider. I went from architect of medical records and caretaker of my patients to having no access to those records of my care.

Now, as my journey has taken me and my old practice down very different roads, I see clearly the dividing point between us: patient-centerdness. Over the three years since opening my doors as a direct primary care doctor, my obsession with patient-centerdness has, if anything, grown. The same certainly cannot be said about my old practice, as it has followed the rest of the healthcare system's lemming march away from patients and toward the cliff of ICD-10, meaningful use, and whatever other requirements the payors demand.

Rather than dwelling on the malfunction of the system, however, I want to turn my eyes toward what most people don't see: what real patient-centered care could and should be. It's not that I am suddenly wiser than my colleagues in the sick-care system. Despite 18 years in practice, I was not able to see what true patient-centered care looked like until I left the system.

Why? What I've explained in the past bears repeating. A successful primary care business is fueled by 3 things: having as many sick patients as possible, doing as many procedures on those sick patients as possible, and spending as little time with each of them as possible. These 3 things are not only the antithesis of what my patients wanted, but they stand directly in the way of any attempt I made to center my focus on their needs. The only way to be a patient-centered doc in the current system in our country is to be lousy at the business of medicine. The soil on which my old self tried to grow good patient-centered care was clearly too hostile to produce anything that promoted health over sickness, reduced cost, or encouraged time spent with people. A good idea of what truly patient-centered care looks like simply cannot grow within of such a system. It dies under the intense heat of ICD, CPT, ACOs, and EMRs. I had to leave that world to understand that.

Now I am in an entirely different world. To catch those up who don't know, my current practice is entirely different than my old one. I don't accept any payments from insurance or other third-party payors. Patients pay a low monthly fee, between $30 and $60 per month with no copays for office visits. Other treatments, procedures, or diagnostic tests are given at the lowest possible cost.

I am now nearly up to 700 patients, and (despite having a doctor running the business) am seeing steady growth of the business in numbers and in the care we are able to give people. We are able to accomplish 4 things that the current system cannot touch:
1. My patients are much happier.
2. My nurses and I are much happier.
3. The care we give is much better.
4. We are saving the system (and our patients) a lot of money.

Nobody who comes to my practice would argue any of these points. The only downside at this point, and the reason this kind of practice has yet to catch on, is that my income is still about half of what I earned in my old practice. That needs to change for this model to truly disrupt our system, and if I want to retire before I am 80.

The lessons I have learned about patient-centered care are in the following areas:
• Patient-centered service
• Patient-centered communication
• Patient-centered medical care
• Patient-centered medical records
• Cost-conscious and responsible care

I've used up my words for this post (shocking as that may sound), so I'll go after each of these in upcoming articles. My goal is to give people a vision of what truly good care can look like. A number of years ago I came up with a pithy summary of the state of the health care system: People don't clamor for better care nearly enough because they don't know how bad the quality of their care is; and the reason they don't know how bad their care is in quality is because they don't know how good it could be.

I feel it is the responsibility of all folks innovating in healthcare to raise the expectations of people for whom the care the should be designed. To quote C.S. Lewis (out of context): ”[We are] like an ignorant child who wants to go on making mud pies in a slum because he cannot imagine what is meant by the offer of a holiday at the sea.” We need to expect more from our system, but the only way we can expect more is to see what the holiday at the sea would look like.
Friday, April 8, 2016

Are GMO foods safe?

The nutrition police are at it again. They demand that food products that use genetically modified organisms (GMOs) in their processing inform us of this on the product's label. They argue, not only that consumers have a right to know how their food is prepared, but also that manufacturers should be required to disclose when evil GMOs are utilized. (Keep in mind that most of the food that we consume includes GMOs, a fact likely unknown by most of us.)

This labeling demand from the nutritionistas is a little hard for me to swallow.

I don't want to hear about polling that demonstrates that most American favor mandatory labeling. I guess we cite poll results when they support our views and dismiss them when we don't. Donald Trump is ahead in every poll. See my point?

There is no scientific evidence that GMOs harm our health. Fear is not evidence. Political correctness is not evidence. Indeed, the Food and Drug Administration requires no GMO labeling as it has concluded that these foods are safe.

What's at stake here? Just a small trifle called freedom of speech. I don't think a person or a business should be forced to “speak” just because a vocal constituency demands it, in the absence of any pressing public need for this. Obviously, I support labeling that highlights specific known dangers of a product. If a food item, for example, contains peanuts, then this should appear on the label to protect individuals who have a peanut allergy.

Why should we stop with just GMO labeling? Why not force food companies to include on their labels what cleaning supplies the companies use so the public can be reassured that they are environmentally friendly? Should a coffee shop be mandated to label their coffee as made with tap water because the filtered-water crowd believes this to be toxic? Should vegetables be required to have labels that specify that this product is not organic?

If a consumer wants to know if their Pop Tarts are tainted with GMOs, then he should feel free to call the 1-800 number on the label to inquire.

What if everyone could be forced to label ourselves according to the whims of others? How about if the nutrition police had to wear the following label: CAUTION!

I MIGHT BE CONTAGIOUS!

I think this is totally reasonable and reasonable. Maybe this individual is harboring a serious communicable disease and is simply unaware that he is infected. Just because there isn't a shred of medical evidence behind this, doesn't mean we can't mandate a public warning. Absurd? Of course.

There's right to free speech. There's also a right to remain silent. You have no right to make me say what you want to hear.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Thursday, April 7, 2016

Public health and citizens, truly united

There are just 2 problems with the prevailing conception of “public health,” the public, and health. Neither means what we think it means.

For starters, there is no public. The public is an anonymous mass, a statistical conception, nameless, faceless, unknowable, and unlovable. I have made the case before that laboring under this crippling fiction, the potential good that all things “public health” might do is much forestalled. We talk, for instance, about the genuine potential to eliminate up to 80% of the total global burden of chronic disease—heart disease, cancer, stroke, diabetes, dementia—but somehow evoke a yawn, rather than shock, awe, and eager passion. We might fix this by putting faces on public health more reliably, demonstrating vividly the skin we all have in the game. That, however, is a topic for other columns.

Health is not what happens in hospitals. I am among the growing number of “health care” professionals who sing out at every opportunity that we do not have a “health care system,” we have a disease care system. My esteemed colleague and good friend, Dr. Richard Carmona, 17th Surgeon General of the United States, said the same, although he said “sick” rather than “disease” at a podium we shared last week.

This may seem a minor matter of terminology, but it is far graver than that, if not even terminal to the pursuit of better medical destinies. We invest fortunes in new ways to treat diseases that never need to happen, and by calling that “health care,” we foster the perception that it's the best we can do. As an Internist with 25 years of patient care in my rear view mirror, I proudly attest to the great prowess of modern medicine in diverse moments of acute need. But as a Preventive Medicine specialist, I append readily, and with great humility, that all the technology and drugs in the modern court of medicine can no more unscramble an egg than all the king's horses and all the king's men. We do much to treat disease, all but nothing to cultivate health at its origins. They are not the same.

This is relevant, because health, then, is more the stuff of culture than clinics. Health is cultivated, or corroded, in the places and ways we spend our days and weeks, hours, years, and lifetimes. It plays out in schools and worksites; supermarkets and churches; restaurants and shopping malls; on radio, television, and the Internet.

All of these are about health: economy; education; the environment; security, and thus the military; and even art, which feeds the human spirit that animates the human body.

This all becomes a bit clearer if we ever pause to ask: what is health for?

Health is not the prize. There is a lamentable tendency for discussions of health to take on moral overtones, the image of an admonishing finger taking shape in our conscience. But being healthy is not in the service of occupying the moral high ground. Being healthy is about having a better life. A better life is the prize. Healthy people have more fun.

Health is about more years in life, yes, but even more importantly, more life in years. You can't get that without education and opportunity; security and a nurturing environment; shelter; and the enrichment of the arts. Every policy and political decision reverberates its influence to health.

Those places around the world where people live the longest, most vital, and to all appearances best and “richest” lives do so by virtue not of supreme personal effort in spite of it all, but by virtue of a culture that leads to just such treasure.

So the public is us, and health is, really, a product of everything that affects us.

I am making that point now, in this season of simmering politics, as we all stand poised to wield or neglect the power democracy accords us. I am in good company.

There was a brilliant, in my opinion, column in the New York Times recently entitled The Conservative Case for Campaign Finance Reform. The author, whom I do not know, is a law professor, and obviously, a conservative.

I love that this well-crafted, citizen-centric essay is from a place in the political spectrum with which I am not associated. I am not shy about expressing my views, and admittedly, I do tend to lean left of center. But I follow the evidence where it leads, and refuse to be held hostage by the confines of any given political pigeonhole. I am not inevitably “liberal,” although when I am, I am proudly so. I am not afraid to be “conservative” when it seems the right answer.

That's the point. None of us should be held hostage by any such partisan designations. At the extreme, the constraints of such labels are like being obligated to choose one favored letter as the answer to every multiple choice question, no matter how obviously wrong. I am a “b” guy, so I must choose “b” even though “a” sure looks like the right choice this time … is nonsense we should all renounce. We might also consider that we are far more likely to learn something when attending closely to a well-articulated point of view we don't already own. I commend Professor Painter's fine column to my “liberal” readers accordingly.

In this season of roiling politics and abundant cause for discontent, we should advance our ideals. When a label reflects what we care about, fine. When what we care about is subordinated to the tyrannies of a label, something has gone badly awry.

Richard Painter and I agree; it's as simple as that. How silly it would be to overlook or discount that agreement because our divergent labels don't allow for it.

Public health is all about doing the best we can for actual people, not a statistical and anonymous horde that exists nowhere outside of actuarial tables. That doesn't always align with the greatest profits for some large corporation. In fact, it almost never does, because of the time horizons involved.

Politicians work in election cycles. Companies work in financial quarters. Companies may have a 1, 2, or even 5-year plan, even as they focus on the next quarterly statement, if not today's stock price. But they almost never have a 30-year plan, or, for that matter, a 100-year plan. And yes, companies spin off other companies that then go on to have their own 5-year plan and focus on quarterly statements.

But human beings spin off other human beings, with a good chance of living the better part of 100 years. Those human beings spin off more human beings. These divestments go by names we all know, worn by the very people we love most in the world: children, and grandchildren.

If you care deeply only about yourself, your own children, and your own grandchildren, you still have a time horizon of acute concern about 140 years longer than even the most far-sighted of companies.

Companies are not people. And the time horizon of almost everything that matters most to health is too long for companies to notice or care. They care a bit about productivity in the next quarter. But climate change? The slow toll of a culture pretending that multicolored marshmallows are a reasonable part of anyone's complete breakfast? The hypocrisy in marketing implying that copiously sugar-sweetened beverages are all about fun rather than trips to the endocrinologist in an age of epidemic obesity and type 2 diabetes among adults and children alike? The fact that cutting down rain forests will not only scar the lungs of the world, but inevitably crash us into the next, new, devastating pathogen? Somebody else's problem.

It doesn't take a Constitutional scholar to know that our founders, fiercely devoted to individual liberty, would be appalled at the concentration of power not only in huge corporations that behave nothing like individual citizens, but huge corporations that at times preferentially send jobs and money offshore, while sidestepping the taxes we citizens pay to help protect the rights we relish. Spin this any way you like, left, right, or center, the founders are turning in their graves.

For us, actual people, the timeline that matters runs cradle to grave. What matters most to us, the people, involves both the immediacy of our days, and also the legacy of our generations. We care a whole lot about the world our children and grandchildren will inherit from us. We citizens, loving parents and grandparents all, of whatever political stripe, are surely united in that.

Everything is public health, and political decisions all matter accordingly. Renouncing control over the flow of cash that controls those decisions is not just calamitous folly toxic to the spirit of democracy, it is a veritable cancer we let grow unchecked in the body politic.

So go the arguments from both poles of the political spectrum. Because we, the people, are truly united by the love of family and in our deep devotion to the common imperatives of our humanity. Because no corporation has ever had a child.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
Wednesday, April 6, 2016

Improving patient experience-within reason

My friend, Dr. Gurpreet Dhaliwal, has a most interesting opinion piece in the Wall Street Journal, “If Only Health Care Would Focus On This One Thing“.

In this post he suggests that we should not worry about multiple aims (the triple aim or the quadruple aim), but rather focus health care design and delivery from a patient perspective. He writes, “In health care, our keystone habit should be taking the patient's perspective. If we could develop the habit of always seeing health care from the perspective of the patient, we would have one guiding principle – not four – for the tough decisions and trade-offs that need to be made as we reform health care. How long should patients have to wait to make an appointment? It is worth investing in e-mail communication systems with patients? If the response is governed by balancing patient experience, quality measurements, costs considerations and worker satisfaction, the answer gets complicated. If instead we habitually ask, ‘What do I want when I'm a patient?’ the answer is clear.”

In general I agree with his major point, however, it does need a major caveat. We see too many patients who make unreasonable demands: overtesting demands or inappropriate medication demands. As professionals we have a responsibility of primum non nocere (First, do no harm). Opiate overprescribing is a great example. How many patients demand opiates, when their use has great danger.

I have written recently that we must strongly consider the patient's perspective on value in health care. However, we must temper our patient centeredness. When 1 patient's concerns impact our ability to help other patients, then we must make the choices.

So bravo to Dr. Dhaliwal, with these cautions.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Tuesday, April 5, 2016

Moving beyond the 0.05 P value


One of my common refrains in research conference and here is that the misuse of P values has negative public health consequences, a phenomenon I call “death by P value.” Of course my level of frustration with P values pales in comparison to what well-trained statisticians must feel. This week, the American Statistical Association Board of Directors led by Ronald Wasserstein released a Statement on Statistical Significance and P values which include six principles on the use and interpretation of P values. These are:
1. P values can indicate how incompatible the data are with a specified statistical model.
2. P values do not measure the probability that the studied hypothesis is true, or the probability that the data were produced by random chance alone.
3. Scientific conclusions and business or policy decisions should not be based only on whether a P passes a specific threshold.
4. Proper inference requires full reporting and transparency. A P value, or statistical significance, does not measure the size of an effect or the importance of a result.
5. By itself, a P value does not provide a good measure of evidence regarding a model or hypothesis.

In addition to the ASA statement I highly recommend the coverage in FiveThirtyEight and Retraction Watch's interview of Professor Wasserstein. We often talk about the post-antibiotic era but even more important for public health is that researchers and journals happily embrace the post P=0.05 era.

Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Monday, April 4, 2016

Our slow motion pandemic

“We keep fantasizing about what will be the next biothreat, the next pandemic. It's actually already here! We're going to save our grandparents with triple bypass, but they're going to die from pneumonia, because we will not have the right antibiotics to save them.”
—Dr. Joanne Liu, International President of MSF, on Here's the Thing.

The CDC released its latest edition of Vital Signs, which is dedicated to the problem of antibiotic resistance (AR) among health care-acquired infection (HAI). Using data from NHSN, CDC investigators estimate that the likelihood an HAI is caused by a targeted AR pathogen is 1 in 7 in acute care facilities, and 1 in 4 in long term acute care.

There's good news in the report—the figure below shows impressive progress in reducing central line associated blood stream infection rates, and to a lesser extent surgical site infections and Clostridium difficile. Catheter associated urinary tract infections, though, are a mixed bag (pun intended), and Mike's covered this ground before. For reasons that Eli Perencevich and our colleague Dan Livorsi outline here, it's a shame that CAUTI has become such a prevention focus. Ironically, an unhealthy focus on CAUTI can drive testing and treatment practices that can result in antibiotic overuse, worsening the AR epidemic.

The CDC has released the “AR Patient Safety Atlas”, a new web app with interactive data on HAIs caused by AR bacteria. I am about to post a more detailed item from Scott Fridkin about this exciting new development. Stay tuned!

Daniel J. Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Friday, April 1, 2016

Incentives and capabilities

The idea that we have to “change incentives” for physicians is all the rage. Oceans of ink are being spilled over the transition away from the traditional fee for service payment model to a menagerie of value-based ones. At the core of much of the discussion about how to make the transition is figuring out how risk-bearing organizations like large physician groups, health systems, accountable care organizations, and the like are going to provide appropriate incentives to the individual, front-line physicians who are providing the clinical care. It is not a trivial problem to solve.

The usual explanation of the challenge goes something like this: In the old days, when organizational success was defined by the number of “heads in beds” in hospitals or patient encounters in the clinic, it was pretty straightforward to “share” that success with physicians. The more patients they saw (or procedures they did) the better it was for everyone, and rewarding “productivity” floated everybody's boats. Under alternative payment models, the measures of success of the organization are different and more complex—generally combinations of quality measures, patient satisfaction, efficiency, etc.—and translating that into new physician payment models is not so easy. If you continue to reward productivity, then it may defeat organization efforts at efficiency; make the payment model too complex by including many different performance metrics, and physicians don't get invested in any of them; make the model too simple, and physicians will be insulated from the organizational goals.

Lost in all of the details of how to create the illusory “perfect” physician incentive program is the fact that incentives are only a part of picture. Combinations of carrots and sticks only work where the capability to respond exists. It is not helpful to patients, doctors, or anybody else to implement incentive programs that reward or punish physicians when the systems of care in which they work have not been redesigned to achieve the new goals. For example, tying a physician's compensation to cancer screening rates in a primary care setting without designing a system to identify appropriate candidates for screening and facilitating the testing is just a demoralizing punishment for the physician.

Here is the key point that many administrators I know just don't get. It is not about the incentives. It is about redesigning the care. Yes, appropriate incentives create the economic viability of the care redesign so, in the example above, a sufficient bonus tied to cancer screening may make it possible to invest in appropriate IT systems and physician extenders to do the work necessary to close gaps in care, but it is the care redesign that gets the job done, not the incentives. Administrators, who are ignorant about how care is actually delivered, tend to believe that if they just got the incentives “right” then all those pesky doctors would just do the right thing. What they don't see is that the only effective path to success in the new world is to engage doctors in the hard work of redesigning care—something that no administrator can do—and reward them for doing so.

Final thought about the difference between incentives and capabilities suitable for spring training. You could promise me a million bucks to crush a fast-ball over the center field fence, but it is never going to happen. But, make me the manager, and allow me to put the right team together, and I can guarantee plenty of balls will leave the park.

What do you think?

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.