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 Journal recently 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? 

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.  

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.

We Are Our Own Typos

Everyone seems to be writing about the recently announced effort by Amazon, Berkshire Hathaway, and JP Morgan Chase to attack their employee health costs.  It is certainly newsworthy, and I am generally interested in whatever Amazon may do in healthcare. 

They may very well have some success with this effort, but until I read a positive story about employee working conditions at Amazon, I'm going to be skeptical that any disruption in healthcare they accomplish with it is something that I shouldn't be worried about. 

So, instead, I'm going write to about why we can't recognize our own typos, and what that means for our health. 

As Wired summarized the problem a few years ago: "The reason we don’t see our own typos is because what we see on the screen is competing with the version that exists in our heads."  They go on to explain that one of the great skills of our big brains is that we build mental maps of the world, but those maps are not always faithful to the actual world.

As psychologist Tom Stafford explained: "We don’t catch every detail, we’re not like computers or NSA databases.  Rather, we take in sensory information and combine it with what we expect, and we extract meaning.”

Thus, typos. 

Unfortunately, the same is often true with how we view our health.  We don't think we're as overweight as we are.  We think we get more exercise than we do.  We think our nutrition is better than it is.  Overall, we think we're in better health than we probably are.

Over the past few decades, the U.S. has been suffering "epidemics" of obesity, diabetes, asthma, and allergies, to name a few.  Over half of adults now have one or more chronic conditions.  Yet two-thirds of us still report being in good or excellent health, virtually unchanged for at least the last twenty years. 

Something doesn't jibe. 

For many years, researchers and physicians have viewed self-reported health status as a strong indicator of our health, with some even calling for it to be a new vital sign.  More recent research confirms that, well, it may not be so reliable after all -- and is especially problematic for the sub-populations for whom one would like a more accurate measure,

Plus, as the Pew Research Center found, no matter how old we get, we think of "being old" as something that happens at a later age.  We think of ourselves as younger than we are, and the gap between our actual age and how old we feel grows as we age. 

When it comes to our health, most of us think we are a younger, healthier person.  That may help explain why many of us do not take better care of our actual selves.

But what about all of those people who belong to a gym, some 57 million of us?  The number has almost doubled from 2000 to 2016.  What about the number of people running races, some 17 million of us?  That number has more than tripled since 1990.   What about all those sales of fitness tracking devices like Fitbits (25 million!) or Apple Watches (12 million, with 6 million in 4Q 2017 alone)? 

Impressive, but all those may be more due to their having become social activities at least as much as fitness ones.  I.e. it's not that fitness efforts are driving athleisure sales, but vice-versa.  We may not be any healthier but we want to look good anyway.

Technology is going to make this even easier.  Unfortunately.

Imagine, if you will, the augmented reality (AR) app that doesn't just put a funny face on you or your friends, but that makes you look the way you think you look.  Or would like to look.  You could walk around with your smart glasses and whenever you see your reflection, it'd be the ideal you. 

Better yet, anyone else with smart glasses and the right app could see the same.  You could all walk around in a shared augmented reality that happily makes you each look younger, healthier, and better looking.  No wonder Intel thinks smart glasses are going to be big.
 

Virtual reality (VR) could take better versions of ourselves even further.  Your avatar could be any "you" that you wanted.  Or anyone, really.  Taller, stronger, fitter, better looking. 

Advances in haptics are making touch more realistic in VR.  It's already being used for those with chronic pain or mental health issues, and to help people with missing limbs.   The VR experience will get even more immersive.

It's all-too-easy to see a future in which our VR selves not only look but actually feel better than our real selves. 

Maybe that is OK.  Perhaps we're all going to live in VR anyway (although it didn't work out so well in The Matrix).  Or perhaps -- just perhaps -- our AR/VR self will help remind us of the self we could still be. 

There is some evidence that having poor perceived health has somewhat of a snowballing effect, causing people to limit their activities and thus further their declines.  Any avenue that helps people feel better about themselves could help combat that.  . 

Then again, why work on getting our real selves healthier when it will be so much easier to just jump into VR?

I'm many years past my twenty-five-year-old self, when I could eat anything I wanted, run as long as I wanted, stay up as late as I wanted, and be full of energy all day. 

Yet that is the me I still have a mental map of, and the me about whom I still often make health decisions. 

That me is my typo. 

The technology to imagine better versions of ourselves is not going away.  It's only going to get more powerful.  Our ability to mentally map better versions of ourselves is not going away.  We have a long evolutionary history that made it part of how we survive. 

The question will be, can we use the technology to help us make more accurate mental maps of ourselves, so that we can figure out how to improve our health?