Sunday, March 18, 2018

Animal Farm Meets Health Care

In George Orwell's classic Animal Farm, the animals revolt against their human masters, and establish a classless society with the inspiring principle, "All animals are equal."  As events play out, their society devolves into a dictatorship with a ruling elite, and the principle becomes "All animals are equal, but some are more equal than others."

This, surprisingly, makes me think of health care. 

I am old enough to remember when maternity coverage was at best only very limited even in employer group health plans.  It took the Pregnancy Discrimination Act (1978) to require them to treat maternity the same as any "illness," and, even then, individuals plans often did not include it until ACA required it.  Similarly, coverage for mental health was typically skimpy until the Mental Health Parity Act (2008) required parity.

Preventive services were usually only available for (the small percentage of) people enrolled in HMOs, until network-based managed care plans grew more widespread in the 1990's.  The same happened with prescription drug coverage, which used to only be available to the minority of people with "major medical" coverage.

It took the Affordable Care Act to standardize what "essential benefits" should be included in health plans, and even then they are almost entirely medical benefits (and are still under attack, such as with "short term" health plans or Idaho's recent attempt to sell low cost plans). 

But, for the most part, medical services are generally covered by (most) health insurance plans.  For services like dental, vision, or hearing, not so much.   Evidently, some services are more equal than others.

We've managed to push our rate of people without health insurance to around 11%, but it's more than double that for dental insurance, and worse yet for vision coverage.  For seniors, the figures are significantly worse

The real question should be, why do we have separate coverages for services like dental or vision, especially when many lack them?

This matters.  According to NCHS, 14% of Americas report hearing trouble, 9% vision trouble -- and 7% have no natural teeth left (25% for those over 75).  There is a well documented link between oral health and our overall health, yet a study found that dental care had the highest financial barriers to care, compared to other health services.
Percentages of National Health Interview Survey respondents who did not get selected health care services they needed in the past 12 months because of cost, by age group, 2014.  Vujicic, et. alia.   
A third of millennials -- whose teeth one would expect to be good -- are reluctant to smile due to their teeth; 28% say it impacts their ability to get a job.  Poor oral health is most pervasive among low income people, yet only 17 states have Medicaid programs with comprehensive adult dental benefits, and the trend is to require that able-bodied people get jobs in order to qualify for Medicaid coverage.

Kind of a Catch-22.

We claim to support preventive services -- to the point ACA mandates coverage at no cost -- but that only applies to services that are medical in nature, performed by physicians.  If you want to get your eyes or your teeth checked, maybe you'll have some coverage for it, maybe it will even be covered at 100%, but, then again, maybe not to either.

Austin Frakt laments: "It’s an accident of history that oral care has been divided from care for the rest of our bodies. But it seems less of an accident that the current system hurts those who need it most."  Nicholas Kristof recounts that historical accident:
It’s virtually an accident of history that dental care isn’t considered part of medical care. The medieval barber-surgeon used to attend to all the human ailments that required a knife: bloodletting, tooth extraction, shaving. In the 1840s in the United States, the heirs to the tradition wanted to become professionals; they didn’t want to keep wandering from town to town selling their services. They asked physicians at the Medical College at the University of Maryland if they would include dentistry in the medical coursework, but the physicians refused. Soon after the dentists opened a separate dental school nearby.
And keep in mind, those weren't post-Flexner educated physicians.

If you break a bone, you'll see a doctor; if you break a tooth, you'll see a dentist.  If you have problems with your throat,you'll see a doctor; if you have problems with your gums, you'll see a dentist.  If you want to correct your vision with glasses, you'll see a optometrist; if you want to correct it with Lasik, you'll see a physician.

Think about the alphabet soup of "doctors" we have: M.D., D.O.s, D.C., Ph.D., PharmD, O.D., and D.P.M., and I've probably missed some. 

Specialization is understandable, as most physicians end up doing, but I have to wonder why some types of specialization start at the beginning of training, rather than after the basic medical training (see my previous article on balkanized medical education).

We accept all this because, well, that's the way it always has been.  That doesn't mean it makes sense, or that it is best for our health.

For example, the microbiome is a hot area of medical research and is starting to be an important option for treatments.  What if, say, microbiologists claimed only they could understand it and should be the only practitioners allowed to treat microbiome-related issues?  It would force us to guess when to see whom for what, but that is essentially what we've done with many other aspects of our health.

We each only have one body.  Although some health issues are fairly specific, we are increasingly realizing that many are systems issues involving multiple parts of the body.  It's time to stop drawing artificial distinctions between what care we get, who gives it to us, and how those professionals get trained. 

Health is not equal to health care.  Health care should not be limited to medical care.  We need to get past "historical accidents" and focus on what is best for our health, and our care.

Unless you actually do believe that all health services, and all health care professionals, are equal, but some are more equal than others.

Tuesday, March 13, 2018

Healthcare's Death Star Thinking

I missed it when it first came out, but a providential tweet from the always perceptive Steve Downs tipped me to a most interesting article from Jennifer Pahlka with the wonderful title “Death Star Thinking and Government Reform.

The article is not directly related to healthcare, although it does include healthcare examples, but Ms. Pahlka’s central point very much applies to most efforts to reform healthcare:
The need to believe that a Death Star-style solution is at hand — that we have analyzed the plans and found the single point of failure — runs deep in our culture.
After all, who among us does not want to be the Luke Skywalker who blows up healthcare’s dysfunctional Death Star? 
Of course, in reality, figuring out exactly who the evil Empire of healthcare is or what they’re using as a Death Star these days is not so easy. Nor is finding the single point of failure that we can exploit to magically make everything better.

Some see the health insurers as the Empire (or, certainly, their supposed agents the PBMs — the Darth Vaders of healthcare?). Others blame the ever-consolidating health systems, which are gobbling up fellow hospitals and any available physician practices. Pharmaceutical companies are also a popular target. 
We can’t quite decide if physicians are the Imperial storm troopers who oppress us or the persecuted Jedi who may yet save us (although many — including a lot of physicians — feel that the AMA is part of the Empire). Nor can we decide if employers are the Imperial tax collectors who have all too passively allowed healthcare costs to steal our wages, or the plucky Hans Solos who are doing their best to fight the Empire. 

Proposed magic bullets to fix supposed single points of failure in healthcare abound. Remove the tax preference for employment-based coverage. Give us more “skin in the game” via increased cost-sharing. Increase the number of physicians, or at least reduce the percent who are specialists. Increase integration between health professionals/facilities. Get more of us covered (or maybe not).

Improve interoperability. Make the healthcare system more digital. Use artificial intelligence (AI) and Big Data to figure out what we humans haven’t been able to. Nanotechnology or robots, even nanorobots, will save the day. Develop even more new drugs, use 3D printing, take advantage of gene splicing/editing. Exploit the microbiome’s power. 

Maybe we’re looking in the wrong places and we should be focusing on social determinants of health (SDOH). 

Or we could all just eat better and walk more. 

A sobering new study from Ashish Jha and colleagues reminds us, though, that there probably is no such single point of failure. As other studies have attempted to do, it compares the U.S. healthcare system to other developed countries. It concludes that, aside from our high level of spending (caused by high prices and administrative costs), we’re not as bad or as unusual as many think. 

It’s not that any country has fixed the single point of failure as it is that every country is also struggling to find it. Harvard Medical School professor Bruce Landon told The New York Times
I don’t think there’s any of these countries where if you went and talked to them individually, they wouldn’t say they’re having a health care cost crisis. They’re all struggling with paying for new technology and the cost of the system.
We’re all engaging in some Death Star thinking.

Whatever the single point of failure might be, many think we need a new hero to fix it, be that Amazon, Google, Apple, or people/companies we haven’t heard of or aren’t thinking about in this space. They’ll come along to rescue us and our health care. For all those people who believe some tech company can ride in to save healthcare, Ms. Pahlka reminds us:
In fact, simply adding technology without understanding the complexity of the bureaucratic processes and how they got to be the way they are can perpetuate the problem, or even make it worse.
She also emphasizes — and this really fits healthcare — “You can’t fix the problem of a system that is based on rigid rules by specifying new rules.” We’re not going to simply legislate or regulate our way out of the mess we’ve allowed our healthcare system to get into. 
Instead, she points out:
There is no “solution,” only continued storytelling that shapes a new narrative and supports a new sensibility. But it is an important, valuable agenda that will get less attention and resources than it should because it doesn’t fit the model of a “solution.”
Fixing healthcare is very much a design issue, one that requires new ways of thinking, better “storytelling,” and involvement of all impacted parties. None of that is easy nor natural for healthcare; as healthcare design guru Dr. Bon Ku said at his recent SXSW presentation: “Healthcare is the black hole of design.” (thanks to Danielle Ralic for the quote):

Dr. Ku is attacking the problem at one of the roots, during medical school, as is Clay Johnston at Dell Medical School and a short-list — too short — of other medical schools. 

A new article in Harvard Business Review by Bhatti and colleagues urges that healthcare use more “human-centered design.” They studied three healthcare innovation centers, identified six common challenges, and made several recommendations for others interested in accelerating human-centered design in healthcare. 

Perhaps their most important statement was a mindset: 
This model isn’t just about getting greater patient feedback during the innovation process. Patients are co-designers, co-developers, and increasingly more responsible for their own and collective health outcomes.
The Empire would hate that. 

If the Star Wars franchise has taught us anything, it may be that there will always be another Death Star. There will always be a would-be Empire. It is never easy to defeat the forces (small “f”!) that seek to keep us from fulfilling our destiny, even if that destiny is better health. But it also reminds us that we should never give up hope.

We didn’t design our way into our current healthcare system, but it is possible — just possible — that we can design our way out of it.

Tuesday, March 6, 2018

Life in the Cloud

The cloud is big. Amazon (AWS), Google (Cloud Platform), IBM (Cloud) and Microsoft (Azure), among others, have made big bets in the space. Indeed, virtually all of Amazon’s 2017 operating income came from AWS. Alphabet’s former Chairman Eric Schmidt had some important advice for attendees at HIMSS18: "Run to the cloud!"

The thing is, I’m not sure we’re thinking about the cloud quite right yet. As evidence, I want to point to the Blade Shadow PC.

Blade is a France company, and Shadow PC is an app designed specifically for gaming. It offers users a virtual machine, giving them access to a high-end PC that is constantly upgraded.

Gamers always want to have PCs with the fastest processor, best graphics card, and sharpest display. It can get very expensive, and as soon as you’ve upgraded your device, it starts to become outdated. With Shadow, in theory, you’ll always have the latest and best.

Shadow doesn’t even care what device you run it on. Your monthly subscription lets you run it on any device you want (one at a time). You could start a game on your home PC, continue playing on your smartphone while you are taking an Uber to work, then pick up playing it on your work computer (during your breaks, of course). The machine you use is pretty much just needed for the connectivity and the screen.

Shadow has received a lot of media attention. The consensus seems to be that it may not always quite live up to the hype, yet, but it is pretty cool. 

Here’s CNET’s review:

I have to admit, I don’t really care about video games, except as a business and cultural phenomena, but the implication of Shadow PC is not so much for video games as it is for everything else we do on devices. As Blade CEO Asher Kagan told The Next Web
If we can do something to prove this is working for the gamer market, it’ll show it can work for anyone. Gamers are very demanding, they’re very sensitive to latency.
The Wall Street Journal’s David Pierce sees it leading to a new future:
Someday soon, what Uber did for cars and Netflix for TV will happen with computers. Rather than buy a suite of gadgets — a PC, phone, Xbox, etc. — you could just access their features when you need them. They won’t need to be distinct, powerful devices with their own hefty allocations of processor and memory. Instead, you’ll have a single virtual computer with all your data and preferences. You’ll reach for a touch screen when you’re on the go, sit down to a larger one with keyboard and mouse when you’re at your desk. Maybe you’ll have a wall-size one, too.
Similarly, Rob Enderle writes in Computerworld
Blade Shadow PC has the potential to become a Netflix for PCs but so does Netflix and all the other streaming providers — including Amazon. I expect by 2020 we’ll have a lot of compelling alternatives to a running apps on locally on a PC and that this will drive a trend similar to what happened to Blockbuster and Netflix. The old will give way to the new and we’ll never have to worry about patches, replacing hardware, or even buying apps the way we do now.
Mr. Enderle’s article is headlined “By 2020, we’ll be using Windows in the cloud,” so we’re not just talking about games or apps or websites. We’re talking about operating systems. It takes the idea behind Chromebooks to the next level.

At this point, it might seem that everything will go to the cloud. After all, with cyberthieves getting ever more sophisticated, it almost seems negligent for you to have your own PC or for your company to hosts its own machines. Let the experts worry about hacking and security, about hardware and software upgrades. We only care that things work.

I don’t think it is going to be quite that simple.

I’m old enough to remember mainframe dumb terminals with arcane commands. I’m thus old enough to remember when PCs came along to help wean us from mainframes, when local computing power was something to be prized, not avoided. 

Moving everything back to a centralized place, this time in the cloud, thus leaves me with a little trepidation. 

I don’t think that is what is going to happen because of ubiquitous computing (also known as pervasive computing), and dispersed computing. They sound similar, and they are related, but they are distinct.

The former is often thought of in the Internet-of-Things gold rush, where everything is connected to the Internet, communicating all the time. It is happening already, and it will develop exponentially over the next few years. We’ll know more, about more things, than we ever could have guessed we might have needed.

The latter, though, is an even newer idea (Darpa is spurring it): all those devices aren’t just connected but they are all also computing. You draw your computing power from whatever is handy and appropriate to/necessary for the task(s) at hand. 

You might access a distant cloud server farm for some needs, but your smart clothes for others. If you lose a connection, or if your computing needs shift, you seamlessly pick up another, or add more. Your screen might just be something you see through your AR contact lens and your “keyboard” might just be your hand gestures, or even a direct implant in your brain.
Credit: Darpa
Think of computing power almost like electricity: it is just there, everywhere, and you won’t even always need wires. You use what you need, and you don’t really care where it comes from. 
Think about your computers as, well, you won’t have to think about them at all. As I said in a previous post
If you’re aware of your device, that’s the past… We’re going to have to get past our fascination with the latest and greatest devices — a new iPhone! a 4D television! — and let their technology fade into the background. As it should.
Healthcare is very proud about how it is finally adopting (if not quite embracing) computers, and many of its thought-leaders are taking Mr. Schmidt’s advice by starting to move to the cloud as the “next” big thing. That’s good. 

I just would like to see them spending more time thinking about the next next big thing.

Thursday, March 1, 2018

Will AI Docs be MDs, or DOs?

There is increasing acceptance that artificial intelligence (A.I.) is going to play a major role in healthcare and in the practice of medicine.

Some see AI as a way to augment human doctors.  Some see it as a way to help patients triage the need to see a human doctor.  Others see it replacing entire specialties (pathology is often cited).  A few even think that, eventually, AI "doctors" could replace humans entirely.

Whatever is going to happen, we need to be thinking about how AI makes its decisions -- and what that might say about our existing system.
AI decision-making has two separate but very much overlapping problems: the "black box" problem and unintentional biases.

The black box problem is that, as AI gets smarter and smarter, we'll lose track of what it is doing.  "Machine learning" refers to the ability of AI to, essentially, learn on its own.  It looks for patterns we might only not have seen, but might not even be able to see.  It may reach conclusions using a logic that is beyond us.

My favorite example of this, as I have previously written about, is Alphabet's Deepmind program AlphaGo Zero.  It learned how to play the fiendishly complex game Go, without humans programming it to play, or even by learning from human games.  It not only mastered the game -- in three days -- but also came up with strategies that left human Go experts agog.

Think about the day when the AI's strategies are not about a game but about treatments for our health.

If we were convinced AI was always making purely objective decisions, we might grow to accept its decisions without question.  After all, most of us don't know how our televisions or smartphones work either; as long as they do what we expect them to, we don't really care how.

The trouble is that we're becoming aware that all-too-human biases can be built into AI.

Programming remains a largely male profession, and those men are usually young, well educated, and from comfortable backgrounds.  It is not a good representation of the world.  Their world views and experiences influence the way they program, and the data that they give to their programs to help them learn.  In most cases, they're not intentionally biasing their creations, but unintentional biases can have the same result.

For example, a recent study from MIT and Stanford on facial recognition AI programs found that they worked very well for faces that were white males; otherwise, not so much.  The researchers discovered that the dataset of one such program was 77% male and 83% white.  The programs were from major technology companies, and certainly weren't intended to be biased, but the AI knew best what it knew most.

This is not the only such example.  As Kriti Sharma points out that the gender stereotyping in having default voice for digital assistants Siri or Alexa be female, but using male names for problem-solving AIs IBM's Watson and Salesforce's Einstein.  ProPublica found that AI used by judges during sentencing to predict the likelihood of future crimes greatly overestimated the likelihood for African-Americans.

The key to both problems may be to increase transparency about what the "black box" is doing.  The Next Web reported that researchers recently "taught" AI to justify its reasoning and point to supporting evidence.   Whether we'll have the time, interest,or expertise to examine these justifications remains to be seen.

Vijay Pande, a general partner at Andreessen Horowitz, isn't so worried, and he specifically points to health care as a reason why:
A.I. is no less transparent than the way in which doctors have always worked — and in many cases it represents an improvement, augmenting what hospitals can do for patients and the entire health care system. After all, the black box in A.I. isn’t a new problem due to new tech: Human intelligence itself is — and always has been — a black box.
We don't really know how physicians make their decisions now, which may account for why physicians' practice patterns are so varied.  Many supposed rational decisions, in healthcare and elsewhere, are based on a variety of factors, most of which we are not consciously aware of and some of which are more instinctive or emotional than intellectual.

Mr. Pande views the so-called black box as a feature, not a bug, of AI, because at least we have a chance of understanding it, unlike the human mind.
Credit: Scott Adams, Dilbert
All of which led me to a thought experiment: as we program healthcare AI, would we want it to be based on allopathic (M.D.) or osteopathic (D.O.) practices?

These are the two major schools of modern medicine.  Their training and licensure have become much more similar over time, but the two remain distinct branches, with separate medical schools and graduate medical education.  Most hospitals are "integrated" but there remain predominately D.O. hospitals.

If you asked either type of physician if the healthcare AI of the future should be based  solely on their own branch, I suspect most would find that acceptable, but not if based solely on the other's.   If you asked if it should be based on both, using all available information, I suspect that would be even more acceptable.

Therein lies the problem: if we don't want our AIs to be either "M.D." or "D.O.," but rather a combination of the best of both, then why don't we want the same of our human doctors?  Why do we still have both?

IBM's CTO Rob High spoke to TechCrunch of the AI work they've done with Sloane Kettering Cancer Center, and admitted the resulting AI has their biases and philosophy.  He says "any system that is going to be used outside of Sloane Kettering needs to carry that same philosophy forward."

Whether it is Sloan Kettering, The Mayo Clinic, or The Cleveland Clinic -- or M.D. versus D.O. --  we should want AI based on as much data as possible.  We don't yet really know what is important, and should not make the same mistakes with silos as we've made before AI.

I don't want my healthcare AI to be either an M.D. or a D.O.  I don't want it to be a physician at all.  I want it to be something new.  If we want the healthcare system of the future to be an improvement over what we have now, we need to stop thinking within our current paradigms.

Monday, February 26, 2018

Speak Truth to Power

One of the unexpected, and inspiring, outcomes of the tragic shootings in Parkland, Florida has been how the students have become the leading voices in the #NeverAgain movement.  Like those involved in the #MeToo movement, they are proving that victims do not have to stay victims, do not have to stay silent, and do not have to wait for "experts" or politicians to get around to action.

More people in healthcare need to "speak truth to power" as well.
One need look no further than the Larry Nassar scandal.  He managed to abuse hundreds of young athletes, including prominent Olympians, for decades, seemingly under the radar of his medical practice, his university, and USA Gymnastics, to name a few.  There had been complaints, or at least questions, about what he was doing for many years, but not until The Indianapolis Star reported on it in 2016 was action taken.

Dr. Nassar is going to spend the rest of his life in prison, but we have to ask: who knew?  Who should have known?  Why didn't they speak up sooner, or investigate more thoroughly?   Dr. Nassar was responsible for his own actions, but many people should be asking themselves what they could have done.

Not everything is as clear-cut as that.  For example, The New York Times just reported on how "gag clauses" from pharmacy benefit managers (PBMs) prevent pharmacists from discussing the "real" price of prescriptions with consumers, such as when having insurance perversely costs them more.  PBMs say the practice is not condoned and is, at most, "an outlier," but pharmacists disagree.

And, as Elisabeth Rosenthal pointed out in An American Sickness, such clauses aren't limited to pharmacists.  Doctors and people working in hospitals or other health care settings have been, and may still be, subject to them.

Gag clauses may be good for revenues, but not for customers.  Who didn't object to signing an agreement with one?  Who didn't object to asking for one?  Who didn't speak up?

They're hopefully not as prevalent as they once where, but even without them, try having a conversation with someone in, say, a healthcare billing office about their pricing, and just see how far you get.  Gagged or not, their billing practices are not something they want to discuss.

I'll make this bold statement: everyone who works in healthcare has seen or been part of something they are, at best, not quite comfortable with.  Maybe not illegal, maybe not even strictly unethical, but something that doesn't sit quite right.  How many of us have spoken up about them?  How strongly?

Maybe it is doing procedures on patients that they don't really need.  Maybe it is charging them eye-opening amounts of money.  Maybe it is sending patients to collections because they can't pay those amounts.  Maybe it is double and triple booking patients, making them wait for hours.  Maybe it is waking hospital patients up in the middle of the night for tests that, really, could wait until the morning.  Maybe it is knowing that doctor whose memory is bad or whose hands are shaky. 

We tell ourselves that it is all for the best, that we're just doing what we're "supposed" to, and that the people in charge know what they're doing.

Tell that to the kids from Parkland. 

Rich Joseph, a resident at Brigham and Women's Hospital, wrote a thoughtful op-ed with the scathing title Doctors, Revolt.  He cites an example of an elderly patient who complained about being poked and prodded.  Dr. Joseph indicated he understood his frustration and said he wished he could do something. 

The patient, who was himself a physician, was blunt in his response: "Understanding is not enough.  You should be doing something to fix the system."  The elderly patient-physician later further urged him: "'doctors of conscience' have to 'resist the industrialization of their profession.'"

It's not just doctors and it's not just "industrialization.  Whether we're physicians, other health care professionals and workers, or just patients, we all need to have a conscience.  We all need to do what we can to fix the system. 

We need to resist, and speak up, whenever we see things in healthcare that just aren't right, where we or others are not being treated right. 

Don't get me wrong; this is not a problem just limited to health care.  The Wall Street Journarecently discussed the "success theater" at GE that has led to masking core problems.  One analyst said: "The history of GE is to selectively only provide positive information."  A consultant who knows GE well added, "GE itself has never been a culture where people can say, ‘I can’t.’”

Much less, "we shouldn't."

In a related story, Robert Bies, a professor at Georgetown university, told The Washington Post,
It's more common than you think.  With GE's 'success theater,' the stakes are so high. But every organization you’re a part of, there’s a challenge to being forthright and honest.
The Post article also cites advice from Andy Grove, Intel's founder, to "embrace the discomfort," and urging leaders "you've got to make it more uncomfortable for people to say nothing than to say something."

It's not just GE -- truly, it's every business and every organization -- but the stakes in health care make speaking up all that much more important.

Medical television shows like The Resident, House, E.R., or even Grey's Anatomy are popular in part because the heroes break the rules.  They question authority, they challenge the bureaucrats, and they always look out first for the patients.  They're following Dr. Joseph's admonition to revolt. 

Maybe, though, what we need is not so much revolt as making sure those stupid rules, those not-patient-friendly practices, don't exist at all.  We need more people who don't just want to break those rules, but to change them into something better. 

After all, we don't want an ad hoc healthcare system, where there are no rules and every situation is a one-off, but we do want one that doesn't keep putting rules over patient needs.  We do want one where people speak up when they see things they don't think are right, and keep speaking up until they are. 

If those kids from Parkland can speak up so boldly and so eloquently after having been shot or having friends that were shot, then who among us are too timid to speak up about what we see wrong in our healthcare system? 

Tuesday, February 20, 2018

The Tyranny of Good Health

It's hard to be healthy.   Unless you are young or genetically blessed,  and even then sometimes, it takes lots of hard work to be healthy.  It is work that only gets harder as you age.  As the saying goes, Father Time is undefeated (Tom Brady notwithstanding).

Unfortunately, we live in a society that thrives on convenience, and working hard on our health is one of those things we don't find very convenient.
Just think about what's involved.  You have to eat the right foods, in the right amounts.  You have to get enough exercise, without overdoing it.  You need to get enough rest, but not spend too much time in bed or on the couch.

It helps to have a purpose, whether that is work, an avocation, or something else that motivates you every day.  It helps to have plenty of friends and family, but it takes good judgment and some luck for them to be ones who will help you stay healthy.  And it helps to avoid some things that many find pleasurable, like tobacco, too much alcohol, and recreational drugs. 

The worst of it is that, despite your best efforts, inevitably your metabolism will slow down, your cardiovascular system will become less efficient, your muscles will get weaker, and your bones will grow more brittle.

It's possible that you'll have a middle-age-crisis attempt at living better, so that you'll claim you feel healthier at 50 than you did at 40, but no matter what you do, you'll almost certainly be less healthy at 70 than you were at 20, and at 80 you'll be looking back at 70 enviously.

And, of course, there's no telling when you'll catch some unexpected bug, or the long tail of a genetic defect will come to haunt you.   

Getty images
Sadly, the payoffs for good health efforts don't last long.  Slip up on your diet or your exercise, and the declines aren't measured in decades or years, but in months or weeks.

No, staying healthy is anything but convenient. And that is a problem.

In The Tyranny of Convenience, Tim Wu, a professor at Columbia, asserts: "In the developed nations of the 21st century, convenience — that is, more efficient and easier ways of doing personal tasks — has emerged as perhaps the most powerful force shaping our individual lives and our economies."

He goes on to say: "Convenience seems to make our decisions for us, trumping what we like to imagine are our true preferences....Easy is better, easiest is best."  

Think about your grocery store experience.  Sure, you can buy all sorts of fresh fruit all year long, plenty of fresh meat every day, but it is so much simpler to buy something pre-packaged that you can just pop in the microwave.  That those pre-packaged meals and products may be loaded with lots of sugar, salt, or fats -- designed precisely to make us crave them -- is the price we pay for that convenience.

You don't even have to go in the store.  Order online and they'll bring your groceries out to your car!  They'll deliver them to your house!  Not for nothing did Amazon buy Whole Foods.  It's easier than ever to get more calories, with less nutrition, while spending fewer calories acquiring them than ever.

We'd rather microwave something unhealthy (or get it from a drive-through) than to fix something healthy.  We'd rather drive than walk, and we'd rather look at our many screens than drive.

Steve Downs, the Chief Technology and Strategy Officer for The Robert Wood Johnson Foundation put it aptly: "We have created lifestyles that do not suit the species we have become."  He urges that we build health into the "operating system" of our culture.  

Right now, he points out. the easy choices -- the convenient ones -- in our lives tend to be choices that are not the best for our health.  He believes this has to change:
It would mean creating environments where healthy choices are the easy choices. And not just the easy choices, but the desirable choices, even the defaults.  It would mean building a culture where people don't have to think consciously about being healthy, but rather being healthy is a natural consequence of going about your day.  
He outlines some promising efforts that use technology to try to achieve these goals, but admits we are still in early days of making the needed changes.

Until they happen, we may be left with what Professor Wu concluded: "We need to consciously embrace the inconvenient — not always, but more of the time...Struggle is not always a problem. Sometimes struggle is a solution. It can be the solution to the question of who you are."

We can try to better resist the "stupefying power" (as Professor Wu describes it) of the convenient choices in order to make the choices that are right for our health.  

Throughout it all, our healthcare system enables our bad behaviors.  It has become the more convenient choice.

We'd rather go to our doctor to get a pill to address our health problems than to make basic changes to our health habits.  We'd rather complain about our health insurance not paying as much of our medical bills as we'd like than to spend money out of our own pockets on better health habits.  We get surgery when our diets fail or when our backs and knees can't support how heavy we've become.

We look first to our health professionals to get us out of the health holes we've fallen into, instead of trying to get out of them ourselves.

Yes, good health imposes a tyranny upon us.  It requires constant vigilance against all the insidious things that would rob us of our health.  There is a famous quote, oft attributed to Thomas Jefferson, that "eternal vigilance is the price of liberty."  The same could be said about the price of good health.

But poor health choices impose a tyranny of their own.  Making poor health choices can be like the mythical frog who will sit in gradually boiling water until it cooks him.  Before we know it, poor health choices cook us too.

Many people spend much time on innovation and technology to improve the convenience of getting medical care, but we need to focus much more attention on how to make staying healthy more convenient.  

Tuesday, February 13, 2018

It's About Time

Chances are, the sun isn't directly overhead for you when it is for me.  The sun probably rises and sets at different times for you than for me.  That's why for most of human existence time was a local matter.

Nowadays, of course, we have Greenwich Mean Time, we have time zones that span the globe, and we have clocks so accurate that satellites have to take into account relativistic time-dilation effects.  You not only can know exactly what time it is where you are, but also at any other point in the world.

Technology made the change possible, and necessary. 

Health care should learn from this.
It used to be that local time was good enough.  You lived most or all of your life in a geographically constrained area, so the village clock served your purposes.  If you traveled, you simply had to adjust to local time.  You probably didn't even think twice about it.

It was the railroads that made this impractical.  People wanted to know when trains would arrive, and when they'd leave.  More importantly, if they were't coordinated, trains traveling in different directions might -- and did -- run into each other.

The railroads made standard time necessary.  The telegraph made it possible. 

Telegraphs allowed people in two locations to agree on what time it was "now."  You could send a virtually instantaneous signal saying, "it's midnight here Greenwich."  We could set up standard time zones.

Surprisingly, it took much decades for people to embrace this.  In the U.S., for example, the railroads moved to standard time in 1883, but the U.S. didn't officially adopted it until 1918.   England, which started the whole idea, had converted by 1880. 

We treat health care much like we used to treat time. 
Dartmouth Atlas, "What Kind of Physician Will You Be?"
That is, it is largely local.  How it is practiced in one community may not be how it is practiced in the next community, or even the next hospital or physician practice within a community.  We know this, and have known it since at least the early 1970's, due to the work of John Wennberg at Dartmouth. 

The care you get will depend on, of course, what is wrong with you, but also on which physician you see.  And where they went to medical school, where they did their residency, what hospital they practice in, who they practice with, what studies they have seen/remembered.  And how they are paid. 

A recent survey found that most clinicians agreed that practice variation should be reduced, but were less confident that it would be.  They thought that some situational variation was justified, but that as much as one-third was unwarranted. 
Very few dispute that there is significant variation in care, or that it is probably bigger than it should be.  We have lots of practice guidelines and protocols that are aimed at reducing variation.  But there's not much evidence that it is getting any less. 

In fact, some argue that it might be getting worse.  In Health Catalyst, Dr. John Haughorn cited four reasons for this:

  1. The healthcare environment is increasingly complex;
  2. There is exponentially increasing medical knowledge;
  3. Despite #2, there is still a lack of valid clinical knowledge; 
  4. There is too much reliance on subjective judgement by clinicians.  
We accept these variations because, well, that's how it has always been.  We accept them because we think our personal situation is unique.  We accept them because we trust our local experts.   

We accept them for all the same reasons we used to accept that time should be local. 

Technology has made it both necessary and possible that we move away from this attitude.

It is necessary because the scope of the problem is clear.  As Propublica put it in a recent expose of unnecessary procedures: "Wasted spending isn’t hard to find once researchers — and reporters — look for it."  All that unnecessary care is bad for our pocketbooks -- and bad for our health. 

Almost twenty years ago the Institute of Medicine estimated as many as 98,000 hospital deaths annually due to medical errors.   More recently, medical errors have been estimated to be the third leading cause of death in the U.S. 

Another study found that 8.9% of U.S. surgeons believed they've made a major medical error within the last 3 months, and 1.5% believe it resulted in the patient's death.   Again, that's just within the last 3 months.

Yes, moving away from "local" health care is necessary.

The good news is that it is possible.  We have the technology to consult with physicians who don't happen to be local, such as through telemedicine.  And not just consult; we're even getting closer to telesurgery.  It is possible to get the "best" doctor for our needs, not just the closest.

We have more data than ever about us and our health.  We have artificial intelligence that can analyze all that data plus all those medical studies that no human can possibly keep up with.  It is possible to come up with the "right" recommendations for us.   

We have to stop thinking of health care as local.  The information it is based on is not.  The people who are best able to apply that information to our situation may not be.

If I get a driver's license, I don't have to get another one when I drive to another state.  If I get on a plane, the pilot doesn't have to have a pilot's license from each state he/she lands in, or flies over.  We've recognized that that kind of local control doesn't make sense.

But if I want to use a doctor who is in a different state (or country), that doctor needs a license from my state.   That doctor may be the best trained person in the world for my needs, with empirical data to prove it, but it doesn't matter.  Someday, the best doctor for us may not even always be a person.

We've always justified such licensing by states wanting to ensure the safety of their citizens, but drivers and pilots can put those citizens at risk too.  It's not really about risk; it's more about controlling competition.  With that attitude we'd never had had Walmart, or Amazon, but in health care we accept it.

There is irrefutable evidence that local health care is rarely what is going to be best.  It might not be bad care, but most likely it's only going to be average. 

Maybe we're willing to settle for that.  I'm not.

Time for a change.